Topic Information
Date:
Purpose of
Research:
January 2012
Topic:
Panel Management
To develop a shared understanding of the Panel Management approach to primary
care delivery and restructuring.
Key Points
A. Background: It would take almost eighteen hours per day to provide care to the average U.S primary care panel
of 2,300 patients. It is no longer feasible for primary care physicians (PCPs) to take sole responsibility for the
acute care, chronic disease management and preventive services for all their patients. Panel Management (PM)
is a recently developed primary care quality improvement strategy that is considered within the context of the
Patient Centered Medical Home to make care provision a better experience for practitioners, staff and patients.
It involves a narrow and specific set of tools for office scheduling and outreach purposes, and has potential to
improve health outcomes by optimizing the use of non-provider staff and patient flow through modified
scheduling and follow up, and is made feasible through electronic records and systematic patient outreach, as
the ability to track patient adherence and results is essential to successful implementation.
Multiple definitions of Panel Management are offered:
- A quality improvement strategy grounded in electronic records and systematic, targeted, and brief patient
outreach to help providers improve care delivery and health outcomes
- An organized, population based, data-driven multidisciplinary team approach whereby a primary care team
jointly plans and manages the care of patients with chronic disease, using a disease registry to identify
clients’ unmet care needs, gathering summary information and communicating with clients
- A set of tools and processes for population care applied systematically at the level of a primary care panel,
with PCPs directive proactive care for their empaneled patients
In a sense, panel management can be thought of as a restructuring of an office’s scheduling and staff
responsibilities to make the best use of staff time. Clinicians (MD/NP/PA) no longer see all the patients for all their
problems. Routine preventive and chronic care issues can be handled by non-physician staff, creating time for
clinicians to spend adequate time with more complex patients. Figures A and B show how a primary care office staff
is restructured through panel management. Note that the physician and the medical assistant have the same
schedule and the doctor (or maybe the NP or PA) assumes all responsibility for patients, makes decisions and
orders others to perform tasks. Patients are also stratified into the fifteen minute visit; this fails to recognize that
different population groups within a practice’s patient population have different needs ranging from minor,
preventive care to complex needs with multiple chronic conditions. In panel management, Figure B, the day is
tailored to take into account various health needs and services. The entire team assumes responsibility for a panel
of patients, team members share responsibility to make the panel of patients as healthy as possible, and tasks are
ideally linked to a sense of responsibility and purpose.
Figure A
Figure B
B. First Panel Management Study: Kaiser Permanente
Health insurance company Kaiser Permanente (KP) was one of the first implementers of panel management, due to
early reports on promising clinical improvements with sites using PM: one community became a top diabetes
performer within two years of PM implementation in controlling low-density lipoprotein levels. Kaiser already had
an approach to population management and regionalized services that were aligned with the PM approach: disease
registries were in place with capacity to perform “low-intensity” outreach: track chronic disease patients, identify
care gaps, flag unmet care needs, and conduct automated outreach by mail or phone to inform patients of
tests/treatments/appointments. In 2007, KP published a qualitative, rapid assessment study on the implementation
of panel management at four of its sites. Methods included focus groups with physicians, staff and patients, as well
as direct observation. At each of the four sites, the PCP was always directing clinical decision making, and the
nonclinical staff carried out the physician orders.
Findings:
- There was wide variation in program implementation across all sites, but each site had the following
components:
o Dedicated physician time for directing clinical decision making
o Dedicated staff members or staff time to support the physician and perform outreach
o IT tools to identify care gaps
o Structured work processes completed on a routine basis
- Physician Satisfaction: Physician’s overall reported satisfaction. There was some initial tension, as the approach
was adding more tasks to their busy day but all agreed that PM can improve patient care and that over time,
the approach can reduce the physician’s time as non-urgent patient needs are targeted by other staff.
- Team (non-physician) Satisfaction: Medical Assistants formerly working in a clinic thought PM represented an
opportunity for job growth and they welcomed the responsibilities. For those MAs previously in Care
Management, transitioning from in-person care management to telephone outreach/communication was a
major shift in their role. While they were satisfied with the concept of PM, they missed the personal approach.
- Patient Satisfaction: Patients overall were pleased with their care and perceived that their PCP was still making
their care decisions. They appreciated the reminders, phone calls, attention and monitoring related to PM
outreach activities and thought this outreach helped them better manage their condition. They expressed
wanting more self-management support in addition to the “lighter touch.”
Lessons Learned:
- Care coordination and skill of the outreach staff in communicating with patients and physicians is essential.
Patients might be less concerned with the staff person’s title, but they want to be sure that their care is
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coordinated and “perceive” that their PCP is still managing their care
Culture change is necessary: Transitioning requires a lot of upfront changes to practice style and to a thinking
style. Over time, office staff came to accept the initial issues (loss of control) or found ways to modify so their
needs/practice style was still met.
The protocol should include clearly defined staff roles and responsibilities
Demonstrating performance improvement to staff and physicians in an ongoing manner was a key strategy to
support implementation
Education sessions led by physician champions to support acceptance was an effective QI tool
Close program oversight was necessary, as was having a standard operating procedure.
Important to closely monitor outreach and ensure scripts are clear, and that staff is effectively communicating
with patients
Tradeoffs occurred between efficiency, cost, clinical effectiveness, and physician engagement
Conclusion: Any further PM implementation should be informed by these findings from early adopters, and should
include continued monitoring of the impact of this approach on quality, patient satisfaction, primary care
sustainability and cost, optimal staffing, workflow and communications. The key element was care coordination,
but overall this new approach can potentially improve quality and improve patient relationships with PCPs and
teams.
C. Key Activities/Standards: Basic components to implementation of a panel management process is as follows:
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Primary Care Office Staff: Involves clinical and non-clinical workers such as: Primary Care Physician, Enrollment
workers, Medical Assistants, Panel Management Assistants, Clerical staff, Registered dieticians, Chronic care
specialists, Health educators/coaches, Pharmacists, Nurses, Social Workers, Case managers, etc.
Electronic Medical Records Capacity: Used to determine the practices current level of performance on certain
indicators, decide what is being targeted and set a performance goal and target date (e.g., 75% of patients with
hypertension will be well controlled within 6 months).
Chronic Disease Registry: Key to the entire process, the registry is pulled from the Electronic Medical Record
(EMR), and clients are targeted and monitored based on it. Groups of patients with similar needs are targeted
to improve their quality of care. The registry is systematically reviewed at regular intervals to ensure that all
tasks related to preventive/chronic care are carried out.
Protocol Development and Messenger Activities: Once the registry is identified, a team-based protocol for
managing the subset of patients is identified. Nurses and/or Panel Management Assistants (PMA’s) review the
list and contact patients for a variety of activities, such as to follow up on an appointment, to provide brief
education, monitor patient adherence, arrange planned visits, encourage patients to participate in care, to keep
their appointments, arrange and track referrals, and monitor indicators of care delivery and corresponding
outcomes. Communication can include phone calls, emails, letters, etc. If calls are made, the literature
recommends developing sets of standardized scripts.
Communication: Regular communication with the PCP and with other team members to discuss panel activities
and client needs is necessary
Defined Roles: Staff job descriptions for PM are written with well-defined roles and activities
Optional components to Panel Management include:
o Health coaching
o Physician-ordered standing orders for common problems, such as high A1C
o Active community involvement and outreach
o Self-management activities: Assisting patients to develop and implement a personal action plan such
as behavior changes, diet and exercise, ongoing self-management education and/or referral to a
support group
Typical Outcomes: Should be indicators of accessibility, continuity, effectiveness, efficacy, efficiency, and client
satisfaction, for example:
- Increase in the implementation of the core PM activities
- The number of PM staff that attend trainings on the basics of Chronic Care Management (CCM) and QI
activities
- Increase in the number of clients at target for approved clinical measures
D. Case Study of a Hypertensive Patient: Traditional versus Team-Based
Hypertension: Traditional Process
- Clinician sees today’s blood pressure
- Clinician refills meds or changes meds
- Clinician makes f/u appointment
- Often blood pressures are not adequately controlled
Hypertension: Panel Management Approach
- MA (or similar position) in role as panel manager
checks registry each month
- Patients with abnormal BP contacted to come for
LVN (Licensed Vocational Nurse) or RN visit
- LVN or RN in health coach role does education on
HBP and meds, med-rec, med adherence/lifestyle
discussion
- Patient is taught home BP monitoring
- If BP elevated and patient is med adherent, RN
intensifies meds by standing orders
- If questions, quick clinician consult
- LVN or RN in health coach role f/u by phone or email if patient does home BP monitoring or by return
visit
- Clinician barely involved
- Processes, outcomes, patient involvement improved
by panel management and health coaching
E. Current Panel Management Implementation Site
New York City Department of Health: Their model was designed for small practices that are live on an EHR. The
DOH provides interested, qualified practices with a Prevention Outreach Specialist (POS) who uses patient registries
to identify chronic disease patients who fall through the gaps, especially those with hypertension, high cholesterol,
smoking and diabetes, working one full day at a practice doing outreach (letters, phone calls, voice messaging),
follow up, tracking, patient scheduling, etc. http://www.nyc.gov/html/doh/html/pcip/panel-management.shtml
Sources:
- http://www.ihs.gov/california/uploadedfiles/gpra/BP2011_AdoptingACareTeamApproach(Chen).pdf
- http://www.nyc.gov/html/doh/html/pcip/panel-management.shtml
- http://www.nyc.gov/html/doh/downloads/pdf/chi/chi30-2.pdf
- http://familymedicine.medschool.ucsf.edu/cepc/html/biblio/index.html#carecoord
- http://xnet.kp.org/permanentejournal/SUM07/panel-management.html
- http://www.acgov.org/health/documents/AlamedaCountyPanelManagementStandardsofCare.pdf
- http://www.acmedctr.org/files/PDF%20HelpingPtsHelpThemselvesImplementSelfMgtSupport.pdf