How Care Plans Can Help Bridge Gaps in Care

The US healthcare system wastes somewhere between $27.2 billion and $78.2 billion annually on insufficient care coordination, according to a study published by JAMA Network. A comprehensive, patient-centered care plan—when implemented properly—is an essential component of effective care coordination that helps address gaps in care, resulting in improved patient health outcomes and a decrease in unnecessary healthcare spending. 

What is a Patient-Centered Care Plan?

A patient-centered care plan is a living document comprised of a patient’s current and historical health data, along with other relevant information, such as cultural nuances, individual preferences, and the names of any family members involved in caregiving. Although the patient ultimately acts as the owner of the care plan, it’s meant to be a collaborative effort between the patient, care team, and any other caregivers involved. 

Overview of Care Plan Objectives

Typical objectives of a care plan include: 

• Eliminating gaps in care 

• Consolidating patient data in one place 

• Better control over chronic conditions 

• Implementing a solid exercise and nutrition regimen 

• Improving medication adherence 

• Facilitating timely interventions and preventive services 

• Enhanced patient engagement and self-management 

Information Required for Creating a Care Plan

The Centers for Disease Control and Prevention (CDC) lists some required information (below), which the care manager obtains through conducting interviews and/or questionnaires with the patient. 

• Name, date of birth, and contact information 

• Health condition(s) 

• Medications, dosages, and details of when and how they’re taken 

• Full list of providers and their contact information 

• Health insurance information 

• Emergency contacts 

  
  

Note: A sample care plan can be viewed via the CDC.

The care plan should be reviewed and updated on a monthly basis, noting any roadblocks or changes in health status. 

What is a Gap in Care?

A “gap in care” refers to the discrepancies that exist between what a patient’s care and health outcomes should look like based on clinical standards, versus the care that the patient is actually receiving and the resulting outcomes. Gaps in care can result from a variety of factors, including but not limited to: Financial or geographic barriers or poor health literacy. For example, a patient with a limited grasp on health literacy may struggle to adhere to the treatment plan due to the use of medical jargon. Care gaps are crucial to address, as they can result in unsatisfactory patient outcomes and unnecessary healthcare spending. 

How Care Plans Help Identify and Bridge Care Gaps 

A care plan proactively identifies gaps in care by centralizing all patient data across the entire care team and combining clinical data with consumer data, ensuring that all parties are aligned and care fragmentation is reduced. It also has the ability to flag overdue appointments, monitor any new symptoms that appear, or assist in keeping the patient fully informed of their treatment plan with barriers to health literacy in mind. 

Leveraging Technology to Close Gaps in Care

The care plan is a powerful tool for closing care gaps, but only if it's done the right way. Failure to implement a care plan correctly can result in missed care gaps, compromised privacy and security, and ineffective data sharing and communication between providers. A premier communication and documentation solution, like Clinii Connect-AI, intelligently recommends ways to personalize care using AI-driven insights, all while remaining HIPAA-compliant within a single convenient interface. 

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