Managing a population of patients – or an entire “panel” – requires proactive effort to ensure no patient falls through the cracks. Our Panel Management solution is about taking a bird’s-eye view of your patient population and systematically closing care gaps, monitoring health maintenance, and targeting interventions to those who need it. In short, we help you move from reactive sick care to proactive health management across your panel.
The Medicare Annual Wellness Visit is a yearly preventive visit offered at no cost to qualifying patients. It’s an opportunity to focus on prevention, wellness, and care planning rather than acute problems.
In today’s healthcare environment, quality metrics and value-based care outcomes are paramount. Brilliant Care’s Quality Management services help your organization excel in these areas by providing dedicated support for meeting and exceeding quality benchmarks, such as those in MIPS, HEDIS, or ACO performance measures.
We track which patients are due (or overdue) for important preventive services: Annual Wellness Visits, cancer screenings (mammograms, colonoscopies), immunizations (flu, pneumonia, shingles), diabetes eye exams, etc. These gaps in care are identified through data analysis of your EHR or claims. Our team then reaches out to patients to schedule those services and educate them on why they’re important. For example, if a 68-year-old woman hasn’t had a mammogram in 3 years, we contact her to facilitate getting one. By ensuring patients receive recommended preventive care, we improve outcomes and help you meet quality metrics. According to the CDC, if everyone received recommended preventive services, over 100,000 lives could be saved each year. We take that statistic to heart and work diligently to get your patients the screenings and interventions that can catch problems early.
We maintain registries for chronic conditions (like diabetes, hypertension, asthma). This allows us to pinpoint patients who aren’t at goal or haven’t been seen recently. For instance, we might find all diabetic patients with A1c >9 or without an A1c check in 6+ months – then take action: arrange a lab test, schedule a visit, or enroll them in our Chronic Disease Management program for extra support. By focusing on those who need extra attention, we can improve overall control rates in your population.
Our Panel Management uses advanced analytics to identify at-risk patients beyond obvious care gaps. We analyze hospitalization and ER data, social determinants, medication refill adherence, etc., to flag patients who may benefit from intervention. Perhaps a patient hasn’t refilled their blood pressure meds for 2 months – a sign of non-adherence – we’ll reach out to understand why and get them back on track (maybe they need a 90-day refill or had side effects to discuss with their doctor). We leverage such data to prioritize outreach, essentially using data-driven insights to improve processes and identify patient risks.
We run campaigns for specific initiatives, often aligned with quality improvement goals. For example, if a health system wants to improve its colorectal cancer screening rate from 60% to 80%, we’ll create a targeted call list and systematically contact those who haven’t been screened, educate them, and help arrange stool tests or colonoscopies as appropriate. We provide weekly/monthly reports on progress. This is how we help you maximize your quality scores and recurring revenue streams from CMS by meeting targets.
Panel management isn’t just patient outreach – it’s also optimizing your practice’s workflows. We work with your staff to implement best practices like pre-visit planning (see Virtual Office Services below) and standing orders for preventive care, etc. Our involvement can help standardize protocols and ensure consistency in care delivery across providers. By doing so, we reduce the chance that a patient’s need is overlooked.
We can utilize population health software or even built-in EHR registries to track progress. If you have a platform (like Epic’s Healthy Planet or others), we integrate our efforts with it. If not, we maintain our own tracking tools and ensure seamless care coordination with your practice’s records. We keep meticulous records of outreach attempts, patient responses, and outcomes – feeding that information back to your system so you have a full picture.
Effective panel management leads to impressive benefits. Patients benefit by having up-to-date, holistic health profiles and receiving more preventive and personalized care. They enjoy better health and longevity by addressing issues early and staying engaged in care. Providers benefit by meeting quality measure thresholds (e.g., Medicare star ratings, HEDIS measures), which can enhance reputation and financial bonuses. Healthcare systems benefit through healthier populations (lower acute care utilization) and decreased burden on resources because preventive care is far cheaper than emergency care. As an example, closing gaps in care such as getting patients on appropriate screenings can help avoid late-stage disease costs. Another benefit: panel management often leads to improved patient satisfaction, because patients feel looked-after and value that their provider reminds them of important health actions.
To illustrate, consider a practice of 1,000 Medicare patients. Before panel management, perhaps only 50% had an Annual Wellness Visit and many screenings were missed. After implementing our program, AWV completion could rise to e.g. 75-80%, dozens of previously undiagnosed issues may be caught early (like high blood sugar, early-stage cancers), and your overall Medicare quality scores could jump significantly. One could see fewer hospitalizations as well; for instance, ensuring CHF patients get seen and educated regularly might reduce their monthly readmission rates meaningfully. There’s evidence that proactive outreach reduces hospital use and improves outcomes, which is exactly what panel management achieves.
Brilliant Care functions as your population health taskforce. We ensure every patient in your panel gets the attention they need at the right time. Think of it as high-level oversight combined with on-the-ground action: we use the data to drive strategy, then pick up the phone and connect with patients to actually get things done (appointments scheduled, tests completed, etc.). This relieves your providers and staff of having to constantly remember every gap – we take that weight off their shoulders, so they can focus on the patient in front of them while knowing the rest are also being looked after.
In summary, our Panel Management solution ensures your patients get the right care at the right time, systematically. It’s a key piece in excelling under value-based care and in delivering superior preventive services. Let us handle the tracking, calling, and coordinating – you will see the difference in both your metrics and, more importantly, in the healthier smiles of your patient population.
