The Practice Support Program: An Essential PCN Stepping Stone For Your Practice
Written by Saira Abrar, Physician Engagement and Support Manager, and Ranjit Sekhon, PSP Lead
Surrey-North Delta (SND) division is currently in the process of creating an integrated network of patient medical homes, called the “Primary Care Networks” (PCNs).
Team-based care is considered foundational for the development of PCNs, aiming to improve provider and patient experience. Among many other valuable resources, PCNs will ensure the addition of various allied health resources to physician offices in SND. However, PCN implementation requires a certain degree of preparedness by primary care practices, the most important being understanding their panels.
"As I have come to the end of the Panel Management and QI modules, I wish to reflect on how this has enhanced my practice and by extension, my patient care. Throughout the process, I have been steadfastly guided by Ms. Ranjit Sekhon from the PSP in the Fraser Region. Ranjit has provided much needed support in choosing, planning, executing, and reflecting on quality improvements to my practice. I have been able to take on some new patients after clearing up my patient panel. My patients have been appreciative of the proactive care initiatives these exercises have resulted in. I have recently been made aware that as a result of these proactive initiatives, a patient of mine had a cancer diagnosed that may have otherwise gone undetected. This is a very real example of the value of the PSP and the modules they provide.” ---Dr. Baby Benjamin
PSP helps physicians in preparing for PCN implementation by restructuring practice improvement processes, enabling them to deploy multidisciplinary teams in the clinics successfully.
PSP supports are available through:
- Coaching and mentoring: Focused on practice improvement and offered directly at physician offices. Compensation and certification are available.
- Learning modules: Focused on quality improvement, patient self-management and team-based care. Interactive online, in-person or blended group sessions
- PSP data tools, including:
- Quality Improvement Projects: Enables practice improvement through PSP’s facilitated quality improvement cycle. These projects have helped physicians immensely to address the challenges faced by their practices during the pandemic.
How Well do You Understand Your Panel?
Panel Management is a systematic approach to using accurate panel data to provide proactive care and to increase physician satisfaction. The Practice Support Program supports physicians in completing manageable activities documented in a three-phase panel management workbook. Panel management is a crucial onboarding step for PCN implementation.
"Panel Management is an organized method to identify complex disease managed and be proactive. Also I have increased my reimbursement for work we already do." ---Dr. Sujatha Nilavar
PSP services are customizable, and PSP coaches can work around physicians’ schedules. Because of the pandemic, panel work is now offered remotely; additional supports are available through peer mentor physicians and MOAs.
In Surrey-North Delta, 57 physicians have completed panel management, and another 47 are nearing completion.
Could Your Patients' Experience and Your Own Be Improved?
Panel work empowers physicians to achieve the “Quadruple Aims.” Physicians can leverage the PSP supports to:
- Optimize their EMR and accurately know their panel size and composition.
- Provide pro-active and preventative care, especially for chronic disease patients
- Engage team members to their maximum potential and build strong relationships
- Identify active/ inactive patients, and assess the feasibility of new attachments
- Program follow-up reminders within EMR according to the clinical guidelines
- Generate auto-populated forms leveraging the EMR
- Reduce billing errors by correctly entering ICD 9 codes
- Implement virtual care confidently, reducing chances for missed clinical diagnosis
What Are the Three Phases of Panel Management?
Panel management work has three phases:
- Confirm yourself as MRP
- Understand you patient panel
- Manage your patients' care
The completion time of each phase depends on various factors: mainly the current state of the data that has already been entered and the availability of physicians and/or MOAs to implement the required changes.
"This was a great program, I learned a great deal about how to better organize my patient panel to better help with patient care and billing. I did not realize the enormous potential of the Oscar EMR to help with complex care billing. Definitely a great experience!!" ---Dr. Nischea Sihota
Supporting participants through the phases is a workbook - a step-by-step guide helping physicians and their teams to make the most of their time by better managing their panels. It offers quick access to clear panel information by identifying the care gaps. It also serves as a clinic manual for current and future teams.
What Are the Benefits of Panel Management?
GPs can receive up to $6000 and three MainPro+ credits for up to 25 hours (maximum 75 MainPro+ credits) for completing the Panel Management Workbook.
Beyond the monetary compensation, PSP members can help you use your EMR to the maximum potential. There are many functionalities in the EMRs that can be used to do searches easily and create preventative care or follow-up plans. If you encounter challenges learning your EMR functionalities, PSP coaches can guide you through the process at the desired pace.
"Significant increase in billing that was missed and established, and a protocol to prevent from this occurring in the future." ---Dr. Jesse Gill
Panel management is a creative way to provide quality care through the lens of patient and provider wellness. It is a valuable building block for efficient and high functioning Primary Care Networks in the community.
Looking Ahead: How PSP Can Move Us Forward
Physicians from other communities who were in wave 1 and 2 of PCN implementation completed their panel work before deploying allied health resources in their practices. Panel work has helped them to develop primary care teams suitable for their practices and, at the same time, delegate tasks among team members seamlessly.
Here is one example from Abbotsford, a wave 1 PCN community.
Physician Name: Dr. John Chan
"It’s getting the whole office up to standards of practice. COPD, for example, is a common problem. I now know how many patients I have with COPD and who they are, so I can make sure that they get an action plan and are updated every time they come in. I use the BC health guidelines. It helps prevent a patient from going to emergency, and ending up in the hospital with COPD exacerbation. That’s one of my goals.
Diabetic patients need an eye examination, foot care, and A1C, blood pressure and cholesterol checked regularly. If they don’t come in, now my MOAs will call them up. So we are giving proactive care. I think it is making a big difference in our practice."
Help Us Understand Your Neighbourhood Needs: Share your Data Anonymously
Panel work allows physicians to get a realistic picture of their panel by identifying active patients that need additional supports. Physicians are then able to share their aggregate data anonymously with the Division by signing a consent form. The data sharing enables your division to make informed decisions and to request allied health and other resources through the PCN service plan.
The clean data also helps us understand the allied health needs in different SND neighbourhoods and customize our ask from the Ministry accordingly.
If you want to know more about the PSP services, please contact:
Saira Abrar
Physician Engagement and Support Manager
Surrey-North Delta Division
C: 604-365-0764
Ranjit Sekhon
PSP Lead, Surrey-North Delta Community
