How to Close Care Gaps as a Solo PCP: A Practical Checklist

Why Care Gap Closure Matters Financially

For primary care physicians in value-based contracts (Medicare Shared Savings Program, commercial ACO arrangements, Medicare Advantage risk contracts), care gap closure directly affects quality bonuses. A solo PCP with a panel of 600 patients in a Medicare Advantage arrangement can see $15,000–$40,000 in annual quality bonuses tied to HEDIS measure performance—or lose that revenue entirely if gaps go unclosed.

Beyond the financial impact, care gaps represent genuine clinical risk. A diabetic patient without an A1c in 12 months may have uncontrolled glucose. A 55-year-old with a 30 pack-year history without a low-dose CT chest is a missed lung cancer screening opportunity.

The Highest-Impact Care Gaps in Primary Care

Diabetes Management (CDC: Comprehensive Diabetes Care)

Diabetes Care Gaps and Closure Criteria

Measure	HEDIS Measure ID	Closure Criteria	Frequency
HbA1c testing	CDC-HbA1c Testing	At least one HbA1c in measurement year	Annual (minimum); q3–6mo if uncontrolled
HbA1c control (<8%)	CDC-HbA1c Control	Most recent HbA1c <8.0%	Snapshot: most recent result in year
Blood pressure control	CDC-BP Control	Most recent BP <140/90 mmHg	Snapshot: most recent reading in year
Eye exam (dilated retinal)	CDC-Eye Exam	Dilated eye exam by optometrist or ophthalmologist	Annual
Kidney health evaluation	CDC-Kidney Health	eGFR or urine albumin-creatinine ratio	Annual
Statin therapy	SPC-Statin Use Diabetes	Statin prescription dispensed during year	Annual (active Rx)

Cancer Screenings

• Colorectal cancer screening (COL): Ages 45–75. Accepted methods: colonoscopy (q10yr), Cologuard/FIT-DNA (q1–3yr), FIT/gFOBT (annual), CT colonography (q5yr), sigmoidoscopy (q5yr). Documentation must specify the test performed and result. A positive Cologuard followed by a diagnostic colonoscopy closes the gap.
• Breast cancer screening (BCS): Women 50–74. Mammogram within the measurement year or year prior. Document laterality, date, result, and ordering provider.
• Cervical cancer screening (CCS): Women 21–64. Pap smear every 3 years (age 21–64) or Pap + HPV co-test every 5 years (age 30–64). Document result date and result.
• Lung cancer screening (LCS): Ages 50–80 with 20 pack-year history, current smoker or quit within past 15 years. Annual low-dose CT chest. Document shared decision-making conversation (required by CMS before ordering).

Cardiovascular Risk

• Statin therapy for atherosclerotic cardiovascular disease prevention (SPC): Patients 21–75 with clinical atherosclerotic cardiovascular disease or LDL ≥190, or patients 40–75 with diabetes. Document statin prescribed and dispensed.
• Blood pressure control (CBP): Patients 18–85 with hypertension. Most recent BP <140/90. If controlled, close the gap with any BP reading in the measurement year documented in the chart.
• Anticoagulation for atrial fibrillation (SAA): AFib patients at stroke risk (CHA₂DS₂-VASc ≥2 for men, ≥3 for women). Document anticoagulant prescribed and active. If declined, document shared decision-making.

Behavioral Health Integration

• Depression screening (DSF): Annual PHQ-2 (or PHQ-9 if PHQ-2 positive). Document screening tool, score, and follow-up plan if positive.
• Follow-up after mental health hospitalization (FUH): If your patient is hospitalized for a mental health diagnosis, ensure outpatient follow-up within 7 days and within 30 days. Document the follow-up visit with a qualifying mental health diagnosis code.

The Practical Workflow for Closing Gaps

Step 1: Run a Weekly Gap Report

Your EMR should be able to generate a list of patients with open care gaps—patients with diabetes who have not had an A1c in 11+ months, patients due for colorectal screening, patients with uncontrolled blood pressure. If your EMR cannot generate this report, you are flying blind and almost certainly leaving quality bonuses uncaptured.

Step 2: Pre-Visit Chart Scrub

24–48 hours before each patient's scheduled visit, have a medical assistant or nurse review the patient's open care gaps. Flag them in the chart so the provider sees them at the top of the visit note. The pre-visit scrub takes 2–3 minutes per patient and dramatically increases same-day gap closure rates.

Step 3: Close Gaps at Every Visit

Any patient encounter—regardless of the chief complaint—is an opportunity to close care gaps. A patient presenting for an acute URI can get a colorectal cancer screening order placed, a PHQ-2 depression screen completed, and a blood pressure reading documented in the same visit. Do not wait for annual wellness visits to close chronic gaps.

Step 4: Outreach Between Visits

For patients with open gaps who have not been seen recently, proactive outreach closes gaps without requiring an office visit:

• Lab order standing orders: Place a standing order for annual A1c and urine albumin for all diabetic patients; patient goes to the lab without an office visit
• Mail/portal outreach: Send secure messages or letters with home FIT kits for colorectal screening
• Nurse triage calls: Brief nurse call for blood pressure documentation can close the BP control gap remotely for stable patients

Step 5: Document to Close

Gaps close based on documented evidence in the chart, not on what the provider remembers or believes happened. Specific documentation requirements:

• Lab results must be documented in the EMR with result values and dates—faxed results sitting in a paper file do not close gaps
• External screening results (colonoscopy at another facility) must be imported or documented by reference with facility name, date, and result
• Prescription drug gaps close based on pharmacy dispensing records, not just prescribing—coordinate with your pharmacy for dispensing confirmation
• Declined screenings: Document the patient's refusal, your counseling, and the date—some measures credit documented refusal as a gap closure

Care Gap Closure and Krasyn

Krasyn's care gap dashboard shows open gaps by patient, gap type, and payer. The AI visit copilot surfaces open gaps during the encounter so providers see them in context. See the care gap workflow.