1. Panel Management: Mining the milestone goldmine from team care to population care to practice improvement Angela Smithson, MD MPH Adrianne Moen, MD Kaitlyn Schoeck, MD UMN St John’s Family Medicine Residency

2. Alternate title: How to help staff and providers learn to love spread sheets?!

3. Disclosures None

4. Objectives Identify how panel management is an opportunity to combine education and clinic improvement activities. List milestones addressed in tackling the improvement of panel management. Analyze panel management tasks that “shares the care” amongst the entire clinic staff and utilizes their full capabilities for these activities.

5. Take Home Points Educationally rewarding to participate in the challenging work of clinic improvement –Understanding the clinic processes builds trust, engages residents and staff, and leads to more enthusiasm for ongoing clinic endeavors Panel management directly ties into daily clinic activities with patient encounters –Outreach activities, previsit planning, at visit completion and post-visit planning Right care at the right time by the right people!

6. Background: What we needed to fix Clinical perspective: Panel management ineffective –Paper printouts handed to resident and staff –Review, call or mail reminders Educational perspective: CCC meeting noting milestone gaps –Unsure if residents were learning or participating in Panel Management Improvement Activities Directing/leading the team at clinic

7. Milestones addressed in panel management activity Improve chronic disease management and preventive care –MK 2: level 4 uses patient panels to address population health

8. Milestones on team work found in panel management Improve their team-based interactions –SBP 4: level 3 engages the care team for appropriate patient care –SBP 4: level 4 accepts responsibility for coordination of care and directs teams Learn how team care can benefit our patients’ health –PC 2: level 4 leads care teams to manage patients with chronic diseases –PC 3: level 3 and 4 mobilizes team members and tracks disease prevention, monitors the population

9. Milestones mapped to improvement of panel management process Learn quality improvement methods –PBLI 3: level 3 and 4 uses an improvement method, registry and protocols to measure outcomes and improve care Improve resident confidence and interest in quality improvement –SBP 3: level 4 seeks to improve the health care system

10. Overview: PDSA Plan: Team meeting to address topic First step (2 meetings) –Form clinic groups for each disease condition (Queen bee teams) –Draft condition specific tasks for all clinic staff Second step (2 meetings) –All groups report and discuss drafted standard work –All trial run their drafted activities Third step (2 meetings) –Queen bee groups review feedback and modify the standard work Fourth step –Implement standard panel management tasks for all conditions

11. DO: Analyze and direct team “Share the Care” Reach out Task: Task and route (Phone call, Letter, Mychart) FrequencyFront Office Staff (FOS) PCSRNHCH Coord HIM Staf f Admin Staff Referral Coord Pharm D Behavior al Health Provide rs Sharing the Care Panel Management: _________________________ Place an M and B in the column of the person/people who is the main role responsible for task (M), consider who might be backup or assist (B) as needed.

12. Do: Drafting Standard tasks

13. Do: Panel management tasks “Share the Care” Asthma Panel-PATIENT CARE STAFF Pre-visit: PCS PVP to include AAP/ACT due Visit Tasks: Print last AAP, put in red folder by exam room Give ACT to patient to complete at every visit Warm/ hot handoff to MD with AAP due reminder If MD didn’t do so, PCS give orange slip for return asthma follow-up if unable to address today Outreach/post visit Send “due” letter yearly, using standard work dot phrase (.asthmadueletter) Call patient that missed ACT, if they are overdue: do one over the phone Add when last AAP was done in the refill encounter (.pvrefill) for inhalers/asthma medication refill requests Asthma Panel-PROVIDER Pre-visit: Update problem list if possible when PVP Visit Tasks: Update problem list with asthma/reactive airway disease Review ACT for accurate ED/Hospitalization and score Give orange slip for return asthma follow- up if unable to address today Outreach/post visit Notify delegated PCS to contact patient after a week for ACT score less than 20, if new meds or med changed Add comments to pharmacy when refilling medication that patient is due for a visit

14. Study: Clinical Results Percentage Optimal Care

15. Study: Panel management process (MK2) Able to complete Tasks:

16. Study: Panel Management Process Time required to complete panel management tasks Nearly all who completed, did so outside of regular work hours, on weekends and a few had time between patients. Often it was a combination of these. The exception was Care management staff.

17. Study: Panel Management Process (MK 2) Barriers to completing panel management

18. Study: Panel Management Process Open ended suggestions for improvement – staff “ health care coordinator that works specifically on these panels” “a lot of work on top of taking care of things for patients in clinic (when done between patient visits)” “time for someone to mainly focus on this” “patients were recently seen for same issue, but then panel list received stating patient needs visit” “due to insurance purposes, find out patient can’t have visit or test done until after a certain date”

19. Study: Panel Management Process Open ended suggestions for improvement - faculty “market the concept in patient-centered terms ” “many on the list were long time patients who are resistant to change” “ see opportunity to intervene without visits…do not have time to do in addition to other responsibilities ” “one more thing on list of many…interested to see if these make an impact” “best to have designated time to do this with my MA” “develop and implement efficient and effective processes to prompt [healthcare provider] to review select (pertinent, high-yield) and accurate patient data to identify patients who would likely benefit from SPECIFIC, pre-defined interventions (prefer evidence-based)”

20. Study: Panel Management Process Open ended suggestions for improvement – residents “info out of date by the time I did the panels ” “missing some of my patients ” “do see value of panel management…want to work through panels…need time and skills to efficiently complete” “didn’t know my role” “time intensive…dedicated panel management time” “many tasks assigned to providers that PCS could be doing…send questions to provider to review”

21. Study Education (SBP 4: level 3 and 4) Engages care team, accepts responsibility for directing team Top three benefits of the team meeting process: 1.Learning our roles 2.Working together as a team: what are our frustrations, what are others perspectives 3.Learning all about panel management and the measurements What didn’t go well: 1.Confusion about the process 2.Disagreements between people 3.Varied attendance

22. Study: Educational Goals (PC2 and PC3) Chronic disease management: monitor, tracking, leading team

23. Study: Educational Goals (SBP 3, PBLI 3) Resident confidence and interest in quality improvement

24. Next Steps: ACT: Review and reassess (Repeat the cycle PDSA!)

25. Take Home Points Educationally rewarding to participate in the challenging work of clinic improvement –Understanding the clinic processes builds trust, engages residents and staff, and leads to more enthusiasm for ongoing clinic endeavors Panel management directly ties into daily clinic activities with patient encounters –Outreach activities, previsit planning, at visit completion and post-visit planning Right care at the right time by the right people!

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