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’Tis the Season to Close Year-End Care Gaps

Published August 20th, 2025

The final weeks of the year move fast. It’s the perfect time to focus your team on closing open care gaps—so families start the new year healthier and your practice captures earned quality revenue. Here’s a simple, clinic-friendly checklist you can put to work now.

Well-Child Visits: Finish Strong

  • Immunizations: Prioritize childhood (0–2) and adolescent vaccines during every visit.
  • W15 & W30 measures:
    • W15 – Identify children who’ve completed 5 of 6 required visits and schedule the final visit before they turn 15 months.
    • W30 – Identify children who’ve completed 1 of 2 required visits and schedule the remaining visit before they turn 30 months.
  • Don’t forget to schedule Annual Well-Child visits for all children ages 3-21 as well.
  • Convert when appropriate: If a child comes in sick and is clinically appropriate for preventive care, complete well-visit components to avoid a missed opportunity.

Spotlight on Women’s Health

  • Breast cancer screening: Order and refer based on evidence-based guidelines. If a prior screening was completed within the last 2 years, document month, year, and summary result in the medical record.
  • Cervical cancer screening: In addition to Pap testing, the FDA now allows primary HPV testing with self-collection in a clinical setting.
    • This option can make completion easier without a full exam or external referral.
    • Want details on implementing HPV self-collection? Our Provider Support Team can help: provider_support@equalityhealth.com.

Chronic Condition Management: Quick Wins

  • Diabetes: Bring in patients due for an A1c—close the gap with a quick test and next-step plan.
  • Hypertension: Re-check any elevated reading after at least 5 minutes of rest during the same visit to improve accuracy and avoid unnecessary follow-ups.

How Equality Health Can Help—Today

  • Care Specialist outreach: We’ll help reach hard-to-contact patients and get them scheduled.
  • Community Health Workers: We address SDOH barriers—transportation, food, housing—and support adherence to the care plan. Refer in CareEmpower® or email carecoordination@equalityhealth.com.
  • CareEmpower® Worklist: Prioritize patients with open gaps and take action in one view.
  • Chart Prep Tool: See critical activities to complete during the appointment so every visit counts.
  • Need a refresher? We’re happy to train your team on these tools. Contact provider_support@equalityhealth.com.

By prioritizing year-end gap closures now, your practice starts the new year focused on wellness—while securing critical quality revenue as the measurement year closes. Together, we’re dedicated to better year-end outcomes for every family you serve.

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