​​​​​​​​​​​​​​​​​​​​Achieving Accountable Care

Patient Panel Definition

Clear definition of the patient panel, its explicit constituents (e.g., individual patients and/or families, and potentially other groups), and its characterized composition are critical initial considerations in the development of accountable care models.

Organizations pursuing this stage are often seeking to answer key analytical questions such as:

  • Who are my patients?

  • What are their Treatments?

  • Wha​t other Providers are they seeing?

  • At What Locations?​

  • With What Frequency?

The following Action Plans are concrete steps organizations must consider for progressively achieving this stage.

<--Return to ACA Staged Implementation Home

Action Plans
​Identify Unique Patients
  • Assemble and integrate Patient Identifiers from multiple source systems, operating units, care settings

  • Identify and resolve duplicate Patient/Person issues

  • Assess data quality issues on all related master data entities: Patients, Persons, Providers, Locations, Encounters, Payers, etc.

Assemble Records of Clinical Care
  • Assemble and Integrate records of clinical care for individual Patients from multiple source systems, operating units,
    care settings

  • Incorporate key encounters, events, observations (e.g., diagnoses, labs), interventions (e.g., procedures, treatments), and providers in various roles; verify provider attribution; include charges and payments where available

  • Establish standard data representations for primary entities such as Patients, Providers, Encounters, Locations, etc. and the related patient experiences

​Define Bundles
  • ​​Assemble and align [normalize] Encounter & Claims (reclaimed encounters) history data

  • Examine assembled Records of Care using bundling rules to aggregate individual Encounters and Events into a unified (clinically, operationally and financially coherent) representation for analytics

  • Examine bundles (e.g., Episodes, Targets) using predictive models to understand risk, projection, forecast, resource mix, quality and financial performance baselines

​​Identify Unique Providers
  • Assemble and integrate Provider Identifiers from multiple source systems, operating units, care settings

  • Identify and resolve duplicate Provider/Group/Practice/[Org Unit]/Location issues

  • Assess data quality issues on all related master data entities: Patients, Persons, Providers, Locations, Encounters, Payers, etc.

​Align Patients & Providers
  • Examine record of encounters and care provided; align Patients with Providers delivering greatest legitimate impact, frequency, effort or preponderance of care-related services; quantify where possible

  • Assess roles and extent or level of responsibility for care for individual Patients across multiple Providers, care Locations, and consumption of resources

  • Designate Primary (or Specialty) Care Provider status and relationships​

​​Measure / Manage Care
Delivery / Relationships
  • Perform analytics to characterize and/or classify Patient-to-Provider care relationships, their durations, transitions, outcomes, resource consumptions, impacts, etc. Examine higher-order relationships or patterns

Patient Panel Analytics
  • Assemble and align patient panels with individual Providers, Groups, Service Lines, Business Units or other entities

  • Perform analytics to align demand (for encounters) with supply (of service providers or other resources) and assess impacts on clinical outcomes, service quality and consistency, financial outcomes and patient and provider satisfaction