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Empanelment: Defining and Establishing Patient-Provider Relationships

Empanelment: Defining and Establishing Patient-Provider Relationships

Curated guidance from the Safety Net Medical Home Initiative, AHRQ, Center for Care Innovations, and More

A panel, put simply, is a list of patients assigned to each provider or care team in the practice. The care team (e.g., a physician, a medical assistant, and a health educator) is responsible for preventive care, disease management, and acute care for all the patients on its panel (AHRQ, 2013). Empanelment is the act of assigning individual patients to individual primary care providers and care teams with sensitivity to patient and family preference. Empanelment is the basis for population health management and the key to continuity of care. The goal of focusing on a population of patients is to ensure that every established patient receives optimal care, whether he/she regularly comes in for visits or not. Accepting responsibility for a finite number of patients, instead of the universe of patients seeking care in the practice, allows the provider and care team to focus more directly on the needs of each patient (Safety Net Medical Home Initiative, 2013).

This is important because, according to AHRQ, many health centers may schedule patients with the next clinician that is available as opposed to an assigned provider or care team. Further, according to 2015 research, only about one third of family physicians could estimate their patient panel size. These characteristics may suggest a reactive model of care that does not help build relationships with patients nor give providers or care teams the opportunity to take responsibility for the care of a specific group of patients. Assigning patients to particular clinicians or care teams helps change this approach. It designates teams as responsible for caring for specific patients and supports continuous relationships between patients and their care teams. It also makes it possible for care teams to “manage” the care of their panel, not just for individual patients as they appear. A key to success of this is, once patient panels have been established, scheduling for continuity with the assigned provider or care team rather than reverting to scheduling for next available appointment. Be sure to engage front desk and scheduling staff in this process so they understand the importance of continuity within the broader context and feel empowered to speak up about access delays or other issues that arise.

The management of these patients’ care, called panel management, becomes a systematic approach to addressing the needs of a group of patients. With this approach, providers or care teams methodically identify risks or gaps in care to enhance preventive care and overall management of chronic conditions. When managing an assigned patient panel, providers and care teams can better use targeted patient outreach to improve follow-up care, and then monitor indicators of care delivery and the corresponding outcomes. Outcomes are improved by focusing on knowing the needs and appropriate clinical interventions for patients in a panel as compared to trying to track, educate, screen, and appropriately intervene with all patients regardless of nature or frequency of visit(s) in order to provide high quality primary care and meet criteria for reporting requirements. For example, by targeting empaneled patients with uncontrolled hypertension to receive intensified treatment and closely monitoring outcomes,  the percentage of patients who achieve optimal blood pressure levels will increase (NYCDHMH, 2011).  Through panel management, accountability and continuity combine to increase effectiveness and happiness for both provider and patient. Another benefit is the ability to monitor the performance of providers or care teams on important metrics by looking at the rates of key screenings and services, as well as health outcomes of their patient panel. Once patient panels have been established, the health center and providers are better positioned to improve care through health IT enabled quality improvement.

Determining Appropriate Panel Size
The target and ideal size of a patient panel are worth considering as well. Panel size is calculated by taking the provider or care team’s “supply” of visit slots and dividing it by the average number of visits by a typical patient during a year. The result is the total number of unduplicated patients a clinician or team can care for in a year.
For example:

  • A clinician who works 230 workdays in a year and sees 24 patients a day has a “supply” of 5,520 slots a year (230 workdays x 24 patients/day).
  • Patients average 3.19 visits to the clinician a year.
  • This clinician could care for a panel of 1,730 average patients in a year (5,520 ÷ 3.19).

Finding the ideal panel size requires demand for appointments matching the supply of appointments if timely service is desired. If the panel is too large, the excess demand results in a never-ending and ever-expanding delay in services in addition to constant deflections to other providers, resulting in discontinuity. On the other hand, if a panel is too small, it may not support health center operations. You can use the following worksheet to help capture the data needed to calculate your current and ideal panel size. Click here to download an Excel version of this worksheet from the American Academy of Family Physicians, which performs many of the calculations for you.

Steps for Empanelment:
(Excerpted from the Safety Net Medical Home Initiative's Empanelment Executive Summary)

  • Review patient visit history.
  • Review initial panel assignments. Sort first by assigned provider for initial panel sizes.
  • For patients not already assigned to a provider, apply the Four-Cut Method from Panel size: How many patients can one doctor manage?
    • 1st cut. Patients who have seen only one provider in the past year: Assign to that sole provider.
    • 2nd cut. Patients who have seen multiple providers, but one provider the majority of the time in the past year: Assign to majority provider.
    • 3rd cut. Patients who have seen two or more providers equally in the past year (no majority provider can be determined): Assign to the provider who performed the last physical exam.
    • 4th cut. Patients who have seen multiple providers: Assign to last provider seen.
  • Review preliminary panel report and amend as necessary.
  • Use panel data and registries to proactively contact, educate, and track patients by disease status, risk status, self-management status, community and family need.
  • Monitor and record requests by patients or providers for panel re-assignment.
  • Alert patients that they can change their provider or care team if desired or needed.
  • Inform patients of their provider assignment when they first visit the practice or immediately after empanelment occurs. Encourage patients to develop a relationship with their provider and care team.
  • Weight panels to assure equity across providers, if desired. Weight by patient age, gender, morbidity, or acuity, for example.
    • Additional information about how to adjust for age and gender can be found in the table within this article.

Maintaining Empanelment
In order for the initial work of empanelment to not age out very quickly, ongoing operational integration is needed. Given the churn in patients, insurances, and sometimes staff, it is essential that empanelment is merged into overall processes.

  • Keys to Building an Empanelment Process from the Center for Care Innovations
    • Define Roles and Responsibilities
      • Assign a Panel Manager to oversee all empanelment processes
      • Assign specific tasks for maintaining empanelment
    • Develop standard process for empanelment and provider assignments
      • How are new patients assigned?
      • How are patients or providers leaving the health center handled?
      • How are requests to move a patient (either by the patient or the provider) to another panel handled?
    • Run supply and demand data regularly to ensure panels continue to be appropriately sized
      • Use to inform ongoing empanelment
      • Use to inform staffing needs
    • Identify unassigned patients regularly and use standardized process for assigning them to a panel
    • Regularly review outcomes for panels and act rapidly for improvement
      • Operational outcomes
        • Are patients being assigned to a panel in a timely manner?
        • Are they being scheduled with the assigned provider?
        • Are registries being used for the patient panel to support care management?
        • Are they being seen regularly by that assigned provider?
      • Clinical outcomes
        • Outcomes of patients within the panel on key metrics such as hypertension or diabetes control, cancer screenings, immunizations, etc.

Additional Resources and Guidance:

Sources:

 

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