1. Safety Net Analytics Program Learning Session #12– September 8, 2015 Thanks for joining us - the webinar will begin shortly!

2. Safety Net Analytics Program Building the Empanelment System Learning Session #12 – September 8, 2015

3. Program Updates 1.Office Hours Jim’s Cohort: emailed link to sign up SA’s Cohort: email directly for time sa@careinnovations.org 2.Module 4: Trends, Tools and Technology Learn about the latest trends in the industry that may impact your analytics strategy Learn about the leading analytics tools that are supporting data- driven health centers Explore challenges and emerging solutions to data integration 3.Upcoming Learning Sessions – Lunchtime (12:00 – 1:00) Webinars Late September – Overview of Analytics Tools and Platforms October 8 th – Buyers Guide: What to Look in Selecting Analytics Tools Late October – Case Study: The Build Option, Lifelong Medical Care 4.November 10 th Knowledge Building Session - San Francisco Survey to select topics and help structure the day

4. Empanelment Building the Empanelment System Presented by: Regina Neal, MPH, MS Presentation for Center for Care Innovations SNAP Program September 8, 2015

5. 5 Learning Objectives At the end of this webinar you will be able to: Identify and describe the steps to establish right- sized patient panels for each provider in your practice Describe the structures required to monitor and manage a well-run empanelment system Identify the empanelment-related policies and procedures needed to sustain the empanelment system over time

6. 6 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; 39:241-259. The Change Concepts for Practice Transformation Learn More at www.safetynetmedicalhome.orgwww.safetynetmedicalhome.org

7. 7 Implementing the Empanelment Process Amy J. Ham, PCMH CCE Chief Data Officer CommuniCare Health Centers

8. 8 Where We Began PCMH recognition process requires empanelment This was our starting point Took steps to ensure all patients were assigned to a provider Have continued that process

9. 9 Current State Working to determine how we can manage panels over time Working with providers to address concerns about match between count of patients and their needs Are panel sizes manageable given the needs of the patients on the panel? Even without all answers, regularly review quality improvement outcomes for patients

10. 10 Empanelment Requires… Leadership support Sustained organizational commitment for empanelment as an ongoing process Structure and policies to sustain empanelment system and process over time Information to drive and inform the ongoing process Support for the culture change required

11. 11 The Key Changes for Empanelment Assign all primary care patients to a provider and confirm resulting panel with providers and patients Establish a process for continuous empanelment of patients –new patients –reassignment of patients for providers leaving practice –patient requests for new provider –provider requests to move patients from their panels Review panels regularly to assess supply & demand; make adjustments as needed Use panel data and registries proactively to identify patient needs and to plan outreach for required care Use data to assess goals of care by panel and for practice overall

12. 12 Empanelment Steps Summary Determine capability of the practice IT system(s) to provide the necessary data Assign a team to undertake the initial empanelment process (one of these could become the Panel Manager for the practice) Follow steps for developing right-sized panels Ask providers and care teams to review panel; make adjustments as necessary Leaders (Executive and Medical) work with providers on empanelment to optimize success in implementation Organization leaders develop policies on panel management, scheduling expectations Review panel reports frequently; share data

13. 13 The Mechanics of Empanelment: Building Patient Panels New Goals, New Thinking

14. 14 System Design for Empanelment Success Depends on Balance between Supply and Demand

15. 15 Steps in the Process 1.Using provider-specific data of actual supply and demand, determine ideal panel size –How many visits do patients make per year on average? –How many visits does each provider have available per year? –Calculate how many patients can be on each provider’s panel 2.Determine the current panel size and compare to the ideal panel size –Who did each patient see for each visit? Use this data to assign patients to the panel of one provider; use four-cut method 3.Review panel with providers for accuracy and to engage and develop ownership 4.Make adjustments to panel size as needed

16. 16 What is the Demand for Visits? Unduplicated number of patients in time period (18 or 24 months) Total number of visits for these patients Average number of visits per patient

17. 17 Who’s on the Current Panel? Determine the current de facto panel to determine if patients are all assigned to the right provider –Who did each patient actually see for each visit? –Often patients see providers other than assigned provider –Patients often see more than one and sometimes more than two providers in the practice These data will be used to assign patients to the panel of one provider Will not be 100% accurate but it is a good starting point for the process of establishing right-sized patient panels with the right patients on them

18. 18 Patients by Provider (Current Panel) Community Health Center Visits by Patient and by Provider Seen Provider  GoodeMonroeSchaferFormer Provider Assigned to Panel of… Patient ↓ A….5810 B…1117 C…3302 D…6001

19. 19 The 4-Cut Method for Panel Assignment CUTPATIENT DESCRIPTIONASSIGNMENT 1 Patients who have seen only one provider To that sole provider 2 Patients who have seen multiple providers, but one provider the majority of the time To the majority provider 3 Patients who have seen two or more providers equally (no majority can be determined) To the provider who performed the last physical 4 Patients without a physical or health check who have seen multiple providers To provider seen most recently Source: Murray et.al,. “Panel Size: How Many Patients Can One Doctor Manage?” Family Practice Management, April 2007

20. 20 4-Cut Method Report Community Health Center Visits by Patient and by Provider Seen Provider  GoodeMonroeSchaferFormer Provider Assigned to Panel of… Patient ↓ A….5810Monroe B…1117Schafer 1 C…3302Monroer 2 D…6001Goode 1.Schafer did most recent PE 2.No PE; Monroe did most recent visit

21. 21 Results

22. 22 Is Current Panel in Balance with Capacity Available Number of patients assigned to a provider using the 4-cut method may be too large or small for the actual provider supply (or capacity) Next step is to calculate each provider’s supply based on the clinical FTE (time for clinical care seeing patients) Use number of visits seen and days worked for past year to get annual capacity for a panel of patients

23. 23 Assess Supply and Demand Formula for determining the number of patients a provider can take care of: Supply= Demand

24. 24 Provider Capacity Community Health Center ProviderSupply (Visits/day)*(Days) Capacity (Actual Visits) Goode5,5995,670 Monroe5,6985,741 Schafer5,4235,490

25. 25 Calculated Demand for Visits

26. 26 Assess Supply and Demand: An Example Solve for # patients (panel size): Fill in values: Provider visits seen/day = 24 Days worked in clinic/year = 240 Patient visits/year = 3.46 Calculate (for Goode): Capacity = (24)(240) = 5,760 visits (supply) Demand = 3.46 visits/patient/year (demand) Right-Sized Panel = 5,760/3.46 = 1,665 patients

27. 27 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

28. 28 Adjusting for Age and Gender Source: Murray et.al,. Panel Size: How Many Patients Can One Doctor Manage? Family Practice Management, April 2007.

29. 29 Consider This Remember: One panel adjusted down requires another to be adjusted up –Can lead to a complicated process within the practice –Can stall or delay the process without material improvement in panel sizes “Practices should consider whether many of the age and acuity factors could be managed more effectively by providing focused team support than by adjusting panels.” -- Mark Murray

30. 30 Final Panel Results 4-Cut, Age-Gender Adjusted and Right-Sized Age Gender adjustment, if applied, is applied to the panel that results from using 4-Cut Method

31. 31 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 Over time panel reports will become more accurate

32. 32 Using Empanelment Data David Lichtenstein Information Systems Database Technician Native American Health Center || Administration/EHR, Ste. 209

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37. 37 Sustaining Empanelment in the Practice

38. 38 Engage Providers and Teams Medical leadership is essential in this process Use a process designed to engage providers and care teams so panels are accepted, embraced, owned Allow all providers to review their panel for correctness; encourage discussion, questions

39. 39 Are Panels Right Sized? Use metrics to assess (continuity, access, outcomes) Ask patients about their experience –Can they get an appointment easily when they want it? –Are they seeing their provider and care team regularly? Ask staff how it is working from their point of view Use these data to determine if panel sizes for any provider need adjustment

40. 40 Engage Patients in the Process Too Involve patients by checking with them when they come into the clinic to confirm that they agree that Dr. Smith or the NP, Ms. Jones, is their provider When patients call the clinic always ask “who is your assigned provider?” and ensure that the call is routed to the right care team Communicate and reinforce provider–patient link in as many ways as possible

41. 41 Panel Management How to assign new patients to provider panels Panel reports monthly (new patients, leaving patients by panel) Building panels for new providers in the practice to meet new demand Reassigning patients from providers who have left the practice (anticipate to minimize patients being without an assigned provider) When to close a panel; who to inform; monitoring to re-open panel Process for responding to patient requests to move to another panel Process for responding to provider requests to move a patient from their panel Monthly reports –% patients empaneled –% continuity for patients with provider Quarterly report –Supply and demand assessment for providers –Patient, provider and care team experience

42. 42 Roles, Responsibility for Panel Manager Must know clinic operations Customer service oriented Must be able to manipulate and analyze data –Works closely with IT Reports to management Prepares reports for management and providers on regular basis to keep panels updated

43. 43 Linking Empanelment to Appointment Scheduling for Continuity Ensure that scheduling is done to prioritize continuity for patient with provider and care team It is easy for scheduling process to revert to look for next available provider vs. the assigned provider Use scripting for appointment scheduling as assist Monitor data to ensure access and continuity

44. 44 Population Health Management Patient panels need to be maintained over time System design must specifically support access and continuity for patients Care teams need –panel data and registries for proactive and planned care; data for process and outcome measures to assess performance –time for team to meet and work together to plan for care & self management, outreach and follow-up

45. 45 Part-time Provider Scheduling & Coverage Minimum days in clinic (no less than x days) Create “practice partners” by pairing part-time providers to cover each other or share a full panel One of two partner providers in clinic all sessions over the week Requires communication between providers for best management (overlap at least one session in week) Cover for one another during vacations and for holiday periods.

46. 46 Part-time Providers Consider empaneling to the care team Maintains meaningful continuity for patients Team is the constant for the patient Requires strong, well-trained and well-supported care teams

47. 47 Resources Safety Net Medical Home Initiative Web-site http://www.safetynetmedicalhome.org/change- concepts/empanelment

48. 48 Source: Murray et.al,. “Panel Size: How Many Patients Can One Doctor Manage?” Family Practice Management, April 2007

49. 49 Summary A leadership-driven process; not once and done Requires an on-going organizational commitment with policies, staff, resources Policies regarding minimum staffing, coverage and panel accountabilities Regular process for on-going empanelment to keep all primary care patients empaneled and to keep panels the right size Time, tools (registry reports) for teams to work together to plan care, prepare, outreach to their patients

50. 50 Questions & Discussion

51. 51 Thank You Regina Neal rneal@qualishealth.org 800-949-7536 x 2066