1. How to measure quality and improvement of panel manager’s work in the Patient Centered Medical Home in a residency practice Daisuke Yamashita, MD Joe Skariah, DO MPH Ann Tseng, MD

2. Disclosures No conflict of interests

3. By End of the Session You Will be Able to Describe work of a panel manager in the PCMH clinical team. Describe tension between quality and quantity in the population health outreach work. Develop appropriate measures for panel management activities at their home institution.

4. What is Panel Management? Set of tools and processes for population care that are applied systematically at the level of a primary care panel 1)process to identify and address unmet care (care gaps) 2) Less-intense individual outreach and follow up Neuwirth EE, etal. Understanding panel management: a comparative study of an emerging approach to population care. Perm J. 2007;11(3):12-20

5. Risk Based Population Management Panel Management

6. What is Panel Management? Reach Out –By mail, phone and patient portal Reach In –Address care gaps while the patient is in the office It is Team Work! Chen E, Bodenheimer T. Improving Population Health Through Team-Based Panel Management: comment on “Electronic medical record reminders and panel management to improve primary careof elderly patients”. Archives of internal medicine. 2011;17(17);1558-1559

7. Components for Successful PM Population base reports –Identification gaps and track outcomes EMR supports identification and display care gap Dedicated Panel Manger, clinician champion and Time Standard work flow and orders

8. Identify Unmet Care Needs Report, Report, Report! –Population level clinical reports Pts who needs specific universal screening –i.e. SBIRT, ASQ Use of EMR reminder –Informs team as well as patients

9. Reports Utilize by PM at OHSU Population Level Reports –Diabetes Registry –CHF Registry –Control Substance Registry –PPSV –HPV –TDAP –MCV 4 –Breast Cancer Screen –Colon Cancer Screen –Immunization at Age 2-3

10. Specific universal screening Identify pts who needs periodic screening Example at OHSU Pediatric Developmental Screening (ASQs): age 9 mo, 18 mo and 24 mo SBIRT/PHQ-2 age >18 y.o annually SBIRT (Screening, Brief Intervention, Referral to Treatment)

11. Maximizing Use of EMR Reminders Allow display gaps to inform the team Automation of reminder placement –Reduces workload for PM and allow more reach-out –Reduces variation and misplacement Pt’s reminder

12. Super Panel Managers

13. Panel ManagerClinicianNurse visitLab/Image/Consu lt Reach Out Review Pt’s Charts/reports Place appropriate Reminder Review and co-sign orders Contact Pt (My Chart, letter, phone) Clinic Visit (ie: Colon Cancer Screen shared decision) Place orders and sign Arrange Orders Nurse visit (Labs, immunizations) Tests/Consults (ie: mammogram, eye visit) Pt message regarding HM “Aha!” Identify All Appropriate gaps for each pts “Aha!” Identify All Appropriate gaps for each pts

14. Panel ManagerMAClinician HM Room Pt, Review HM Pend orders Sign orders Perform orders Update HM modifiers EHR reminder placement/ Other specific reminders in the schedule (ie: ASQ, SBIRT) Discuss HM Review Schedule Reach In

15. OHSU Family Medicine University Based Four practices with mixed setting (Urban, Rural, commercial, FQHC/Rural HC)

16. Panel Management at OHSU FM South Waterfront Gabriel ParkRichmondScappoose Urban Rural # Panel Manager 20.545 Model PM PM/CM # clinical Team4444 CredentialMA MA or BachelorLPN # of Clinicians (Residents) 24 (11)17 (11)18 (12)10 (2) Clinical FTE10.88.0127 Panel Size18,43312,13612,2699,827

17. Staffing Model for Panel Management PCP/MA Incorporate in regular MA work PCP/MA/RN or LPN Incorporate in clinic nursing/care management PCP/Team/PM Dedicated panel manager (PM may cover more than one team)

18. Risk Based Population Management Panel Management Hybrid Panel/Care Management

19. Hybrid CM/PM Model 5 areas of focus –Women’s health, Cardiovascular, Pulmonary, Behavioral Health, Long Term Care LPN driven –Include higher complex care management Additional administrative support

20. Balancing Measures Identifying the work domain of PM work Recognize importance of balancing measures to achieve outcomes Focus on tension within Panel Management –As in Triple Aims

21. Working Domains for Panel Manager Shared Accountability Identify care gaps Standing Orders (Standard Work) Counsel about gaps Rogers EA, Hessler D, etal. The Panel Management Questionnaire; A Tool To Measure Panel Management Capability Perm J 2015 Spring;19(2):4-9

22. Accountability Population Report (Total outcome)

23. Accountability Visit Base Reports (Reach in outcome)

24. Outreach Encounter (Process Measure)

25. Work Audit (process + identification of care gaps)

26. Peer Review Sessions ( Assess care gap + ability to counsel about gap) Once a month Pick 2 to 3 patients Semi Structured Feedback Listening to outreach activities by peers Participants: Panel Manager, Lead MA, QI Faculty Champion

27. Sample Reports

28. Challenges Time Competing demand PCP ownership Standardized reporting workflow to capture variant Reporting/EMR changes or upgrades Cost Change in guidelines

29. How is your panel management?

30. Please evaluate this session at: stfm.org/sessionevaluation

31. Other Resources Panel Management Observation Checklist http://cepc.ucsf.edu/panel-management UCSF Center for Excellence in Primary Care (CEPC)