Closing Care Gaps: How Data and Teamwork Improve High-Risk Patient Outcomes

On this episode

About this episode

In this follow-up conversation with Dr. Andy Mayberry, a longtime rural family physician with Chiricahua Community Health Centers, we explore how to close care gaps and strengthen care for high-risk patients through better data, communication, and teamwork. Dr. Mayberry explains why annual wellness visits are the foundation of preventive care and how consistent provider-patient relationships drive better outcomes. From care gap reports to risk adjustment scores, he offers a clear-eyed look at the systems behind high-quality primary care—and why every health center should prioritize care coordination and chronic care management. Listeners will also hear honest insights about provider…