A nonprofit health center developed best practices in identifying and addressing gaps in care.

  • Closing a gap in care requires a team effort.
  • Gaps can include diabetes check-ups, flu shots, preventive health screenings, etc.
  • Care connectors can help organizations reach out to patients to complete check-ups, screenings, vaccinations, and other care gaps.

When gaps in care reports began popping up, leaders at Alcona Citizens for Health knew something had to be done.

“We got these reports and started noticing deficiencies in certain areas,” says Karen Koenig, RN, care management department manager at Alcona Citizens for Health in Alpena, MI. Alcona is a federally qualified nonprofit health center that serves populations covered by Medicaid, Medicare, and private pay.

The deficiencies were due to inadequate staffing, inconsistent workflow, and knowledge deficits in using the electronic medical record (EMR).

It was clear that the gaps were not something that one person could close. It would take a team of people, including providers, medical support staff, RN care managers, and care connectors, she says.

Care managers provide patient education, self-management goals, and follow up with patients after hospital stays. Their job is to make sure patients are not readmitted and have received appropriate education and goal-setting. There also are community health workers to address patients’ social determinants of health, including housing status, transportation, and behavioral health issues.

“We have six care managers, seven care coordinators, and six community health workers,” Koenig says.

Care connectors primarily are LPNs. Their job is to review insurance reports to see which check-ups, vaccines, and preventive care patients have missed and need scheduled before the year’s end. These gaps might include the following:

  • body mass index (BMI) reports;
  • checking diabetic patients’ A1c level;
  • checking blood pressure for hypertension patients;
  • performing diabetic eye exams and foot tests;
  • screening diabetics for kidney problems;
  • flu shots;
  • ensuring children are up to date on immunizations;
  • lead testing in children by their second birthday;
  • testing children with sore throats for strep infection;
  • breast cancer screening;
  • cervical cancer screening;
  • chlamydia screening;
  • medication management;
  • smoking cessation education;
  • making sure asthma patients are using inhalers as prescribed.

Patients must receive all of the screenings and preventive care needed, per insurance incentives for closing care gaps. Care connectors work to make sure patients come to the center on time and receive the screenings, immunizations, and other care they need.

“In a given month, there might be 700 gaps,” Koenig says. “They won’t get to all of them, but by working on it monthly, we have been able to address the most that is possible.”

One strategy is to follow a calendar year schedule. “At the beginning of the year, we schedule complete physical exams [CPEs] and child wellness exams,” she says. “We get those patients in for more comprehensive visits, and that’s a big focus at the beginning of the year.”

The following are some other seasonal priorities:

• First quarter: “It’s a continuous process, and even at the end of the year, we will schedule people due for a well child check-up,” Koenig says.

But the health center’s workflow is smoother if care connectors can get some patients in for wellness exams and physicals at the beginning of the year. Also, patients might have some other care gaps identified after their physicals, so it works best to have enough time remaining in the year to schedule those after the physical and lab work is complete, she adds.

• Second quarter: In Alpena, patients start returning to the northern Michigan region from warmer climates and they often need CPEs and primary care provider visits, Koenig says.

“April is when they may be returning from Florida or Arizona, and so we see an increase in patients then,” she says. “Their gap is highest at the beginning of the year because everyone is due for everything, and then it closes.”

• Third quarter: Summertime is when the health center schedules many well child visits because these are combined with sport physicals. “They want the sports physical completed before the next school year,” Koenig says. “We don’t separate well child visits and sports physicals.”

• Fourth quarter: Flu shots are scheduled in the fall, and this is when care connectors try to get patients to come in for any other preventive visits that are needed.

“We catch up on anything we haven’t focused on,” she says.

Care connectors also help reconcile insurance records for patients with what the health center has in its records.

For example, sometimes a patient will call the health center to say he or she has a new provider. But when the patient’s payer sends over a list of care gaps, that patient still is listed. Care connectors have to call the payer and make sure the patient is taken off the center’s list and put on the new provider’s list, Koenig explains.

In another case, there might be a person who signs up for the state health plan and does not indicate who the provider will be.

“If they don’t respond, they’re auto-assigned to a provider, and they might be auto-assigned to us even if they end up going to a doctor at another facility,” she says.

“Because the insurance says we’re the primary care provider, any gaps that are not closed are impacting our scores because we’re responsible for that patient,” Koenig adds. “So we have to clean up that list, and the care connectors tell the patient to call the number on their card and let them know that Dr. Jones is their doctor.”

It takes some effort to get people off the list, but the care connectors make it happen, she says.

“They see those lists constantly and know who our patients are and which people are not in our system, and so they reach out to them to see if they need a primary care provider,” Koenig says.

When patients first sign up for Healthy Michigan plans, they need a health risk assessment to identify chronic illnesses and risk behaviors. Then they might need education, smoking cessation classes, or nutritional and exercise information. Some payers also require annual depression screening and smoking status reports, she says.

“We have a clinical event manager in the electronic medical record that will put out alerts about patients’ gaps, but mostly care connectors work on the gap list from insurers,” Koenig says.

The EMR list could tag a gap that actually was a coding error, so they need to be checked manually.

“It’s more important for care connectors to address what the insurance is saying the patient needs versus what the EMR is saying,” she says. “Insurers send gap reports every month, saying which patients need this or that.”

The care connector’s job is to reconcile the insurer’s gap report with what the EMR says the patient has had done. When there are coding errors, this is how the care connector identifies and rectifies them. “The care connector is the middle person to make sure that what we say we do is the same thing the insurance said they received from us,” Koenig explains.

As the care connector program began, there were full department meetings with care connectors each month. That is no longer necessary, so the meetings are held quarterly or as needed, she notes.

“We’re spread out across seven counties in Northern Michigan, so we can do a Skype meeting with a representative from an insurance company when we take on a new payer plan,” she says. “We have a conversation with them about how they want their gaps reported, and we explain that this needs to be faxed, rather than entered online.”