Closing Care Gaps: Collaborative Approaches for Population Health

Closing Gaps in Care for Chronic Conditions During the Pandemic

The COVID-19 public health crisis had a disproportionate impact on people with chronic health conditions like type 2 diabetes. It also increased the risk of missed diagnoses for acute conditions like colorectal cancer as people skipped and delayed routine in-person screenings. SWHR’s mission to improve outcomes while lowering the total cost of care drives a focus on closing gaps in care for both at-risk and rising risk populations — even in a pandemic.

The problem

More than one-third of adults reported that COVID-19 interfered with their ability to receive medical care for chronic conditions and preventive screenings. Colonoscopies, in particular, dropped by 90% in the spring of 2020. As regional outbreaks extend the pandemic, people are likely to continue to skip and delay care, leading to poorer outcomes and higher healthcare costs for years to come.


The opportunity

Successful gap closure relies on targeting and engaging patients who need care. In August and September of 2020, SWHR aligned its existing infrastructure of data analytics, physician support and care management, to identify rising and identify patients in need of colorectal screenings, diabetes management and retinopathy screening beyond baseline quality metrics.

The solution

The process required SWHR to align community providers and partners on three-pronged, analytics-driven approach. First, advanced analytics identified at-risk patients through geographic, claims and utilization data, as well as co-morbidities. Along with an awareness campaign to the public, the initiative relied on 200,000 multi-channel direct communications from physicians to patients. Then, in-home test kits and services were provided to targeted patients.


The results

Nearly one-third of the colorectal test kits were returned, of which 5% were positive for colon cancer. Positive tests were followed up on, resulting in a 32% gap closure rate, exceeding the original goal of 25%. Retinal screening outreach to diabetic patients resulted in 194 scheduled visits, with 98 in-home screenings. Of these, 5% tested positive for retinopathy, enabling earlier interventions and better outcomes at lower total cost of care. The initiative proved that baseline quality metrics can be exceeded with data, intensive communications and coordinated outreach.