Through collaborative use of improvement science methods, reduce preterm births &

improve perinatal and preterm newborn outcomes in Ohio as quickly as possible.

Panel Management in a Patient Centered Medical Home

Ted Wymyslo, MD, Chief Medical OfficerOhio Association of Community Health

Centers Jennifer Bailit, MD, MFM, OPQC

Martha Rome, QIC

THE MEDICAL HOMETed Wymyslo, MD

PCPCC 2015. All rights reserved.Source: www.ahrq.gov

Defining the Medical HomeThe medical home is an approach to primary care that is:

Committed to Quality and SafetyMaximizes use of health IT,

decision support and other tools

AccessibleCare is delivered with short

waiting times, 24/7 access and extended in-person hours

CoordinatedCare is organized across

the ‘medical neighborhood’

ComprehensiveWhole-person care provided by a team

Person-Centered Supports patients and families in managing

decisions and care plans

3

PCPCC 2015. All rights reserved.

PCPCC 2015. All rights reserved.

PCMH enhances ability to identify and manage high-risk, high-need populations

• Risk stratification and diligent monitoring for all patients

• Track care plans and medication adherence

• Proactive outreach from care team with collaboration among specialists and primary care

• Patient engagement and activation

5

PCPCC 2015. All rights reserved.

Need to change “Supply” and “Demand”“Supply side” reformsReimbursement changes that impact health care delivery:• Increased payment for providers who adopt PCMH model• Increased use of shared savings , bundled payments, capitated payments • Alignment across all payers through multi-payer or all-payer initiatives

“Demand side” reformsReimbursement changes that impact consumers and employers:• Consumers pay less in premiums/copays to use higher-value, PCMH

services• Limit co-pays for wellness visits/primary care• Use of tiered pharmacy benefits that encourage the use of cost effective

prescriptions (including generics)• Improve consumer understanding of the PCMH model and primary care to

better manage health

THE CHRONIC CARE MODEL: POPULATION/PANEL MANAGEMENT

Martha Rome, RN, MPH, Senior Quality Improvement Consultant OPQC

The Chronic Care Model

Clinical Information Systems

• Organized approach to collecting, summarizing, and reviewing individual or aggregate patient data to facilitate care.

• Assure access to timely, relevant data about individual patients and populations of patients

• Includes critical information about each patient and the performance and results of important aspects of care enables care teams to call in patients with specific needs, deliver planned care, receive feedback, and implement reminder systems.

Panel Management• Group patients with similar needs to

improve their quality of care and health outcomes

• A system where patients are systematically identified for gaps in care

• Use registry/log to measure performance

PANEL MANAGEMENTJennifer Bailit, MD

Population

Panel Management

• Who are my people?– Geographic responsibility– Managed care assignments– Patients seen in the past

Panel Management

• How are they assigned?– Insurance assignment– Walk-ins

Panel Management

• Who do I care about?

Panel Management

• How do I contact them?• What are you contacting them about;

what are the priorities?

Discussion: how do you track your patients?