Empanelment Guide

The content for this Q&A was drawn from a knowledge building session on empanelment offered by the Safety Net Medical Home Initiative. The audio recording and the slides are available online: Safety Net Medical Home Initiative.

Q: How has empanelment changed your practice as a PCP?

A: As I practiced before we did empanelment, in reality, I really had no idea who my patients were. I maybe knew who walked in the door and saw me regularly. But I certainly didn’t know who my panel of patients were and, more importantly, who the people I had to outreach to were. Patients who identified me as a primary care provider didn’t necessarily know how to access me because the system was so cumbersome, and didn’t even know that I was the primary care provider. So, really, it’s the systematic way to let patients see their own PCP. And that’s one of the core principles that I want to emphasize: because we’re in the business of patient-centered medical home, it’s the business of relationships. Empanelment is a way to ensure that those patients who have identified me as their PCP, that you can ensure that continuity.

Q: How does empanelment support population health management?

A: It allows for a group of patients to be easily identified, including those who don’t come. And I really want to emphasize that as another key concept. You know, I think primary care in general, we’re in the business of direct patient visits and that has been one of the problems that we’ve had with doing things from a population care management perspective. We have to be able to outreach to those patients who aren’t choosing to come in directly. We have to find a way to outreach to those people and say, “Hey, you haven’t been in. So, how can we get you to come in? How can we get those labs done? How can we follow up on this report, and how can we outreach to you?” You can’t do that proactive management if you have no idea about the patients you are caring for.

It will allow teams to customize their service to the specific needs of the client. When you think of your organization’s population management, that’s all the patients you’re seeing. You want to get down to the panel view and have that provider team being able to look at the patient population on their panel and identify what specific needs there are. For the first time, a PCP can actually say, “Wow, I didn’t realize that I actually have an enormous amount of patients with congestive heart failure. I didn’t even realize that I had that much of a population problem with that.” You can target your work and your efforts toward that population need. We weren’t able to identify that before, and you can really drive your reports in a population-based, very specific way to the population that you’re caring for.

Q: How does empanelment help with managing supply and demand?

A: Historically, what happens is you see whoever’s on the schedule. It’s that sort of emergency room mentality, where you walk in the clinic, and you and the team just see whoever walks in the door. Some providers work hard to see everyone who needs to be seen and others don’t. That’s just the reality of it. The variability in the complexity of the patients also depended on the provider. There was no way to understand that if I’m seeing 18 people today and this provider next to me saw 20, does that mean that this person who saw 20 is better than me?

We had no idea what that meant, so we lived in that volume-based world where we just said 20 is better than 18. I think most people would agree that’s not what primary care is about. Empanelment can help us to really start driving primary care to a different type of model that’s more about the relationship and less about the volume.

Q: How do you think about the mathematics of empanelment?

A: Specifically for managing supply and demand, there is a rational formula for determining the number of patients it’s possible to take care of. You’re not trying to get down to the most exact, precise thing you can imagine because you’ll kill yourself with the numbers. You’re trying to get to a ballpark to a close enough approximation that you could start with the number of patients you think that a person’s panel could be started with. That allows for data-based decisions. So, for example, who can be open, who’s not, have we reached capacity, now we need to hire more people–or not? But you can’t just simply assign patients to a PCP and assume that’s a panel. You want to weigh by age and gender and utilization. Start simple. That can get you 80% there and land with it. And, as you evolve, you can move into some other methodology of weighting complexity, either by disease or by higher utilizers or whatever you think is more appropriate for your system.

This is about cultural change. It’s about using the evidence that’s out there, tools that are out there; you don’t have to make this up. It’s about starting simple and getting more complex as needed, but simple is always the best way to go first. It’s about getting buyin with your teams and your clinics and your providers, and understanding the real issue, which is about relationships. It’s about spending time and energy to socialize this. It’s about getting your patient input and making sure that this fits. It’s about developing the policies and procedures that support where you want to go and support this process. And it’s about leadership and management change. And I think when you think about how complicated it is, you realize, like I said in the beginning, it’s not about the math. The math is the easiest part, no matter how complicated these little equations seem. The math is the easiest part. It’s the other stuff that’s the hard part. So, if you could work on spending the time on the other things, the math part comes very easy.

Q: What do you think is most important for supporting change with empanelment?

A: I want to emphasize: this does not have to be you putting the space shuttle to the moon. You don’t have to get every equation done perfectly. You need to just come up with a process. You need to be able to understand how to do it. You need to be able to look at what your population looks like. You need to be able to model it, and then you need to be able to talk about it. And what does talking about it mean? What does it mean to do this cultural shift of, now you have a panel of patients, not that you walk into the clinic and I’ve got 18 slots and I’m going to double book a couple, so Amit’s day is 20 today? Instead, my day today is Amit’s panel. My day tomorrow is Amit’s panel. My day the next day is Amit’s panel.

It’s a cultural shift, and where you’ll succeed is having an understanding of why empanelment is important, why you’re doing it to ensure continuity, why it’s important for the relationship, why is it important to do proactive management. You can do those things by creating an empanelment process and you need to have some policy and procedures around how you’re going to deal with empanelment, because it opens up a can of worms or a Pandora’s box of all these things that you never really thought about.

We had to create a panel management policy, which meant, how do you change providers? We had to come up with a policy of how many new patients you see based on the percentage full a panel is. We had to develop some strong policies around minimum staffing, and it was hard to do this. But, really, the numbers and the empanelment really showed us what we needed to do. For example, we created a minimum number of days in the clinic. We said we don’t care what your FTE is. If you’re .6, traditionally you’d work three days a week, and you’d have two days off. We said whatever your FTE is, you have to work a minimum of four days a week.

That created a lot of accountability, and it really emphasized that point that if we’re really going to believe that we can deliver this care and it’s relationship-based, then there’s gotta be some time commitment.

Q: What is most important for leaders considering empanelment in their organizations?

A: I think the ramification for leadership is that you have to have commitment from your leadership that this is the process that they believe in, and the buy-in from the leadership all the way down to the provider teams, the provider, and the patient is about the relationship. It’s a whole system-wide change, and the reason why you’re doing it is for relationship. It’s to build that relationship to be able to engage the patient, to proactively manage them, to identify the patients you’re caring for, to identify them on an individual level, a disease-specific level, be able to manage them in a populationbased level, and to be able to report on all of that. It’s to be able to paint a very different picture of the kind of care that you’re giving when you do these changes.

I’ll give you an example of how this happened in our organization. We have about 140 or so providers, and you know this was so important to our leadership, it’s so important to me that, basically, I met with every individual provider, and I reviewed this down to the nitty gritty of their panel with them. And the reason why I did that, and you could imagine how much time that took, because if there isn’t an understanding of why we’re doing it, it doesn’t matter if I send this out, and I prove the math of it, and I give them all these references–no one’s going to really listen to it or follow it. That one-on-one time that I spent with each one of them, one, it showed them what this is all about. Two, it gave the opportunity for them to give feedback because they gave great feedback that helped us. Three, it gave us that opportunity to be able to really hone in that empanelment is one of the many pieces we have to put together to create this medical home. And why do we want this medical home? We want it for relationship. We want it for better care. We want to improve quality and we want to be able to demonstrate it.