What it is
What others have done
How to get started
How to succeed

What should I know before beginning implementation?

There are numerous reasons why stakeholders may determine that empanelment would be a worthwhile intervention. Empanelment can improve health outcomes by ensuring responsibility for a group of patients regardless of if they seek care, rather than reactively treating patients who access health services. Empanelment also gives stakeholders a stable and updated “denominator” to understand the population for which a primary health care clinical service unit is responsible. Empanelment creates a process for knowing and understanding who and which communities the clinical teams are accountable and responsible for over time. Without understanding this baseline measure, and the segments of the population (numerators) that make up this denominator, it is difficult to effectively plan and implement population health strategies. Further, in order to shift PHC service orientation from a purely reactive one to proactive over time, empanelment is necessary and will make proactive population outreach more effective.

Some indications that empanelment is needed may include:

  • A significant portion or specific segments of the population do not have a usual source of care
  • Patients are over-utilizing higher levels of care for needs that can be addressed in primary care settings
  • A population experiences significant morbidity and mortality from preventive causes
  • Patients feel that care is of poor quality and not responsive to their needs

Providers or care teams receive too few or too many patients relative to their capacities.

  • While complete empanelment is a key goal for effective population health management, very few countries have achieved 100% empanelment in practice (some countries that have achieved >90% empanelment include: England, Scotland, Netherlands, Denmark, Finland, Estonia, and Costa Rica). Countries may choose to begin empanelment by selecting target groups that are particularly vulnerable or in need of specialized services and placing these populations under the purview of specific care teams.

    The Sustainable Development Goals (SDGs) released by the UN in 2015 included health targets for priority groups under Goal 3: Ensure healthy lives and promote well-being for all at all ages. The targets call for efforts that will support reductions in maternal and under-5 mortality, end the epidemics of AIDS, tuberculosis, and malaria, reduce mortality from non-communicable diseases, and ensure access to sexual and reproductive health services.1 Additional information on the SDG goals can be found on the Global Goals website. While working towards full empanelment, these priority groups – women of reproductive age, children under 5, people living with HIV/AIDS, and individuals with chronic diseases – are all segments of the population that could be initially empaneled and would benefit from proactive services and monitoring by providers. For instance, a few community health workers may be responsible for all women of reproductive age within a given geographic catchment and provide these women with necessary referrals to prenatal care and birthing services, ensuring access to preventive services that may eventually result in a reduction in maternal mortality.

    This form of empanelment can also create a population denominator for these sub-groups of the population and help countries measure and achieve specific targets. It is important to note that this method of empanelment is meant to lead towards a holistic goal of widespread empanelment as it will naturally exclude segments of the population. The selection of sub-groups and accompanying services is discussed in greater detail in proactive population outreach.  

  • In addition to empanelment of sub-populations based on health needs, there are three general methods of empanelment: geographic, voluntary, and insurance-based (though other forms can exist, including empanelment to private provider groups). These methods are not mutually exclusive and can occasionally co-exist, such as in Turkey. A brief case study on Turkey is described in “What others have done”. Countries may also choose to begin empanelment by focusing on target groups with specific health needs, as discussed above. However, this should be supplemental to efforts to achieve widespread empanelment using one or a combination of these three methods.

    Geographic empanelment uses pre-existing geographic or municipal boundaries to assign individuals to a provider or care team. While this is the simplest method of empanelment and supports strong geographic access to PHC, it may be perceived as limiting the autonomy of patients to choose their providers and subsequently decrease patient trust in the system. Geographic empanelment is also dependent on PHC services provided by a governmental entity, and low rates of private PHC use.

    Voluntary empanelment prioritizes patient autonomy and allows patients to choose their provider or care team.2 It is often more adaptable to mixed private-public PHC markets. The final method of empanelment is insurance-based, which may be feasible if providers and patients are linked to a specific insurance scheme, and a care team only sees or is responsible for particular enrollees in an insurance scheme. In these cases, the insurer may assign the provider or care team. Insurance-based empanelment can work in a variety of public, private, or mixed systems, but it is dependent on a formal insurance entity and broad universal health coverage by that entity or mix of entities.

    Stakeholders may ask some of the following questions to help identify which method would be best in a given context:

    1. Are there sufficient numbers of providers within a geographic area to give patients a choice of providers while also ensuring that they are geographically accessible?
    2. Are there certain insurance schemes in place in the region such that providers’ workload or logistical requirements would be significantly more efficient if they only provided care to enrollees?
    3. Are there any insurance schemes in place that already have an informal or formal empanelment systems but are not at a national level?
    4. Are there sufficient information systems in place to track patients if they were given the choice to switch providers? Are they capable of tracking a panel for facility and outreach care?

    After establishing the appropriate method for assigning panels, stakeholders must determine how many individuals or families should be included in each panel. This requires consideration of patient-provider supply and demand to ensure that providers are not overburdened and can effectively care for all people within their panel. However, the size of a panel and the specific considerations involved in determining panel size will differ based on local context. Population profiles and needs should be considered to ensure that care teams are not overburdened by caseload or by substantial health needs. In general, stakeholders should consider the number and capabilities of the providers within a care team, the time and human resources needed to fulfill various activities undertaken by the team (i.e. education, community outreach, curative care, preventive care), and any data on the specific needs of the population that may influence the degree of care they require. Once patients are linked to a provider or care team, a patient’s first point of contact has been clarified and should be deliberately reinforced during subsequent visits to the facility and during community-based care.

    An implementation guide developed by the Safety Net Medical Home Initiative in the United States highlights various considerations for implementers when instituting empanelment. Although these guides were developed for a high-income setting, they provide relevant information on the sequential steps needed to empanel a population and tools that would facilitate decisions regarding appropriate panel sizes.

    Recognizing that empanelment relies upon data on the relevant populations, the absence of a civil registration and vital statistics (CRVS) system may present a bottleneck to the establishment of patient panels. Without a CRVS system, stakeholders seeking to empanel their population may have to perform a census which is timely, costly, and often not within the scope of providers’ training. More information on CRVS systems is provided by the WHO and the Health Data Collaborative.

  • Empanelment is an important foundation for population health management. In addition to providing logistical structure and clarity to patients, empanelment can enable a patient-centered model of care where providers assume proactive responsibility for their panel, regardless of whether or not patients visit the facility. While empanelment is a critical component, this must be achieved in conjunction with the other elements of population health management, namely local priority setting, community engagement, and proactive population management. When empanelment is not technically feasible, other parts of population health management can be prioritized until policy and community contextual elements enable empanelment to be implemented.

    One method for promoting continuous, accessible, and coordinated care within a panel is a gatekeeper method for accessing higher-level or specialist care for non-emergencies. In an “explicit” gatekeeper model, patients can only receive care from secondary or tertiary facilities if they first seek an approved referral from their primary care provider. By contrast, “implicit” gatekeeping occurs if patients are encouraged but not required to visit their primary care provider before seeking secondary or tertiary care.2 Gatekeeper systems can help reduce over-utilization of higher levels of care while ensuring that primary care providers are aware of all of the health needs of their panel, even when they must be addressed by specialists. This can improve coordination and continuity of care. However, it is important to note that gatekeeper models can limit access to needed specialty care if the system is not well-planned. Gatekeeping is only effective if the following elements are in place: clear communication of patient panels; trust and respect between patients and providers; timely appointment availability at primary and specialty care facilities; effective referral systems, including communication between levels of care; and geographically and financially available primary and specialty care services.

    Reorienting a health system to actively manage the care of a panel of patients often requires a conceptual shift for all providers involved. In order to facilitate this change, facilities must have strong and engaged leadership and managers who can communicate the goals of empanelment and guide employees through new systems or processes.3 Leadership qualities are discussed in greater detail in the facility organization and management Improvement Strategies module.

Suggested citation: “Population Health Management: Empanelment.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/improvement-strategies/population-health-manage.... Accessed [insert date].

What has been done elsewhere to improve empanelment?

While the merits of empanelment have been documented in high-income settings, particularly throughout Europe, little peer-reviewed literature exists evaluating different models of empanelment in LMIC. Despite this gap in the literature, many countries have adopted various models of empanelment as a means to achieve population health management. Costa Rica, Ghana, Brazil, Turkey, Estonia, and Ethiopia are among the countries that have integrated empanelment into various health care reforms over the last few decades, demonstrating the effect that empanelment can have on access, high quality PHC, and eventually outputs and outcomes. Because empanelment is often integrated into a package of reforms, it is difficult to attribute positive outcomes to empanelment alone, though many of these case studies have demonstrated tangible improvements in service delivery and health outcomes.

  • The experience in Turkey demonstrates a mix of geographic and voluntary empanelment. Under the Health Transformation Programme (HTP), Turkey established geographically distributed medicine centers with assigned patient panels (HTP). Initially, patients are assigned a physician based on geographic catchment areas as a means to improve geographic and timely access to care. However, after this initial geographic empanelment, patients were free to switch providers at will.2 4 While this system does prioritize patient choice and establishes a first point of contact, there are multiple opportunities for improvement. First, catchment areas are not determined based on population profiles and burden of disease, resulting in panels with needs that surpass other panels of equal sizes. Secondly, patient registers are not capable of tracking when patients switch providers, compromising coordination of care and underscoring the necessity of pairing empanelment – and all population health management activities –  with strong information systems. Learn more about Turkey in our Promising Practice case study.

  • In contrast to Turkey’s challenges with tracking patients during voluntary empanelment, the Southcentral Foundation (SCF) Nuka System of Care serving Alaska Native and American Indian people in Alaska, United States has achieved efficient voluntary empanelment through the support of an Empanelment Department. The population served by SCF is largely poor, rural, marginalized, and suffers from high rates of chronic disease. Catalyzed by a law passed by the United States Congress, SCF has been tribally owned and managed since 1997. As such, patients are called “customer-owners” and have significant oversight into the functioning of their health system. Customer-owners can join open enrollment panels at any time or join a panel to which his or her family already belongs, even if it is not accepting new patients otherwise.56 Each panel includes approximately 1500 customer-owners, and care teams comprise a primary care physician, nurse case managers, certified medical assistants, and administrative staff. The Empanelment Department and SCF staff assist in all aspects of panel placement and management, helping to improve relationships between primary care providers and customer-owners if conflicts arise or matching customer-owners with a new panel as needed. In addition to checking empanelment status at each visit, staff work to ensure continuity of information and communication between providers when patients switch panels. This constant monitoring and support requires significant human resources and efficient information systems.5

  • Empanelment was a central component of health care reforms introduced in the early 1990s in Costa Rica, Brazil, and Ghana. The Equipo Basico de Atencion Integral de Salud (EBAIS) model in Costa Rica and the Family Health Strategy (FHS) in Brazil established multidisciplinary care teams to provide comprehensive care to a geographically empaneled population of approximately 3500 and 4500 individuals, respectively.78 A similar reform took place in Ghana where trained nurses called Community Health Officers (CHOs) provided health services to an empaneled population both by way of door-to-door services and at Community-based Health Planning and Services (CHPS) compounds. All three countries demonstrated significant gains in access to PHC: during the first decade of implementation, access to PHC services in Costa Rica increased from 25% to 93% 7, coverage in Brazil increased from 4% in 1998 to 62% in 2014 9, and the pilot experiment for strengthening CHPS implementation in a Northern region of Ghana demonstrated an eight-fold increase in encounters with health services.10

    As demonstrated by these countries, the most immediate result of geographic empanelment was the establishment of a geographically accessible first point of contact in the health system. Additionally, Costa Rica, Brazil, and Ghana all coupled empanelment with the deployment of CHWs to communities. After establishing panels, CHWs were able to provide integrated, person-centered care and form continuous relationships through regular home visits and community-based care. More information on community-based care can be found in proactive population outreach and provider availability.

    Learn more about Costa Rica, Ghana, and Brazil.

Suggested citation: “Population Health Management: Empanelment.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/improvement-strategies/population-health-manage.... Accessed [insert date].

What questions should be considered to begin improvements?

The questions below may be a useful starting place for determining whether empanelment is an appropriate area of focus for a given context and how one might begin to plan and enact reforms:

If empanelment does exist, how is the population assigned to a provider or care team and what portion of the population is empaneled?

As discussed in “what it is”, populations can be empaneled in a variety of ways, including geographically, voluntarily, or through insurance. As a country’s health system changes, it may be important to re-evaluate methods of empanelment. Additionally, countries may begin by empaneling only a segment of the population and adopt new methods as the context becomes more conducive.

If empanelment exists, who is tasked with updating and maintaining patient panels? What is the process for managing patient panels to ensure they are accurate and reflect the patients for whom the providers or care teams are responsible/accountable and wh

It is important to have a clearly identified person within a care team who is responsible for updating and maintaining patient panels. This will differ facility to facility, but some options include: administrative staff members or nurses who confirm, communicate, and make changes to panel assignment as needed during facility visits or community-based providers who assess empanelment during community outreach.

How do you ensure that providers are care teams understand empanelment and how it impacts them?

Providers must understand how they can access patient panel information and how to contact or provide outreach to these individuals in order for the community to benefit from empanelment. This functionality should be integrated into facility-based information systems. Additionally, if empanelment is a new intervention, it is important for facility leaders to create protected time for providers to ask relevant questions and understand how this change will impact their responsibilities.

Between visits to the facility, what is the process to identify which segments of patients are contacted when? How are evidence-based guidelines incorporated into this process? How are gaps in care identified and addressed when patients visit the facility

Proactive population outreach can be facilitated through empanelment. Using patient registers for the empaneled population, facility managers can consider the type and frequency of outreach needed. More information can be found in the proactive population outreach module.

Which type(s) of empanelment would be most appropriate in a given setting?

Factors that may impact this choice include: geographic availability and skill mix of providers; informal empanelment systems already in place through geographic catchment areas or insurance schemes; and availability of information systems to track patients as they move between panels.

What are the current health needs of the panel, and what mix of provider team can best meet these needs?

This will depend upon the training, capabilities, and availability of the health workforce as well as the national Basic Package of Essential Health Services. More information can be found in local priority setting and team-based care organization.

What is the appropriate size and mix of patient panels?

This should be determined in conjunction with the question above; the capacity of the provider team and needs of the population will help determine the appropriate panel size.

What is or should be the process to ensure that providers and/or care teams know how and where to reach patients, including those who do not come into the facility? What resources are available to contact patients and conduct outreach (i.e. community-base

Providers should be able to easily access patients when needed to ensure that patients are receiving care whether or not they proactively contact the health system. This will depend on the reliability of contact information, the ability for providers to spend time in communities, and communication technology. Proactive outreach to the panel is an important component of empanelment, and the relevant providers should be identified to conduct this outreach. These services are typically provided by Community Health Workers or similar cadres. More information on community-based providers can be found in proactive population outreach and provider availability.

Suggested citation: “Population Health Management: Empanelment.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/improvement-strategies/population-health-manage.... Accessed [insert date].

What elements should be in place to support effective improvements?

In order for interventions aimed at improving empanelment to be most successful, the following elements of the PHCPI Conceptual Framework should be in place or pursued simultaneously:

  • Empanelment may be challenging in fee-for-service payment environments without additional incentives. A recent study evaluated revenue gains under different payment models supporting patient-centered medical home models in the United States, finding that per-member-per-month payments increase net annual revenue while increased fee-for-service payments do not. 11 Providers who receive fee-for-service payments typically estimate panel sizes based on those who actively seek care, overlooking those who do not have access to PHC.12 By contrast, capitation payment systems may enable providers to allocate time and resources based on the size and health needs of their panel. Capitation is common in many European countries with national health systems and universal patient registers.

  • Successful empanelment depends on information systems with broad, fundamental capacities to track and stratify a given patient population.  Patient registers and civil registration and vital statistics (CRVS) systems are crucial for care teams to locate, contact, and list their panel for planning purposes and must be coupled with medical record systems that enable a provider to track the health of individual patients in order to provide the most appropriate, continuous, and coordinated care.12

    In addition to information systems capable of retaining patient panels and recording patient medical information, further efficient, effective, and innovative use of these systems has been shown to contribute to population health management in empaneled populations. During monthly household visits, community health agents in Brazil collect individual and household-level data to keep updated vital registers and data on burden of disease and health needs.9 Similarly, in Costa Rica, data feedback loops and efficient communication of information enable the development of targeted action plans and management contracts, targeting the specific health needs of the population.7 Additionally, information systems that incorporate personal health records have the potential to engage patients in their own care and improve health literacy.13

  • There must be an adequate number of reliable providers to serve an empaneled population, thus provider supply is a crucial component in determining panel size. If supply and demand are unbalanced, population health management will not be feasible. Additionally, the composition of the workforce is an important consideration when determining if and how to integrate multidisciplinary teams. While there are no guidelines or toolkits in LMIC on the appropriate provider to patient ratio for panels, care teams in Brazil and Costa Rica have managed panels of approximately 3500 and 4500 individuals, respectively.714 A study in the United States found that a single provider can reasonably manage care for 983 individuals, while a care team with substantial delegation may be capable of managing care for a panel size of 1947 individuals.15 These panel sizes are meant to be guidelines and not prescriptive as panel size depends on myriad contextual factors such as demographics, burden of disease, and the capabilities of members of the care team.

  • In many LMIC, multidisciplinary teams have been the cornerstone of population health management and pursued in tandem with empanelment. Delegation of care between team members can result in more efficient and comprehensive care. A 2012 analysis using data from the United States found that delegating care to non-physicians on the team could help teams support double the size of a panel compared to care provided by a physician alone.15 It is important to note that delegation – or task shifting – should always be accompanied by the appropriate training for providers who assume new responsibilities. Care teams can drive improvements in health outcomes by increasing the contact individuals have with the health system, often through the provision of community-based care. The value of care teams working with an empaneled population has been seen empirically as well. The FHS teams in Brazil include a physician, nurse assistant, and four to six community health workers each, and Costa Rica’s EBAIS teams are comprised of a doctor, a nurse, a technical assistant, a medical clerk, and a pharmacist.78 Not only are these teams able to see patients more efficiently through defined roles, but they can also contribute to comprehensive care by tapping into different expertise of team members to identify who can provide care appropriate to patients’ need.

Suggested citation: “Population Health Management: Empanelment.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/improvement-strategies/population-health-manage.... Accessed [insert date].

References:

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