Block 6: Population management

High-performing practices stratify the needs of their patient panels and design team roles to match those needs. Three population-based functions provide major opportunities for sharing the care: panel management, health coaching, and complex care management. Panel management involves a staff member, usually a medical assistant or nurse, periodically checking the practice registry to identify patients who are due for routine services (eg, mammograms, colorectal cancer screening, and HbA1c or low-density lipoprotein cholesterol laboratory work).

Alternatively, the panel manager can check the health maintenance screen on the electronic medical record before a huddle or medical visit to look for care gaps for these services. Standing orders enable panel managers to address care gaps without involving the clinician. In some practices, most routine care is completed before the clinician enters the examination room, so that visits can focus on patients’ concerns, issues requiring the clinician’s level of expertise, treatment options, and shared care plans.

For patients with chronic conditions, health coaching entails assessing patients’ knowledge and motivation, providing information and skills, and engaging patients in behavior-changing action plans known to improve outcomes. Diabetes patients working with health coaches, whether medical assistants or other, may have better outcomes than patients without health coaches. When medical assistants, nurses, health educators, or pharmacists act as health coaches, they are usually given protected time to assume this time-consuming function.

Complex care management has emerged as a way to address patients’ needs that are medically and psychosocially complex, as well as patients who are high utilisers of expensive services. Teams headed by registered nurses or social workers have been shown to improve care and reduce costs for patients needing complex care management. Health coaching and complex care management take considerable time, and small practices can benefit from outside organisations assisting them with these functions.