The concept of panel management—caring for a population of patients whether or not they come in for a visit—is
a key change in mindset in becoming a PCMH. Care should
be approached not as a string of loosely connected appointments, but rather proactive connections with patients to
develop continued relationships and continuity of care leading
to high-quality, consistent care. 5 Professor Anthony R. Kovner,
Ph.D., notes, “Doing what is right to improve the patient experience is increasingly complex, but every indicator suggests
that a seamless delivery system is the solution.” 6
Merging the PCMH concept with our unique data-driven
care model allows us to fully realize our aspiration of being an
integrated healthcare delivery system. Rather than perceiving it as a visit with their primary provider, patients view the
PCMH as a medical home where care is seamlessly connected during sickness and in health.
Expanding on the Concept
Consider how the sepsis model cell can be developed and
spread to benefit other populations in our communities.
Chronic kidney disease (CKD) affects approximately 14%
of the general population. Early stages of kidney disease
are often asymptomatic, detected during the evaluation
of comorbid conditions, and may be reversible. Left
unchecked, the patient can progress to kidney failure, need
for dialysis or transplant, and eventually death. Although
the need for treatment of chronic kidney failure with
dialysis and/or kidney transplantation arises in only 1%
of people with CKD, it remains the most expensive chronic
disease and reduces lifespan significantly. 7 Failure to
recognize CKD results in neglect of its consequences, com-
plications, and late referral of people with advanced CKD,
resulting in worsened renal replacement therapy (RRT) out-
comes. Timely identification and appropriate management
are key to improving both clinical and economic outcomes.
Currently, identification of CKD is dependent on the patient
visiting their primary care physician (PCP) and providers not-
ing decline in kidney function in lab work during a visit. What
if we use Epic to identify patients with an estimated glomer-
ular filtration rate (eGFR) under a certain threshold who do
not have a diagnosis of CKD and/or do not have a relationship
with a nephrologist? Such opportunities could be served to
a care team tasked to review these cases to confirm. If a
care gap indeed exists, the patient is contacted to set up an
appointment with an appropriate provider (PCP, nephrologist)
for further evaluation. When patients arrive for an appoint-
ment, they have a clearly defined care opportunity. The
Kidney Disease Improving Global Outcomes (KDIGO) clinical
practice guidelines offer a roadmap for management of CKD
patients throughout the progression, which can be incorpo-
rated into care protocols and order sets. 8
Achieving Full Potential
Much-hyped “disruptive” technology is seldom disruptive
by itself and requires concomitant changes in how work
is performed to realize its full potential. 9 With the rise of
EHRs, we have new tools at our disposal to improve care
processes, but incorporating them into legacy, point-of-care
approaches leads us to fail to realize their potential—and
creates monstrosities clinicians despise. We have a tremendous opportunity to rethink “business as usual,” employing
the CAT model of care as a roadmap for redesigning how care
is provided in the age of the EHR. Our patients and providers
will thank us.
Emily Edleblute, M. S., R.N., ACNS- BC, CCRN-K, is program director,
Medicine Service Line, at WellSpan Health, and Steven L. Delaveris,
D.O., is vice president, Medicine Service Line, at WellSpan Health.
1. M. Graban. 2015. Model Lines and Model Cells to Start
a Lean Transformation Strategy. Lean Blog, August 17,
2015. Accessed May 1, 2019 at leanblog.org/2015/07/
2. J. Touissaint. 2015. Management on the Mend: The Healthcare
Executive Guide to System Transformation. Appleton, WI:
ThedaCare Center for Healthcare Value.
3. A. Gawande. 2018. Why Doctors Hate Their Computers. The New
Yorker, November 5, 2018. Accessed May 15, 2019 at newyorker.
4. American Academy of Family Physicians, American Academy
of Pediatrics, American College of Physicians, and American
Osteopathic Association. 2007. Joint Principles of the Patient-Centered Medical Home. Accessed May 15, 2019 at aafp.org/
5. Agency for Healthcare Research and Quality. 2013. Practice
Facilitation Handbook: Module 20. Facilitating Panel Management .
Accessed May 15, 2019 at ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/ mod20.html.
6. A.R. Kovner. 2010. Case Study: What More Evidence Do You Need?
Harvard Business Review, May 2010. Accessed May 5, 2019 at hbr.
7. National Institute of Diabetes and Digestive and Kidney
Diseases. 2016. Kidney Disease Statistics for the United States.
Accessed May 1, 2019 at niddk.nih.gov/health-information/
8. Kidney Disease Improving Global Outcomes. KDIGO 2012 Clinical
Practice Guideline for the Evaluation and Management of Chronic
Kidney Disease. 2013. Kidney International, 3( 1):1-150.
9. L.R. Burns and M.V. Pauly. 2019. Detecting BS in Health Care
2.0. Leonard Davis Institute of Health Economics. Accessed
May 5, 2019 at ldi.upenn.edu/sites/default/files/pdf/LDI%20