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Safety Net Analytics ProgramLearning Session #12– September 8, 2015
Thanks for joining us - the webinar will begin shortly!
Safety Net Analytics ProgramBuilding the Empanelment SystemLearning Session #12 – September 8, 2015
Program Updates
1. Office Hours• Jim’s Cohort: emailed link to sign up• SA’s Cohort: email directly for time
sa@careinnovations.org2. 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 8th – Buyers Guide: What to Look in Selecting
Analytics Tools• Late October – Case Study: The Build Option, Lifelong
Medical Care4. November 10th Knowledge Building Session - San Francisco
• Survey to select topics and help structure the day
EmpanelmentBuilding the Empanelment System
Presented by: Regina Neal, MPH, MS
Presentation for Center for Care InnovationsSNAP Program
September 8, 2015
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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
6Wagner 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 TransformationLearn More at www.safetynetmedicalhome.org
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Implementing the Empanelment Process
Amy J. Ham, PCMH CCE
Chief Data Officer
CommuniCare Health Centers
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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
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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
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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
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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
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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
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The Mechanics of Empanelment: Building Patient Panels
New Goals, New Thinking
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System Design for Empanelment
Success Depends onBalance between Supply and Demand
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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
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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
Practice Patients and Visits (Demand)
Unduplicated Patient Count 6,872 patients
Total Visits 23,780 visits
Average Visits/Per Patient 3.46 avg. visits per patient
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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
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Patients by Provider (Current Panel)
Community Health Center
Visits by Patient and by Provider Seen
Provider Goode Monroe Schafer Former Provider
Assigned to Panel of…
Patient ↓
A…. 5 8 1 0
B… 1 1 1 7
C… 3 3 0 2
D… 6 0 0 1
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The 4-Cut Method for Panel Assignment
CUT PATIENT DESCRIPTION ASSIGNMENT
1Patients who have seen only one provider To that sole provider
2Patients who have seen multiple providers, but one provider the majority of the time
To the majority provider
3Patients who have seen two or more providers equally (no majority can be determined)
To the provider who performed the last physical
4Patients 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
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4-Cut Method Report
Community Health Center
Visits by Patient and by Provider Seen
Provider Goode Monroe Schafer Former Provider
Assigned to Panel of…
Patient ↓
A…. 5 8 1 0 Monroe
B… 1 1 1 7 Schafer1
C… 3 3 0 2 Monroer2
D… 6 0 0 1 Goode
1. Schafer did most recent PE2. No PE; Monroe did most recent visit
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Results
Community Health CenterProvider Panels (de facto using 4-Cut Method)
Provider Number of Patients
Goode 1,746
Monroe 1,690
Schafer 1,902
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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
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Assess Supply and Demand
Formula for determining the number of patients a provider can take care of:
Supply = Demand
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Provider Capacity
Community Health Center
Provider Supply (Visits/day)*(Days)
Capacity (Actual Visits)
Goode 5,599 5,670
Monroe 5,698 5,741
Schafer 5,423 5,490
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Calculated Demand for Visits
Practice Patients and Visits (Demand)
Unduplicated Patient Count 6,872 patients
Total Visits 23,780 visits
Average Visits/Per Patient 3.46 avg. visits per patient
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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
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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
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Adjusting for Age and Gender
Source: Murray et .al,. Panel Size: How Many Patients Can One Doctor Manage? Family Practice Management, April 2007.
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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
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Final Panel Results4-Cut, Age-Gender Adjusted and Right-Sized
Community Health CenterProvider Panels (de facto
using 4-Cut Method)
Age-Gender Adjustment
Applied
Right Sized using Supply
& Demand
Difference(+ over- under)
Provider Number of Patients
Adjusted Number of
Patients
Goode 1,746 1721 (-25) 1,665 +56
Monroe 1,690 1702 (+12) 1,723 -21
Schafer 2,251 2176 (-75) 1,784 +392
Age Gender adjustment, if applied, is applied to the panel that results from using 4-Cut Method
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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
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Using Empanelment Data
David Lichtenstein
Information Systems Database Technician
Native American Health Center || Administration/EHR, Ste. 209
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Sustaining Empanelment in the Practice
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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Resources
Safety Net Medical Home Initiative Web-sitehttp://www.safetynetmedicalhome.org/change-concepts/empanelment
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Source: Murray et .al,. “Panel Size: How Many Patients Can One Doctor Manage?” Family Practice Management, April 2007
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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
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Questions & Discussion
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