Panel Management

About | What PM Can Do For You | Who Qualifies | Intervention | Contact PCIP

What is Panel Management?

Panel Management connects 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 contacts patients who would benefit from a follow up appointment or additional education.

To assist providers who want to adopt this model, PCIP provides practices with a dedicated Prevention Outreach Specialist (POS) who uses patient registries to identify patients who routinely fall through the gaps, especially those with hypertension, high cholesterol, smoking, and diabetes. The POS works one full day at a practice, very week and calls high-risk patients who have not visited the provider in over a year.

Through outreach and education, this Panel Manager connects patients with preventative services and timely intervention.

What can Panel Management do for you?

• Provide you with a free resource, a Prevention Outreach Specialist (POS), who will help you identify gaps in care through registries (e.g. at-risk patients who may benefit from preventive services)
• Reach out to patients who need to return for additional care through the use of letters, phone calls, voice messaging
• Track and follow up with referrals, lab tests and diagnostic procedures, scheduling and confirming appointments, and ensuring patients take the appropriate actions between visits

Who qualifies for Panel Management?

• Small practices providers who are live on an EHR for at least 6 months through PCIP
• Practicing Family Medicine or Primary Care Providers
• Providers with a dedicated computer and phone line that can be used once a week by the Prevention Outreach Specialist (POS)
• Providers able to devote 1-2 hours per week to coordinate efforts and guide outreach activities

Intervention

Prevention Outreach Specialists coordinate 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 makes phone calls and sends letters to patients recommending that they make appointments, fill prescriptions, understand the importance of following up with recommended lab tests and vaccines. They also document and track outreach efforts in the practice’s EHR and alert practices when barriers prevent a patient from achieving the desired health goals.

“At-risk” patients are 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.

Contact PCIP

For more information or to apply for the program, contact Alexis Kowalski at akowalsk@health.nyc.gov.