4 Patient Engagement Strategies to Close Patient Care Gaps

Begin risk stratification

Central to the pursuit of closing care gaps is risk stratification, or the practice of segmenting patient populations on their likelihood of falling ill. Healthcare organizations need ample data to assess who is high-risk for an illness, as well as data about that patient’s treatment history.

“The first thing we can do for our existing members is to identify who has gaps,” Andrew Ziskind, MD, senior executive officer of Southwestern Health Resources explained in a previous interview. “Our data is robust enough that we can see where the targets are geographically, age-wise, and so forth.”  

For SWHR, this process is more seamless than it may be for others. The organization is a clinically integrated network, meaning it has access to both claims data and clinical data. However, claims data is more of a lagging indicator, Ziskind said, so more traditional provider offices and health systems can still make good use of the clinical data they have on hand.

Nevertheless, a good payer-provider relationship will be essential for effective data mining, which can lead to more effective risk stratification and patient segmentation.

“Documentation around gap closure is often very challenging. The more we can mine the data and identify alternatives, the better,” continued Ziskind. “We’re using the breadth of data that we have access to for identifying where the gaps are. Once we know what they are, we can then use a gap-targeted approach for each specific one.”

Conduct patient outreach

After a medical provider has identified high-needs populations, or ones for whom there are extensive care gaps, it can begin the patient outreach process.

Patient outreach and communications need to be judicious, as different populations may be more responsive to certain outreach strategies than others. There’s a lot of data suggesting that patients would rather be contacted via text message or email, with preference for phone calls waning. That was Ziskind’s experience at SWHR.

“Patients are suspicious about phone calls. They sometimes are confused as to if the call is from the hospital or health system or insurance company,” highlighted Ziskind. “We found that the highest success rate is if the patient is contacted on behalf of their physician.”

For other healthcare experts, like Kevin Pawl, MS, FACMPE, senior director of Patient Access at Boston Children’s, it’s important to host any patient outreach medium and take note of a specific patient or family’s preference.

“It’s essential to get to people in the way they want to be communicated with, so honoring the family preference and patient preference,” Pawl said in a separate interview. “That may be getting long texts, a phone call, or maybe they want it via email. We honor the preferences that we have recorded for those families in our in our system, and communicate that way.”

Healthcare organizations want to be mindful about how often they are contacting patients who might have care gaps, with some data showing that message volume rates that are too high could result in the patient hitting the unsubscribe button.

Instead, it will be valuable for a healthcare organization to deliver a more personalized message that contains patient education and health information that empowers the consumer to make a healthcare decision.

Emphasize patient education

As part of patient outreach, healthcare organizations should consider different patient education techniques that outline the importance of preventive care access. Patients in a low- or rising-risk cohort may not think they need to access preventive care because they are not yet sick, so strong patient education and guidance from providers will be essential.

Currently, clinicians aren’t able to walk patients through every applicable preventive service, largely due to time constraints, according to data from the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University.

“Just 8% of US adults attain all guideline-recommended services,” the researchers said. “Although patient nonadherence is an important factor, in many practice settings, physicians also have limited time to discuss preventive care.”

Particularly, clinicians can prioritize preventive care discussions based on a patient’s specific clinical risk factors, as well as the likelihood a certain preventive screening will impact the patient’s quality of life. Certain preventive measures have a higher impact than others, and clinicians often prioritize those during shorter care encounters.

Patient outreach and marketing campaigns can also fill in the education gap, some health experts have found. Organizations can tap email marketing campaigns to outline the importance of certain medical services with the intent to fill in care gaps for certain populations.

At Nemours Children’s Health, all pandemic-era patient outreach came paired with a resource from the organization’s online educational resource, KidsHealth. That outreach strategy allowed the organization to recoup some of the well-child visits lost during the COVID-19 pandemic and get childhood vaccine schedules back on track.

“Whenever we sent out any kind of communication to a family, we always referenced KidsHealth in the communication so that they always knew there was a place to go to with reliable, understandable information,” Gina Altieri, EVP and chief communications officer at Nemours, explained in an interview.

“We could pull up all of the patients who were due for a specific visit, follow-up visit, or a vaccine, and say, ‘Okay, it's time to come in.’”

Identify, address SDOH barriers

Even as healthcare organizations successfully develop risk stratification models and patient outreach and education programs, there still might be reasons for care gaps. The social determinants of health can serve as key care access hurdles that keep patients from getting the preventive care they need.

Although a number of common social determinants of health can serve as care access barriers—geographic location, racial bias, income—transportation has emerged as one of the most salient topics in healthcare. This is a measurable barrier for which many organizations have developed interventions.

Specifically, non-emergency medical transportation programs have helped fill in the gaps. Industry-specific organizations have long partnered with major public payers like Medicaid to help get patients to their healthcare appointments.

And in the private sector, both payers and providers are partnering with those same industry leaders as well as rideshare companies popular in other consumer segments, like Uber and Lyft. Data has shown that medical rideshare can be cost-effective and cut down on unnecessary ambulance use.

As healthcare continues toward more value-based reimbursement, it will be critical organizations and payers alike can get patients in for key preventive screenings. This type of service is essential to the early detection of disease and effective care management.

Failure to close care gaps could result in higher medical costs and more invasive patient treatment.