5 Steps to Close Gaps in Care and Hit Your Quality Benchmarks
Every healthcare organization tracks care gaps. Far fewer actually close them. The difference often comes down to whether clinical information reaches the people responsible for taking action or stops somewhere along the way.
Care gaps represent the distance between recommended care and the care patients actually receive. This article explains why gaps persist, outlines five practical steps to close them, and explains how to measure progress against the quality benchmarks that affect your HEDIS scores, STARS ratings, and value-based care revenue.
What Is a Gap in Care?
A care gap is the difference between the medical care a person should receive—like preventive screenings, chronic disease monitoring, or vaccinations—and the care they actually receive. Think of it this way: if a patient is due for a mammogram but never gets one, that's a care gap. If someone with diabetes skips their annual eye exam, that's a care gap too.
You might assume care gaps happen because patients forget or don't prioritize their health. Sometimes that's true. But more often, the breakdown happens somewhere in the healthcare system itself. The right information didn't reach the right person at the right time.
Here are a few examples of how care gaps show up in practice:
Missed preventive screenings: A patient due for a colonoscopy never receives outreach because their primary care provider changed practices and the health plan's directory wasn't updated.
Chronic disease monitoring gaps: A diabetic patient's lab results sit in one system while their endocrinologist works in another, so the follow-up appointment never gets scheduled.
Vaccination lapses: A patient eligible for a shingles vaccine falls through the cracks because the reminder was faxed to a closed clinic location.
Notice the pattern? Each scenario involves a communication breakdown—not a patient who simply didn't care.
Why Care Gaps Put Quality Scores and Value-Based Care Revenue at Risk
Care gaps aren't just a clinical problem. They're a financial one too. Health plans and provider organizations are measured against quality benchmarks like HEDIS (Healthcare Effectiveness Data and Information Set) and Medicare STARS ratings. When gaps stay open, scores drop.
The financial impact can be significant. A health plan that falls from a 4-star to a 3.5-star rating may lose millions—with $13.4 billion in quality bonus payments at stake industrywide in 2026. Provider organizations in value-based care contracts can forfeit shared savings or face penalties when they miss quality targets.
| Impact Area | What Happens When Gaps Persist |
|---|---|
| HEDIS performance | Lower scores on measures like breast cancer screening and diabetes care |
| STARS ratings | Reduced ratings affect plan competitiveness and bonus payments |
| Value-based contracts | Missed benchmarks trigger penalties or lost shared savings |
| Patient retention | Patients who don’t receive timely care often seek services elsewhere |
Beyond the financial picture, there's a human cost. Delayed screenings can mean later-stage diagnoses—a BMJ study linked missed breast screenings to 40% higher mortality risk. Missed follow-ups can lead to preventable complications. The good news? The financial and clinical incentives point in the same direction.
What Causes Gaps in Care?
Patient-side barriers certainly play a role. Transportation challenges, high out-of-pocket costs, and difficulty taking time off work all contribute. However, many gaps persist because of operational and communication failures that healthcare organizations can directly address.
Fragmented Provider Communication
Clinical information frequently fails to reach the people responsible for acting on it. A specialist sends a referral recommendation, but the primary care office never receives it. A hospital discharges a patient with follow-up instructions, but the discharge summary arrives at the wrong location—or doesn't arrive at all.
This fragmented communication between primary care providers and specialists is a leading cause of care gaps. When information stops at organizational boundaries, patients fall through the cracks.
Outdated Provider Directory Data
Outreach efforts often fail before they even begin. Fax numbers are disconnected. Providers have moved to new practices. Digital addresses are outdated or incomplete.
Organizations invest significant resources in gap-closure campaigns, only to discover that a meaningful portion of their outreach attempts fail because of bad contact information—nearly 49% of directory listings contain at least one inaccuracy according to a CMS review. That's not a patient engagement problem—it's a data quality problem.
Manual Referral and Outreach Workflows
Many organizations still rely on spreadsheets, phone calls, and manual fax follow-ups to manage gap closure. A care coordinator juggling hundreds of patients simply cannot make enough phone calls or send enough faxes to close every gap before the measurement period ends.
Manual processes also introduce delays. By the time someone follows up on a failed fax, weeks may have passed—and the patient may have disengaged entirely.
Limited Visibility Across the Care Team
Even when outreach is sent, organizations often lack visibility into what happens next. Did the provider receive the notification? Did the patient complete the screening? Was the referral acted upon?
Without closed-loop tracking, gaps persist undetected. Organizations may believe they've addressed a gap when, in reality, the communication never reached anyone who could take action.
5 Steps to Close Gaps in Care
Closing care gaps takes more than good intentions. It takes a systematic approach that moves from identification through confirmation. Here's a practical workflow that works.
1. Identify Care Gaps With Data and Analytics
The foundation of any gap closure program is knowing which gaps exist. This typically involves analyzing EHR data, claims data, and population health platforms to flag overdue screenings, missed follow-ups, and lapsed prescriptions.
Most organizations already have access to this data. The challenge isn't finding gaps—it's acting on them efficiently.
2. Prioritize High-Impact Gaps Tied to Quality Measures
Not all gaps carry equal weight. A missed diabetic eye exam affects HEDIS scores differently than a missed wellness visit. Organizations that prioritize gaps tied to their most important quality measures—whether HEDIS, STARS, or specific value-based contract requirements—see better returns on gap-closure investments.
Prioritization also helps care teams focus their limited time on the highest-value opportunities rather than spreading effort thin across every open gap.
3. Reach the Right Care Team Through the Right Channel
Here's where many gap closure programs stumble. Identifying a gap is one thing. Actually reaching the provider or care team responsible for closing it is another.
Effective outreach requires three things working together:
Identify the right recipient: Confirm the provider, location, and communication endpoint before sending. A notification sent to the wrong office is worse than no notification.
Select the right channel: Some providers prefer Direct Secure Messaging to their EHR inbox. Others rely on fax. Still others check a secure web portal. Using the recipient's preferred channel dramatically improves the likelihood that they'll see your message.
Validate delivery: Sending a message isn't the same as delivering it. Confirming the communication actually reached someone who can act makes all the difference.
This step is often the most operationally complex—and the most frequently overlooked.
4. Embed Gap Closure Into Point-of-Care Workflows
Gap closure rates increase when clinicians see relevant gaps during patient encounters. If a patient is due for a screening and that information surfaces in the EHR during their visit, the provider can address it immediately.
The alternative—expecting providers to check a separate system or act on a notification they received days ago—creates friction that reduces closure rates. Meeting clinicians where they already work removes that friction.
5. Confirm Delivery and Track Follow-Through
Sending a notification isn't the finish line. Organizations that excel at gap closure track whether outreach was received, whether the patient completed the recommended service, and whether the gap actually closed.
This closed-loop approach reveals bottlenecks. Maybe outreach to a particular specialty consistently fails. Maybe certain gap types take twice as long to close. Without tracking, patterns like these remain invisible.
How to Measure Progress Against Your Quality Benchmarks
What gets measured gets managed. Organizations serious about gap closure track several key metrics over time:
| Metric | What It Measures | Why It Matters |
|---|---|---|
| Gap closure rate | Percentage of identified gaps successfully closed | Indicates overall program effectiveness |
| Time to closure | Days from identification to resolution | Reveals workflow efficiency and bottlenecks |
| Outreach delivery rate | Percentage of communications successfully delivered | Exposes provider data or channel issues |
| Quality measure performance | Progress against HEDIS, STARS, or contract benchmarks | Connects gap closure to financial outcomes |
Tracking over time helps organizations identify what's working and where to focus improvement efforts. A sudden drop in delivery rates, for example, might signal a provider directory issue worth investigating.
Turn Communication Gaps Into Closed Care Gaps With careMESH
Many care gaps persist not because organizations lack data or motivation, but because clinical information fails to reach the right care team. That's a communication infrastructure problem—and careMESH addresses it directly.
careMESH helps healthcare organizations identify, reach, and activate the right care team by reliably delivering clinical information. Rather than forcing organizations to manage the complexity of provider communication themselves, careMESH handles the hard parts:
Healthcare Communication Directory: Continuously maintained provider, location, and digital endpoint data covering more than 6 million providers nationwide ensures outreach reaches the right recipient.
Intelligent Message Routing: Automatically selects the best delivery method—Direct Secure Messaging, intelligent eFax, or secure web application—based on recipient preferences.
Delivery Confirmation: Confirms that clinical information reached someone who can act on it, not just that it was sent.
EHR Integration: Embeds gap closure workflows directly within existing clinical systems, so providers see relevant information without switching applications.
The result? Faster care team communication, improved referral completion, and fewer patients lost to follow-up.
Contact careMESH today to learn how reliable care team communication can help close gaps in care and improve quality performance.
Frequently Asked Questions About Closing Gaps in Care
What are the 5 C's in care coordination?
The 5 C's typically refer to Communication, Collaboration, Continuity, Comprehensiveness, and patient-Centeredness. This framework helps ensure coordinated care across providers and settings, with communication serving as the foundation that enables the other four.
How do HEDIS and STARS measures relate to gaps in care?
HEDIS (Healthcare Effectiveness Data and Information Set) and Medicare STARS ratings evaluate health plan performance using specific quality measures, such as cancer screenings, diabetes management, and medication adherence. Unclosed care gaps directly lower scores on these measures, affecting plan ratings, bonus payments, and competitive positioning.
How does Direct Secure Messaging help close gaps in care?
Direct Secure Messaging enables encrypted, HIPAA-compliant delivery of clinical information between providers. Organizations can send gap-in-care notifications, referrals, and care summaries directly to the responsible care team's EHR or secure inbox—eliminating the uncertainty of traditional fax workflows.
Who is responsible for closing gaps in care?
The care team shares responsibility, including primary care providers, specialists, care coordinators, quality teams, and health plans. Effective gap closure, however, depends on communication infrastructure that connects all parties and confirms follow-through. Without that infrastructure, accountability becomes difficult to establish.