What is Panel Management?
Panel Management connected primary care providers with patients most in need of ongoing care. Rather than waiting for high-risk patients to make appointments when something is wrong, the Panel Management approach proactively contacted patients who would benefit from a follow up appointment or additional education.
To assist providers who want to adopt this model, PCIP provided practices with a dedicated Prevention Outreach Specialist (POS) who used patient registries to identify patients who routinely fall through the gaps, especially those with hypertension, high cholesterol, smoking, and diabetes. The POS worked one full day at a practice, very week and called high-risk patients who have not visited the provider in over a year.
Through outreach and education, this Panel Manager connected patients with preventative services and timely intervention.
Prevention Outreach Specialists coordinated with practices to prioritize and conduct outreach activities, using registry features of the EHR to identify “at-risk” patients in each category. The POS then made phone calls and sent letters to patients recommending that they make appointments, fill prescriptions, understand the importance of following up with recommended lab tests and vaccines. They also documented and tracked outreach efforts in the practice’s EHR and alerted practices when barriers prevent a patient from achieving the desired health goals.
“At-risk” patients were defined as those with the following criteria who don’t have an appointment in the next month:
- All patients with IVD who have not been seen in the last 6 months and no appt. in the next month.
- All patients with HTN but not DM and not CKD and a BP reading of 140/90 or greater who have not been seen in the last 3 months and no appt. in the next month.
- All patients with HTN and DM with a BP reading of 130/80 or greater who have not been seen in the last 3 months and no appt. in the next month.
- All patients with Hyperlipidemia who have not been seen in the last 6 months and no appt. in the next month.
- All patients with a BMI of 30 or greater with a diagnosis of DM who have not been seen in the last 6 months and no appt. in the next month.
To date the panel management program has scheduled 2,409 primary care visits for patients enrolled in the program. What a participating provider said about Panel Management:
- “[A patient] came to see me after not coming in for eleven months. His blood pressure was out of control. He had run out of meds. He said he came in because a panel manager had called. I told [the panel manager] that she saved his life”
This program has ended and results from the program are currently under evaluation. For more information about panel management or to inquire about future opportunities, please contact us at PCIP@health.nyc.gov