Medical Director for Healthcare Informatics, Qualis Health PCMH Change Concept 3: Empanelment Jeff Hummel, MD, MPH Medical Director for Healthcare Informatics, Qualis Health December 8, 2016

Goals for this session The definition of empanelment The importance of empanelment The steps for empanelling a practice Strategies for getting panel sizes right The structure required to monitor and manage a well-run panel system The role of leadership in making this happen

Empanelment means.. Assigning every patient assigned to a PCP/care team Definition of “population” for population management and care coordination Population health on a scale clinicians can handle Basis for data transparency A paradigm shift: it holds clinicians accountable for decisions that patients make

The SNMHI Framework: The Change Concepts for Practice Transformation Technical assistance helped sites understand and adopt an evidence-based framework we developed to guide practices through the PCMH transformation process and make key operational changes. We called this framework “The Change Concepts for Practice Transformation.” "Change concepts" are general ideas used to stimulate specific, actionable steps that lead to improvement. Our framework includes eight change concepts in four stages, which Dr. Wagner will describe in more detail. Each Change Concept includes three to five "key changes." These provide a practice undertaking PCMH transformation more specific ideas for improvement. The Change Concepts were derived from reviews of the literature and discussions with leaders in primary care and quality improvement. They have been extensively tested by the 65 sites that participated in the SNMHI; they have also been adopted by other improvement initiatives nationwide. While they were developed specifically for safety net practices, they have proven useful to a wide variety of practice types, and we believe they are generalizable throughout primary care. Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.

Leadership: Creating a Change Culture Articulate a vision of practice with care teams with adequate resources for panel Create a quality improvement culture Create a team-work culture Time for huddles and other team meetings Training support clinical team in patient education & motivational interviewing Engaging all staff in patient engagement, care continuity, outreach Extend incentives to teams

A Quality Improvement Culture Basing decisions on data Making RPI Cycles to improve workflow part of care team culture Following through on QI decisions and processes Appling effective strategies to improve care processes and clinical outcomes

Empanelment is tied to Care Teams Sharing the care expands access Whole person care requires: acute episodic, chronic illness, preventive care, with close attention to health equity Multi-disciplinary team with defined panel is prepared to higher level change concepts Using data to manage population outcomes Care transitions Patient-centered care coordination

Operationally what does it mean? First see where a practice is Set up a structure to support empanelment Assign patients using an algorithm Identify practices where demand & capacity are not balanced Enact policies to “right-size” panels

Pre-Empanelment Work Ensure sufficient analytic capacity Identify active and inactive patients Determine practice’s AVPY Determine right panel size for each provider Determine pt demand for services Determine providers’ supply for pt access

Admin Structure: Panel Manager Role depends on organizational size > 10 providers: Centralized panel manager < 10 providers: RN/LPN/MA supporting teams Tasks: Develop and run panel reports Assign outlier pts and facilitate transitions Follow trends in panel size: recommend closing and opening Assure data reported correctly to registries

Admin Structure: Population Manager Quality Improvement Role Assure benefits of panels are visible to all Triple Aim at local level Tasks Oversee data used for population mgmt Run action reports Review trends and inform the organization Overlap with care coordination & care mgmt

Which providers gets empanelled? All providers > 60% FTE Providers 50-60% FTE share a panel Providers < 50% FTE work locums NPs & PAs: consider shared panel with Physician Other issues: Specialists Residents

Empanelment Steps Run Pt visit history report MRN, Name, DOB, Visit dates PCP, provider seen, Pts not assigned Sort by PCP to determine care continuity % visits seen by PCP Pts assigned to PCP who has left 17 yr olds assigned to pediatricians

Empanelment Steps 3. Four-cut methodology Pt saw 1 provider: that provider Pt saw > 1 provider: majority visits Pt saw > 1 provider; no majority: PE provider Pt saw > 1 provider; no PE: provider last seen 4. Providers review the results and amend Compare the final number to “right panel size” Pts confirm assignment when they call for appt Process in place to quickly reassign

Adjusting Panel Size Age/Gender based on actuarial data is considered standard Morbidity/Acuity: About resource allocation, so internal political acceptance may require compromise Based on visit frequency for morbidity patterns Based on needs associated with longer visits Impaired cognition Language barriers

Getting Panel Size Right Formulaic systems are useful, but imperfect The goal is to make a serious effort to appropriately match resources to need Whatever system is used should be both transparent and flexible

Keeping it Patient-Centered Encourage patients to pick PCP when they first register for care Verify PCP assignment with patient at each clinic visit Encourage continuity, but make it relatively easy to change PCP Over time panel reports will become more accurate

Managing Panel Size

What if a panel is too large? Verify with team Close the panel Remove from duty covering other PCPs Add new providers Review team work – sharing care Improve workflow – add exam rooms Review alternatives to office visits Remove patients from panel

On-going Monitoring/Adjustment Provider generated changes Changes in FTE, LOA, provider leaving On-boarding new providers Provider requests to move patient Patient generated changes New pts need PCP Adolescents transition from pediatrics Transfer on request of patient or care-giver Pt leaves clinic, or deceased

Monitoring Continuity of Care Measure percent of visits with Pt’s Care Team Clinic needs to set target for continuity Approach gaps in meeting continuity goal as a QI project Brainstorm ways to improve Test improved workflow on small scale with RPI cycles

Next Steps Use panel reports to decide: Who is in our panel? What the most important target populations? What are the standards of care for each target population? Who in each target population have we adequately assessed? What did we find on assessment? What did we do?

Summary Empanelment is a key part of a clinic structure capable of supporting whole person population care There are specific steps to empanelment that will enhance probability of success A well run panel system requires a management structure and resources to support it

Resources: SNMHI: Coach Medical Home website: PCMH-A: http://www.safetynetmedicalhome.org/change-concepts/empanelment Coach Medical Home website: http://www.coachmedicalhome.org/ PCMH-A: http://www.safetynetmedicalhome.org/sites/default/files/PCMH-A_7.pdf

Questions? jeffh@qualishealth.org http://www.safetynetmedicalhome.org/ http://www.qualishealth.org/