Introduction As the U.S. health care system increasingly prioritizes the value of services provided to patients and establishes reimbursement models that incentivize efficiency and quality, our...

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As the U.S. health care system increasingly prioritizes the value of
services provided to patients and establishes reimbursement models
that incentivize efficiency and quality, our physician training programs
must similarly adapt.
In primary care graduate medical education (GME), physician training
programs have recognized the importance of prioritizing new models
of primary care to ensure that the future primary care workforce
is adequate in supply, skilled at meeting the needs of patients and
populations, and ready to meet the demands of high-value care. These
skills are the “building blocks” of a high-functioning primary care
practice and are outlined in a 2016 AAMC report, High-Functioning
Primary Care Residency Clinics: Building Blocks for Providing Excellent
Care and Training.1
Population health management (PHM) is one building block of high-
functioning, high-value primary care but is inconsistently understood
and operationalized in practice and training settings. As we train the
next generation of physicians and as our delivery system shifts to focus
on managing populations and individuals, a framework for approaching
this work is necessary, particularly in residency training.
On June 25-26, 2018, the AAMC sponsored the meeting “Population
Health Management in Primary Care Residency Training Programs.”
Held in the AAMC’s Washington, D.C., offices, the meeting included
representatives of the AAMC, University of California, San Francisco
Center for Excellence in Primary Care (UCSF CEPC), and Centers for
Disease Control and Prevention (CDC) and leaders from seven residency
programs in family medicine, internal medicine, and pediatrics that
were identified as exemplary in key aspects of PHM.
The meeting was funded in part by CDC’s Division of Scientific
Education and Professional Development, Centers for Surveillance,
Epidemiology, and Laboratory Services, through cooperative agreement
5 NU36OE XXXXXXXXXXThe AAMC asked the UCSF CEPC to assist with
meeting planning and facilitation, based in part on their efforts to
investigate high-functioning primary care in GME practice sites,
including PHM. The lessons from these prior visits were captured in two
AAMC reports, one in 2016 and one in 2018.1,2
The purpose of the meeting was to describe best practices in PHM
in primary care residency teaching practices, with an emphasis on
how residents are trained. Intended for residency program directors,
this report summarizes the components of PHM and offers vignettes
describing how several of the seven participating residency programs
The following terms represent
the consensus of the meeting
Clinician refers to physicians,
nurse practitioners (NPs), and
physician assistants (PAs) — those
professionals authorized to make
diagnoses, prescribe medications,
and bill for clinical services provided.
Population health management
(PHM) refers to a systematic
approach to ensuring that all
members of a defined population
(e.g., all patients receiving care at a
primary care practice or all patients
receiving care from their personal
clinician) receive appropriate
preventive, chronic, and transitional
care.3 PHM also helps providers
identify and address health care
inequities among subgroups within
that population and includes
screening and assistance for those
clinic patients facing barriers
to optimal health such as food
insecurity, insufficient income,
precarious or unsafe housing,
and domestic or neighborhood
violence. PHM broadens the
traditional approach of focusing
only on individual patients.
Population health is defined
as the health outcomes of a
group of individuals, including
the distribution of such outcomes
within the group.4 These
groups are often geographically
contiguous populations, such as
nations or communities, but can
also be groups such as employees
Association of
American Medical Colleges3
implemented these components. The vignettes may provide ideas to
residency practices that wish to improve their PHM competency.
The seven programs described in this report vary significantly in the
practice of PHM. Similarly, programs that wish to develop a PHM
system may do so in different ways, applying either a narrow, targeted
approach or a more comprehensive approach to adopting the elements
of PHM into their practices. The descriptions provided here can be
applied in a variety of combinations and illustrate how these elements
are operationalized in diverse clinical settings.
Meeting participants identified 10 interrelated requirements that
comprise a comprehensive PHM system.
Figure 1. The 10 interrelated requirements of a comprehensive
population health management system.
of a company, ethnic groups,
disabled persons, prisoners, or any
other defined group. Population
health includes the broader
determinants of the health of
people within a defined population
and addresses health inequities
within subgroups. Population
health goes beyond specific
clinical metrics and considers
what interventions in addition
to medical care are needed to
keep a population healthy (e.g.,
access to jobs, healthy food, safe
environment, reasonable income).
Meeting participants often referred
to PHM as focused on the “small
p” population and noted that it
addresses the needs of clinic and
clinician panels, while “large P”
population health is concerned
with populations not necessarily
associated with one clinic, clinician,
or health system. The distinction
between PHM and population
health is analogous to the
distinction between health care
and health.
Patient risk-
of health
health equity
Complex care
nity engagement
Association of
American Medical Colleges4
Foundational Elements
1. Data infrastructure: Data infrastructure is the organizing, tracking, reporting, and making
transparent demographic and clinical data within the electronic health record (EHR) and
specific data registries.
2. Team-based care: Team-based care is the process of creating teams with a variety
of health professions represented, including physicians, nurse practitioners, medical
assistants, pharmacists, social workers, and others.
3. Community engagement: Community engagement requires an understanding of
local community needs and assets and the development of intentional partnerships with
community members near the clinic, including residents, community-based organizations,
and health departments.
Key Activities
4. Panel management: Panel management ensures that all patients in a population (the
entire clinic’s patients or the panel of one clinician or one team) have their routine evidence-
based preventive and chronic care tasks performed in a timely manner, including recognizing
and addressing inequities. This process includes addressing “care gaps” and actively
engaging patients at risk of poor health outcomes while in the clinic and between visits.
5. Patient risk stratification: Risk stratification is the process by which patients are placed
into subgroups that are determined by the area of focus of the clinic.
6. Care management: Care management for patients with chronic conditions, often
done by nurses or pharmacists, assists patients with behavior change and medication
7. Self-management support: Self-management support helps patients acquire the
knowledge, skills, and confidence to participate actively in the care of their chronic
condition or for preventive health measures.
8. Complex care management: Complex care management is a program to identify high-
needs and high-cost patients and systematically address these patient needs using a team-
based interprofessional approach.
9. Addressing social determinants of health: Addressing social determinants of health
requires systematic efforts to meet patient’s social needs that may affect their well-being,
as identified by the care team and denoted in the EHR.
10. Ensuring health equity: PHM can be fully realized only if an equity lens is applied to
ensure a reduction of health disparities while improving health outcomes for the patient
population. Addressing health inequities among a population requires stratifying clinical
data by factors such as race/ethnicity, language, gender identity, sexual orientation, ZIP
code, and insurance status to identify any gaps in health outcomes within subgroups of
the patient population.
The rest of this report further describes the foundational elements and key activities of PHM and
concludes with an overview of how to integrate these principles into a primary care residency.
Association of
American Medical Colleges
Teaching Residents Population Health Management
November 2019
1. Data Infrastructure
Individual patient care requires data — from the history, physical exam, lab tests, and imaging
tests. Similarly, PHM relies on health systems and teaching clinics’ collecting, aggregating,
organizing, tracking, and reporting demographic and clinical data. Data are critical to tracking
quality measures that primary care practices are expected to collect. Increasingly, health system
reimbursement partly depends on quality performance metrics that in turn require data.
A teaching clinic’s data often derive from the data infrastructure of the health system in which
the clinic is embedded. Usually an information technology (IT) specialist or IT department at the
larger health system builds the data system. For teaching clinics, establishing a close relationship
with the health system’s IT specialist is essential. Smaller health systems, for example Federally
Qualified Health Centers (FQHCs), may have an IT specialist within the clinic. IT specialists are
not clinicians, so a data-savvy clinician within the teaching clinic must work with the IT specialist
to build a data system that serves the clinic’s PHM needs. If a clinic’s health system lacks an
engaged and accessible IT specialist, the teaching clinic’s leadership needs to make the case for
the resources that are needed to hire one.
A key component of a teaching clinic’s data system is the data registry. Registries are lists of
all patients enrolled in a clinic or empaneled to a clinician, with patient-specific clinical, social,
and demographic data. In the past, EHRs lacked a registry function and many practices used
stand-alone registries. Increasingly, EHR systems feature registries populated from patient charts
and laboratory results. Registries may be comprehensive, providing data on multiple chronic
conditions and preventive care. Alternatively, registries may be disease-specific, providing data
on diabetes, depression, or asthma, for example.
Once the registry is built, the IT specialist and data-savvy clinician(s) work together to create
daily, monthly, or quarterly reports for clinicians and staff at the teaching clinic. The reports
can provide data by clinician and team so that individual clinicians and teams can see and
discuss whether their preventive and chronic care metrics are improving and whether there are
disparities among subgroups. The reports may also aggregate the data longitudinally (run charts)
by metric so the clinic can judge its progress.
Many health care organizations fail to track data on health inequities.5 If data on race/ethnicity,
education, income, and health insurance, for example, are included in the demographic data for
each patient, registry reports can be run that show inequities in measures such as blood pressure
control or cervical, breast, and colorectal cancer screening. Practices that fail to collect, track,
and analyze these data are missing an opportunity to address health inequities.
For future clinicians to be competent in PHM, they must learn about data systems, including
what a registry is, how it is created, and how registry reports are run. They must also learn how
these reports are used to improve the health outcomes of their panel of patients and identify
inequities. Residents do not need to become IT specialists, but a training goal for residents might
be to master the role of the data-savvy clinician who makes the data “actionable.”
Association of
American Medical Colleges6
Data-Driven Improvement at Washington University
The Washington University in St. Louis/Barnes-Jewish Hospital internal medicine residency
clinic has a 6 + 2 scheduling model (six weeks of in-patient or elective rotations and
two weeks of ambulatory rotations). The clinic is a main outpatient training site for 140
residents who are divided into teams; a registered nurse (RN) supports each team. The
clinic also has a pharmacist, diabetes educator, nutritionist, and social worker. The
faculty do not have patient panels, but they precept the 16-20 residents in clinic each
half-day session.
From 2008 to 2011, the clinic began using the National Committee for Quality Assurance
Diabetes Recognition Program to benchmark diabetes performance. A data extraction
tool abstracted information from the EHR into a spreadsheet. Individual panel data were
emailed to residents quarterly with clinic metrics and goals, but residents inconsistently
evaluated and changed practice patterns based upon the data. During 2011 to 2012,
residents were asked to use Plan-Do-Study-Act cycles to improve one diabetes quality
metric. The project had variable resident engagement and a high administrative burden
and did not clearly improve care.
From 2012 to 2013, the clinic switched to a team structure with 16 residents per team.
Because residents often saw the patients of other residents, individual performance data
had little meaning, so residents received quarterly data on team performance. During
2013 to 2014, the Washington University IT department took the data abstraction
Data-Driven Improvement at the University of North Carolina
The UNC Family Medicine Center (FMC) uses data to improve PHM. FMC not only collects
and tracks data on a large variety of clinical and operational metrics but also posts these
data everywhere. Walking through the FMC, one views data walls at every turn.
The IT specialist who collects, tracks, and reports on the data is part of the clinic
leadership team. Clinical metrics include cancer screenings, immunizations, diabetes
process and outcomes measures, and depression and fall-risk screening. Operational
metrics include third next available appointment, continuity of care, on-time start
rooming, on-time start provider, calls answered within 30 seconds, and cycle time.
The system also tracks patient, provider, and staff satisfaction. The data are drilled
down to the team and provider level, including residents. Each provider’s performance
is transparent for all to see, and the data are updated every day.
On a large white board at each team’s work area are the team’s clinical metrics for
the previous month and operational metrics that are current FMC priorities (e.g., on-
time starts for staff and providers). For each metric, the target is listed in red or green
to indicate whether the team is passing. There is friendly competition among faculty,
residents, and staff to have the highest number of green metrics.
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Teaching Residents Population Health Management
November 2019
tool from the EHR and turned it into a web-based registry, making it possible to easily
generate reports for patients with diabetes seen within the last year. The reports included
each patient’s team/physician, diabetes metrics, and demographic information. Residents
and attendings received monthly reports with eye exam rates, the percentage of patients
with HbA1c>9%, the percentage of patients with HbA1c<7%, and the percentage of
patients with blood pressure >140/90.
In 2014, the clinic started focusing on improving performance on foot exams since
completion and documentation of the exam had previously been inconsistent. From
January 2014 to May 2018, the percentage of patients with diabetes who had a foot exam
increased from 40% to 73%. Twice per year, residents receive diabetes metrics on their
patients with overall team and clinic performance. This report includes data on inequities in
diabetes metrics based on race, gender, primary language, and insurance type.
The clinic has sustained improvement in the diabetes quality metrics related to screening
and treatment for nephropathy and hyperlipidemia. The ability to access the performance
data for these metrics was a critical first step. No significant changes have been observed
for HbA1c and blood pressure control, which is likely multifactorial, including physician
and patient factors. Challenges for improving the diabetes metrics include lack of
continuity between resident and faculty physicians and patients and lack of administrative
support to analyze the data. The clinic has improved some metrics through physician
education, partnerships with ancillary clinic services, and linking diabetes metrics with the
Accreditation Council for Graduate Medical Education (ACGME) milestones (read on for
a discussion of PHM and milestones).
Data Infrastructure Checklist
Implement electronic health records (EHRs)
Create data registry
Designate IT staff or clinician lead
Establish metrics or targets for clinical outcomes/improvements
Regularly review reports by disease, strategy, and population
Ensure care teams discuss data
Association of
American Medical Colleges8
2. Team-Based Care
Teams in most primary care practices consist of a core team and an extended care team. In
residency teaching practices, the core team is generally a small group of clinicians and support
personnel, often medical assistants (MAs), but in some clinics they are licensed practical nurses
(LPNs), RNs, or a mixture of nursing and assistant personnel. The extended care team, which
supports several core teams, often includes RN care managers, pharmacists, behaviorists, and
social workers. It may also include physical therapists, nutritionists, community health workers
(CHWs), patient navigators, and health coaches.
The responsibility for the continuity of PHM resides with the core team. Each participant
of the team should be closely involved to the level of their expertise. In residency clinics,
team-based care is critical to implementing PHM for several reasons:
• Residency clinics should promote continuity of care for residents to the highest extent
possible. However, because residents and many faculty are commonly in clinic for only a
small portion of their time, teams are needed for optimal continuity of care. Usually, teams
with many residents and faculty are too large to provide high rates of care continuity by
the team’s physicians; continuity in large teams is often best achieved by full-time nurse
practitioners (NPs), physician assistants (PAs), or RNs who are familiar with and are trusted by
those patients with chronic health care needs.6
• Because physicians have many health issues to address in the average patient visit,
they lack time for identifying and closing chronic and preventive care gaps during the
visit. Core team members, usually MAs and less commonly RNs, are best tasked with the
responsibility for panel management; ideally, they are empowered with standing
order sets.7
• Members of the extended care team, in particular RNs, pharmacists, behaviorists, and
social workers, generally assist high-needs, high-cost patients.
To become competent in PHM, residents need experience working in care teams in which non-
physician team members are empowered to take responsibility for all or portions of the PHM.
Residents can learn the scope of practice of each professional team member, what is clinically
appropriate, how and when to communicate with team members, which tasks can be delegated
to other team members, which tasks must be done by the resident, and how generally to “share
the care” with team members. Communication is key. Because many teaching practices have not
yet created and nurtured high-performing teams,1 residents may not experience true team-based
care in their training. Programs should consider ways to reduce this risk for their residents, who will
be expected to lead and contribute to team-based care models in their future practice settings.
Association of
American Medical Colleges9
Teams at Family Medicine Residency of Idaho (FMRI)
FMRI has four clinics divided into seven teams, each consisting of two to four faculty,
four to eight residents, one full-time NP or PA, three to four MAs, one to two RNs, and
a licensed clinical social worker. Residents work with the same MA 60% of the time
and with the team RN virtually all the time. All residents are matched with one of their
team MAs, who manages their desktop. Clinicians, MAs, and nurses are co-located to
enhance minute-to-minute communication. Centrally located data extractors evaluate
patient charts before the session to identify care gaps. Behavioral health staff are on the
floor every day at all clinics to help with patient care; clinical pharmacists, CHWs, and a
dietician float between clinics and integrate their services into provider appointments.
Residents shadow each team member, including billing staff, front office staff, medical
coders, nurses, and MAs. Residents attend their monthly team meetings, which begin
with kudos to members across the full spectrum of the team to build team culture
and appreciation. Each staff category presents successes and challenges, after which
the team reviews its clinical and operational metrics. Team members hear a talk on a
common outpatient medicine topic, after which faculty, residents, and nursing staff do
registry management of their patient panels. Residents’ clinic and rotation time shuts
down so they can attend their team meeting, which is part of their curriculum and
learning. Many clinic staff explain that FMRI “feels like a family” and that “everyone here
feels empowered and important.”
Teams at the University of Cincinnati
The University of Cincinnati’s internal medicine residency has pioneered a resident
scheduling model, the “long block,” in which residents in this three-year program spend
the entire second year of their residency providing ambulatory care.8 The resident practice
has five core teams, each with one MA or LPN working with five long-block residents,
with RNs acting as team leaders. Patients stay on the same team with the same MA or
RN for years, ensuring longitudinal continuity. Because RNs work with the same patients
over several years, they often know the team’s panel of XXXXXXXXXXpatients better than a
patient’s resident.
RNs are responsible for in-reach and outreach panel management (see definitions on
page 16), ensuring accuracy of panel lists, coordinating care, triaging calls to the team,
screening inbox messages, and providing care management visits for hypertension and
diabetes. They are also central in the transition from one long-block resident to the next.
Residents value working with their team nurse: “They really teach us, especially early in
long block.” With the recent addition of a team of care coordinators, residents can refer
patients to these nurses, who call patients in for follow-up, help arrange appointments
with specialists, and coordinate home health care.
Association of
American Medical Colleges10
Surrounding the core teams is an extended care team, including pharmacy, social
work, depression care management, and diabetes educators. Clinical pharmacists
support medication adherence, medication titration for diabetes and hypertension,
anticoagulation, and smoking cessation. Residents do warm handoffs to the depression
care manager to ensure transitions are as seamless as possible between providers.
Residents finish their long-block year with a deep and positive experience of working
in team-based care.9
Team-Based Care Checklist
Develop a core clinical team
Develop an extended care team
Distribute responsibilities among team members
Establish effective communication channels to which all team
members can contribute
Ensure that residents understand team roles and learn from team members
Association of
American Medical Colleges
Teaching Residents Population Health Management
November 2019
3. Community Engagement
According to CDC, community engagement is “the process of working collaboratively with and
through groups of people affiliated by geographic proximity, special interest, or similar situations
to address issues affecting the well-being of those people. It is a powerful vehicle for initiating
environmental and behavioral changes that will improve the health of the community and its
members. It often involves partnerships and coalitions that help mobilize resources and influence
systems, change relationships among partners, and serve as catalysts for changing policies,
programs, and practices.”
The community that teaching practices may engage with is often geographically close to the
practice and includes multiple potential community partners: neighborhood organizations and
leaders, faith-based organizations, community-based health practitioners, and governmental
agencies. These communities can be viewed as complex systems composed of individuals,
organizations, interest groups, city councils, and state and local public health departments.10,11
Community engagement in primary care residencies is varied. Some programs focus on
community service, and others have long-standing partnerships with community organizations
to meet shared health improvement goals.
As related to PHM, primary care residency programs are beginning to align their patient
population work to the overall needs of the community. Typically, nonprofit health systems in
the geographic area perform community health needs assessments (CHNAs) every three years
as a requirement for obtaining tax-exempt status. In addition, local health departments are also
required to complete a community health assessment (CHA) every five years to maintain their
accreditation. Residents should become familiar with the CHNA of their hospital and the CHA
for the surrounding area. Residents should consider engaging in community health outreach or
service-learning projects in alignment with the institution’s CHNA and in partnership with other
community-based organizations that have a sustainable commitment to the project. Particularly
forward-thinking GME programs may consider how to involve residents in the CHNA process.
Community Engagement at FMRI
At FMRI, population health is both an internal (“small p”) and external (“big P”)
journey. The internal journey involves providing the highest quality care to FMRI’s panel
of 25,000 Idahoans. On the external journey, FMRI develops outreach strategies to
reduce health disparities in nearby communities, specifically those of refugees and
Latino seasonal farmworkers.
FMRI has provided health care to the large refugee population since the late 1990s,
when Bosnian immigrants began arriving in Boise. In 2017, the top countries of origin
for individuals in FMRI’s area of Idaho were the Democratic Republic of the Congo, Syria,
Iraq, Afghanistan, Bhutan, and Eritrea. In 2011, FMRI took over the refugee-screening
contract for Southwest Idaho; since then, every refugee entering Boise has come to the
clinic within their first month to receive blood tests, immunizations, and mental health
Association of
American Medical Colleges12
screening. Sixty percent of refugees screened through the program become patients of
FMRI’s primary care doctors, including residents. The refugees also benefit from FMRI’s
HIV Ryan White and tuberculosis clinics.
In 2015, FMRI opened the Refugee Continuity Clinic to better support refugees during
their first year in the United States. A case manager screens all patients for social
determinants of health and helps patients with complex medical or mental health needs.
The clinic has dedicated transportation and scheduling coordinators to make sure that
patients come to their appointments. A community health worker helps refugees with
health insurance and disability applications. Four interpreters speak Arabic, Swahili,
Kirundi, Kinyarwanda, and French.
Residents are involved in refugee care in several ways. All interns spend at least one day
in the refugee-screening clinic. All residents receive one hour of didactics on “Refugee
101” and a yearly half-day didactic session targeted at infectious disease issues refugees
face. Two second-year residents and two third-year residents care for their continuity
patients in the refugee clinic and meet with faculty every four weeks to discuss refugee
care topics. These residents design a quality improvement project for refugee patients
and present regionally and nationally on a topic related to refugee care.
In addition, FMRI facilitates a monthly meeting of community agencies and institutions
— health clinics, hospitals, the local health department, and resettlement agencies —
to coordinate refugee care. FMRI organizes periodic health fairs where dentists and eye
care specialists volunteer to provide refugee services.
FMRI’s journey working with seasonal farmworkers began in 2014. At that time, the
clinic cared for only 10 seasonal farmworkers. When the clinic became a FQHC, a CHW,
or “promotora,” began to work with the seasonal farmworker population, which is
predominately Latino. Since then, the CHW department has grown to six employees,
three of whom are bilingual in Spanish and provide outreach to the seasonal farmworker
population. FMRI expanded its clinic system to a city closer to Southwest Idaho’s
agricultural regions. CHWs organized joint events with local Spanish radio stations,
listened to by 70% of the Latino community. CHWs went to all the tree nurseries in the
Boise area to meet with seasonal workers. In July and August, CHWs go into corn, onion,
wheat, alfalfa, potato, and hops fields to distribute water to farmworkers.
Over 450 Latino seasonal farmworkers are now patients at FMRI. Bilingual residents
have been featured on local Spanish radio to talk about diabetes, colorectal cancer, and
women’s health. Resident physicians and Spanish-speaking CHWs have worked together
to provide care to farmworkers with chronic conditions. FMRI collects narratives of
patients who have been helped by resident-CHW teams and hires employees who grew
up in these cultures.
Staff learn culturally appropriate ways to serve the variety of populations coming to the
clinic. Residents participate in culturally appropriate care with multiple populations and
take these skills with them into the wider world after graduation.
Association of
American Medical Colleges
Teaching Residents Population Health Management
November 2019
Community Engagement Checklist
Ensure that residents and faculty are familiar with the local community health
needs assessment (CHNA)
Align PHM work with the local CHNA
Align community service projects with the needs of the local community and
the needs of the patient population
Develop partnerships with local community organizations that are aligned with
the CHNA and the PHM work of the clinic
Association of
American Medical Colleges14
4. Panel Management
The term “panel management” has two meanings in primary care, which has led to some
confusion. In one version, panel management is the process of empanelment. This is defined
as linking every patient to a primary care clinician, making sure each clinician’s panel is not
too large or small; risk-adjusting panels for patient complexity so that clinicians with many
complex patients have smaller panels than clinicians with many healthy patients; and having
clear guidelines for transferring patients from graduating residents to other residents or faculty.
Empanelment allows clinicians and care teams to identify whose care they are responsible
for in the long term. With a defined panel, care teams can regularly review their patients and
think beyond the office visit to improve preventive and chronic care for their panel of patients.
Without empanelment, many elements of PHM would not be possible.12
This report focuses on the other meaning of the term “panel management,” which ensures
that all patients in a population (the entire clinic’s patients or the panel of one clinician or one
team) have their routine evidence-based preventive and chronic care tasks performed in a timely
manner; it also includes recognizing and addressing inequities. For example, panel management
allows a clinician to know which patients in their panel are overdue for colorectal cancer
screening or which patients with diabetes are overdue for retinal screening. Panel management
also allows a clinician to know which patients with diabetes in their panel have HbA1c levels
above 9% and thus need more intensive management. Panel management, concerned with all
patients of a clinic or of a clinician’s panel, is a key part of PHM.13
Re-empaneling patients from graduating third-year residents is an aspect of panel
management specific to teaching practices. Prior to graduation, residents identify: (1) patients
who might be better served by a specific clinic or provider; and (2) complex patients who
should be assigned to more senior residents instead of incoming interns. Residents are asked
to “say goodbye” to families as graduation approaches and are provided with literature to
guide these discussions.14 A clinic team member, ideally one known to the patients, also sends
letters to all families notifying them when a resident is graduating and introducing them to
their new provider. Panels are assigned to new interns with the same supervising attending to
provide continuity of care at the attending level.
Without reliable and current data, panel management is not possible. Two crucial data platforms
are needed: the registry (as described above) and the EHR health maintenance screen. On many
EHRs, the health maintenance screen is one of the first screens seen by clinicians when opening
a patient’s chart. It lists the current standard recommended health maintenance (preventive
and chronic) services appropriate for that patient, which services have been performed, and
which are overdue. The health maintenance screen provides data for one patient, while the
registry includes data for all patients of a clinic or a clinician’s panel. Additionally, to track health
disparities within the population, the EHR needs to collect information on race, ethnicity, and
other demographic characteristics.
Care Gaps
The term “care gap” refers to services that are overdue (e.g., no mammogram on a 60-
year old woman for five years) or outcome measures that are abnormal (e.g., HbA1c of 9%
or blood pressure of 160/100). To identify a care gap, a practice must know the evidence-
Association of
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based guidelines regarding that service — for example, that women over 50 years old are
recommended to have a mammogram every two years or that patients with diabetes are
recommended to have HbA1c levels below 7% or 8%. The medical leadership of each clinic
decides on clinical practice guidelines for each metric, often relying on guidelines recommended
by the U.S. Preventive Services Task Force.14 Both clinician and non-clinician team members
responsible for panel management need to know their clinic’s guidelines to determine whether
a care gap exists. Studies show that when non-clinician team members are trained and given
responsibility for identifying and addressing care gaps, performance improves because clinicians
lack the time to perform this important but relatively routine function.7
When a clinic begins to perform panel management, the team must first decide which preventive
and chronic care services to actively measure. Early on, a clinic may provide panel management
for only a limited array of measures, such as colon cancer screening and flu vaccines. Over time,
clinics expand their panel management activities to include other cancer screenings, vaccinations,
diabetes care processes, outcome measures for diabetes and hypertension, fall-risk assessment,
depression screening, and more as their expertise in panel management improves.
Registries and EHR health maintenance screens will often visually highlight which patients
have care gaps. This requires that the clinical practice guidelines agreed upon by the health
system or clinic medical leadership be embedded into the registry. For example, if a guideline
recommends HbA1c tests every six months for patients with poorly controlled diabetes and a
patient has not had a HbA1c test for nine months, the registry or health maintenance screen
may highlight the HbA1c test in red to indicate that a care gap exists. When the HbA1c test is
performed, the notification disappears.
In-Reach and Outreach
Identifying and addressing a patient’s care gaps when the patient is present in clinic is called
“in-reach.” Identifying and addressing a patient’s care gaps when the patient is not present in
clinic is referred to as “outreach.” Outreach involves contacting patients on a clinician’s panel
who do not have scheduled visits and arranging for them to close their care gaps. An example
might be sending e-messages through the patient portal to patients who have diabetes but have
not had a HbA1c in the last six months, reminding them that a HbA1c test has been ordered and
requesting that they come to the lab. Outreach can also be conducted through letters or phone
calls. In many practices, in-reach and outreach are the responsibility of the MA or nursing staff.13
Panel Management at Johns Hopkins
With about 16,000 visits each year, the Harriet Lane Clinic is the main general pediatrics
training site for Johns Hopkins residents. The goals of panel management in pediatrics are
(1) providing preventive and routine chronic care services and promoting wellness among
the clinic’s entire population; (2) tracking metrics, including well child visits in the first 15
months of life, well child visits in preschool age children, and well child visits in adolescence;
(3) delivering immunizations to children and adolescents; and (4) providing lead screening,
asthma and weight assessment, and counseling for nutrition and physical activity.
Association of
American Medical Colleges16
The EHR provides reports of the population of patients with specific diagnoses (e.g.,
asthma, obesity), medications (e.g., which patients are on Fluticasone), and vital sign
abnormalities (e.g., high blood pressure or elevated BMI). The Johns Hopkins Health
System provides metrics, including immunization rates and preventive visit rates for the
patient population, at the provider level and the clinic level. Data provided by a Medicaid
managed care plan representing most patients served by the clinic are another resource
for panel management in the clinic.
Each resident receives a monthly dashboard from the EHR with metrics sorted by
resident provider. The dashboard includes all patients assigned to a resident’s panel,
whether or not they have attended a clinic visit. There is dedicated time during clinic
sessions throughout the year to review patient panels and, working with CHWs, to
conduct outreach to patients with care gaps. Residents also receive data related to the
prevalence of specific diagnoses (obesity, asthma, etc.) within their patient panel.
In-Reach at UNC
At the UNC FMC, clinical teams include about six faculty and six residents (two from each
residency year), about four credentialed medical assistants (CMAs), and a team clerk.
Each team is made up of provider-CMA “teamlets”; each CMA is linked with three to
four providers, generally a mix of faculty and residents. Each day a schedule is created
called “Where is my clinic today and who am I working with?” For each team, it lists
the doctors working that session and the CMA they are paired with. Before each clinic
session (morning and afternoon), the provider and CMA discuss the patients on the
schedule and review care gaps.
CMAs have a long list of pre-visit responsibilities, written down in a standard work
document, which includes panel management in-reach. CMAs screen patients for
tobacco, alcohol, drugs, falls in the past year, pain, and depression. To identify and
address care gaps, CMAs rely on an EHR function called BPAs, Best Practice Advisories.
If the patient has a care gap for a cancer screening, immunization, or routine diabetes
service, the BPA “fires” (i.e., it is highlighted in yellow on the EHR health maintenance
screen). CMAs can pend lab and mammogram orders on the EHR and perform some
BPAs (e.g., give FIT/FOBT tests for colon cancer and do diabetes foot exams under
standing orders). For colonoscopies, the CMA advises the patient to have a discussion
with the provider. Residents learn how to use the BPAs and receive BPA alerts, but the
CMA’s role is to implement the workflow.
CMA clinical training is generally accomplished through peer training with the lead CMA
and by shadowing experienced CMAs. Lead CMAs supervise new CMAs in all their
responsibilities, quiz them, and document competency milestones within a standard list
of required job responsibilities. Supervisors regularly audit staff members using a checklist
to evaluate how they are carrying out their responsibilities. Audits are used as a coaching
opportunity and are not punitive.
Association of
American Medical Colleges
Teaching Residents Population Health Management
November 2019
Figure 2. Example of UNC run chart, statin use.
The FMC’s system allows the team to track how many individual patients have care gaps
for each metric; for example, the clinic may need to screen 100 more patients to reach
its colon cancer screening target. Moreover, each provider knows how many (and which)
patients need care gaps addressed for the provider to reach an individual performance
target. The care gaps for the day for each provider are listed on a printout on the work
desk and posted on a white board. Each teamlet huddles to review daily opportunities to
close care gaps. The in-reach motto is “Even if it’s not your patient, close the gap.” The
entire clinical team meets monthly in front of their white board to discuss progress and
how to achieve not-yet-reached targets.7 Figures 2 and 3 illustrate some metrics that the
clinical teams track each month.
May June July Aug Sept Oct Nov Dec
Jan Mar Apr MayFeb
UNC Family Medicine Chapel Hill
Association of
American Medical Colleges18
In-Reach and Outreach at the University of Arizona
The University of Arizona health system in Phoenix merged with Banner Health in 2015
to create the Banner-University Medical Center Phoenix (BUMCP). The Family Medicine
Center resident teaching practice has developed two MA positions that will specialize
as “population health MAs,” each working with two of the four teams. The population
health MAs review the schedule for the day, look for patient care gaps in the EHR health
maintenance screen, and place electronic notes in those patients’ charts. Each morning,
the residents review the notes with the “rooming” MA they are working with that
day and create a task list for the rooming MA using standing orders. The population
health MAs often place orders the day before for items that have standing orders (e.g.,
mammograms and HbA1c labs).
After the visit, patients check in with their population health MA to go over logistics for
mammography and colorectal cancer screening and to check whether all care gaps on the
notes have been addressed. If not, the population health MA can do needed counseling
and pend orders that physicians sign later. For items not addressed by the rooming MAs,
patients meet with the population health MA. The clinic creates a monthly performance
scorecard (see Figure 4).
Figure 3. Example of UNC run chart, pap smear.
Association of
American Medical Colleges
Teaching Residents Population Health Management
November 2019
BUMCP Clinical Performance Scorecard 2018
October 2018
2018 Performance
2018 Performance
Stretch Target
Family Medicine
Future Fall-Risk Screening 61.0% 63.0% 89.1%
Influenza Vaccination 73.0% 74.0% 86.6%
Pneumococcal Vaccination 70.0% 70.0% 80.1%
Depression Screening 80.0% 90.0% 86.3%
Cancer Screening
68.0% 72.0% 68.9%
Breast Cancer Screening 74.0% 78.0% 67.0%
Diabetic Control (HbA1c <9%) 69.0% 73.0% 72.6%
Hypertension Control 71.0% 75.0% 74.2%
Figure 4. Banner-University Medical Center Phoenix clinical performance
scorecard example.
Panel Management Checklist
Ensure that all patients in a population are included in a panel to
regularly observe evidence-based preventive and chronic care tasks and
recognize health dispartities
Develop a system to identify care gaps
Develop a process to close care gaps and inequities with “in-reach”
Develop a process to close care gaps and inequities with “outreach”
The population health MAs are entirely responsible for panel management outreach.
Each second- and third-year resident meets monthly with their population health MA to
review their panel list and identify care gaps. During this process, the MAs actively teach
residents how to do PHM. The population health MAs contact patients with care gaps —
usually by phone — and ask them to come in for needed lab work, cancer screening,
or immunizations. As more patients sign up for the patient portal, the center will
use it for outreach.
Association of
American Medical Colleges20
5. Patient Risk Stratification
PHM addresses the needs of various subgroups within a population. Risk stratification is the process
by which patients are placed into subgroups that are determined by the area of focus of the clinic.
The subgroups might be based on age, gender, race/ethnicity, neighborhood, or other characteristics.
Primary preventive services aimed at mitigating risks can be variably applied to different subgroups
depending on the prevalence of poor health outcomes experienced among these subgroups.
Another way to define a population’s subgroups is by risk of poor health outcomes or high
health care costs.15 Using this latter approach, a clinic’s population can be risk-stratified to
determine the level of services required for each of three overall risk strata:
1. Many patients are healthy and need only routine preventive services.
2. About half the patients in a clinic or clinician’s panel have one or two chronic conditions
in fair control (e.g., patients with diabetes and hypertension). These patients generally
require care management visits for health coaching and routine medication management.
3. Perhaps 5% to 10% of a clinic’s or clinician’s panel has complex health care needs, often
with multiple diagnoses, many medications, and frequent emergency department visits
or hospital admissions.
Some practices risk-stratify within clinical conditions. A child with asthma may have rare attacks
and require only patient education and a rescue inhaler as needed. Other children with frequent
asthma exacerbations need regular follow-up, asthma action plans, and both rescue and controller
inhalers. Children with severe asthma and multiple emergency department visits require intensive
asthma management, including screening to identify and address asthma triggers, particularly in
the home, and self-management training of the patient and family with an asthma educator or
health coach. As a result, clinics will often aim to ensure an asthma action plan is created for the
population with this chronic condition, clarifying their risks and attendant care plans.
More complex patients are often risk-stratified using likelihood-to-be-hospitalized formulae,
which look at numbers of diagnoses and medications, past hospitalizations, and the presence of
serious mental illness, drug addiction, homelessness, and social isolation. In addition to computer
algorithms, clinicians can rely on their experience to help identify patients at risk for catastrophe.6,15
Residents can learn the concept of risk stratification, estimating risk and planning the
appropriate intensity of care for their patients. At UNC and the University of Cincinnati, residents
attend practice management discussions that involve risk stratification. The University of Arizona
uses meetings with specially trained population health MAs and other experiential learning
methods to teach risk stratification. At Johns Hopkins, pediatrics residents are asked to identify
medically complex patients in their panel. FMRI is starting to have residents look at their most
costly Medicaid patients and devise plans to potentially reduce their overall costs. Hopkins
residents also pay considerable attention to the neighborhoods where their patients live and
the attendant risks associated, such as the risk of lead poisoning and need to engage with
community resources around lead abatement in the home. Washington University residents
risk-stratify by race/ethnicity as described on page 31.
Association of
American Medical Colleges21
Patient Risk Stratification Checklist
Risk-stratify by population subgroup (race, ethnicity, neighborhood, insurance,
languages spoken, citizenship, etc.)
Risk-stratify by disease burden
Risk-stratify by co-morbidity
Risk-stratify by frequency of visits to emergency room or hospital admissions
(see Complex Care Management)
Association of
American Medical Colleges22
6 and 7. Care Management and
Self-Management Support
Care management usually involves an RN care manager who meets with patients to help them
set and achieve health behavior-change goals, including medication adherence, and to guide the
management and self-management of patients’ chronic conditions. Because care management has
become a common part of chronic illness care, residents benefit from learning how it functions.
RN care managers generally assist patients with one or two uncomplicated chronic conditions such
as diabetes and hypertension. High-needs, high-cost patients with multiple chronic conditions
may receive intensive care management from an interdisciplinary team (see the following section,
Complex Care Management). For patients with diabetes, care managers are most effective when
they are empowered to adjust medication doses without awaiting physician approval.16 Compared
with standard patient visits that have multiple agenda items, care management sessions are
planned in-person, by phone, or electronically; the only agenda item is managing the patient’s
chronic conditions. Planned visits with a professional who is not the patient’s primary care
practitioner can overcome the “tyranny of the urgent,” in which acute concerns curtail the patient
education and goal-setting that is so important for improving clinical outcomes.17
Implementing care management is challenging because it requires new workflows, assessment
tools, and available resources. Practices struggle with many decisions including how to structure
the overall program, hire and train care managers, determine which patients are eligible, and
standardize the content of care management visits.18
While care management is generally performed by an RN (or sometimes by a pharmacist or
social worker), self-management support (health coaching) can also be provided by specially
trained unlicensed staff such as MAs, patient navigators, or CHWs. Health coaching equips
patients with the knowledge, skills, and confidence to become active, informed participants in
managing their chronic conditions, which can lead to better health outcomes.19 For example,
low-income patients working with trained medical assistant coaches or peer health coaches
have better diabetes outcomes than patients without health coaches.20,21
Care Management at Cambridge Health Alliance
Cambridge Health Alliance has developed the role of “Care Partners,” most frequently
recruited from a pool of high-performing MAs or LPNs, who are trained in motivational
interviewing and health behavior change, including medication adherence. Care Partners
help facilitate warm hand-offs, whereby the clinician recognizes the need for services
during a visit and introduces the patient to the Care Partner in real time, enabling an
initial personal connection and, depending upon the circumstances, initiation of care.
Care Partners may address several conditions, including depression, anxiety, sleep
hygiene, and smoking cessation. They support and develop care plans documented
in the EHR, discuss mobile apps, and provide motivational interviewing, goal-setting,
and coaching for healthy behavior change. Care Partners are paired with patients with
Association of
American Medical Colleges23
Care Management and Self-Management Support Checklist
Designate staff to create individual care plans for patients with chronic conditions
Develop a system for patients to obtain self-management support
Educate residents on this pathway and create a seamless referral system
uncontrolled diabetes (HbA1c >9%) and depressed patients who have scores of >15
on the Patient Health Questionnaire-9 (PHQ-9), a depression and diagnostic severity
measure. Residents may refer any other patients they feel would benefit by interacting
with Care Partners. Care Partners participate in weekly team meetings. Cambridge Health
Alliance budgets one full-time equivalent Care Partner for every 10,000 patients.
For patients with complex health care needs, a social worker and RN team work together
to perform care management. The team provides patients with team members’ phone
numbers, coordinates with home health and adult day programs, assists with inpatient
discharge transitions, and does home visits if needed. Residents can use the team for
their patients, and the RN or social worker will frequently join the patient’s resident
during office visits.
Association of
American Medical Colleges24
8. Complex Care Management
Academic practices are increasingly implementing programs for high-needs, high-cost patients
by assessing patient needs, training complex care managers, supporting patient/caregiver
involvement, and partnering with social service organizations.22 High-needs, high-cost patients
are best cared for by a complex care management (CCM) team with a small caseload. CCM
teams often include physicians, RNs, social workers, pharmacists, behavioral health professionals,
and sometimes unlicensed personnel such as MAs, patient navigators, health coaches, or CHWs.
The goals of CCM teams are to improve care and reduce costs for their patients.
Several models of complex care management are functioning throughout the United States in
both teaching and non-teaching practices. Traditionally, the health plan model involves a team
employed by a health plan that provides telehealth care management, embeds care managers
in primary care practices, or both. In the primary care model, patients remain with their primary
care practitioner; a CCM team within the primary care practice assists with the intensive level of
care appropriate to each patient’s needs. The ambulatory intensive caring unit model involves
transferring high-needs, high-cost patients away from their primary care practitioner to a
separate high-risk clinic with a team led by a physician and RN. A hybrid model allows patients
to choose to remain with their primary care practitioner, supported by the CCM team, or to be
transferred to a CCM team that includes a physician.23 Increasingly, these staff-intensive models
are being augmented by telehealth modalities and related technologies that help facilitate timely
check-ins and provide a stream of relevant data on these patients’ health status.
Complex Care Management at the University of Arizona
The University of Arizona’s residency clinic focuses on four categories of high-risk
populations: recently hospitalized patients, behavioral health patients, patients with
substance use disorder (SUD), and patients with uncontrolled chronic conditions.
For recently hospitalized patients, a nurse navigator rounds on all clinic patients
hospitalized at the Banner-University Medical Center Phoenix. A Transitional Nurse
Practitioner completes a transitional care visit. Residents round daily with the nurse
navigator on the family medicine inpatient service and can consult with the nurse
practitioner on care transition plans. Patients admitted to BUMCP from the family
medicine residency clinic have 30-day readmission rates lower than the entire in-patient
population of BUMCP.
For behavioral health patients, faculty and residents refer appropriate patients to an RN
behavioral health manager. Eligible patients are those with new or uncertain psychiatric
diagnoses or with suboptimal response to treatment, not including patients with serious
mental illness or dementia. The program uses the University of Washington’s Advancing
Integrated Mental Health Solutions model by which medical practitioners work with
an RN behavioral health care manager, who is supported by a psychiatrist consultant.
Residents coordinate with the behavioral health care manager on their patients’ care.
Association of
American Medical Colleges25
Patients with SUD are referred to an outpatient addiction recovery center with in-patient
consultation as needed. They are co-managed by residents, who spend some time at
the recovery center during their second-year psychiatry rotation. An addiction medicine
elective rotation enables residents to obtain buprenorphine prescribing waivers and learn
how to use medication-assisted treatment in their patients’ care.
The uncontrolled chronic conditions category includes patients not meeting their
hypertensive or diabetic control targets. Care of these patients is managed by
an interdisciplinary team including pharmacists, social workers, nutritionists, and
psychologists. Residents have monthly meetings with team members to discuss these
patients. Residents also lead quality improvement noon conferences attended by
interdisciplinary team members.
Complex Care Management at Johns Hopkins
Johns Hopkins Children’s Center, part of Johns Hopkins Hospital, is financed by a global
budget that aims to cap hospital spending while maintaining or improving quality of care;
this provides a strong incentive to reduce hospital admissions and treat patients effectively
earlier in their disease course. The hospital-based Harriet Lane Clinic uses several strategies
to manage high-risk populations.
Children With Medical Complexity
ICD-10 codes are used to identify children with medical complexity and highlight these
individuals on resident panels. As appropriate, they are enrolled with their insurer’s case
management program or the Maryland Medicaid Rare and Expensive Case Management
(REM) program. Many of these children are technology-dependent (e.g., dependent on
tracheostomy/ventilator or gastrostomy tube), are on three or more medications, or are
followed by multiple pediatric subspecialists.
Most children in the clinic are insured through the Johns Hopkins Medicaid Managed Care
Organization. Medically complex children with this insurance can receive case management
from an embedded nurse case manager co-located in the clinic; this case manager is hired
by the managed care organizations but works side-by-side with clinic providers. The case
manager can meet with patients and caregivers during clinic visits, schedule home visits,
and communicate with families via secure messaging and telephone.
Children qualifying for Medicaid’s fee-for-service REM program are assigned off-site case
managers (RNs or licensed clinical social workers) who connect with families by telephone
or home visits and sometimes accompany families to clinic visits. Case managers provide
patient education and family support services, coordinate provider services, and follow up
on the recipient’s progress. REM case managers can communicate with patients’ resident
physicians via secure email.
Association of
American Medical Colleges26
Complex Care Management Checklist
Develop a process to accurately identify complex care patients
Develop a small Complex Care Management (CCM) team for
high-needs, high-cost patients
Create the technology infrastructure to support the CCM team (telehealth,
mobile application, etc.)
Include nonclinical team members to provide wrap-around services
(social worker, community health worker)
Children With Asthma
Another group of high-risk children that are identified by the clinic are those with more
than two asthma emergency department visits or hospitalizations in a year. These children
are followed by clinic-based Asthma Community Health Worker teams of two physicians
and two CHWs who provide outreach and advocacy. The Asthma Community Health
Worker teams see children treated for acute asthma exacerbations and follow-up visits.
Families can access their CHW by text, phone, or email. The team coordinates in-school
controller therapy, health department home visits for environmental controls, medication
refills, and regular follow-up. Residents are taught an asthma treatment algorithm and
attend a teaching session on asthma PHM.
Maternal Mental Health
The maternal mental health team consists of a case manager, mental health consultant,
CHW, and part-time therapist with access to a psychiatrist who specializes in women’s
mood disorders. This team is located within the clinic and works closely with residents
during their ambulatory block when they are seeing newborns. Residents and team
members share a team room to promote consistent communication. A team member
screens all mothers for post-partum depression and intimate partner violence during
routine infant visits throughout the infant’s first year. A subset of mothers participates
in an on-site evidence-based parenting program (Circle of Security) that may
include home visits.
Association of
American Medical Colleges
Teaching Residents Population Health Management
November 2019
9. Addressing Social Determinants of Health for
Residents’ Patient Panels
A recent PHM innovation is “social prescribing,” which involves (1) screening for social needs
(such as housing or food insecurity), (2) addressing patient needs with clinic or hospital resources
such as a food bank or transportation vouchers, (3) referring patients with two or more
comprehensive community-based services (such as housing support or meal delivery programs),
and (4) supporting patients to access relevant services (often using a care coordinator or CHW).24
A leader in social prescribing is Health Leads, a nonprofit national organization that trains and
supervises volunteers to provide social support to patients.25,26 Patients can be referred by their
primary care provider or identified by screening positive on a questionnaire that patients fill out
in the clinic waiting room. Health Leads advocates typically occupy a desk within the clinic and
work with patients to identify and navigate relevant community-based resources. Advocates
maintain contact with patients as required and provide updates to the clinical team.
Community engagement is distinct from social prescribing in that the latter is associated with
patient panels in a practice, while the former addresses the larger community, whether or not its
members are patients of the practice. The “big P” population of the community may or may not
be patients in the “small p” patient population of a resident or a clinic.
Residency programs are beginning to teach about social determinants of health (SDOH) and
social prescribing using both didactic and experiential learning.27,28 Also, several residencies
have initiated medical-legal partnerships in which medical and legal faculty and learners assist
patients with health-harming legal needs.29
Addressing the Social Determinants of Health at Johns Hopkins
Pediatricians from Johns Hopkins Harriet Lane Clinic capture families’ basic resource needs
in a social history section of the pediatrician’s note in the EHR. Residents can refer families
with identified needs to the in-clinic Health Leads desk staffed by trained college student
advocates, whom the institution has granted patient-approved EHR access. Alternatively,
families can fill out the screening questionnaire to access a Health Leads advocate. Once
a referral through the EHR has been made, for example, for food insecurity, an advocate
provides family education, makes appropriate referrals to community resources, and follows
up with the family. An online teaching curriculum covers foundational pediatric primary care
topics, including social determinants of health.
Association of
American Medical Colleges28
Addressing Social Determinants of Health (SDOH) for Residents’
Patient Panels Checklist
Create a pathway within the EHR to collect information about SDOH
Identify a member of the care team who can address SDOH
Provide a list of social services/resources that can be used to meet the
identified patient needs
Develop a referral system for clinical team members to refer to the appropriate
staff member to have these needs met
Addressing the Social Determinants of Health at Cambridge Health Alliance
Cambridge Health Alliance has developed the role of Patient Resource Coordinator (PRC).
PRCs help patients identified by any member of the primary care team who need support
around social determinants of health. They are available for warm hand-offs or referrals.
PRCs assist patients with transportation, develop and initiate plans to meet food and
housing security needs, and connect patients with community and area resources
(e.g., job training/placement, legal services, child care, or personal care assistants).
Association of
American Medical Colleges
Teaching Residents Population Health Management
November 2019
10. Ensuring Health Equity
While PHM often looks at care gaps of patients receiving preventive interventions, identifying
gaps among patient subgroups is also important. Even well-intentioned clinical interventions
may result in overall health improvement in a patient population, while certain subgroups
experience worsening outcomes. Part of PHM is looking at data through an equity lens to ensure
improvement in the health outcomes of all subpopulations.
Addressing health inequities among a population requires reporting clinical data by several
factors, which could include race/ethnicity, language, gender, gender identity, sexual orientation,
insurance status, and geography. Several of the seven residency programs that participated in
the meeting teach residents about health inequities. However, few routinely report on quality
metrics categorized by race/ethnicity, language, gender, or insurance status.
ACGME’s Clinical Learning Environment Review (CLER) was designed to “provide US teaching
hospitals, medical centers, health systems, and other clinical settings affiliated with ACGME-
accredited institutions with periodic feedback that addresses […] six focus areas.” Of these six
areas, Health Care Quality is one area in which the program has identified health care disparities
as a key factor of resident education.30 CLER expects that residents and faculty receive education
on identifying and reducing health care disparities in their patient population and participate in
projects that demonstrate this knowledge.31
FMRI has a four-week community health block in which all second-year residents learn about
health care disparities through readings and experiential learning. They visit a prison and
homeless shelter and spend time with the clinic’s CHWs to learn about caring for Latino migrant
farmworkers. In addition, the behavioral health staff lead a half-day resident conference on
cultural humility. The University of Arizona schedules noon conferences that discuss the impact
of health literacy and community resources for vulnerable populations. Two dedicated lectures
focus on social determinants of health and health disparities. At UNC, residents have experiences
in a FQHC, critical access hospital, migrant farmworker camps, inpatient prison facilities, and
other programs chosen to highlight the realities and disparities within the health care system.
Ensuring Health Equity at Washington University
Twice a year, residents receive a report with data on inequities in diabetes metrics based on
race, gender, primary language, and insurance type (see Figure 5). The residency program
was motivated to create and spread the health disparity report because St. Louis is a highly
segregated city with significant health inequities. This was partially motivated by several
high-profile police cases highlighting inequities in the region. Consequently, local and
regional initiatives focused on the health of African Americans have also emerged.
The residency program informs residents of these data through multiple venues. The
health disparity report is discussed at clinic quality improvement meetings, which
residents attend, if possible. Residents can also attend lectures and grand rounds about
disparities. The clinic has launched initiatives to address disparities, including diabetes
Association of
American Medical Colleges30
Health Disparity Report for Team 6
Race/Ethinicity Language Gender Insurance status
Black/AA Other English Non-English Male Female Self Medicare Medicaid
Number of
%HbA1c <8 63% 61% 63% 62% 56% 66% 57% 71% 64%
% Scrn for
Nephropathy 90% 90% 90% 87% 94% 88% 95% 92% 83%
% Ophtho
exam 41% 29% 38% 37% 41% 36% 19% 46% 43%
BP>140/90 47% 41% 47% 31% 44% 46% 47% 49% 41%
Figure 5. Washington University health disparity report example.
education for non-English speaking patients and a retinal screening project to remove the
eye clinic’s high co-pay for uninsured patients. The clinic is beginning work to understand
how the disparities data may influence physician behavior and ultimately reduce
disparities within the clinic population.
Ensuring Health Equity at Cambridge Health Alliance
The residency program has pioneered Quality Equity and Safety Rounds. Morbidity and
mortality (M and M) conferences are traditionally used as opportunities to reflect on
error, both at the individual and system level, but these conferences rarely address clinical
behavior and patient outcomes in the context of systemic racism and other structural
inequities. Cambridge Health Alliance Department of Family Medicine transformed the
traditional M and M format into a series of conferences that focus on quality through the
lens of health equity. The department believes that quality or safety cannot be achieved
without addressing fundamental questions of equity.
Initial sessions laid the groundwork by building a common language of race and equity
work and created commitments for how the group would approach the difficult work
of exploring race and equity issues respectfully and honestly, acknowledging that
“we can’t make it all seem nice.” Through these sessions, the residency program has
explored institutional policies such as dress code and maternal drug screening policies
Association of
American Medical Colleges
Teaching Residents Population Health Management
November 2019
Ensuring Health Equity Checklist
Collect data on a variety of demographic factors such as race, ethnicity,
gender identity, sexual orientation, languages spoken, and citizenship
Ensure PHM and quality improvement intitatives have an equity analysis
Provide data to residents and faculty on health inequities found within the
patient population
Once an inequity is identified, create a plan of action and accountability
within the team to address the problem
Incorporate lectures and case discussions that address inequities found in
the clinic’s patient population
that contain racial and gender equity issues, some of which have led to a change in
hospital and residency policies.
The residency program has also developed a Community Health and Equity Syllabus to
teach residents the skills, knowledge, and attitudes needed to promote health equity.
Residents must develop and complete a 22-hour community health project collaboratively
with a community agency, describe the project using a racial equity impact assessment
toolkit, and present the project through a poster and an audio-visual conference.
Association of
American Medical Colleges32
Integrating Population Health Management
Into Residency Training
Training primary care residents in PHM is challenging because residents have a vast amount of
clinical medicine to learn and spend less than half their residency time in primary care clinic. Resident
schedules are complex, making resident attendance at population health conferences and team
meetings inconsistent. Also, many faculty physicians lack the expertise to teach PHM to residents.
Resident PHM training includes both didactic sessions to teach PHM principles and experiential
learning during which residents practice PHM while caring for their patient panels.32 Moreover,
PHM training can be linked to the ACGME milestones. The following narrative and vignettes
describe various aspects of PHM, including (1) PHM didactics, (2) PHM experiential learning,
(3) making time for PHM teaching, (4) faculty development in PHM, and (5) PHM curricula and
milestones. Didactics and experiential learning often overlap with one another.
PHM Didactics at Johns Hopkins
Pediatric residents receive a didactic lecture on social determinants of health,
population health, and health disparities, with a specific focus on Baltimore. Residents
also receive a lecture on social determinants of health and home visitation during
an inpatient rotation at an affiliated community hospital. The residency clinic uses
modules on a web-based platform used by several programs nationally, which address
a wide array of primary care issues that highlight population dynamics of common
pediatric conditions and how social determinants of health drive health outcomes.
Examples of modules include clinic and community resources, advocacy training in
pediatrics, outpatient asthma management (including epidemiology and environmental
control), screening for intimate partner violence, screening for and addressing maternal
depression, and childhood injury prevention.
PHM Experiential Learning at the University of Cincinnati
Each month during their long block, residents receive performance metrics on
hypertension, diabetes, immunization rates, PHQ-9s, and other preventive measures for
their own patients. In addition, residents can consult a real-time dashboard in the EHR for
this same information. As part of their patient care education, residents learn to address
many barriers to care faced by the clinic’s vulnerable populations. Moreover, residents
learn to work in interdisciplinary teams with pharmacists, a depression care manager,
social workers, and an outreach case manager.
Before the start of the long block, residents are assigned a single outcome measure
and asked to perform a literature review of the measure, termed the Defense of the
Measures. Residents are required to attend Defense of the Measures conferences, with
Association of
American Medical Colleges33
Protected Time for Residents to Learn PHM
Integrating PHM into residents’ complex schedules is a challenge for all teaching practices.
Cambridge Health Alliance and the University of Arizona have rebalanced their programs to
reduce some in-patient and subspecialty time, while still meeting ACGME requirements, and
prioritize residents’ attendance at meetings in which PHM is discussed. UNC and FMRI also
protect resident time for meetings and registry management. The University of Cincinnati’s long
block is ideal for immersing residents in PHM and starts with a several-day orientation on how
to interpret their patient registries. During long block, residents are excused from other clinical
duties to attend weekly team meetings that address PHM issues. Residents are expected to use
their registries to prep for clinic daily.
Faculty Development in PHM
Residency faculty members are not necessarily trained in or comfortable teaching PHM. UNC
has many faculty with master of public health degrees who can teach PHM and a few experts
responsible for resident education in PHM. Other programs rely on a few faculty members with
PHM expertise. Because the University of Arizona has a small number of full-time faculty in the
clinic, the entire faculty learns PHM through attending PHM noon conferences and — for their
own patient panel — monthly meetings with the panel management MAs. Among the seven
programs that participated in the 2018 PHM meeting, formal faculty development in PHM was
rare and represents an opportunity for future development.
PHM Curricula and Milestones
Starting in 2013, residency programs have been required to assess resident development based
on milestones in six general competency areas: patient care, medical knowledge, practice-based
learning and improvement, interpersonal and communication skills, professionalism, and system-
based practice.34 The 2015 report Population Health Milestones in Graduate Medical Education
maps population health teaching to the milestones, as summarized in the following vignette.35
teams of residents evaluating, for example, the evidence supporting the importance of
the current diabetes measures and the strength of the medical literature that supports
the continued use of these measures to improve patient outcomes. Long-block residents
present their review to their entire team, including nurses and allied health professionals.
The review concludes with a recommendation of whether the measure should be
kept, changed, removed, or added. The entire team discusses the evidence presented
and votes on what should be done. Since the inception of Defense of the Measures,
outcomes measured in the practice have changed substantially, including a change in
glycemic targets (HbA1c levels), new vaccinations (herpes zoster), or new screening
recommendations (HIV, hepatitis C).
After Defense of the Measures was implemented, teams have not spent time arguing
the value of measurement. Team members have also realized that they cannot track
and measure everything, even if there is good evidence; thus, they must decide which
measures are most critical for better outcomes in their population. The Defense of the
Measures intervention empowers team members to critically examine the outcomes they
are measured by and prepares residents to use these skills in their future practice.33
Association of
American Medical Colleges34
PHM Curriculum at the University of Arizona
The program recently implemented a web-based longitudinal curriculum for second-
and third-year residents to complete four self-study population health modules over the
two-year span. Each block needs to be completed over a five-month period, prior to
each meeting of the Clinical Competency Committee. The blocks include readings from,
for example, the Family Practice Management journal and from the American Medical
Association (AMA) STEPS Forward website. In addition to milestone evaluations, which
include population health, residents are evaluated with pre-tests and post-tests on
introduction to population health, team-based care, registries, standing orders,
and payment models.
A bimonthly interdisciplinary quality improvement noon conference focuses on team-
based quality improvement projects. Residents also attend sessions on team-based care,
how to develop standing orders, and payments related to population health.
The goal of the curriculum is to foster an understanding of the role of patient registries
and quality markers in managing the preventive and chronic health of the resident’s patient
population. With faculty supervision, residents lead a team in monitoring and coordinating
the care of their continuity panel over the course of two years. The skills and procedural
pathways learned are transferrable to managing population health in a wide variety of
settings upon graduating.
By the end of this longitudinal experience, University of Arizona residents should be able
to demonstrate competencies tied to the following ACGME Competencies:35
• Patient care: Demonstrate how to access primary care provider-specific
population health data collected by Banner Health; use these quality markers
to evaluate the care of their patients; display an understanding of the role that
registries play in managing patient and population health; and achieve base target
scores for all routine Banner quality initiatives.
• Medical knowledge: Demonstrate improvement in quality measures over the
course of the longitudinal experience.
• Systems-based practice: Demonstrate responsibility for the coordination of
a care team to optimize the health of a continuity panel.
• Practice-based learning and improvement: Effectively use patient registries
to assess and manage population health.
• Professionalism: Describe how Medicare/Medicaid, commercial insurers, and health
systems utilize quality measures with regards to population health and physician
payment; complete assigned curricular readings, assignments, and self-assessments
in a timely fashion; and actively participate in semi-annual feedback sessions.
• Communication: Demonstrate how to accurately capture quality data within
Banner Health’s EHR and communicate collaboratively with the population
health MAs.
Association of
American Medical Colleges
Teaching Residents Population Health Management
November 2019
For decades, residency programs have taught and emphasized the clinical care of individual
patients. Now, primary care residency programs in family medicine, internal medicine, and
pediatrics are responding to an additional need: to teach physicians in training how to prevent
illness and improve care for a population of patients. Thinking about populations involves
knowledge and skills separate from traditional clinical care. Just as individual clinical education
requires not only didactic learning but also the experience of actual patient care, so does training
in PHM require both didactic learning and actively conducting PHM with a panel of patients
and an interdisciplinary team.
This report has covered a series of topics in PHM and population health, relying on vignettes
from high-performing residency teaching clinics to illuminate this body of knowledge. Residency
programs can self-assess their competency in PHM by examining their data systems; their panel
management workflows, including in-reach and outreach to identify and address care gaps; their
capacity to risk-stratify their panels and provide more intensive services for high-needs and high-
cost patients; their uncovering of health inequities among their population; their concern for social
determinants of health; and their alignment with community health needs and engagement with
their local community. Twenty-first century physicians need to be skilled clinicians and experts
in PHM. GME training programs are critical to developing a physician workforce that is culturally
prepared and equipped to improve population health and reduce health inequities.
Association of
American Medical Colleges36
Appendix: Full PHM Checklist
Foundational Elements
1. Data Infrastructure
Implement electronic health records (EHRs)
Create data registry
Designate IT staff or clinician lead
Establish metrics or targets for clinical outcomes/improvements
Regularly review reports by disease, strategy, and population
Ensure care teams discuss data
2. Team-Based Care
Develop a core clinical team
Develop an extended care team
Distribute responsibilities among team members
Establish effective communication channels to which all team members can contribute
Ensure that residents understand team roles and learn from team members
3. Community Engagement
Ensure that residents and faculty are familiar with the local community health needs
assessment (CHNA)
Align PHM work with the local CHNA
Align community service projects with the needs of the local community and the needs
of the patient population
Develop partnerships with local community organizations that are aligned with the
CHNA and the PHM work of the clinic
Association of
American Medical Colleges37
Key Activities
4. Panel Management
Ensure that all patients in a population are included in a panel to regularly observe
evidence-based preventive and chronic care tasks and recognize health disparities
Develop a system to identify care gaps
Develop a process to close care gaps and inequities with “in-reach”
Develop a process to close care gaps and inequities with “outreach”
5. Patient Risk Stratification
Risk-stratify by population subgroup (race, ethnicity, neighborhood,
insurance, languages spoken, citizenship, etc.)
Risk-stratify by disease burden
Risk-stratify by co-morbidity
Risk-stratify by frequency of visits to emergency room or hospital admissions
(see Complex Care Management)
6 and 7. Care Management and Self-Management Support
Designate staff to create individual care plans for patients with chronic conditions
Develop a system for patients to obtain self-management support
Educate residents on this pathway and create a seamless referral system
8. Complex Care Management
Develop a process to accurately identify complex care patients
Develop a small Complex Care Management (CCM) team for high-needs,
high-cost patients
Create the technology infrastructure to support the CCM team (telehealth, mobile
application, etc.)
Include nonclinical team members to provide wrap-around services (social worker,
community health worker)
Association of
American Medical Colleges38
9. Addressing Social Determinants of Health (SDOH)
Create a pathway within the EHR to collect information about SDOH
Identify a member of the care team who can address SDOH
Provide a list of social services/resources that can be used to meet the identified
patient needs
Develop a referral system for clinical team members to refer to the appropriate
staff member to have these needs met
10. Ensuring Health Equity
Collect data on a variety of demographic factors such as race, ethnicity, gender identity,
sexual orientation, languages spoken, and citizenship
Ensure PHM and quality improvement intitatives have an equity analysis
Provide data to residents and faculty on health inequities found within the patient population
Once an inequity is identified, create a plan of action and accountability within the team
to address the problem
Incorporate lectures and case discussions that address inequities found in the clinic’s
patient population
Association of
American Medical Colleges
Teaching Residents Population Health Management
November 2019
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Association of
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Association of
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November 2019
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Answered 1 days AfterMay 11, 2021


Sayani Chakraborty answered on May 12 2021
31 Votes

Running Head: LESSON 13 ESSAY1
Table of Contents
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