1. Panel Identification Improvement Facilitator Training Session 1 Day 2

2. Objectives • Define Panel Identification • Identify the importance of Panel Identification • Understand elements of effective Panel Identification • Understand tasks necessary to build effective processes • Build your confidence to engage with clinics to solidify their Panel Identification processes

3. Panel Identification Guide F1 • Provincial resource, in development with multiple partners

4. What is a Patient Panel? “The number of unique, unduplicated patients that have an established relationship with a primary care provider, underscored by an implicit or explicit agreement that the identified provider will provide primary care services”

5. ASaP Alignment • AsaPrequires identification of panel attachment process as a first step • Panel identification process will allow practices to identify those 1/3 of patients who do not usually present for screening A6

6. Process Change in Practice Hypertension Dyslipidemia Diabetes Breast Cancer Cervical Cancer Colorectal Cancer Tobacco Obesity Exercise Diet Alcohol Opportunistic and/or Outreach Methods Screening Panel Identification/Maintenance & Continuity

7. Why is Panel Identification Important? • Allows equitable distribution of work across providers • Assigns accountability → reliable follow-up • Defines workload • panel size and demographics determines demand for services which must be matched by clinical capacity (supply) in order to achieve access to services which is inherently tied to quality care • Establishes platform to promote continuity of care • Understanding clinical needs of patient population via demographics → clear basis for defining opportunities for improved clinical care, screening and prevention

8. Continuity of Care • Percentage of time patients see their own identified primary care provider with whom they have a continuous relationship rather than other care primary care providers.

9. Patient Demographics and Clinical Care • Factors in predicting demand for services • Age • Sex • Clinical Diagnosis • Understanding of panel demographics allows for: • population based care planning • guided decisions for clinical processes • Identifying screening, prevention and disease management priorities

10. Standardization • Identification of a panel requires standardized processes to ensure accuracy and maintenance of lists over time • EMR based clinics have an advantage in generating panel reports with the EMR acting as a database • Paper based clinics also have the ability to create and maintain panel lists as the inherent processes are foundational to both systems.

11. Elements of Panel Identification Processes • Patients are assigned to a primary care providers panel through mutual agreement to develop and maintain a healing relationship • As patients are assigned, information is documented on the chart in a standardized manner (or with paper, entered in an electronic database or manual list) • Panels undergo periodic and/or regular review to ensure accurate records are maintained • Descriptive demographic data is collected and maintained to allow for population based care planning

12. Role of EMRs • A tool for data collection and analysis • Standardization of processes and adherence to procedures for data entry is crucial

13. Facilitating Teams to Identify, Improve or Create Processes • Leverage team, ensure strong leadership • Assess and document baseline processes • Identify accuracy of panel reports generated and where gaps may exist • Identify opportunities for improvement with clear measurable goals • Move forward with structured plan for change

14. Structured Change and Improvement • “Jumping to solution” can result in: • adoption of processes that are not effective as intended • not well planned resulting in unexpected, negative outcomes that may be difficult to retract • Use a structured approach • Model for Improvement

15. Leadership and Team – Keys to Success • Physician/Provider leadership and commitment • Engage with all clinical and non-clinical staff who are involved in the process • Leadership communication of overall goals creates alignment of objectives and plans Those who do the work must change the work

16. Panel Discussion at Blue Meadow We’ve been validating patient attachment at check-in since AIM and PDI, right? I thought those were over??

17. Panel Process Development Checklist C1 Two critical questions: • Does the patient record indicate the provider responsible for providing screening? • Can the provider or team generate a list of the patients attached to the provider?

18. Panel Process Assessment Tool

19. Summary • Panel identification and demographics are critical to understanding the clinical needs of a patient population • Standardization of process and adherence to procedures across the practice is key • EMRs are helpful tools for recording and analyzing data when strong processes are in place • Assessing, planning and testing processes requires strong leadership and input from the team • Utilize a structured methodology for developing, testing, and changing processes