Collaborative Care - Tips for Panel Management

Effectively managing a large panel of patients can be challenging, but it is achievable with a well-organized structure. To help you connect and engage with your patients, while ensuring that you dedicate appropriate time to each individual, consider implementing these tips.

Tip 1: Scheduling and blocking time is crucial

Scheduling all collaborative care tasks into your calendar will help you structure your day and ensure all patient needs are met. Time blocking for patient meetings and other tasks helps guarantee proper follow-up and adequate time for your entire panel of patients.

Care Manager Action Steps:

1. Schedule patient appointments
   • 60 minute time slots for new CoCM patients
   • 15-30 minute time slots for enrolled patients
2. Schedule time for weekly psychiatric case consultation
3. Block time for non-patient facing tasks
4. Block time for warm hand offs 

Tip 2: Getting in Touch, Patient Contact

There may be a number of reasons why you need to reach out to your patient, including scheduling appointments, care coordination, and/or follow ups (just to name a few). Regular contact with your CoCM panel patients is important to build relationships and maintain engagement. This may be challenging due to busy schedules, so consistent communication and connection is key to success.

Care Manager Action Steps:

1. At the beginning of every month, take some time to review your panel and schedule a time to meet with each patient. 
2. For the patients you do not reach, create yourself a task to call them in 2-3 days. 
3. Repeat steps 1 & 2 throughout the month to ensure that you are reaching everyone. 

Tip 3: Use your Status Badges as a prioritization tool 

Mirah's color-coded Status Badges provide Care Managers with a quick overview of their CoCM patients' self reported symptoms. The badges use a traffic light system -- red for high risk, yellow for moderate risk, and green for minimal risk -- to indicate risk level, treatment effectiveness, and overall patient function.

Care Manager Action Steps:

1. Look at your panel of patients and review all red badges. 
   • Reach out to your patient and follow up 
   • Consider: bringing the case to psychiatric case consultation; referral to specialized behavioral health care
   • Maintain close communication with the referring PCP regarding safety plans, care plans, and any changes to the patient's self-harm risk
2. Look at your panel of patients and review all yellow badges.
   • Reach out to your patient and follow up
   • Consider: if patient is declining or not improving by week 9-12 of treatment, bring to psychiatric case consultation
3. Look at your panel of patients, for any results that seem out of the ordinary for a patient
   • Reach out to your patient and follow up
   • Consider: a change in care plan to address any new or worsening symptoms ; bring the case to psychiatric case consultation

Tip 4: Measurement Adherence

CoCM requires regular assessments to track patient progress and symptoms. Ideally, patients would complete these assessments monthly. However, realistically, some patients will not always complete their assessments. The following action steps can help to increase patient adherence and provide care managers with more data to guide patient care. 

Care Manager Action Steps:

1. Block time to follow up with patients who have not completed their measures.
2. Log into Mirah and navigate to your Care Manager Dashboard
3. Identify patients who have not completed their measures
   • First, try resending the measurement link 
   • If patient still has not completed the measures, reach out to them to complete assessments via interview
4. Use this opportunity to complete the assessments with them. 

Tip 5: Utilize the Billing Insights tool

The "Billing Insights" tool helps care managers optimize their time and reach their monthly billing goals by allowing them to track billable minutes and care units.  Care managers can view their entire patient panel and see which patients have available minutes (and those that do not have any billable minutes), which have returned assessments, and which require additional steps to meet the next billing threshold.

Care Manager Action Steps:

1. Periodically check the billing insights tool in order to track progress
2. During the last week of the month, check this tool daily to ensure that there are no loose ends (assessments, tasks, or minutes)
3. Follow the recommended next steps in the tool to optimize your time and care of your patients. 

Final Tip: Spreading the wealth of time among your patients

Are you unsure of how much time you should spend with each of your patients every month? Here are our recommendations based on patient acuity: 

*Note for Severe Patients:

The goal is to stabilize the patient, initiate baseline interventions such as psychopharmacology, and facilitate referral to higher-level care. Duration may vary based on available community resources and wait times.