Interprofessional Academic Patient Aligned Care Team Panel Management Model

At the population level of chronic disease management, preliminary evidence demonstrates that primary care clinic patient panels are increasingly within target for DM and blood pressure measures, as assessed by periodic clinical reports to providers. Some of the PM topics have resulted in systems-level improvements, such as reducing unnecessary ED use for nonacute conditions and better opioid prescription monitoring. Moreover, PM supports everyone working at the top of his/her professional capability. For example, the RN care manager has the impetus to initiate DM education with a particular patient.

Since CoEPCE began teaching PM, the Seattle primary care clinic has committed to the regular access and review of data. This has encouraged the alignment of standards of care for chronic disease management so that all care providers are working toward the same benchmark goals.

Patient Outcomes

At the individual level, PM provide a mechanism to systemically review trainee panel patients with out-of-target clinical measures, and develop new care approaches involving interprofessional strategies and problem solving. PM also helps identify patients who have missed follow-up, reducing the risk that patients with chronic care needs will be lost to clinical engagement if they are not reminded or do not pursue appointments. The PM-trained PACT reaches out to patients who might not otherwise get care before the next clinic visit and provides new care plans. Second, patients have the benefit of a team that manages their health needs. For example, including the clinical pharmacists in the PM sessions ensures timely identification of medication interactions and the potential AEs. Additionally, PM contributes to the care coordination model by involving individuals on the primary care team who know the patient. These members review the patient’s data between visits and initiate team-based changes to the care plan to improve care. More team members connect with a patient, resulting in more intense care and quicker follow-up to determine the effectiveness of a treatment plan.

PM topics have spun off QI projects resulting in new clinic processes and programs, including processes for managing wounds in primary care and to assure timely post-ED visit follow-ups. Areas for expansion include a follow-up QI project to reduce nonacute ED visits by patients on the homeless PACT panel and interventions for better management of care for women veterans with mental health needs. PM also has extended to non-Co- EPCE teams and to other clinic activities, such as strengthening huddles of team members specifically related to panel data and addressing selected patient cases between visits. Pharmacy residents and faculty are more involved in reviewing the panel before patients are seen to review medication lists and identify duplications.

The Future

Under stage 2 of the program, the Seattle CoEPCE intends to lead in the creation of a PM toolkit as well as a data access guide that will allow VA facilities with limited data management expertise to access chronic disease metrics. Second, the CoEPCE will continue its dissemination efforts locally to other residents in the internal medicine residency program in all of its continuity clinics. Additionally, there is high interest by DNP training programs to expand and export longitudinal training experience PM curriculum to non-VA based students.