A care gap is what happens when a transition of care goes wrong: a patient who doesn't understand discharge instructions, doesn't fill a prescription, or has uncontrolled hypertension or diabetes that no one ever adjusts the care plan for. Stacey Richter is re-airing this conversation with Carly Eckert, MD, PhD(c), MPH, a year later because she keeps finding herself quoting Dr. Eckert — even though the interview didn't go the way Stacey originally planned. She wanted to talk about closing care gaps; Eckert redirected the conversation toward something more fundamental: whether "closing care gaps" is even the right model of care to begin with, or just a reactive game of whack-a-mole. WHAT YOU'LL LEARN ✅ Why "closing care gaps" can function as reactive whack-a-mole — treating each missed preventative opportunity as it surfaces rather than building a genuinely nonfragmented system of care ✅ What a truly nonfragmented state of care would actually require, and why identifying and addressing care gaps is only one piece of a much bigger population health picture ✅ Why taking small, individualized steps with patients matters more than a one-size-fits-all approach, and why peer support carries real, underused power in closing gaps ✅ Why workforce diversity is a meaningful lever for closing care gaps, and where providers still have room to improve transparency with patients ✅ Why provider organizations so often default to reactive, appointment-based care gap closure instead of proactive whole-person population health programs — and why, per Stacey's own follow-up reflection, weak financial incentives are usually the real reason why WHY THIS MATTERS Care gaps are expensive and dangerous in ways that compound: uncontrolled hypertension and diabetes left unaddressed for too long lead to heart failure, and chronic kidney disease is often the very thing driving those heart failure readmissions back up. But per Carly Eckert, treating each individual care gap as it appears is a fundamentally reactive model, not a fix. Real progress requires the harder, more upstream work of building genuinely coordinated, nonfragmented care — and, as Stacey noted after a follow-up conversation with Dan O'Neill (EP359), providers won't make that shift until payment models actually reward it. MENTIONED IN THIS EPISODE EP322 with Monica Lypson, MD, MHPE: Apple Podcasts | Spotify | Other Apps EP347 with Ian Tong, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 05:31 What is the true goal in making population health successful? 05:58 How does the clinical pathway need to manifest in population health? 06:29 How do we get a nonfragmented state of care? 06:54 What is the best model of care? 08:37 "Identifying and addressing care gaps is an important element of population health." 11:30 Closing care gaps vs creating a nonfragmented system of care. 15:38 "I think you have to take small steps with people." 16:45 "There's a lot of power in peer support." 17:18 Why should provider organizations connect with peer groups? 19:05 "The key is that it's not going to be the same for everybody." 23:09 Why is diversity of the workforce key to closing care gaps? 28:36 Where can providers improve transparency to help close care gaps?