A care gap closure plan for the last weeks of the year, in the order that works

There are only a few weeks left in the year. The question for every quality team now is not whether to work hard on open care gaps. Everyone will. The question is what order to do the work in.

That sounds like a small thing. It isn't. A care gap closure plan for the end of the year is really a chain: each step only pays off if the one before it is already done. Book visits before the list is clean and some of those appointments go to members whose care already happened. Chase results before the visits are booked and there is nothing to chase. Do it in the right order and every week sets up the next one.

Here is how we would spend the time that's left, and why each step sits where it does.

Why does the order of a care gap closure plan matter?

Because the calendar does not stretch. Most quality measures follow the calendar year, and the last part of that year is crowded. Patients travel, offices close for the holidays, and appointment calendars fill up. Results from care delivered late in the year can arrive weeks after the visit. Work that starts too late does not finish in time, no matter how many people are on it.

So the plan below runs backward from the end of the year. The step that everything else depends on goes first. The step that depends on everything else goes last. We've written about how much shorter the real performance year is than the calendar in you don't get the whole year to close a care gap. This is what to do with the part that's left.

Start by cleaning the list

Start by finding care that already happened and was never counted. A screening done at an outside office. A result that came back in a format the reporting missed. A test recorded in a lab result but never matched to the measure.

Every one of these you find is a member who does not need another reminder call. That matters twice. It spares the member an outreach call about care they already had, which is not a small thing for someone who has been asked the same question more than once. And it takes a row off the list that would otherwise eat a care coordinator's time for the rest of the year.

This step goes first because everything after it depends on the list being true. We walked through how completed care goes missing in the mammogram happened in July.

Then rank by member, not by measure

Many care gap lists are organized by measure. One list for screenings, another for diabetes care, another for blood pressure. Each gets worked separately, often by different people.

Turn it around. Put members with several open gaps, or a chronic condition that is getting worse, at the top. Picture a composite member, call her Ruth. She is overdue for a diabetes eye exam, her blood pressure has not been under control, and she is due for a screening. On a list sorted by measure, Ruth is several rows in several places. On a list sorted by member, she is one person who needs one well-planned visit.

One visit can close several gaps for the members who need it most. That only happens if someone sees them as one person.

There's more on why the members with the most at stake tend to drift to the bottom in the members who need care most are at the bottom of your care gap list.

Book the visits now

Appointment calendars fill in December. Gaps that need a visit, a lab, or a follow-up have to be on the schedule before Thanksgiving. Waiting until the list feels finished means waiting until the openings are gone.

This is where the earlier steps pay off. A clean list means the scheduling team is not booking visits for care that already happened. A list ranked by member means each booked visit is planned to address everything the member needs, not just the measure that happened to be on someone's sheet that day.

Chase the results

A completed test that never reaches the record does not close anything. Follow every appointment through to the result.

This is the step that is easiest to underestimate. The member showed up. The test was done. Everyone moves on to the next name. Then the result sits at an outside lab or in a report nobody matched to the measure, and the gap stays open. Late in the year, there may not be time to notice and fix it. Someone has to own the last mile: confirming that each piece of care made it back and counted.

Protect the last visits

Some members will be seen in the final days of December. Those visits are the last chance of the year for them, and they are easy to waste. A busy clinician can see the reason for the appointment and little else.

Make sure every clinician seeing a member in late December can see that member's open gaps. That means preparing the visit before the member walks in, not reviewing the chart afterward. A gap noticed after the patient leaves is much harder to close before the year ends.

What does it take to run this plan in one place?

On paper, the plan is simple. In practice, it often falls apart in the hand-offs. Finding completed care lives in one system, the ranked list in a spreadsheet, scheduling somewhere else, and result checks with yet another team. Each step depends on the last, and each hand-off is a place where the chain breaks.

ElevateCare 360's Quality Module runs that whole plan in one place, from finding the gap to confirming it closed. Claims, the medical record, lab results, and payor quality files are combined, so a screening completed outside the network or recorded only in a lab result still counts. Open gaps are ranked by patient need and by their weight in quality measures and Star ratings. Patient lists flow straight into scheduling, reminders, and pre-visit preparation. Completed screenings and results are matched back to the measure automatically. See how it works on the care gap closure page.

And the same plan works better when it doesn't wait for the fall. Run it all year and the final weeks become much less of a scramble.