Closing the Gaps – One Patient at a Time

A care gap occurs when a patient is overdue for a recommended screening, such as a mammogram, colonoscopy, missed A1C check, or even a late well-visit. Care gaps can lead to missed diagnoses, increased treatment costs, and deteriorating quality of life. These gaps can stem from various sources, including simple oversight or patient barriers to care. Closing care gaps is crucial work.    

To help our patients, All Care has a team dedicated to closing care gaps. You can think of the team as part of a patient’s concierge service. This concierge team, also called Access Services, works behind the scenes and directly with patients. The Access Services members may ask patients if they need transportation to appointments or assistance with the sliding fee scale. They may also ask about other needs stemming from social determinants of health. Our Access Services goal is to assist in meeting those needs.  

Through a partnership with Main Street Health, All Care recently grew the team with a Healthcare Navigator – Jazmine. Jazmine’s day starts by sharing Care Coordination Assessments with provider teams. These assessments are created by a communication process between Medicare systems and All Care’s electronic health records. The assessments highlight a patient’s chronic conditions and possible conditions due to other issues they may be experiencing. The provider teams use Care Coordination Assessments to be sure patient issues are addressed. Patients may also meet Jazmine or one of All Care’s Care Coordinators to discover needs and solutions to care. Jazmine fills the gaps in her day by finding resources for patient needs. These needs could be rent assistance, affordable phone plans, day-to-day assistance around the house, food resources, or even pots and pans so the patient can cook healthy and affordable meals at home.