Care Gap Worklist

Note: The first time you access the Care Gap Worklist, a training module appears to lead you through the steps of creating a Care Gap Worklist. This training module appears each time you access the Care Gap Worklist if you haven't yet created a worklist.

1. Display the Care Gap Worklist:
   • On the Main Menu, click Patients. Under Care Coordination, click Care Gap Worklist.
   • Click the CARE GAP WORKLIST icon in the athenaOne status bar at the bottom right of the athenaOne window.
2. Click Edit Filters.
   The Care Gap Worklist filters page opens.

Specify an appointment date range

3. Appointment dates - Required — Set a dynamic or custom date range:
   • Dynamic date range (updates nightly) is selected by default. Select an option to view patients with upcoming appointments:
     • Today
     • Today and tomorrow
     • Tomorrow
     • Next 7 days
     • Next 14 days
   • Custom date range (does not automatically update):
     • From - Required — Enter or select the start date of the date range for upcoming appointments (you cannot select a date before today's date). The date range must span two weeks or less.
       
     • To - Required — Enter or select the end date of the date range for upcoming appointments (you cannot select a date before today's date). The date range must span two weeks or less.
       

Specify at least one department or scheduling provider

Note: You must select at least one department or one scheduling provider to create a care gap worklist.

4. Departments - Required — Select one or more departments from the list to create a care gap worklist for patients with appointments in the selected departments.
   Note: When you select a department, all providers in that department are selected (you do not need to select the providers using the Scheduling providers - Required filter).
5. Scheduling providers - Required — Select one or more scheduling providers from the list to create a care gap worklist for patients who have upcoming appointments with the selected providers.

Select one or more optional filters (if you choose)

6. Primary insurances — To filter the care gap worklist by the primary insurance reporting category (IRC), select one or more IRCs from the list.
   Note: To display open care gaps for all primary insurances, leave this field blank.
7. Care gaps — To filter the care gap worklist by specific care gaps, select one or more care gaps from the list.
   Note: To include all open care gaps in the worklist, leave this field blank. When you select one or more care gaps, the Care Gap Worklist includes only patients who have at least one of the selected care gaps. However, all open care gaps appear for each patient included in the worklist.
8. Appointment types — To filter the care gap worklist by appointment type, select one or more appointment types from the list.
   Note: To display open care gaps for all appointment types, leave this field blank.

Create the worklist

9. Click Create Worklist to generate the list of patients with care gaps.
10. Click any column heading to sort the worklist by the contents of that column, for example, by provider or by the number of open care gaps.
    
    
11. You can hover over the Open icon in the athena Status or External Statuses column to display details about that care gap.
    
12. To print the Care Gap Worklist, click the Print icon at the top left of the worklist.

Note: The first time you access the Care Gap Worklist, a training module appears to lead you through the steps of creating a Care Gap Worklist. This training module appears each time you access the Care Gap Worklist if you haven't yet created a worklist.

1. Display the Care Gap Worklist:
   • On the Main Menu, click Patients. Under Care Coordination, click Care Gap Worklist.
   • Click the CARE GAP WORKLIST icon in the athenaOne status bar at the bottom right of the athenaOne window.
2. If you do not already have a worklist, click Edit Filters and set your filter parameters (see To create a Care Gap Worklist).
3. For the patient whose exam you want to work on, click Exam Prep in the Next Visit column.
   
   athenaOne opens the patient briefing.
4. Click Go to Exam Prep.
   The stages of an encounter appear in the patient banner, and the patient banner indicates that you are working in Exam Prep mode.
   
5. Complete exam prep. When you finish exam prep, click Done with Prep.
   Note: For complete information, see Encounter Preparation (Intake and Exam Prep).
6. After you complete exam prep, return to the Care Gap Worklist via the Patients menu or by clicking the CARE GAP WORKLIST icon in the athenaOne status bar at the bottom right of the athenaOne window.
   The row for the patient on the worklist is now gray and the notation PREPPED appears.
   Note: For any appointment marked PREPPED, you can hover over PREPPED to see who performed exam prep and when.

In addition to care gaps identified by athenahealth-supported quality programs, care gaps identified by payers that have global integrations with athenahealth show open Stars/HEDIS gaps alongside athenahealth data; for example, care gap data can be sourced from Humana Medicare Advantage (MA).

Note: You can see the list of athenahealth Participating payers for care gaps and risk gaps on the Success Community.

As of November 2022, Anthem, Humana, and Optum care gap data appears in the Care Gap Worklist. In future releases, you'll see data from other payers, as well as from other applications, such as athenahealth Population Health.

The Care Gap Worklist includes Humana data about open care gaps for any patients who have active Humana Medicare Advantage (MA) listed as the primary insurance policy and who have upcoming appointments in the next 14 days. If your practice is also enrolled in HEDIS or MIPS measures in athenaClinicals, you'll see a comparison of data between care gaps identified by athenahealth and care gaps identified by Humana (see External Statuses column).

Note: If you do not want to display care gap data from payers in the Care Gap Worklist, create a support case from athenaOne > Support > Success Community > Contact Client Support Center to request that this feature be turned off. The practice setting to turn off care gap data from payers is "Display payer care gap data in the care gap worklist and quality tab."

Using the Care Gap Worklist, you can:

• Create a list of patients with open care gaps.
• See the status of a patient's care gaps as calculated by athenahealth (for quality measures that your practice is enrolled in) or as calculated by third-party sources.
• See open care gaps that athenahealth does not support, such as Medication Adherence measures, from third-party payers or services.
• Sort the worklist by filters such as upcoming appointment, provider, and primary payer.
• Use this list in conjunction with other data — such as reports from the Report Library — to close care gaps.

Tip: After you start using the Care Gap Worklist and begin your work closing care gaps, you'll find that if you pause and later resume your work, you are returned to the point in the worklist where you left off. The worklist can generate a list of up to 1500 patients at a time, but very large lists may require additional load time.

You can create a Care Gap Worklist based on your organization's needs. Following are a few examples of how you can use the Care Gap Worklist.

• A clinical staff member can use the list to identify patients with open care gaps who are coming to the office the next day; the staff member can queue orders or add notes accordingly.
• A quality manager may want to identify patients with upcoming appointments who require certain preventive care measures.
• A provider can create a list of patients with appointments next week who have open care gaps to help with chart prep. Each morning, the provider can go back to that list to review each patient's open care gaps.
• During Breast Cancer Awareness month, office staff can go through a list of upcoming appointments to see which patients need a breast cancer screening.

You can create a filtered list of patients in the Care Gap Worklist based on how you like to work to close care gaps.

For each patient, you see patient demographics, as well as other details including:

• Upcoming appointment details
• Primary insurance
• Number of open care gaps
• Care gap names and any information about recent satisfaction
• Icons that indicate the status of the care gap according to athenaOne and according to third parties (when applicable)

From the Care Gap Worklist, you can act on patient care gaps as follows:

• Click the Patient Name to access the patient chart and then return to your place in the worklist to continue closing care gaps.
• Click Exam Prep to queue orders, add notes, and take other actions to close the patient's open care gaps (see To complete pre-encounter prep from the Care Gap Worklist).

The filters that you configure for the Care Gap Worklist remain in effect until you change them. When you leave the Care Gap Worklist and return to it later, the same filtered list is displayed. You can click the Refresh option to refresh the worklist and display any updates of the care gaps shown on the worklist — for example, care gaps that were open may now be closed or new patient appointments may have been scheduled during the configured time frame.

To change any of the filters on the worklist, you must click Edit Filters (see To create a Care Gap Worklist).

You can access the Care Gap Worklist if your organization is enrolled in an athenaClinicals quality program. The athena Status column in the Care Gap Worklist indicates the number of open care gaps identified by athenaClinicals quality programs. For each open care gap, data from all quality programs integrated with athenaClinicals is grouped together; for example, all open gaps related to Breast Cancer Screening are displayed together in the athena Status column.

Note: The athena Status column is always displayed in the Care Gap Worklist, even if your organization is not enrolled in an athenaClinicals quality program that is integrated with the Care Gap Worklist.

You can hover over the Open icon in the athena Status column to display details about that care gap.

The External Statuses column indicates the number of open care gaps identified by an external source (currently, Humana Medicare Advantage plans). If the report includes no patients with open care gaps identified by external sources, the External Statuses column does not appear in the Care Gap Worklist.

Note: If your organization requested that athenahealth disable the integration of payer care gap data with athenaClinicals, the External Statuses column does not appear in the Care Gap Worklist (this integration is enabled by default).

In the following example, the payer (in this case, Humana) sends data on open care gaps directly to athenaClinicals on a nightly basis for patients with an appointment scheduled within the next 14 days.

• If your practice is enrolled in quality measures in athenaClinicals, the Care Gap Worklist displays athenaClinicals data in the athena Status column, along with the quality measure data sent by Humana in the External Statuses column.
• If your practice is not enrolled in quality measures in athenaClinicals, the Humana data appears for each patient in the Care Gap Worklist, but without any relationship to data calculated by the athenaClinicals quality engine.

This example shows two open Humana care gaps for the patient, as indicated by the orange labels in the External Statuses column.

• The Breast Cancer Screening gap is also open in athenaOne, but a result is pending for an existing order, as noted in the Last Activity column.
• The second open Humana gap ("Patient is non-adherent to their diabetes prescription") is not currently calculated in athenaOne (as indicated by the "None" status in the athena Status column for this care gap.

The "None" status in the athena Status column can occur for any of these reasons:

• athenaOne does not support the measure.
• Patient does not meet the denominator criteria.
• Patient is excluded from the measure in athenaOne for documented clinical reasons.
• Patient's provider is not enrolled in the corresponding quality measure in athenaOne.

In the following example, the "Care for older adults - Advance care planning (COA)" measure is noted as open by Humana, but athenaOne shows it as closed, as indicated by the green icon and the notation in the Last Activity column.

Care gaps available from Humana Medicare Advantage

 

You can expect to see data for the following care gaps from Humana (Medicare Advantage plans) if any of these care gaps are open for a patient in the worklist.

 

Humana care gaps in the HEDIS/Stars category

 

Some of the care gaps in the HEDIS/Stars category are not supported in the athenaClinicals quality engine. These care gaps are preceded by an asterisk (*).

• Breast cancer screening
• COA - Functional status assessment
• COA - Medication review
• COA - Pain screening
• Colorectal cancer screening
• Controlling blood pressure
• Diabetes - Blood sugar control
• Diabetes - Eye exam
• Diabetes - Nephropathy
• * Medication reconciliation post-discharge
• * Osteoporosis management
• * Plan all-cause readmissions
• * Rheumatoid arthritis management
• * Statin therapy for cardiovascular disease

 

Humana care gaps in the Stars Patient Safety category

 

None of the care gaps in the Stars Patient Safety category are supported in the athenaClinicals quality engine.

• Medication adherence: Cholesterol (statins)
• Medication adherence: Diabetes medication
• Medication adherence: Hypertension (ACE/ARB)
• Statin use in persons with diabetes