Many health systems are engaging in pay-for-performance agreements with payers that focus primarily on improving ambulatory preventive screenings. These also are referred to as gaps in care. Gaps in care are typically measured by the Healthcare Effectiveness Data and Information Set measures of health care quality. To address gaps in care effectively, the physician-led Gaps in Care program at Northwell Health works to improve processes related to measurement, data attribution, patient outreach, and patient engagement. Following a structured framework to address patient gaps in care is a successful strategy for accomplishing complex value-based care delivery.
Keywords: accountable care measure; gap; model of care; value based.