A Practice Facilitation Blueprint Guide
Getting Started with Care Gap Closure Improvement
Developed By:
Lyndee Knox, PhD & Kevin Thomas, MD
LA Net & Florence Western Medical Clinic
Contributors:
Geraldine Sanchez, Demetrio Cardenas, DSc (ViaCare), Grace Floutsis, MD (White Memorial CHC), Heidi Winkler, MD (Community Pediatrics Center, Inc) , Dakota Letterman (Community Pediatrics Center, Inc), Susie Yagubyan (Central Medical Business Management), Ciara Murphy & Zeina Bahgat (LA Net)
Sponsored By
Get Started with Care Gap Closure Improvement
Quick Start Guide
See the Quick Start Guide for a summary of the essential steps for working with a practice to enhance their care gap closure processes. Click Here.
Practice Facilitator Guide
Purpose of This Guide
This guide is for Practice Facilitators, Primary Care Providers (PCPs), office managers, medical assistants (MAs), and quality improvement (QI) teams.
It’s a step-by-step blueprint designed to help you improve how your practice identifies and closes care gaps — whether in preventive care, chronic disease management, or behavioral health.
You’ll find:
- A quick start guide if you only have a few minutes at a time to work on this
- List of essential tasks for improving care gap closure processes in a PCP
- Worksheets for each task you can use to help practices reflect on and plan improvements
- Real-world case examples from “exemplars” in care gap closure
- “PEARLS” — pro tips from the field
- A reusable structure you can use to address different care gap closure processes or HEDIS-like metrics
Contents of This Guide
The Care Gap Closure (CGC) improvement process begins with three essential prework steps:
- engaging practice leadership,
- forming a dedicated CGC project team, and
- conducting af brief current state assessment of the clinic’s current gap closure processes.
Following this Pre-Work, the practice team completes a structured sequence of 12 tasks that guide them through the full cycle of quality improvement—from selecting a care gap and mapping workflows, to testing changes, training staff, evaluating results, and fully integrating the new process into the clinic’s quality infrastructure.
Together, these 15 activities provide a practical roadmap for a PF, office manager or PCP QI team for building sustainable, team-owned workflows that close care gaps efficiently and equitably.
Ways to Use this Guide
This guide is designed to be practical and flexible—whether you’re a Practice Facilitator supporting multiple clinics or a clinic leader (such as an office manager or lead clinician) guiding your own team.
Ways to Use This Guide:
- Facilitator-Led: Use the guide as a roadmap to structure your coaching sessions with a practice, focusing on one task at a time.
- Practice-Led (No PF On-Site): Clinic leaders can walk their team through the guide, using it to lead short, focused improvement huddles or meetings.
- Peer Coaching: Share the guide with a trusted peer or colleague at another clinic and work through tasks together.
- Support from Health Plan or IPA: Ask your health plan or IPA if they can provide a facilitator or quality coach to help you implement the guide.
“[The Guide] should be self-explanatory enough that Geraldine could train office managers. Walk through each task, complete each worksheet, and by the end, you’ve improved something or built something new.”
- Kevin Thomas, MD
Defining Care Gap Closure
Care gap closure refers to identifying and addressing missing clinical services — such as screenings, immunizations, or follow-up care — that patients are due for based on clinical guidelines and quality measures.
Care gaps commonly include:
- Missed preventive services (e.g., mammograms, colonoscopies)
- Missed chronic disease care (e.g., A1C or blood pressure checks)
- Missing or inaccurate documentation (e.g., uncoded services, missing LOINC codes for PHQ-9s)
Addressing care gaps directly impacts your practice’s performance on HEDIS-like metrics and improves patient outcomes.
Practices use a variety of strategies to close care gaps. These include:
- Opportunistic/At-Visit Closure: Embedding real-time alerts and workflows to address care gaps during patient encounters.
- Between-Visit Outreach: Using automated and manual reminders (SMS, calls, letters) to engage patients between visits.
- Problem-Specific Campaigns: Running targeted outreach efforts for a particular care gap with automated follow-up and manual engagement.
- Unseen patient outreach: Focused outreach on patients who have not been seen in a specified period of time 12-24 months, or who have been assigned to the practice but have not established care.
- Remote Monitoring: Utilizing devices and data tracking for chronic conditions (e.g., BP monitors, glucometers).
- Administrative Closure: Ensuring proper reporting and documentation of closed care gaps through EHR coding, supplemental data uploads, and accurate billing.
“You have to do it all — patient-level closure, population reports, and validating plan data like in Cozeva.”— Grace Floutsis, MD, CEO/CMO at White Memorial CHC
Equity Practice Transformation (EPT) HEDIS-Like metrics
The EPT Initiative is focused on closing the following high-impact care gaps for each population of focus (POF):
| Population | HEDIS-like Measures |
|---|---|
| Pregnant People | Postpartum care (PPC) Timeliness of prenatal care (PPC) Postpartum depression screening (PDS-E) |
| Children/Youth | Child immunization status (CIS) Well-child visits first 30 months (W30) Child and Adolescent Well-Care Visits (WCV) Depression screening (DSF) |
| Adult Preventive | Breast cancer screening (BCS) Cervical cancer screening (CCS) Colorectal cancer screening (COL) Depression screening (DSF) |
| Adult Chronic Care | Controlling high blood pressure (CBP) Glycemic status assessment (GSB) Depression screening (DSF) |
| Behavioral Health | Depression screening (DSF) Depression remission or response (DRR) Pharmacotherapy for Opioid Use Disorder (POD) |
Specifically for EPT practices during the initiative period: EPT practices are eligible for milestone payment on a given measure if either:
- They meet or exceed the 90th percentile HEDIS benchmark during any one reporting cycle, or
- they achieve the improvement target outlined in the table below,
- achievement must be sustained over two consecutive submissions or met in the final submission.
"Assuming a minimum denominator of 30 members."
| KPI | Improvement Threshold | Attainment Target |
|---|---|---|
| For each HEDIS - Like Measure** | If starting above the 75th percentile, 5% gap closure towards the 90th percentile OR If starting below the 75th percentile, 15% gap closure towards the 75th percentile | If at or above the 90th percentile, maintain performance |
Benefits of Closing Care Gaps
- Better health outcomes for patients
- Fewer hospitalizations and ER visits
- Improved patient engagement and trust
- Higher performance on quality metrics
- Increased practice revenue from incentives and value-based payment
- Enhanced teamwork
Determining What “Good” Looks Like
“If you don’t know where you are going, any road will take you there.”
When working to improve care gap closure, knowing what “good” looks like helps the PCP gather ideas and jump-start their own design and implementation work in these areas.
Find examples of what “good” looks like:
- Review resources and literature online
- Attend trainings
- Identify and then learning from “exemplars”
A special word on exemplars
An exemplar is a clinic, team, staff person or clinician that is performing at a high level on specific metrics (e.g., HEDIS-like measures) or demonstrating success with a particular care gap closure process that your practice is working to improve.
Identify exemplars through:
- peer nominations,
- practice facilitators working with other practices on care gap closure, and
- reviewing performance data for high-performers on a specific metric - both internal (an exemplar may be from your own practice) and external.
Note: relying only on performance data can cause you to miss some excellent exemplars who may developed scalable best practices for a part of the process of focus but not its entirety. Because of this, it is best to use a combination of all of these methods to identify best practices and exemplar PCPs to study and learn from.
Also, exemplars do not need to be good at everything. They may be an exemplar in one specific process, or even, more frequently, a part of a process. Engage with them and learn about the process or portions of a process they have mastered.
To facilitate knowledge transfer of these best practices, arrange a virtual or in-person visit between the practice you are supporting and the identified exemplar site. This allows the team to observe key practices firsthand, ask questions, and engage in peer-to-peer learning.
Recognize that exemplars may excel at the entire process or only at specific parts of it. Use a combination of peer nominations and performance data to identify strong performers for the process, or elements of the process, that you want to improve. Continue this approach until you’ve identified exemplars for each important part of the process. You can then link these exemplar components together to construct a complete, start-to-finish workflow grounded in best practices.
See the next section for a brief description of how you can set-up a virtual visit for your practice with an exemplar PCP.
Arranging virtual visits to exemplars
One of the most powerful ways to jump-start change in a practice is for the practice to see "exemplars" in action and have the opportunity to ask them questions in real-time. To do this, as PF, you can help the practice identify "exemplars" on the or processes that the practice is interested in improving, and then a virtual visit to these practices.
A virtual visit is a video conference where the "exemplar" shares their process, workflows, and “top three lessons learned” to your practice, and where you and the practice get to ask questions to inform your own care gap closure design process.
In an ideal circumstance, you are able to see the exemplar "in action" during the virtual visit. For example, if the process you are wanting to learn about is "huddling" and you've identified an "exemplar" practice for huddles, in an ideal world you would want to be able to observe them holding a "mock" huddle (with HIPAA considerations of course).
This said, direct observation of the process is often not possible, so the next best thing is an explanation of the process by the "exemplar" or peer - followed by question & answers from the practice interested in learning about and possibly replicating their effective process.
A typical virtual visit lasts 45 minutes to an hour, and takes place over lunchtime or end of day when key staff from both practices have time available to participate.
As a PF you can help the practice:
- Identify "exemplars" through peer nomination, through PF recommendations, through review of performance data from the state and health plans
- Define their goals for the visit
- Create their lists of questions for the virtual visit,
share these with the "exemplar" or peer practice in advance of the meeting, - Set-up the virtual visit meeting time
- Send out calendar invites, and
- Facilitate the discussion during the session
Ask for permission to record the session for you and the practice to be able to return to and study in-depth later… and for you to share with the larger EPT community (with permission from the exemplar of course).
And … in the rare event the practices are close by and there is time to travel you might even consider an actual site visit!
If you are unable to find a time where both practices can meet, you can create an "asychronous" virtual visit. As the PF, you can be the "honeybee" that gathers information from the "exemplar" or peer and brings it back to the practice you are working with.
Do this exactly like you would arrange a virtual visit- gather questions from the practice you are supporting, then hold and and record the visit and ask the practice's questions - and then share the video with your practice.
Optional Virtual Visit Worksheet
Care Gap Closure Case Studies - Exemplar & Peer Practices
Here are some case examples from exemplar and peer EPT practices in care gap closure for one or more HEDIS-like metrics.
Table 1. Partial list of case examples
| Name | Practice Types | Size | EHR | PHM/Gap data |
|---|---|---|---|---|
| Case example: ViaCare Demetrio Cardenas, DSc, CMIO Contact: dcardenas@viacarela.org | FQHC | Medium FQHC | eCW 12 | Azara, Innovacer, Cozeva |
| Case example: White Memorial CHC Grace Floustis, MD, CEO/CMO Contact: floutsg@ah.org | FQHC | Medium CHC | eCW | Azara, Cozeva |
| Case example: Community Pediatrics Clinic, Inc Dakota Letterman, HIT Manager Contact: hwinklermd@gmail.com | Independent, 1 FTE | Solo Independent | Reli-Med | Cozeva, manual |
| Case example: Central Medical Business Management Susie Yagubyan, Operations Director Contact: gmcmg2000@gmail.com | Independent, 2 FTE | 2 FTE Independent | Office Ally | Cozeva, manual |
Virtual Visits with Exemplars in Care Gap Closure
Demetrio Cardenas, DSc, CMIO from Via Care
Contact: dcardenas@viacarela.org
MORE Virtual Visits TO COME!
Tools Shared by EPT Practices, Practice Facilitators & Peers
Explore and download tools shared by EPT practices, practice facilitators, and peers to enhance your care gap closure processes:
Key Tasks
Pre-Work Task 1:
Engage Leadership
As a first step in care gap closure improvement, meet with practice leadership to discuss their interest in this improvement work, their goals for their care gap closure processes, and the area they would like to focus on first and why. Also identify who will be the "champion" for the CMP at the practice. This individual should have sufficient authority to ensure the implementation of the processes at the practice and a personal interest or passion for the CMP or the practice's goals for implementing it.
Pre-Work Task 2:
Form a Care Gap Closure Project Team
For the next step, identify the team that will lead care gap closure efforts. This may be an existing QI team, or a new group brought together for this purpose. Also remember, the most critical voices are not always the most obvious. Successful care gap closure depends on engaging the right people from across the workflow—those who play a hands-on role in identifying, addressing, and documenting gaps in care—make sure these roles are present on the team.
“Include people who know the work... the ones touching the process every day.” — Chey Douglas, Practice Facilitator
Pre-Work Task 3:
Review the practice's current care gap closure processes
Work with the project team to review their current care gap closure processes and identify areas of strength and areas where they are experiencing challenges. Use the assessment worksheet below to get started.
Task 1:
Select a care gap or closure process to improve
Work with the project team to set their first care gap closure process improvement goal.
Use the Worksheet below to help the practice select which care gap they will focus on first. Use the worksheet below to guide the practice through this selection process.
“We’ll look at Cozeva and say, ‘We’re at 87th percentile, if we just fix 100 more, we’ll hit the 95th.’ So, we do it for the care and the dollars.” - Practice owner
Task 2:
Use a last 10 patient chart audit to identify barriers to gap closure
Next work with the practice to conduct a small n chart audit to identify reasons the selected care gap is not being closed. Use a "last 10 patient" chart audit to review the records of the last 10 patients this week (or day) that should have received the indicated preventive care service and the most common reason/s they did not.
A “Last 10” Patient Chart Audit is a simple, hands-on way for practices to understand how their current workflow is (or isn’t) closing the selected care gap. It looks at what actually happened with recent patients, rather than relying only on reports or assumptions. This gives the team insight into where things are working and where they break down that they can use to design changes to their processes.
Steps to complete a Last 10 Audit on the care gap or gap closure process:
- Pull the records for the last 10 patients seen in the practice who were eligible for that service/care process.
- Review each record to see whether the gap was: identified, addressed, closed.
- Document where and why the service was not delivered (e.g., no flag, patient declined, staff didn’t act).
- Calculate your “missed opportunity” rate: the % of patients who did not receive the indicated service or associated action (e.g. referral, visit scheduled).
- Look for patterns in the reasons for missed opportunities: Were multiple patient records missing alerts? Was the gap closure missed on particular types? Or with a particular care team?
Use the audit sheet below to collect and organize the data and calculate your “missed opportunity” rate. As you do improvement work, the missed opportunity rate should decline.
If you need a resource to train practice staff on how to conduct a “last 10” audit you can use this module: https://www.ahrq.gov/downloads/ncepcr/pf-modules/chart-audit/story.htm
Task 3:
Identify root cause/s for missed opportunities in gap closure
Next examine the results of the Last 10 Audit for patterns and root causes. The practice can then use the findings to design improvements to their current processes.
- Pick a few missed opportunities from the Last 10 Audit.
- Look for patterns across patients that did not receive the care.
- Use the 5 Whys technique to dig deeper into why the patients did not receive the indicated care.
- Use the findings to inform the new workflow design and future tests.
The 5 Whys is a simple but powerful tool for identifying the root cause of a problem. It works by asking “Why?” five times—or as many times as needed—to dig beneath the surface of a missed opportunity and uncover the underlying reasons it occurred.
For a brief training on the “5 whys” and other tools for conducting root cause analysis, view this module: https://www.ahrq.gov/downloads/ncepcr/pf-modules/5-whys/story.html
It’s especially effective when used as a team activity and should be applied to both problems and successes to identify what’s working well and where improvements are needed.
PEARL: Last 10 Chart Audits and 5 Whys are not just for identifying what’s broken. ALSO use them to identify what is working well! The things that facilitate gap closure that you can scale and spread.
Task 4:
Select a care gap closure approach
Using insights from the Last 10 Chart Audit and Root Cause Analysis, identify the care gap closure approach the practice would like to focus on first. Each approach involves different workflows, staff roles, and technology supports. While most practices eventually use a combination of strategies to fully address care gaps, starting with one can help your team test changes, build confidence, and learn what works best.
Common Care Gap Closure Approaches:
- Opportunistic (at-visit) care gap closure
- Between-visit outreach
- Gap-specific campaigns
- Outreach to patients not recently seen or who have not yet established care
- Administrative closure
Choose the approach that best fits the barriers identified in earlier tasks and the resources currently available in your practice. Think about where your efforts can have the most immediate impact while staying feasible for your team.
For example:
- If your Last 10 audit revealed that most missed opportunities were due to documentation gaps or incorrect coding, starting with administrative closure processes could be most effective.
- If the primary issue was care team members not being aware of open gaps during visits, your team might focus on improving at-visit gap closure workflows.
Over time, your practice may decide to layer in additional approaches—either to focus on a high-priority gap (e.g., colorectal cancer screening) or to adopt a more comprehensive “whole-person” approach that addresses all open gaps whenever possible.
Task 5:
Inventory practice resources for care gap closure
Work with the practice to inventory the health IT, human and point of care resources that can be used to enhance its care gap closure workflows; and to identify technology gaps that the practice may want to add.
Use the worksheet below to inventory resources the practice has in these areas as well as the practice’s level of expertise and current use of these tools:
- Health IT tools (such as EHR alerts, patient reminder systems, and pop health management platforms)
- Manual tools (like paper logs or outreach lists),
- Technologies (like patient portals, remote blood pressure monitoring tools, digital eye screening devices), and
- Human resources (including available staff, dedicated time for outreach, etc.)
Also, use the worksheet to create a “wish list” of technologies and tools the practice would like to add in the future to enhance its work in care gap closure.
Task 6:
Design and map gap closure workflows
Work with the practice to map the current care gap closure process, begin by identifying the starting and ending points, and creating a high-level process map. Then create a detailed swimlane maps that show the workflow for each member of the staff and care team related to the care or administrative process.
Map current processes as they are
Begin with the process as it currently is, not how the practice would like it to be. Process mapping works best as a group activity, with the individual who conducts the actions, completing the mapping of their part of the process -based on actual actions – not memory.
Any steps involving HIT—such as generating care gap reports, sending automated patient reminders, updating the EHR, or triggering clinical decision support—should be labeled with the name of the tool or system used (e.g., EHR, registry, patient portal, HIE). Use specific symbols or annotations (e.g., icons, shaded boxes, or color codes) to distinguish HIT-supported steps from manual tasks.
Re-design existing workflows or create new ones
Once the practice has mapped the current process, work with them to improve the process using information they learned from the last-10 chart audit and the root cause analysis, and also from reviewing approaches used by any exemplars they have identified.
If the practice does not have a current process for closing the care gap it is working to improve, they can use the results of the Last 10 audit and root cause analysis and review of exemplars to guide design of a new process.
High Level Process Map Worksheet
Detailed Workflow Map Cheat Sheet
For a brief review of process mapping to share with a practice go here: https://www.ahrq.gov/downloads/ncepcr/pf-modules/process-mapping/story.html
Task 7:
Test and refine the workflows using Plan-Do-Study-Act cycles
Use Plan-Do-Study-Act (PDSA) cycles to test the new or enhanced workflows. PDSAs are “small tests” of the new or redesigned process. It is an iterative process where you test your new workflows with one patient, or with one care team, or for one day, study what worked and didn’t work, refine the process based on that information, test again, until the process is ready to fully implement.
Use PCP and staff and patient feedback and modified Last 10 chart audits to study the workflows. Do as many small tests as you need to do until you are ready to scale and spread to the entire practice.
You can use this module to provide a quick training to the practice on PDSA cycles: https://www.ahrq.gov/downloads/ncepcr/pf-modules/model-pdsa/story.html
PDSA Worksheet (Option 1)
PDSA Worksheet (Option 2)
Task 8:
Create job aids and train staff
Once the PDSA testing is complete and the team feels confident in the new workflow, it’s time to prepare to implement.
- Create simple job aids for staff and PCPs to train staff and clinicians on the new processes.
- Schedule trainings. In an ideal world, have the PCPs and staff who participated in the PDSAs and are already familiar with the new workflows deliver this training.
For a brief training on how to create a job aid, use the module at U.S. AHRQ here: https://www.ahrq.gov/downloads/ncepcr/pf-modules/scale-improvements/story.html
PEARL: To save time, drop the process map (or list of steps) the practice made earlier in this Guide into an AI engine like Chatgpt with the prompt: “create a simple job aid” and it will generate a first draft that then you can edit and refine.
Task 9:
Create staff & clinician buy-in to care gap closure
Making care gap closure part of your practice’s culture requires consistent reinforcement in daily conversations, visible tracking of progress, recognition of contributions, and meaningful rewards that make the work feel worthwhile.
Start by integrating care gap closure into the rhythm of practice operations. Talk about it often and tie it to your team’s identity. Reinforce that this is a shared goal, not just another task handed down from leadership. Motivate your team by helping them feel their progress and success.
Saying “We closed 20 gaps today” builds energy and pride—and helps replace a culture of doing the minimum with one that values excellence.
Specific strategies to operationalize this culture include:
- Use slogans like “Every visit is an opportunity to close care gaps” to keep the goal visible and memorable.
- Include care gap metrics in regular staff and clinician meetings to keep performance on the radar.
- Produce monthly dashboards that highlight care team and site-level performance to stimulate friendly competition.
- Offer incentives such as paid time off for meeting group care gap closure targets (e.g., “Close 100 gaps and everyone earns 8 hours of PTO.” Kevin Thomas, MD)
These approaches help create momentum and signal to staff that care gap closure is a priority—one that brings real rewards and shared wins.
"It took months and months of doing provider meetings to continue hammering the idea of quality, the idea of quality, of quality, because quality is good medicine. ... You need to change the culture of providers, medical assistants. They tend to only do the job they have right in front of them.”
- Demetrio Cardenas, DSc, Via Care
Task 10:
Implement and monitor
Once new workflows are launched, monitor how well they are being adopted by both staff and clinicians and gather feedback from them and patients to continue to refine the new workflows.
Use the following strategies:
- Use Last 10 Chart Audits to monitor adoption of the new workflows, and to track the “missed opportunity” (MO) rate for the care gap the practice is working to close. This rate should steadily decline from the baseline MO rate calculated in Task 2.
- Identify patterns and root causes for deviation from new or redesigned workflows, and for missed opportunities and use these to refine steps, training and job aids.
- Conduct Audit & Feedback Sessions where you meet with individual staff/clinicians and conduct individual “Last 10” audits, gather feedback to improve processes, and celebrate improvements.
- Deliver Elbow Support, one-to-one individualized coaching to staff and clinicians with high MO or low adoption rates, to support adherence to the new workflows, and gather feedback to continually improve them. This peer-level coaching can be especially effective when delivered at the point of care.
For a brief training on audit and feedback and "elbow-support" to support new workflow adoption view this module: https://www.ahrq.gov/downloads/ncepcr/pf-modules/scale-improvements/story.html
Task 11:
Add gap closure metrics to practice QI plan and administration
Work with the practice to include the new care gap closure process into their QI plan and dashboard. Use the worksheet below to help the practice draft recommendations to their QI team/director or office manager on possible metrics to add to the practice's overall QI program.
Use the worksheet below to generate a guidance letter to the practice’s QI team/director/data governance team.
Recommendations to the QI Team for Metric
Also add a description of the new process/es to the practice’s:
- Standard Operating Procedures (SOPs) manual
- Job descriptions
- Job evaluations
- Onboarding training as appropriate
Use the worksheets below to document additions to administrative documents.
Task 12:
Share what you’ve learned with other PCPs and use this guide again
Your insights—whether a simple workflow tweak, a training guide, or a practical workaround—can be invaluable to others trying to implement similar improvements.
Click here to share your tools and what you've learned: https://www.surveymonkey.com/r/TXB7MZG
Or email them to: rkochhar@pophealthlc.org
Exemplar Case Studies
A. Exemplar Case Studies:
https://www.lanetpbrn.net/caregapclosure
B. Virtual Visits to Exemplar Practices:
https://www.lanetpbrn.net/caregapclosure
C. Tools shared by EPT Community:
https://www.lanetpbrn.net/caregapclosure