1. 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

2. 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

3. 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

4. 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:

5. 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

6. 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

7. 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

8. 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

10. 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

11. 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

12. 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

13. 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

14. 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

16. 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

17. 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

18. 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

19. 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

20. Managing Panel Size

21. 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

22. 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

23. 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

25. 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?

26. 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

27. Resources: SNMHI: Coach Medical Home website: PCMH-A:
Coach Medical Home website:
PCMH-A:

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