Towards proactive, integrated care across boundaries: Panel Management Next Level

Introduction: There is an urgent need for reforming healthcare so that all involved stakeholders can be enabled to deliver high-quality people-centered care while keeping costs under control. One of the paths towards a sustainable healthcare system is offering more integrated care. The aim of integrating care is to better coordinate care around people’s needs and across organisational boundaries. ‘Fully integrated’ care is characterised by integrated teams working in an organisation with a single set of governance and accountability rules and common budgets and incentives. For people with complex needs, this implies a flexible network of care providers.

Aim:  A promising approach for integrated care in the clinical healthcare setting is structured Panel Management. This was first described by Kaiser Permanente as a set of tools and processes for population care that are applied systematically at the level of a primary care panel. However, true integrated care also crosses boundaries with the social domain and continuous evaluation and improvement cycles are needed. We aimed to develop an innovative panel management approach towards an iterative process across boundaries: Panel Management Next Level. Hereto we adapted Kaiser Permanentes definition of panel management. In addition, we described the process of the approach.

Results: We define Panel Management Next Level as a structured set of tools and processes - based on medical and social needs - that are applied systematically at the level of a patient panel sharing the same risk on an adverse event, with physicians directing proactive care for their empanelled patients.

The process of Panel Management Next Level approach includes four iterative steps; 1) empanelment of (patient)groups that share the same risk, based on a risk stratification algorithm; 2) allocation of the appropriate intervention to each panel of patients based on medical and social needs; 3) periodic surveillance of care gaps for each panel; and 4) effect- and process evaluation on the triple aim (disease control, patient satisfaction for lower costs).

Conclusions:  Panel Management Next Level is a proactive, integrated care approach which can be applied within different domains of (care) settings. It has the potential to prevent harm and waste from overuse and overtreatment, freeing up resources currently used without benefit to clinical outcomes, in order to close care gaps.

Implications: Our panel management approach can be embedded in and across different (care) settings. Challenges are patients with multimorbidity in different panels, combining different ICT systems and financing which is usually organised in silos and not for integrated care purpose.