NEW Care Delivery Model!!!! Shifting from “Visit-Based” to “Value-Based Panel Management”
Shifting from “Visit-Based” to “Value-Based Panel Management”
Traditionally, primary care has been organized around individual office visits—patients seek care when they feel sick or need a specific service. While that model addresses acute issues, it often misses proactive, population-level health management. Our Care Delivery Model (CM-1 through CM-3) transitions GSCC to “panel management,” where each care team takes responsibility for the health of a defined patient panel rather than reacting only to face-to-face appointments.
Key Goals of Panel Management vs. Visit-Based Care
Proactive Outreach: Rather than waiting for patients to call, we identify high-risk or preventive needs (vaccines, chronic-disease checks, screenings) and reach out first.
Right-Level Support: Patients receive exactly the level of care coordination they need—no more, no less—avoiding both duplication and gaps.
Data-Driven Decisions: We use registry reports, quality metrics, and scheduling analytics to monitor every panel’s status—tracking who’s up to date on screenings, due for follow-up labs, or needing intensified support.
Team-Based Accountability: Care is delivered by a multidisciplinary team (providers, nurses, medical assistants, care coordinators, referral coordinators, behavioral health specialists) working under a unified care-team structure. Everyone is responsible for keeping their assigned panel healthy.
CM-1: Care Coordination
Who It Serves
ALL patients.
Patients with stable chronic conditions (e.g., well-controlled diabetes or hypertension)
Patients due for preventive screenings and visits (e.g., immunizations, annual wellness visits, well-child exams, mammograms)
What Happens
Registry Screening & Outreach: Care Coordinators (CCs) run monthly registry reports (e.g., overdue labs, missing cancer screenings) and identify patients with care gaps.
Standardized Protocols: If a patient is due for an annual visit or routine lab, the CC calls or messages to schedule the appointment—often before the patient realizes they’re due.
Patient Self-Management Resources: Educational materials (handouts, portal messages) on topics like diet, exercise, and medication adherence are sent proactively.
Team Roles
Providers: Oversee the clinical care of their patient panels—diagnosing conditions, developing treatment plans, and adjusting therapies based on real-time panel data and patient feedback. They participate in regular huddles to review CM-1 patients who need outreach, authorize standing orders, and ensure each patient receives the appropriate level of care (CM-1, CM-2, or CM-3).
Clinical Pharmacist: Performs detailed medication reviews and reconciliation for CM-1 patients whose lab results or prescription refills signal potential issues. Identifies and resolves drug-related problems, collaborates with providers and CCs to optimize pharmacotherapy (including cost-effective alternatives), and educates patients on medication adherence and safety.
LPN Ops: Supports and oversees daily clinic workflows and nursing team. Streamlines patient flow solving daily operational issues that affect care delivery, ensure that the care teams are ready and prepped for the day, and escalates urgent clinical issues to RN Care Managers or providers as needed.
LPN Admins: Manage assigned work queues (“buckets”), handles all incoming nurse calls, verify insurance authorizations, and enters essential clinical data into the EHR. Their timely documentation and follow-up on lab orders allow providers and care managers to make data-driven decisions without delay.
Medical Assistants (MAs): Conduct patient intake, prepare exam rooms and equipment for procedures, complete standing-order tasks (e.g., vitals, point-of-care testing) when the patient arrives, and assist with bucket management.
Referral Coordinators: Manage incoming referral orders for patients needing specialty services or diagnostics, schedule appointments, track authorizations, and follow up to confirm referral completion—closing the loop on every referral.
Behavioral Health Consultants: Conduct brief mental health screenings, provide short-term counseling, and develop collaborative care plans for CM-1 patients whose social or emotional needs affect medical outcomes. They consult with providers, RNCMs and CCs to integrate behavioral health interventions—such as stress management or motivational interviewing—into each patient’s overall care strategy.
Care Coordinators: Generate and analyze registry reports to identify patients due for preventive screenings or chronic disease follow-up. They proactively reach out to schedule appointments, screen for Social Determinants of Health, and verify and close referral loops for needs like food insecurity, housing instability, and transportation barriers—connecting patients with community resources and resolving care gaps promptly.
Why It Matters
Keeps stable patients “in the loop” so they don’t slip through the cracks.
Reduces last-minute demand on scheduling and providers, smoothing daily workflows.
Improves preventive metrics (e.g., immunization and cancer screening rates) across our entire patient population.
Provides timely, consistent care and keeps panels healthy before issues escalate.
CM-2: Episodic Care Management
Who It Serves
Patients with moderate complexity or temporary exacerbations (e.g., recently discharged from the hospital, new onset of a chronic disease needing education)
Patients with unstable or newly diagnosed chronic conditions (e.g., newly diagnosed heart failure)
What Happens
Risk Stratification: RN Care Managers assign a CM-2 “flag” when a patient’s recent data (e.g., A1C > 9%, readmissions, or new specialist referrals) indicate higher short-term risk.
Structured Care Plans: An RN Care Manager develops a customized plan—medication reconciliation, post-hospital discharge follow-up, initiates a brief behavioral health screening, or social needs assessment.
Regular Check-Ins: RN Care Manager schedules weekly or biweekly phone or telehealth check-ins to monitor symptoms, adherence, and social factors (transportation, food security).
Collaborative Huddles: RN Care Manager brings CM-2 patient updates to weekly team huddles—providers, pharmacist, behavioral health—to ensure alignment and promptly address any changes.
Team Roles
RN Care Manager: Creates and executes episodic care plans; coordinates transitions of care; communicates with specialists and providers; tracks progress and adjusts interventions as needed.
Behavioral Health Counselor: Provides brief interventions (e.g., screening for depression or anxiety) when emotional or mental health challenges impede medical adherence and refers to higher-level behavioral health services, if necessary.
Clinical Pharmacist: Reviews medications, performs medication reconciliation, identifies compliance issues or cost barriers, and collaborates with the RN Care Manager and providers to optimize regimens.
Providers: Oversee clinical decisions for CM-2 patients, adjust treatment plans, and review progress in team huddles.
Why It Matters
Prevents avoidable readmissions or ED visits by addressing issues as soon as they arise.
Delivers tailored support for patients who can’t “self-manage” effectively on their own.
Strengthens continuity of care after hospitalization or during a care transition, reducing fragmentation.
CM-3: High-Risk, Longitudinal Care Management
Who It Serves
Patients with multiple chronic conditions, frequent hospitalizations, or high utilization (e.g., advanced COPD, severe heart failure, complex behavioral health)
Patients with significant social determinants of health (housing insecurity, high transportation barriers, multiple comorbidities)
Patients 70+ years of age.
What Happens
Comprehensive Assessment: The High-Risk Care Manager conducts a detailed biopsychosocial assessment—including health literacy, mental health status, community resources, and social needs.
Intensive, Ongoing Support: High-Risk Care Manager schedules weekly home visits (in the future), telehealth meetings, or in-clinic care conferences. They partner with community agencies (e.g., housing services, food banks) to address non-medical barriers.
Rapid Response & Escalation: If a patient’s condition worsens, High-Risk Care Manager triggers immediate provider or specialist outreach to prevent a crisis.
Data & Quality Monitoring: Care plans are tracked in registry dashboards to monitor key metrics (e.g., readmission rates, ED utilization, HCC risk scores). The High-Risk Care Manager updates plans monthly or whenever a major change occurs.
Team Roles
High-Risk Care Manager: Leads in-depth assessments; coordinates with PCP, specialists, behavioral health, and community partners; manages 24/7 on-call support protocols for this panel; and ensures continuous, wraparound care.
Behavioral Health Consultant: Provides ongoing, in-depth therapy or psychiatric evaluation for co-occurring mental health conditions, collaborating with the High-Risk Care Manager to integrate behavioral health into the overall plan.
Clinical Pharmacist: Performs complex medication management—dose adjustments, polypharmacy reviews, cost optimization—and works closely with the High-Risk Care Manager and providers to minimize adverse effects.
Care Coordinator: Facilitates long-term wraparound services (housing, transportation, disability benefits, community support programs) and advocates for patients’ social needs.
Providers & Specialists: Actively co-manage high-risk patients in weekly multidisciplinary care conferences, making real-time treatment adjustments.
Why It Matters
Significantly reduces avoidable hospital admissions and ED visits by providing continuous, high-touch support.
Addresses root causes of poor health (social determinants) rather than only treating symptoms.
Improves patient satisfaction and quality of life for our most vulnerable populations, building trust and engagement.
How CM-1 to CM-3 Support Panel Management
1. Risk Stratification & Registry Use: Every patient on a provider’s panel is continuously assessed via registry reports. High-risk flags move patients into CM-2 or CM-3; stable patients remain in CM-1.
2. Proactive Communication: Instead of waiting for patients to request care, the care team reaches out based on clinical need—closing gaps before they become crises.
3. Right Care, Right Time, Right Place:
CM-1: Automated reminders and standing orders for stable patients.
CM-2: Brief RN-led interventions for transitional or worsening conditions.
CM-3: Intensive, wraparound support for complex, high-risk cases.
4. Data-Driven Continuous Improvement: Weekly huddles and monthly panel reviews (e.g., uncontrolled A1Cs, missed preventive screenings, hospital readmission rates) allow each team to adjust strategies in real time.
5. Shared Accountability: Providers, nurses, care managers, and support staff share responsibility for panel outcomes—no single clinician is “on an island.”
What This Means for Your Daily Work
Front-Desk & Scheduling Teams: You’ll see changes in how appointments are booked. Many visits for preventive care will be scheduled automatically by Care Coordinators—your role shifts toward verifying patient contacts and helping with education on why these visits matter. Future online self-scheduling will handle many patient-requested visits, allowing you to focus on more complex scheduling needs.
Medical Assistants & Nurses: You’ll prepare for new workflow patterns—pre-visit planning for CM-1 and CM-2 patients (e.g., prepping charts, gathering standing-order labs) and participate in huddles to review panel snapshots. Triage protocols will direct high-risk patients to RN Care Managers or High-Risk Care Managers.
Providers: Instead of only seeing walk-in or scheduled “problem visits,” your panel will be structured based on risk. You will spend time in multidisciplinary huddles reviewing who needs extra outreach. You’ll also have panel dashboards displaying key metrics—so you can identify and address gaps during a patient’s visit.
Care Coordinators & Care Managers: You’ll drive proactive outreach. For CM-1 patients, that means monthly calls for overdue labs or screenings. For CM-2, weekly check-ins, medication reconciliation, and brief behavioral health screenings. For CM-3, home visits (future), social-needs assessments, and deeply layered support.
Behavioral Health & Pharmacy Staff: You’re essential collaborators in CM-2 and CM-3. Behavioral health specialists offer brief and ongoing interventions to improve medical adherence; pharmacists conduct medication reviews and cost-optimization calls. Your expertise directly impacts chronic disease control and overall panel outcomes.
Leadership & Support Staff: You’ll monitor panel metrics in real time, provide feedback on workflows, and ensure continuous training so teams can adapt. Periodic reviews of key performance indicators (e.g., percentage of patients up to date on A1C checks, avoidable hospitalizations, preventive screening rates) guide resource allocation and future process improvements.
In Summary
Our CM-1 to CM-3 model represents a paradigm shift:
From “See you when you call” to “We’ll see you when you need us.”
From reactive, volume-driven encounters to proactive, value-driven engagement.
From isolated visits to coordinated panel management.
By organizing care around a patient’s overall risk and needs—rather than individual appointments—GSCC will:
Improve health outcomes through timely interventions.
Enhance patient satisfaction by reducing no-shows and wait times.
Strengthen financial sustainability by optimizing resource use and minimizing avoidable high-cost events.
Thank you for embracing this shift. Together, we’re moving beyond the four-wall office visit to a holistic model that truly places each patient’s health in the hands of a dedicated, multidisciplinary team.
— Teresa