uw medicine panel maintenance · 13 primary care and population health provider transitions how can...
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UW MEDICINE PANEL MAINTENANCE SUPERUSER TRAINING
UW MEDICINE POPULATION HEALTH
AUGUST 2019
Erica Strait, MHA, BSN | Program Manager, Population Health Management Candace Vig | Clinic Manager, UWMC General Internal Medicine Clinic Susana Orozco | Business Operations Manager, HMC Adult Medicine Ellen Broweleit, MHA | Assistant Director, Primary Care Northwest Region Jacqueline Perez | Clinic Manager UWNC Ballard Chesna Briceno | Assistant Director, UWNC Southeast Region Van Chaudhari, FACHE, MHA | Administrator, Population Health Management
HISTORICAL MILESTONES
2 Primary Care and Population Health
REDESIGN CORE TEAM
Crystal Kong-Wong, MD Associate Medical Director
UWNC Central Region
Jacob S Berman, MD, MPH Medical Director, GIMC
UW Medical Center
Kathryn Harris, MD Physician Lead Transition NWH/UWP Primary Care
Sara L Jackson, MD, MPH Medical Director, Adult Medicine
Harborview Medical Center
SUMMER 2016
UW Medicine Empanelment
FALL 2018
Population Health and Primary Care integration
WINTER 2019
Population Health Design Sessions
SPRING 2019
Empanelment and Panel Maintenance Workgroup
SUMMER 2019
Training and Go Live!
WHY?
3 Primary Care and Population Health
• Empanelment: Link a patient to a General PCP, promoting shift from sickness to wellness care and volume to value based care.
• Empanelment, panel maintenance and team based panel management are key competencies to ensure participation in value based contracts.
Contractual agreements
Quality of care / better outcomes
Provider satisfaction
Improved panel metrics
Successful provider
transitions
METRICS
4 Primary Care and Population Health
% EMPANELED PATIENTS, ACTIVE
- Numerator: # of patients seen at least twice in the last 2 years with an empaneled PCP in the Gen PCP field
- Denominator: total # of patients seen at least twice in the last 2 years at a UW Medicine primary care clinic location
% UN-EMPANELED PATIENTS, ACTIVE
- Numerator: # of patients assigned to a UW Medicine primary care location but not assigned to a UW Medicine PCP
- Denominator: total # of patients seen at least twice in the last 2 years at a UW Medicine primary care clinic location
93% by end
of FY2020
<7% by end
of FY2020
77%
23%
97%
3%
Empaneled Un-empaneled
UWNC Ravenna empanelment rate*
UWMC GIMC empanelment rate*
*as of 6-15-19
SAMPLES: CURRENT EMPANELMENT METRICS
HOW DO WE GET THERE?
5 Primary Care and Population Health
Team effort
Population Health support – central resources
Empower the Clinic Team
“It’s everyone’s responsibility!” “Every patient, every time!”
Clinic resources allocated to ‘difficult cases’
PANEL MAINTENANCE CYCLES
6 Primary Care and Population Health
• Clinic staff: Verify and update Gen PCP field
• Clinic staff: PCP continuity patient education
• Population Health: Verify Gen PCP and route changes to clinic
DAILY
• Clinic staff: Panel management meetings and organic panel clean up
• Population Health: Patient outreach to empaneled, less engaged
• Population Health: Patient outreach to un-empaneled, engaged
MONTHLY • Clinic leadership:
Monitor clinic empanelment metrics
• Population Health: Track, assess and report clinic->system empanelment metrics
QUARTERLY
• Clinic leadership: Resident transitions
• Clinic/entity leadership and Pop Health: Patients Are First metric year-end data
ANNUALLY
• Clinic leadership: Provider transitions
• Clinic staff: Bulk PCP re-assignment for departing providers
• Entity contact: All panel updates to [email protected]
PRN
7 Primary Care and Population Health
WHY PCP CONTINUITY?
• Gets to know the patient over time
• Oversees patients’ health as they move through life
Personalized care
• Providers routine health screenings
• Diagnose and treat acute and chronic illnesses
Wellness and prevention
• A PCP takes a holistic approach to assess from many angles
• Takes mental and social factors into account, not just your physical symptoms
The bigger picture
• A PCP provides treatment based on several factors that can result in preventable trips to the ED and hospitalization
Utilization
• A primary care team that works closely together with the patient to provide individualized, holistic care
Team based care
Primary Care and Population Health 8
UPDATING THE GENERAL PCP
1
It is expected that all primary care clinical staff should, with each patient visit, review, verify and update the Gen PCP field with the patient, to ensure:
[1] Maintenance and accuracy of General (‘gen’) PCP field
[2] Patients who use our primary care services are assigned to a PCP
[3] Maintain and improve performance on key population health metrics impacted by panel metrics
Click here for more detailed information on updating the Gen PCP field in Epic
Primary Care and Population Health 9
UPDATING PCP FIELD in EPIC: HOW TO (part 1)
1
2
3
Primary Care and Population Health 10
UPDATING PCP FIELD in EPIC: HOW TO (part 2)
4 5
UPDATING PRIMARY LOCATION in EPIC
Primary Care and Population Health 11
Click on Primary Location in patient header to activate Location Update Activity
If known: Select specific, known location
If unknown: Select ‘Outside Location’ option
Why is it important to change the Primary Location, in addition to the Gen PCP?
• To ensure patients do not remain on a clinic’s panel
• To ensure and maintain integrity of patients who are truly un-empaneled to a PCP, but do belong to a UW Medicine Primary Care location (Reports BO0337)
1
2
Primary Care and Population Health 12
POPULATION HEALTH OUTREACH
The Population Health Team conducts outreach on behalf, and in support, of the primary care teams to patients who:
[1] Are empaneled to a UW Medicine PCP but are less engaged
[2] Are actively using UW Medicine primary care services, but are not yet empaneled to a PCP
No visit with PCP or
primary care
location in last 24, 30
or 34 months
Patients populate onto Epic reports
daily
Pop Health team sends
letters once
monthly to patients on
reports
At 36 months
without a visit with
PCP or primary
care clinic, patients removed
from panels
Inactive patients no longer on PCP panel or clinic
panel
Workflow: Empaneled, less engaged
At least 3 visits with primary
care in last 12 months but no PCP
assigned
Pop Health team sends letters once
monthly to patients who are
un-empanele
d
Pop Health team sends Panel
Maintenance Letters
once monthly to
patients on reports
During telephonic outreach,
Pop Health team
identifies active un-empaneled patient
TE routed to clinic
front office pool in
Epic
Workflow: Un-empaneled, engaged (phase 1)
Primary Care and Population Health 13
PROVIDER TRANSITIONS
How can we ensure successful provider transitions and shifting of patients?
Bulk PCP re-assignment
Warm hand off complex
patients
Patient outreach
letters
Click here for more detailed information on bulk PCP re-assignment
Primary Care and Population Health 14
CLINICAL SCENARIOS (patient visit/face-to-face)
Gen PCP field is unknown, none,
outside, or somewhere not in your primary care
network
Provider listed in Gen PCP field is not a UW
Medicine PCP
Ask patient if they want to establish care with PCP seeing that
day or with your clinic location
YES – Confirm panel open
YES – Change/update Gen PCP field
NO – Let patient know PCP not accepting new pts, but can
establish with other PCP in clinic
NO
Talk to/educate patient on importance of PCP and continuity of care – invite patient
to establish care
“I see [PCP name] has an opening, would you like to establish care with her/him?”
“All medication refills, questions or forms will go to this provider, It becomes challenging when the pharmacy calls regarding a medication or form needing to be filled out, and you do not have a PCP. We don’t know who can take care of this for you.”
Download patient brochure handout here
Primary Care and Population Health 15
CLINICAL SCENARIOS (patient forms, med refills, referrals)
Often, patient requests are received regarding:
• Prescription refills
• Home health recertification
• Referral requests
• Paperwork completion
Did patient see a provider in your clinic location?
YES – Send to last provider see
NO – Call patient to confirm the
request was in fact intended by the
patient
YES – patient requested
Confirm PCP and send to that
individual; update PCP field
NO – Inform patient of who sent the request and
encourage the patient to call about correct PCP
RESOURCES
16 Primary Care and Population Health
Did you know there is a central resource available to all UW Medicine staff, that provides the tools needed to answer and perform population health activities? It includes clinical toolkits, workflows, how-to’s, rules, and much more for your empanelment and panel maintenance activities. Click here – UW Medicine Empanelment & Panel Maintenance
Can’t find what you’re looking for? Please reach out to Erica Strait, Program Manager for Population Health Management –
NEXT STEPS
17 Primary Care and Population Health
[1] Redesign core team meets in October 2019
[2] Check-in on implementation
[3] Agree on check points and maintenance cycle
[4] NEXT WORKGROUP: Panel Management
[5] PANEL BASED QUALITY
QUESTIONS?
18 Primary Care and Population Health
Crystal Kong-Wong, MD, Associate Medical Director UW Neighborhood Clinics
Clinical Assistant Professor, UW Department of Family Medicine [email protected]
Erica Strait, MHA, BSN
Program Manager, Population Health Management [email protected]