The project reported here was designed as an early, rapid assessment of the potential and transferability of panel management and is subject to several limitations. The number of sites studied (four) is small. The site selection and interviewee selection processes were nonrandom, which could have introduced bias. Also, although there was some indication that two of the four study sites were able to provide better coordination of care from the patient's perspective, the data are not sufficient to attribute this advantage to any specific practice, because multiple confounding factors complicate interpretation of the findings. The two sites that appeared to have stronger coordination of care had been in place much longer than the other two sites, giving the former time to fine-tune the programs and processes. In addition, these two sites implemented panel management in a sequential manner over time, rather than implementing in many modules at once. Although causality cannot be established, this study provides value by identifying potential strengths and limitations that can accompany panel management implementation, so that potential adopters have an opportunity to put in place measures that benefit from the experiences of other sites.
A related limitation of these findings is the lack of quantitative measures to more fully evaluate models. Panel management is spreading across KP in the absence of comprehensive quantitative data on its impact. The changing nature of all components—information technology, people, and process—across KP challenge our ability to develop compelling data on impact. There remains great variation among adopter sites. Issues such as optimal staffing, amount of dedicated physician time, workflow, and communication are still the subjects of experimentation. Currently, programs are not fixed and continue to develop and change. These factors make it challenging to identify superior models or to evaluate models more rigorously at this stage. As a result, the findings summarized here should be regarded as hypothesis-generating. The remaining discussion focuses on hypotheses regarding two specific issues: care coordination and self-management support.
Panel Management and Coordination of Care
A key element in high-quality primary care is care coordination, with all caregivers having detailed knowledge of care the patient is receiving from other sources. Numerous studies have shown that coordination of care is associated with greater levels of population health and patient satisfaction.8–11
In light of patient experiences documented in this study, coordination of care within the panel management process seemed to represent an important area for greater inquiry and attention. For example, in one focus group a patient reported that she was told by panel management staff that medications were ordered, but when she went to the pharmacy there were no medications there. A few examples of this type of experience surfaced in each of the two sites where some patients experienced challenges related to coordination-of-care.
The two relatively more coordinated sites (most patients experiencing their care as coordinated) shared certain features, but as noted, we cannot determine whether these factors directly contribute to the observed differences across sites. Possible contributors to coordination include limited roles for nonphysician staff in clinical decision making; tightly coupled physician–staff relationships with clearly defined and transparent roles for support staff; and program size, maturity, and evolution (see ).
Research on using telephone support to manage chronic disease suggests that using clinic-based staff and tightly linking these types of programs to clinic-based care can contribute to greater program effectiveness. The most effective programs, research suggests, are those that link phone outreach to outpatient care and clinician follow-up.7
However, the evidence of the impact of staffing decisions on program effectiveness is not conclusive.
We hypothesize that one contributor to patient perceptions of coordinated care may be team preparation—more specifically, staff preparedness for the role that they take on in panel management. Patients overwhelmingly expressed tremendous satisfaction with their PCPs and a strong desire to have their PCPs involved in directing their care, but their satisfaction with outreach staff was mixed. It is possible that staff who are accustomed to having a directive role and semiautonomous relationship working with patients may implicitly convey a sense of authority that is inconsistent with the explicit message that the physician is directing the care; this ambiguity of authority may confuse patients. In contrast, nonlicensed staff may give a stronger impression that their role is to support communication between patient and physician, thus preventing any misunderstandings.
We also hypothesize that a second pathway by which use of licensed staff (eg, registered nurses or pharmacists) in the PMA role may affect coordination is the reduction of physician engagement in panel management. At sites where medical assistants conduct outreach, it is possible that physicians are delegating fewer panel management activities and retaining greater personal ownership and responsibility for clinical decisions. By contrast, at sites where PMAs are licensed staff, PMAs—under protocol—have the authority to draft treatment orders for physician review. Physicians with licensed PMA staff may spend less time generating their own orders, thus decreasing their role in directing care and decreasing their role in assuring coordination. Choice of PMA staffing—licensed or unlicensed—is influenced by a tension between the greater efficiency of having orders drafted by nonphysician staff and the potential for decreasing coordination and/or weakening patients' confidence that their physicians are fully overseeing their care.
Other possible factors that might improve the patient experience and contribute to a more coordinated patient experience include “warm handoffs,” with physicians explaining to patients the new roles of panel management staff or activities; strong communication skills for outreach staff, coupled with training programs and education and skills development; and ongoing program oversight. Other factors may also contribute to differences in patient experiences, and these should be factored into further evaluation of panel management activities. Some additional factors might be panel size, collocation of panel management staff and physicians, staffing ratios, and the amount of physician and nonphysician designated time.
Panel Management and Self-Management Support
A second issue, also related to choice of staffing, is the role of self-management support in panel management. Some study sites are coupling proactive outreach with self-management support. Other sites are not doing so, and at these sites, the transition from traditional care management to panel management—with its emphasis on briefer patient contacts—may be decreasing capacity for self-management support. Because self-management support has been identified as an integral aspect of chronic disease care and one that favorably affects health status and health care utilization,12–14
this issue is an important area for additional attention and inquiry.