Care Transformation

Panel & Gap Management


What is Panel Management?

Panel Management is a proactive approach to health care. “Population” refers to the panel of patients associated with a provider or a care team. Population-based care means that the care team is concerned with the health of the entire population of its patients, not just those who come into the clinical setting for visits.

The panel (a group of patients assigned to a PCP) allows care teams to oversee and track proactively the health care needs of patients on their panels and ensure that all patients receive the services they need to optimize their health and well-being.

Panel management ensures that all patients, not just those who come in for appointments, are getting the preventive and chronic condition care they need. For example, a practice may use panel management to ask “Have all of our patients between 50 and 75 years of age received colorectal cancer screenings at the appropriate time intervals? Have all of our patients with a diagnosis of diabetes had lab tests for HbA1c, eye exams and urine microalbumin at the appropriate times?”

What is Gap Management?

Gap Management is a collaborative, deliberate effort to oversee, track and analyze primary care quality metrics and performance to identify, and then actualize a team-based approach to closing gaps in care. Gaps include preventive measures, chronic conditions measures, HCC updates (risk gaps), information gaps and completion of Annual Wellness Visits. Success metrics include: percentage of panels with care gaps closed, percentage of patients not attributed to a PCP with care gaps closed, percentage of preventive screenings and immunizations complete, percentage of panels with chronic disease management states that are “controlled.”

System-wide, a dedicated approach is used to identify and then prioritize commonalities in below-threshold performance on HEDIS measures (care gaps) across the health system. The intent is to evaluate, foster and operationalize a systematic approach to adopt best practices in workflows and patient care approaches, respective of the diversities that exist in care team models and patient populations.

Ambulatory Quality Measures

The UW Medicine health system is accountable for a variety of ambulatory quality measures across a complex payer mix; Commercial, Medicare Traditional, Medicare Advantage, Medicaid and the Accountable Care Network (Boeing, PEBB). Knowledge of not only the metrics to which we are measured, but also the targeted performance thresholds, is integral to UW Medicine’s performance goals, as well as the provision of the highest quality of care for all our patient populations.

Ambulatory Quality Measures Grid 2018 – Open & View

Panel Management Lexicon

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