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Developing Successful Panel Management Processes:Tracking Care for Patients with Preventive and Complex Care Needs

March 15, 2016

Continuing Education

In compliance with the ACCME/NMMS Standards for Commercial Support of CME, Rebekah Bally, MPH, CPH; Marcelle Thurston MS, RD, CDE; Marci Silberstein, MA; Scott Zahlmann; Rashae Burns and Emma Abiles have asked to advise the audience that they have no relevant financial relationships to disclose.

HealthInsight New Mexico is accredited by the New Mexico Medical Society to provide continuing medical education for physicians.

HealthInsight New Mexico designates this live course for maximum of 1.5 AMA PRA Category 1 Credits(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the

activity.

Continuing Education

The presenters have asked to advise the audience that they have no relevant financial relationships to disclose. No

individual involved in the planning or presentation of this activity has relationships with industry or other conflict of

interest to disclose

• HealthInsight Nevada is accredited to provide continuing medical education for nurses.

• HealthInsight Nevada designates this live course for maximum of 1 Continuing Education Unit (CEU). Nurses should claim only the credit commensurate with the extent of their participation in the activity.

HealthInsight

• Quality Innovation Network (QIN)

• Quality Improvement Organization (QIO)

• CMS Quality Strategy:

– Eliminating disparities

– Strengthening infrastructure and data systems

– Enabling innovation

– Fostering learning organizations

5Quality Improvement Organizations. 2014. About QIN-QIOs. Retrieved at: http://qioprogram.org/about/why-cms-has-qiosQIO Program Fact Sheet – Handout.

We Want To Hear From You!

Type questions into the Questions Pane at any time

during this presentation

Introducing the Speakers

Marcelle Thurston MS, RD, CDEPrimary Care Innovation Specialist

CareOregon

Marci Silberstein, MAPanel Manager/Purchasing Manager,

Physicians Medical Center, McMinnville OR

Introducing the Speakers

Scott ZahlmannPopulation Health

Supervisor, CareOregon

Rashae BurnsPanel Coordinator,

CareOregon

Introducing the Speakers

Emma AbilesPrimary Care Innovations Specialist

CareOregon

Empanelment vs. Panel Management

The act of assigning each patient to a primary care provider who, with support from a care

team, assumes responsibility for coordinating comprehensive services for

his/her panel of patients.

Safety Net Medical Home Initiative. (2013).

Complex Care Management vs. Panel Management

Programs or process in which specially trained, multidisciplinary staff/teams coordinate closely with primary care providers to meet the needs of patients with multiple chronic conditions or advanced illness, many of whom face social or

economic barriers in accessing services.

Hong, C.S; Siegel, A.L.; and Ferris, T.G. (2014)Murray, M.; Davies, M.; and Boushon, B. (2007).

POLL: What is Panel Management?

A. A small focus group of people brought together to discuss and problem solve ways to manage chronic disease.

B. A system where patients are systematically identified for gaps in care, preventive services or chronic condition management.

C. A call back system used to track patients with chronic disease only.

D. A and B only.

Learning Objectives

1. Define the difference between traditional and non-traditional panel management

2. List at least 3 areas of readiness to implement a successful panel management process

3. Clearly articulate the process for developing a sustainable panel management model locally

4. Define outreach vs in-reach strategies

5. List at least 2 key elements for sustainability

Traditional vs Non Traditional

Panel Management

Traditional Model

• Clinic/Organization hired

• Can be co-located with team or done off-site

• Chronic disease/preventative medicine focused

• Identify gaps, provider or organization driven

• Close gap through inreach or outreach

• Monitor, track, and follow up

CareOregon’s

Non-Traditional Model

• Health Plan hired and placed in clinic system (many members)

• Can be co-located with team or done off-site

• Work in service to Health Plan members and CCO (an Oregon thing) incentive metrics

• Close gap through inreach or outreach

• Monitor, track, and follow up

What is the benefit of Panel Management?

Quadruple Aim!!

From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.

Bodenheimer and Sinsky, Ann Fam Med 2014;12:573-576.

Patient Satisfaction

Decreased Healthcare

Costs

Clinical Outcomes

Staff Satisfaction

Ideal Skill Sets for a Panel Manager

• Medical Assistant, LPN, CHW (Community Health Worker)

• Bilingual

• Customer service skills/Soft skills

– Internal and external rapport

• Some medical knowledge (i.e. in work hx);

– but not too much where they may get pulled!

• Motivational Interviewing

• Multi-task; project management experience

• EHR experience; data management/excel knowledge

Is your clinic ready?

• Empanelment – Are your patients assigned to a provider? This makes identifying patient's and who has responsibility of their care much easier.

• How are gaps identified? Is this provider driven, organization driven? Who decides? This should be standardized.

• What platform are you using to pull your gaps? Is this EHR driven, separate platform, who pulls?

• Are there standing orders, P&P’s, workflows and processes for outreach and inreach?

• Are roles defined? Team based care, and working to top of license!

QUESTIONS?

Type questions into the Questions Pane

Physicians Medical Center (PMC)

Traditional Model

• Who? – Who does the work/credentials?

• What? – What is the target population? How was this decided?

• When? – Frequency of data pull and from where?

• How? – How is data used? How is data communicated to

provider?

• Lessons Learned?

Our Panel Management Team

• Marci Silberstein- EHR specialist– Large amount of clinical experience

– Chart audits, manages CCO member lists, pulls reports from within EHR system/CQR system.

• Giac Nguyen- Access Specialist– Able to build specialized reports that EHR does not

pull for CCO and manages external rosters.

• Kevin Dao- EMARS Specialist– Uses custom built panel and risk assessment tool to

get internal rosters and manipulates data for teams.

EMR Mining, Analysis and Reporting System

(EMARS)

• Pulls panel sizes

• Calculates risk assessment for every patient and ranks them 1-5.

• Target risk score ‘5’ patients for additional contact

• Data is run quarterly

• Meet with teams quarterly to provide:

– list of ‘5’ patients

– metrics score card

(!)

Scorecard

TEAMMEANINGFUL USE BENCHMARKS/METRICS

DECEMBER PERFORMANCE DECEMBER PERFORMANCE

>% 1 2 3 4 Team 1 2 3 4 Team

1 CPOE Medication Orders 60% 91% 92% 98% 100% 95% PATIENT POPULATION

2 CPOE Laboratory Orders 30% 99% 88% 100% 100% 97% # of High Risk Patients (5's) 19 1.3% 9 0.5% N/A N/A 28 0.9%

3 CPOE Radiology Orders 30% 100% 90% 100% 100% 98% Total # of Diabetic Patients 135 9.3% 152 9.1% N/A N/A 287 9.2%

4 e-Prescribing (e-Rx) 50% 91% 94% 88% 92% 91% # of Diabetic Patients w/ HbA1c ≥ 9* 13 9.6% 21 13.8% N/A N/A 34 11.8%

5 Demographics 80% 99% 98% 97% 98% 98% # of Patients with LDL ≥ 100 46 3.2% 79 4.7% N/A N/A 125 4.0%

6 Vital Signs 80% 97% 97% 100% 98% 98%

7 Smoking Status 80% 99% 99% 98% 99% 99% METRICS (AMOUNT DONE IN 1 MONTH)

8 Patient e-Access A 50% 91% 93% 97% 91% 93% ASQ 3 5 N/A N/A 8

9 Patient e-Access B 5% 21% 31% 32% 14% 25% AWC 2 4 N/A N/A 6

10 Clinical Summaries 50% 87% 91% 59% 96% 83% SBIRT 74 72 5 16 167

11 Pt-Specific Education Res. 10% 36% 59% 45% 27% 42% CRAFFT 5 4 2 0 11

12 Medication Reconciliation 50% 98% 97% 100% 99% 99%CRC - YCCO ONLY (# DONE/TOTAL # OF PATIENTS THAT

QUALIFY)*- - N/A N/A -

13 Summary of Care A 50% 80% 80% 75% 92% 82%

14 Summary of Care B 10% 30% 27% 25% 57% 35% PANEL (running year)

15 Secure e-Messaging Y/N Y Y Y Y Y PCP Panel Size 1/2015-2016 1448 1671 N/A N/A 3119

16 Electronic Notes 30% 100% 100% 100% 100% 100%

17 Imaging Results 10% 100% 100% 100% 100% 100%

18 Family Health History 20% 82% 79% 75% 79% 79%

We try to maintain all data as up to date and accurate as possible.

As data is dynamic, new patient visits, labs, etc., may not be reflected in the data shown above.

*Diabetics ≥ 9 denominator is "Total Diabetics Patients," not panel size. CMS benchark is 14%; YCCO benchmark is 34%.

*CRC data is YCCO only because currently that is the only data we readily have access to. EHR limitations would require manual chart reviews for clinic-wide data.

Summary of Care B: > 10 % of SOC-A were e-transmitted via either (a) CEHRT, or (b) a Nation-wide Health Info Network Exchange participant.

QUESTIONS?

Type questions into the Questions Pane

CareOregon

Non-Traditional Model

• Who? – Who does the work/credentials?

• What? – What is the target population? How was this decided?

• When? – Frequency of data pull and from where?

• How? – How is data used? How is data communicated to

provider?

• Lessons learned?

CareOregon Population Health Team

• Panel Coordinators– Individuals embedded in the health care

organizations.

– Diverse medical backgrounds and experience within healthcare.

– Knowledge of CCO metrics, EMR systems navigation, billing assistance.

– Acts as a liaison to the patient with assisting on access to care and understanding of their total health.

Lessons Learned

• Collaboration is the best way to get patients activated in their care.

• Less errors in billing.

• Faster fixes and reimbursements turnarounds for the organization.

• Patients feel better about their care from both their healthcare organization and their insurance provider = More Activated in care

QUESTIONS?

Type questions into the Questions Pane

Outreach vs In-reach

Outreach• Connecting with patients via

phone, letter or health portal

• For the purpose of closing gaps in care

• Engaging with patients who may not regularly be seen at the clinic

In-reach• Auditing charts of patients

on the schedule

• For the purpose of closing gaps in care

• In order to huddle with the team and prepare for the visit

Process: From preparation, to

implementation and sustainability

• Staffing model - Team Based Care!

• Roles and responsibilities – clarity for all

• What reports to generate – where do you get them?

• Choosing priorities to track – input from leadership

• Communicating to providers – get buy in!

Checklist for Sustainability

Registry upkeep

Clinical practice guidelines – up to date

Consistent meeting agenda – problem solving

Policy and procedures

Staff competencies

Lessons Learned

• Panel Managers as CMAs

• Rolling out multiple new roles at the same time

• Training timeline

QUESTIONS?

Type questions into the Questions Pane

Resources

COMPLEX CARE MANAGEMENT

• Hong, C.S.; Siegel, A.L.; and Ferris, T.G. (2014). Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program? Commonwealth Fund Issue Brief

PANEL MANAGEMENT

• Agency for Healthcare Research and Quality (AHRQ). (2013). Practice Facilitation Handbook: Module 20 Facilitating Panel Management. Retrieved from: http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod20.html

• Bodenheimer and Sinksy. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med 2014;12:573-576.

• Chen, E.H. and Bodenheimer, T. (2011). Improving population health through team-based panel management. Arch Intern Med 171(17): 1158-1559.

• Hatcher, P. (2013). Panel Management: Applying population health and best evidence. Video retrieved from: https://www.youtube.com/watch?v=kjMrCPof9Gs

• Neuwirth, E. (Estee) B., Schmittdiel, J. A., Tallman, K., & Bellows, J. (2007). Understanding Panel Management: A Comparative Study of an Emerging Approach to Population Care. The Permanente Journal, 11(3), 12–20.

• UCSF Center for Excellence in Primary Care. (2013). Panel Management. Retrieved from: https://cepc.ucsf.edu/panel-management

EMPANELMENT

• Empanelment: What do you do after every patient has an assigned care team?

• Murray, M. Davies, M., and Boushon, B. (2007). Panel size: How many patients can one doctor manage? Retrieved from the Family Practice Management web site at: www.afp.org/fpm

• Safety Net Medical Home Initiative. (2013). Empanelment: Establishing patient-provider relationships. Retrieved from: http://www.safetynetmedicalhome.org/sites/default/files/Implementation-Guide-Empanelment.pdf

Contact Information

• Marcelle Thurston

thurstonm@careoregon.org

• Scott Zahlmann

zahlmanns@careoregon.org

• Emma Abiles

abilese@careoregon.org

• Marci Silberstein

mcrafton@PMCMAC.com

• Rashae Burns

burnsr@careoregon.org

Thank You!

• Please complete post-webinar survey

• Next webinar:

Using Quality Reporting and HIT to

Improve Patient Care

Thursday, April 21st

11am – 12pm PDT

12pm – 1pm GMT