At Bellin Health System, James Jerzak, MD, is piloting a new team-based care model. His team medical assistant, Jami, rooms his patients and prepares them for the visit. During the rooming process, Jami performs in-reach panel management. In diabetic and prediabetic patients, Jami assesses the patient's lab results to see how well the HbA1c is controlled. She also takes their blood pressure and determines whether it appears to be under control. She reviews the patient's chart to see if there are any upcoming screenings that are due or will be due before the patient's next appointment. If the patient has upcoming or overdue care needs, Jami can see yellow and red flags in the electronic health record. If the patient needs a mammogram, colonoscopy or other preventive screen, she will schedule it for the patient during rooming. If the patient needs any immunizations, Jami can provide them based on standing orders.
When Dr. Jerzak enters the examination room, Jami does a brief handoff, telling him why the patient came in for the appointment and any concerns related to blood pressure, lab results, diagnostics, or hospitalizations since the last appointment. Jami stays in the room during the visit to document it for Dr. Jerzak, making notes of education to provide to the patient and prompting Dr. Jerzak to discuss the patient's high blood pressure reading that was uncovered during rooming.
Jami and Dr. Jerzak are not alone in using panel management to improve the health of their patients. Team members working in registration are empowered to use their “best practice alert” to notify patients of overdue tests or services, and to schedule necessary appointments when patients call for any reason. Bellin Health System plans to augment their out-reach approach as their team-based care model spreads throughout the organization.