Care Gap Reduction and Coordination

• A care gap refers to the absence or delay in providing necessary healthcare services, including screenings, vaccinations, follow-up exams, and preventive measures.
• Care gaps can cause adverse health outcomes for patients, potentially leading to undiagnosed or untreated conditions.
• Closing care gaps is crucial for improving overall patient health and ensuring effective preventive care.

The Role of the Care Gap Coordinator

• Care Gap Coordinators identify, track, and ensure that patients complete necessary health measures.
• Care Gap Coordinators contact patients, coordinate with healthcare providers, and educate patients about screening importance.
• Care Gap Coordinators also ensure follow-up appointments are made.

Benefits of Closing Care Gaps

• Closing existing care gaps provides health improvement, cost reduction, quality metrics, and value-based care.
• Improvements in health outcomes is achieved through timely preventive care like screenings and vaccinations
• Reductions in cost are achieved by addressing conditions early, preventing costly treatments.
• Improved scoring happens from care quality and better patient satisfaction.
• Now, many healthcare providers use value-based care models which provide financial incentives to improve patient health outcomes.

Financial Success and Prioritization

• Doctors that focus on closing care gaps can improve financial outcomes through higher reimbursements and reduced penalties.
• Better patient retention and efficient operations, all provide significant financial implications.
• Healthcare providers can improve the overall line by providing comprehensive care when prioritizing care gap closure.

Correct Coding

• Coding the correct procedure for care gap closure ensures accurate reimbursement and compliance with healthcare regulations.
• Proper coding goes beyond finances, and extends to quality of care, better patient outcomes, and improved system efficiency.

Legal and Ethical Considerations

• HIPAA guidelines are paramount for care gap coordinators to protect patient confidentiality.
• Showing cultural diversity and being respectful is key when discussing sensitive health topics.

HIPAA and Patient Information

• HIPAA ensures health data is securely shared and used solely within the healthcare system to identify care gaps.
• HIPAA ensures security when using data about missed screenings, overdue appointments, or treatments is secure.
• It protects patient privacy when healthcare providers, payers, or other organizations are identifying or coordinating existing care gaps.

Data Sharing, Patient Consent, and Communication

• HIPAA establishes guidelines for secure data sharing to identify care gaps effectively
• The patient needs a preventive screening or vaccination, HIPAA ensures providers can securely exchange information.
• Informed consent from patients is needed before using their health data.
• In cases where the patient needs privacy like scheduling appointments, that is also protected.

Tracking and Follow Up

• HIPAA allows the tracking of care gaps by provider, while ensuring patient data and information is kept private and secure.
• Any communications between providers, insurers, and other organizations should comply with HIPPA to ensure confidentiality.

Time Frames

• Time frames are usually dictated by medical guidelines and business requirements.
• The time frames vary, including annual screenings, every 2-3 years for screening tests, and periodically based on patients' conditions.

Tracking

• It's the job of the care gap coordinator to track patient measures with the insurance company.
• These tasks include due dates for each patient using insurance portals, automated reminders, and follow ups near deadlines.
• Patients are generally contacted 2–4 weeks before the deadline.

Prioritization

• Not all care gaps are created equally, for example, breast cancer screenings are more important than routine eye exams.
• Each care gap should be prioritized based on severity of health risk involved and time to patient deadline.

Portal Access by Insurance Provider

• MetroPlus Health: Login to provider’s website.
• Healthfirst: Sign into Healthfirst portal and go to the "Quality Measures" or "Care Gap" reports.
• Fidelis Care: Go to "Provider Portal” under "Quality Management".
• Wellcare: Log in, then select “Care Gap Management.”
• Elderplan: Login for patient-specific care gaps.
• BCBS: Patient data from Insurance representative.

Exporting Reports

• Reports can be exported as CSV or Excel.
• Information to ensure during exports include patient data, identification numbers, measures and due dates.

Reading Reports

• Information shown includes date of birth and ID number.
• Care gap measures show specific measures, for example, breast cancer screenings.
• Status shows if the gap is closed or open.
• Next Steps, will provide instruction on how to close gaps.

Exporting Reports from a Portal

• Login to insurance provider using specified credentials.
• Navigate to "Care Gap" or "Quality Reporting".
• Select measure report.
• Select applicable measure reports, (e.g., Breast Cancer Screening).
• Specify reporting period.
• A report will be downloaded for analysis as a CSV or Excel file

Value-Based Care Models

• They pay providers based on quality, not quantity, including financial incentives for meeting specific closing care gap targets.

Bonuses for Closing

• Insurers offer incentive programs for closing care gaps, specifically preventive services and chronic disease management.
• Providers may get proceeds from the risk pool if they achieve certain benchmarks such as 90% closure rate.
• Each insurer has their own reimbursement for closing care gaps.
• Documentation, follow-ups and patient engagement also affect money-making.

Rules for Coding

• Coding procedures is crucial for not only just financial reasons but overall care.
• Correct coding helps compliance with regulations, operational efficiency and patient satisfaction.
• It also maximizes reimbursements while improving patient outcomes and stability of the practice.

Breast Cancer Screening Measures

Reaching out to Patients

• Women 50-74 should have a mammogram every 2 years
• Those with family risk factors may need more frequent screenings
• Explain why mammograms are used to detect potential issues at a very early stage.
• Provide resources and assistance for scheduling, and ensure insurance coverage.
• Explain/Assure any fears.

Cervical Cancer Screening Measures

Key Facts

• Women 21-65 should have a Pap Test every 3 years, or Pap test with HPV testing every 5 if both tests are negative.
• The screening detects abnormal cell changes that lead to cervical/uterine cancer.
• Screenings should be regularly conducted
• Explain the importance of tests in preventing cervical cancer and reassure them about the safety.

Colorectal Cancer Screening Measures

Key facts:

• Adults aging 45-75 should be screened, with earlier screenings allowed for those with family risks.
• Early detection of cancer can prevent growth.
• It can be done via stool test or colonoscopy.

Diabetes Care Eye Exam Measures

General:

• Diabetic patients that are over 18 should have an eye exam to monitor diabetic retinopathy.
• The purpose is early detection to prevent damage to blindness and perserve vision.
• Complications can develop without noticeable symptoms.

Addressing the requirements:

• Explain that diabetes affects vision and that screenings are to catch issues very early on.
• Assistance can be provided in helping the patient locate a nearby ophthalmologist.
• It is important to verify if the patient has coverage to reassure the patient by verifying.

Diabetes Kidney Health Evaluation Measures

Key Points

• Diabetic patients that are over 18 should have kidney function tests annually.
• Kidney function is connected with diabetes and early detection is critical.
• For tests (e.g., urine analysis) the patient should be reassured that it's simple with maintenance.
• Patients should schedule appointments at your clinic to complete testing.

Chlamydia Screening Measures

General

• All sexually active females that are under 25 need an annual screening.
• High-risk populations should be screened even with condomless sex.

Key Details

• Testing helps prevent serious health complications, including infertility.
• Make sure that their insurance covers costs .

Non-Users

General

• Non-users are eligible patients that have not completed the doctor's visits exams etc.
• Care gap reports help identify these users.

Actions to take

• Educating non-users will encourage preventative care measures.

Annual Visits

• Annual visits help to ensure and monitor the health of the patient.

Recommendations:

• Action is a call to patients, and the scheduling should occur with follow ups closer to the scheduled date.

Well-Child Adolescent Visits Measures

Recommendation for Child-Patient Care

• Growth, development, and vaccinations need to occur from infancy through adulthood .
• It is a task to explain the checkups and vaccines with doctors and family to ensure appointments occur.

High Blood Pressure Recommendations

Best Practices:

• Adults (18+) with hypertension should have regular monitoring to control pressure below 140/90 mmhg.
• Support must be providen.

Older Adult Care

• For patients that are older (65+) providers need to meet them to assess their needs.

Depression for Screening

• Depression screen should occur for adults with screenings every year.

Adhering to Medications

• Ensure patients take medications as ordered to prevent complications.

HbA1c Monitoring

Diabetic:

• Diabetic patients (18+) every 3-6 months need HbA1c testing
• It is recommended to manage HbA1c levels to below 7% to reduce risk of complications.

90% Target

• Prioritize urgent care gaps and use all types of approaches to outreach, including communications, calls, and emails.
• Use a mix outreach methods.
• Track data response to patient progress, and offer incentives.

Communication with Patients

Keys to communicating:

• Be patient.
• Be understanding.
• Be empathetic.
• Know the benefits that come from completing the process and explain them!

Notes for each call

• Verify a correct identity, privacy, and provide clear instructions to allow them to achieve action.
• Handle any objections that may occur and try to resolve them in a friendly fashion.
• Ensure you are following up for your patient so that all questions are resolved by providers.
• For test reassurances provide important keys and ensure the time frame allows to schedule appropriately.

Long-Term Goals

• Continue to assess management services
• Expand awareness in what testing can achieve.
• Track any performance metrics and have continuous reporting.
• Set new targets for all teams.

Additional Keys for Best Practice

• Use Proactive Actions.
• Report and Track Data.
• Use technology to track patients.
• Remember to collaborate all action in all teams.

Maintain Approach

• It is an action to always listen and show interest and help.
• Ensure that decisions of the client are given out to make sure we get consent.
• HIPAA regulations need to be followed, and privacy is important.
• Ensure their autonomy by respecting their concerns.