1. Greg Vachon Lori Weiselberg Meghan Kirkpatrick
Empanelment
Greg Vachon
Lori Weiselberg
Meghan Kirkpatrick
Welcome … we introduce ourselves and then (?) ask for participants to introduce themselves ?? : name, organization, role

2. November 9, 2018
What is “empanelment”?
Simple answer: Assigning each patient to a provider Functional answer:
each PCMH care team has a group of patients for whom they are responsible
each patient can identify to whom they can turn for their health care needs

3. Patient Centered Medical Home
November 9, 2018
Patient Centered Medical Home
Central (proven) Principles:
Access
Continuity
Coordination
These are the central principals that, if you look at the Commonwealth data on making a difference in underserved populations, this is what made the difference. And how does empanelment support these three core principles?

4. Patient Centered Medical Home
November 9, 2018
Patient Centered Medical Home
Central (proven) Principles:
Access
Empanelment matches supply and demand
Continuity
Coordination
And how does empanelment support these three core principles? Common sense, not fancy formulas and studies, tells us that in order to have access you have to have a limited number of patients. This is what concierge medicine is about. Limit the practice size to 200 patients. This will make access very, very good. Well, the PCMH model is one in which there is, in actuality, meaningful access 24/7. And who does access have the most meaningful impact for? High risk patients. Low SES patients. Not the typical concierge medicine practice patient.

5. Patient Centered Medical Home
November 9, 2018
Patient Centered Medical Home
Central (proven) Principles:
Access
Empanelment matches supply and demand
Continuity
Patient and provider (& team) are tied together in IT system
Coordination
Continuity: this is what empanelment is all about at the core. Promoting the relationship between patient and provider, patient and team over time.

6. Patient Centered Medical Home
November 9, 2018
Patient Centered Medical Home
Central (proven) Principles:
Access
Empanelment matches supply and demand
Continuity
Patient and provider (& team) are tied together in IT system
Coordination
Tasks are directed to right team member
Coordination of the patients care happens when there are assigned roles and responsibilities. In a small practice, this might be Josie that does all of the referral follow ups for all of the patients. But in a large practice, certain staff will be on teams with certain providers. And directing of tasks related to the patients empaneled to that doctor is facilitated and really made possible by having the patients empaneled.

7. Safety Net Medical Home Initiative Change Concepts
November 9, 2018
Safety Net Medical Home Initiative Change Concepts
Engaged Leadership
Quality Improvement Strategy
Empanelment
Continuous & Team- Based Healing Relationships
Patient-Centered Interactions
Organized, Evidence-Based Care
Enhanced Access
Care coordination
Empanelment is one change amongst many that gets you to the PCMH nirvana. Importantly, if you look at NCQA standards or Joint Commission, you are not going to see the word empanelment, or panel, or even assign. The concept is embodied however in several components.

8. 2011 NCQA Standards Enhance Access and Continuity
November 9, 2018
2011 NCQA Standards
Enhance Access and Continuity
Access During Office Hours
Access After Hours
Electronic Access
Continuity (with provider)
Medical Home Responsibilities
Culturally/Linguistically Appropriate Services
Practice Organization
Identify/Manage Patient Populations
Patient Information
Clinical Data
Comprehensive Health Assessment
Use Data for Population Management
Plan/Manage Care
Implement Evidence-Based Guidelines
Identify High-Risk Patients
Manage Care
Manage Medications
Electronic Prescribing
Provide Self-Care and Community Resources
A. Self-Care Process
B. Referrals to Community Resources
Track/Coordinate Care
Test Tracking and Follow-Up
Referral Tracking and Follow-Up
Coordinate with Facilities/Care Transitions
Measure and Improve Performance
Measures of Performance
Patient/Family Feedback
Implements Continuous Quality Improvement
Demonstrates Continuous Quality Improvement
Report Performance
Report Data Externally
Optional Patient Experiences Survey
Here they are and you don’t see empanelment

9. + = 2011 NCQA Standards EMPANELMENT Enhance Access and Continuity
November 9, 2018
2011 NCQA Standards
Enhance Access and Continuity
Access During Office Hours
Access After Hours
Electronic Access
Continuity (with provider)
Medical Home Responsibilities
Culturally/Linguistically Appropriate Services
Practice Organization
Identify/Manage Patient Populations
Patient Information
Clinical Data
Comprehensive Health Assessment
Use Data for Population Management
Plan/Manage Care
Implement Evidence-Based Guidelines
Identify High-Risk Patients
Manage Care
Manage Medications
Electronic Prescribing
Provide Self-Care and Community Resources
A. Self-Care Process
B. Referrals to Community Resources
Track/Coordinate Care
Test Tracking and Follow-Up
Referral Tracking and Follow-Up
Coordinate with Facilities/Care Transitions
Measure and Improve Performance
Measures of Performance
Patient/Family Feedback
Implements Continuous Quality Improvement
Demonstrates Continuous Quality Improvement
Report Performance
Report Data Externally
Optional Patient Experiences Survey + =
EMPANELMENT

10. Access vision TODAY TOMORROW
November 9, 2018
Access vision
TODAY
TOMORROW
Team responsible for the care of ≈1500 patients
Poor control = Nurse protocol by phone adjusting medication
“Form is done. Drop by when you want to pick it up”
Just out of hospital: you get a call at home – when can you come in?
Providers responsible for 10 – 12 patient visits per session
“Your BP is in poor control. Come back in three weeks.”
“You’ll need to see the doctor to fill that form out”
Just out of hospital: no energy to deal with making an appointment
Ok, we’ve established, I hope that the activity of empanelment is important and foundational to the PCMH concept.

11. November 9, 2018
But is everyone in?
Perhaps, perhaps not Will there need to be alternative delivery models for some patients? Institutions without unlimited capacity should think about empanelment criteria Turn-over rate should be low
KEEP LOAD ’EM IN
YOU ARE PUSHIN’ EM
OUT
AS WELL

12. November 9, 2018
Before we begin
“Communication is the problem to the answer” The Things We Do For Love - 10cc -1976
Communicate:
Why / What / How
Impact on providers and staff
Long term vision: Accountable Care

13. Initial empanelment Looks back in the records Four cut method
November 9, 2018
Initial empanelment
Looks back in the records
Four cut method
Only one provider for all visits
Provider seen the most times
Multiple providers, same number, then whoever saw for physical/health check
None of above, last provider seen

14. Empanel to the highest scoring provider IF threshold of 0.6 is met
November 9, 2018
Single cut method
Visit score for patient with 8 visits in 3 years
Visit Score
0.0
0.15
0.36
0.5
0.6
1.0
24 months
12 months
3 months
18 months
6 months
Present
Red dot provider
= = 1.96
Purple dot provider
= = 1.65
Empanel to the highest scoring provider IF threshold of 0.6 is met

15. Making it happen Depends on starting line:
November 9, 2018
Making it happen
Depends on starting line:
Is visit data available? How good is the visit data? How is the current PCP data?
Options:
Have EMR vendor run a script to insert PCP in new or old data field
Export to Excel and apply rule and then key in results

16. Early-phase empanelment
November 9, 2018
Early-phase empanelment
Give PCPs the opportunity to review and make corrections before “release” Have less stringent control of changes in the PCP field for ≈ 3 months Prepare staff for the next phase

17. November 9, 2018
On-going Empanelment
Patient Equivalents (weighting the panel) Opening/Closing panels Adding new patients Embedding/interacting with rest of the IT infrastructure

18. November 9, 2018
Why weight the panel?
Different providers have different practice characteristics
Specialty
Age ranges
Focus areas
Even when similar, providers tend to believe there are differences

19. What determines weight?
November 9, 2018
What determines weight?
The number of hours (visits in old thinking) expected of each PCP Degree of provider efficiency allowed by system Reference number of total Patient Equivalents

20. November 9, 2018
Breaking it down
Provider = 36 hours per week, 46 weeks per year = 1656 hours If: 2000 Patient Equivalents (PEs) Then: 50 minutes per year per PE Who can your providers take care of in 50 minutes in your system?

21. Key characteristics of any weighting system
November 9, 2018
Key characteristics of any weighting system
Fair
Inspires ‘faith’
Hard to cheat

22. November 9, 2018
THE SECRET FORMULA

23. Base Weight: Age & Gender
November 9, 2018
Base Weight: Age & Gender
AGE
MALE
FEMALE
0 – 24 months
3.00
2 to 5 years old
1.50
5 to 15
1.00
15 to 45
0.25
0.75
45 to 65
1.0
65 +
1.5
Assumptions:
2000 PEs per FTE
50 minutes per year per PE
Low team-based care efficiency
(with increasing efficiency of PCMH teams,
the weights should be decreased over time)

24. November 9, 2018
Additional Factors

25. November 9, 2018
Reduction Factor

26. What the reduction factor looks like:
November 9, 2018
What the reduction factor looks like:
Months
Weight 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1.0
0.92
0.83
0.75
0.67
0.58
0.50
0.42
0.33
0.25
0.17
0.08
2.0
1.92
1.75
1.58
1.42
1.25
1.08
3.0
2.75
2.5
2.25
1.5
0.5
Reduction factor can be more aggressive depending on actual data / experience of patients returning to care after long absence

27. Opening and closing panels
November 9, 2018
Opening and closing panels
Panels will need to be closed at some threshold (suggest 110%) Turnover rate will inform process of slowly ‘turning down the faucet’ New patient slots: Passé?

28. Putting it all together
November 9, 2018
Putting it all together

29. Policies and Procedures
November 9, 2018
Policies and Procedures
Criteria for Empanelment
PCP Assignment and Changing Providers
Scheduling

30. Policies and Procedures cont.
November 9, 2018
Policies and Procedures cont.
Call Routing
Proxy Tasks When Team Members are Absent
Provider Transfer or Termination

31. November 9, 2018
Discussion