1. Attributing Patients to Primary Care Physicians in Teaching Practices Bruce Soloway, M.D. Vice Chair Department of Family and Social Medicine NYS HMH Site Visit November 12, 2013

2. What is a “Medical Home”? The site that provides most of a patient’s primary care serves as a patient’s first point of care for most problems is ultimately responsible for a patient’s chronic and preventive care Principle: Every patient should have one and only one “medical home”

3. What is a “Primary Care Provider”? Within a “medical home”, the provider who is: the first source of care for each patient ultimately responsible for each patient’s chronic and preventive care Principle: Every patient should have one and only one PCP

4. What is a “Site Panel”? The list of patients for whom each site serves as the medical home The source of demand for appointments and other services for the site The basis for accountability for patient care and outcomes continuity of care patient satisfaction

5. What is a “Provider Panel”? Within a “medical home”, the list of patients for whom each provider serves as PCP the source of demand for appointments and other services for each provider The basis for accountability for patient care and outcomes continuity of care patient satisfaction

6. Why are provider panels important? Within a “medical home”, provider panels Allow individual feedback to providers on aggregate demographics, processes and outcomes for the patients they treat Help to define and equitably divide the work of the practice, improving access, efficiency and continuity Allow rational transfer of patients from one PCP to another when a provider enters or leaves a practice

7. The challenge of teaching practices Residents as PCPs Residents need continuity panels for their training Continuity, but what level of accountability? Not recognized by insurers Multiple part-time providers Frequent cross-coverage Frequent resident turnover Need for systematic, rational reassignment

8. Stabilizing teaching practices in Family Medicine Attending-resident teams 1 Attending (Team Leader) + 3 residents Team Leader supervises and is accountable for residents’ patient care Basis for cross-coverage and provider transitions Consistent clinic sessions each week Inpatient rotations built around ongoing outpatient responsibilities Basis for resident continuity and panel-building

9. How big should a panel be? FHC 12,780 unique patients / 9.5 FTE = 1345 patients per FTE x 2.77 visits/yr/pt = 3740 visits per yr per FTE WB 8814 unique patients / 6.1 FTE = 1452 patients per FTE x 2.59 visits/yr/pt = 3724 visits per year per FTE

10. Ideal panel size by provider Assuming 1400 patients per FTE: Based on ACGME (FM) expected visits/year

11. Defining terms EMR PCP The provider identified for each patient in the “PCP” field in the EMR Should be controlled by clinicians based on real primary-care relationships negotiated with patients, but… Clinical and administrative personnel can change this field Often inaccurate due to provider turnover, unrecorded patient migration, administrative good intentions…

12. Defining terms Visit-based PCP The active provider seen most often by each patient in the last 18 months Or, if there is a tie, the active provider seen most recently in the last 18 months Some patients are “orphan patients” No visit-based PCP, no active EMR PCP During the past 18 months, have only seen providers who have since left the practice

13. Panel Reports Available on demand for each practice Patient lists for each provider: Band 1 – Patients for whom the provider is both the EMR PCP and the Visit-Based PCP Band 2 – Patients for whom the provider is the EMR PCP but not the Visit-Based PCP Band 3 – Patients for whom the provider is the Visit-Based PCP but not the EMR PCP

15. Who is really the PCP? The EMR PCP is regarded as the provider responsible for the care of the patient Clear, unique assignment across the enterprise Easily queried for generation of reports and registries Requires frequent updating to remain meaningful

16. Patient reassignment algorithm An automated process available to all practices Reassignments are based on: Roster of active providers in practice Including FTE, panel status (open vs. closed) Patient-level data Current EMR PCP May reflect long-standing relationship (or may not) Recent visit history Rational reassignment of “orphan” patients

19. Patient reassignment algorithm For the past four years, the Department of Family Medicine has updated PCP assignments for its teaching practices on a quarterly basis. With each update, panel reports are distributed to all providers as Excel files and PDF documents. Providers have learned to update the EMR PCP themselves when care is transferred and to accept responsibility for the patients on their panel lists.

20. Outcomes of panel management

24. Outcomes of Panel Management Measuring continuity of care by provider From the patient’s perspective During a given interval (e.g. 18 months), at what percent of all visits made by members of a provider’s panel did the patient see the PCP (rather than another provider)?

27. Outcomes of Panel Management Measuring continuity of care by provider From the provider’s perspective During a given interval (e.g. 18 months), what percent of all visits with each provider are with members of that provider’s own panel? What percent of all visits with each provider are devoted to cross-coverage of other providers’ patients?

30. Conclusions Patients can be rationally assigned to unique PCPs based on past assignments and retrospective visit histories in the hospital database Patient assignments have many potential applications: Correction of panel sizes to balance productivity and access Rational transfer of patients to new providers Characterization and balance of panels Accountability for patient care and outcomes Measurement of continuity of care

31. Questions?