1. The UCSF Double Helix Curriculum:
Facilitator Guide
Time: 30 minutes / 21 slides
Audience: R1
Objectives: Define empanelment, Understand benefits of empanelment, Define continuity, Know measures of continuity from patient and provider perspective
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:

2. Empanelment and Continuity
Who are my people?
How will my people see me?

3. The UCSF Double Helix Curriculum:
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
What does it mean to be a primary care physician for a “panel” of patients? How is this good for patients, good for us, and good for system?

4. Empanelment: who are my peeps?
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
A quick definition of empanelment from provider perspective – who are the patients on my panel?
Empanelment is a process of assigning those patients in a systematic way

5. The UCSF Double Helix Curriculum:
Empanelment Is…
Empanelment is the process for ensuring that every patient has an assigned Primary Care Provider (PCP), which sorts patients into populations
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
A more formal definition of empanelment from a systems perspective

6. Case: Lee Needs an Assigned Primary Care Provider
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
CASE NOTES:
--Lee is a 57 year old woman with diabetes who has been coming to the Family Health Center for 3 years.
--She does not believe in taking medications because her father was on insulin and ended up on dialysis. She believes that the medications injured his kidneys.
--Lee comes to clinic irregularly and sees a different provider every time she comes in.
--Each time she sees someone, they tell him that her A1C of 11 is too high and that she needs to take her medications.
--They refer her to a diabetes educator, but she does not go. She does not believe that the providers know her, and does not trust their medical judgment.

7. Why is Empanelment Important? Think – Pair - Share
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
What benefits are there for patients, physicians, and the healthcare system?
Have each pair brainstorm for each question, or divide up pairs to work on separate questions

8. Empanelment Benefits Patients
Relationship = Increased Trust = Better Outcomes
Ease of scheduling appointments
Coordination for ongoing symptom management, work-ups, population management
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
Pair report out ideas – scribe up on whiteboard or flipchart
Then show slide
BENEFITS FOR PATIENTS
--Develop relationship; relationship = increased trust
Studies show that patients who trust their PCP more have better adherence to treatment recommendations, medications, etc
--More organized way to schedule appointments
--Allows for ongoing care plans / monitoring of ongoing symptoms / serial exams / organized population management

9. Empanelment Benefits Physicians
Relationship = Fulfillment, Satisfaction, Joy
Systematized empanelment = Balanced Panels = Balanced clinic days
Allows variation in practice scope
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
Pair report out ideas – scribe up on whiteboard or flipchart
Then show slide
BENEFITS FOR PHYSICIANS
Relationship! Relationship = fulfillment, satisfaction, joy in practice
Makes sure panels are balanced – right number and right complexity of patients for each doctor
Allows for variation in practice scope – can assign patients to providers that emphasize different ages, gender, practice (msk, women’s health, procedures, etc)

10. Empanelment Benefits System
Sorting patients into populations = Population Management
More easily identify care gaps – PCP and team has responsibility
PCP directs healthcare team in their own panel (population) management
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
Pair report out ideas – scribe up on whiteboard or flipchart
Then show slide
BENEFITS FOR SYSTEMS
--Empanelment is foundation of population management – ensures someone is accountable for monitoring patients with chronic conditions and updating preventive needs
--Can make manageable registries (lists) of patients per provider, can identify those with care gaps / unmet needs / over-due for appointments
--Can track data on health markers/health outcomes, and have someone (PCP/care team) accountable to make improvements (data-driven improvement)
--PCP is the leader/director of healthcare team that can manage larger/more complex population needs. Bodenheimer article: empanelment capacity increases as care team takes on more of the panel management needs

11. Continuity: I see my peeps and they see me
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
Empanelment and Continuity go hand in hand.
Once you have your list of people, you want to see them and they want to see you

12. Continuity according to Google
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
A general definition of continuity
Slide source: USCF CEPC Practice Coaching for Primary Care Transformation Curriculum

13. For a Patient, Continuity is…
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
What is continuity according to a patient? Ask for ideas
“I get my care from the person and the team I know”

14. The UCSF Double Helix Curriculum:
Continuity is Healthy
Nearly 6 in 10: prefer more regular contact with the same caregiver
More likely to perceive care as excellent or very good (65% vs. 38%).
More likely to feel very informed about their health (64% vs. 37%)
More apt to be highly comfortable asking questions about their care
More likely to be very confident in their ability to make healthcare decisions
(source USCF CEPC Practice Coaching for Primary Care Transformation Curriculum)
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:

15. For a Provider, Continuity is…
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
What is continuity according to provider? Ask for ideas
“I provide care to patients that I know well”

16. The UCSF Double Helix Curriculum:
Measuring Continuity
Patient Perspective:
“Percentage of my appointments that are with my own doctor or care team”
Provider/Care Team Perspective:
“Percentage of visits that are with my own patients”
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
How do we measure continuity from a patient perspective? From a provider or care team perspective? Think-Pair-Share, then show slide text

17. What Does Different Continuity Mean?
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
Is this “good” continuity? From whose perspective?
Good continuity from patient perspective; not as good from provider perspective
Possible reasons: scheduling protocol problems (does not emphasize appts with PCP as priority), too small a panel (too many open appointments, being filled with patients that are not assigned to that provider)
Slide source: USCF CEPC Practice Coaching for Primary Care Transformation Curriculum
Data from Multnomah County Health Department

18. What Does Different Continuity Mean?
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
Is this “good” continuity? From whose perspective?
Good continuity from provider perspective, not as good for patient
Possible reasons: provider panel too large, provider not in clinic enough days/times to accommodate their panel size
Which graph is more likely to represent continuity of a resident PCP? (2nd one – resident only in clinic certain days, maybe not at all certain months; will most likely fill with their own patients all the time but patients will also be seeing multiple other providers when resident not there)
Slide source: USCF CEPC Practice Coaching for Primary Care Transformation Curriculum
Data from Multnomah County Health Department

19. Maximizing Patient Continuity (in Residency)
“I get my care from the person and the team I know”
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
Residents assigned as PCP
Scheduling Protocols
Resident PCP “Teamlets”
What are some of the challenges of continuity in a residency clinic?
--residents with fewer days in clinic
--set days in clinic (not a lot of variety)
--rotations that don’t accommodate much clinic (or any clinic)
--rotations at different sites, electives, night float
What are some ways that residents can help maintain as much continuity as possible for their patients?
Scribe up ideas on whiteboard/flipchart first
Essential principles of continuity (in any clinic) are:
--Assign patients to PCP panels
--scheduling protocols that emphasize continuity with PCP
--Panel Management (maintain good control of chronic conditions, minimize extra appointments”
--minimum staffing (minimum number of days in clinic, or practice-shares)
For a residency clinic, these principles might look like this:
--Residents are assigned their own patients (have “panels”) – this allows schedulers to preferentially schedule your patients with you
--Schedulers have protocols to prioritize patient-PCP continuity – offer appt with PCP first and work with pt to find one that works, rather than offering soonest date first. Encourages patients to prioritize appt with PCP unless the need is truly urgent
--Resident PCP “teamlets” – patient gets to know small trio of providers, trio schedules are organized to cover most/all days of clinic. Same idea as a practice share

20. Improving the Continuity Experience in Residency
Unbroken and consistent existence; state of stability
Continuity with Clinic Team
Think “outside the clinic”: virtual care
Warm Hand-offs and Sign-outs
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
What are some ways that residents can help maintain as much continuity as possible for their patients?
Remind group definition of continuity from google: unbroken and consistent existence of something over time, a state of stability with the absence of disruption
Scribe up ideas on whiteboard/flipchart first
Strategies:
--Make continuity with clinic team also a priority – if cannot be with PCP or teamlet, at least in module with familiar staff, receptionist, etc
--Think outside the clinic box: use “virtual” encounters if and when possible. Phone calls/ s to patients to assist with their needs can be done remotely, PCP can still direct care team remotely to help with patient needs even if you are not physically present in clinic
--Warm hand-offs/sign-outs to colleagues and team members – a personal hand-off of a patient to a colleague (“I’m going to schedule you with my partner Dr. X. She is excellent, I know you will get great care”) and a sign-out to the relevant team member (“you will be seeing my patient Mr. Smith. We are working on titrating his insulin, and he was in the ER last week for hypoglycemia”). This helps patient feel like care experience is seamless and coordinated. This are principles of good transitions of care.

21. Case: Lee Has a Personal Provider
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
CASE NOTES:
Original case (to remind group): --Lee is a 57 year old woman with diabetes who has been coming to the Family Health Center for 3 years.
--She does not believe in taking medications because her father was on insulin and ended up on dialysis. She believes that the medications injured his kidneys.
--Lee comes to clinic irregularly and sees a different provider every time she comes in.
--Each time she sees someone, they tell him that her A1C of 11 is too high and that she needs to take her medications.
--They refer her to a diabetes educator, but she does not go. She does not believe that the providers know her, and does not trust their medical judgment.
How might having a PCP help Lee in this case?
Ask for ideas, then can offer this potential ending:
--Lee is scheduled to see her primary care provider for the second time.
--At the second visit, the PCP notes that even after increasing her dose of medication, his A1C has not changed at all. She asks the patient gently about adherence and learns that the she “sometimes” misses her medication. They discuss the importance of medication adherence.
--At the third visit, the PCP again notes no change in A1C.  She asks again about adherence and this time, the patient feels safer because of her growing trust in her new clinician.
--She admits that she has never picked up the medication and states that she is afraid it will harm her kidneys. The patient and provider are able to have a real discussion of the risks and benefits of medications.

22. Get to Know your People! A Panel “Scavenger Hunt”
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
Introduce Panel Scavenger Hunt Exercise

23. The UCSF Double Helix Curriculum:
Evaluation
Transformation of High-Performing Primary Care in Education
The UCSF Double Helix Curriculum:
Evaluation after Didactic and Exercise complete