How do we identify gaps in care? A guide for providers

In this guide, we’ll explore how to optimize gaps-in-care identification, provide examples of gaps in care, and discuss strategies for analytics, coordination, and management.

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Closing care gaps for better health and efficiency

Delivering high-quality healthcare demands a proactive approach to identifying and addressing gaps in care.

These gaps occur when patients fall behind on managing their health, lack access to necessary medical services, and face challenges with rising costs – health systems face declining population health management and inefficiencies within their healthcare system.

What are gaps in care?

Gaps in care are the disparities between the healthcare services patients should receive and interventions they should take – vs. the services they actually receive and steps they actually take. These gaps can arise due to missed screenings, lack of follow-up care, barriers to access, poor care coordination, or lack of care plan adherence.

Common gaps in care include:

Missed preventive screenings (e.g. delayed cancer screenings or immunizations)
Ineffective chronic disease management (e.g. uncontrolled diabetes due to lack of follow-up or making lifestyle behavior changes)
Breakdowns in care coordination (e.g. missing referrals between providers)
Limited access to mental health services

Gaps-in-care analytics Using data to identify care gaps

Gaps-in-care analytics leverage patient data, predictive algorithms, and population health insights to pinpoint areas where patients are not receiving recommended care.

How analytics help identify gaps in care:

EHR data tracking – Analyzing patient records to detect missed screenings, overdue check-ups, or incomplete care plans.
Claims data analysis – Identifying trends in billing data that reveal treatment gaps.
Risk stratification – Using AI-driven tools to flag high-risk patients who may need intervention.
Patient engagement metrics – Tracking appointment adherence, prescription refills, and follow-up visits.

patient on her laptop at a different angle

Gaps-in-care coordination Breaking down silos

Poor gaps-in-care coordination lead to fragmented healthcare experiences, where patients struggle to receive seamless treatment across different care settings.

Common care coordination gaps and how to identify them:

Lack of follow-up after hospital discharge – Patients may not receive necessary post-discharge care, leading to readmissions.
Referral breakdowns – Specialists and primary care providers may not communicate, resulting in lost or delayed referrals.
Medication non-adherence – Patients may stop taking prescribed medications due to confusion or lack of follow-up.

Solutions for better care coordination:

Integrating virtual primary care to ensure follow-ups and chronic disease management.
Using care navigators to guide patients through complex treatment plans.
Implementing shared care plans that connect specialists, primary care, and mental health services.

Examples of gaps in care and how to identify them

Each healthcare setting has unique challenges when it comes to care gaps. Below are key gaps in care examples across different specialties and settings.

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Gaps in primary care

Primary care is the first line of defense in preventing disease and promoting health and overall wellbeing. However, gaps in primary care arise when patients do not receive recommended screenings, immunizations, or chronic disease management. Poor health management results in overcrowded EDs, leakage to out-of-network sites of care, and disparate health data.

How to identify primary care gaps:

Review patient records for missed preventive screenings (e.g. mammograms, colonoscopies).
Use patient outreach programs to remind patients of overdue check-ups.
Analyze chronic disease registries to identify unmanaged conditions.

Gaps in nursing care

Gaps in nursing care occur when patients do not receive timely interventions, and medication administration is delayed or discharge instructions are unclear.

How to identify nursing care gaps:

Monitor nurse staffing levels and workloads.
Track patient incident reports, such as medication errors or falls.
Evaluate patient satisfaction surveys for complaints about communication or delays in care.

Gaps in mental healthcare

The gaps in mental health care stem from provider shortages, stigma, and difficulty accessing services. Without better management of a patient’s mental health, their journey to recovery or condition management is faced with additional challenges in managing their health beyond in person care.

How to identify mental health care gaps:

Implement mental health screenings during patient intake processes.
Analyze wait times for therapy and psychiatric care appointments.
Identify patients with chronic conditions who lack mental health screenings.
Monitor medication adherence rates for psychiatric prescriptions.

Gaps in health care system access

Systemic barriers such as insurance limitations, transportation challenges, and socioeconomic disparities lead to gaps in health care access.

How to identify system-wide care gaps:

Assess patient demographics to identify underserved populations.
Use population health mapping to track healthcare accessibility in rural areas.
Analyze insurance claims data for disparities in service utilization.

Gaps-in-care measures Tracking and improving care quality

To effectively close care gaps, healthcare organizations need gaps-in-care measures — metrics that assess how well providers are delivering recommended care.

Key performance indicators (KPIs) for tracking care gaps:

Preventive care adherence rates – Percentage of patients receiving vaccinations, cancer screenings, and annual exams.
Follow-up visit completion rates – Number of patients attending scheduled follow-ups after hospital discharge.
Medication adherence rates – Percentage of patients consistently filling and taking prescribed medications.
Readmission rates – Tracking preventable hospital readmissions as a sign of care gaps.

By monitoring these metrics, providers can proactively address care gaps and improve patient outcomes.

The role of virtual care in closing gaps

Technology plays a crucial role in identifying and addressing healthcare gaps. Virtual health care services provide solutions such as:

Digital care for chronic disease management – Ensuring ongoing care for diabetes, hypertension, and other conditions.
AI-driven analytics – Identifying high-risk patients in need of intervention.
Remote patient monitoring – Tracking vital signs and symptoms to prevent complications.

Tech solutions to close care gaps and boost health outcomes

Identifying and closing care gaps is essential for delivering high-quality, patient-centered healthcare. By leveraging gaps-in-care analytics, improving coordination, and tracking care quality measures, providers can proactively address care disparities and improve outcomes.

At Amwell, we help healthcare organizations implement technology-driven solutions to close care gaps and create a more seamless, efficient healthcare experience.

To learn more about how we support providers in closing care gaps, visit our provider solutions page.