As Medicare Advantage plans strive to improve performance, closing care gaps quickly has become a top priority. But here's what many plans miss: transitions of care are where coordination most frequently breaks down—and where health plans have the greatest opportunity to influence outcomes across multiple quality measures. CMS and HEDIS measures now emphasize time-critical interventions, especially around these critical moments. For example, the FMC HEDIS measure requires follow-up within seven days of an emergency department visit for patients with multiple chronic conditions.
The Four Critical Measures
Four HEDIS Transitions of Care (TRC) measures now carry triple weight in Star Ratings calculations after their first year:
- Notification of inpatient admission
- Receipt of discharge information
- Medication reconciliation post-discharge
- Patient engagement after inpatient discharge
Without timely insights, it’s impossible to report on or react to these measures effectively. In fact, the national average for meeting the “receipt of discharge information” measure was just 23% in 2024.
Effective post-discharge coordination creates a compounding impact: better medication adherence, closed chronic care gaps, stronger member engagement that breaks recurring utilization patterns. One operational improvement, multiple measure impacts.
Challenges to Closing Care Gaps
Many health plans still rely on delayed census and claims data, which can lag by one to three weeks. This is far too slow for measures that require action within days. When critical information about discharges, medication changes, or ED visits arrives weeks after the event, care managers aren't preventing complications—they're managing them. Manual workflows and fragmented data make it difficult for payers and providers to share critical patient updates, hampering collaboration and timely intervention.
Collaboration Is Key
Efficient plan-provider collaboration is essential. Both plans and providers need seamless communication and data visibility to close gaps and improve ratings. But outdated reports, phone calls, and disparate electronic health records (EHRs) often stand in the way.
The Real-Time Data Imperative
For time-sensitive measures, real-time awareness is crucial. Members are most open to behavior change immediately following a care event. That brief window of impact demands systems that trigger action in real time, not weeks later when claims data finally cycles through.
For example, documentation of inpatient admission must be sent to the member’s primary care physician within three days. Delays in claims data, often one to three weeks, make it nearly impossible to meet these requirements. The result? Lower Star Ratings and missed opportunities for quality improvement.
The Bottom Line
Closing care gaps is not just about compliance—it’s about delivering better outcomes for patients and securing the financial future of health plans. The challenge is clear: health plans must move beyond outdated data and manual processes to achieve real-time collaboration.
How can health plans overcome these obstacles? In Part 3, we’ll reveal how health information technology is transforming care coordination and driving real results.
Timely collaboration is the key to higher Star Ratings. See how PointClickCare connects plans and providers to act on care gaps at pointclickcare.com.
