Milestone 8 Summary

Description: Practice uses a data-driven approach to assign patients to a provider panel and confirms assignments with providers and patients. Practice reviews and updates panel assignments on a regular basis


What does success look like?


1 2


Practice does not consistently assign patients to a provider panel or has no way to track the assignments in the PM or EHR systems. Practice has an approach to assign patients to a provider panel but not all patients have been assigned and their assignment confirmed. Practice has assigned patients to a provider panel according to its defined method and confirms the assignments as patients are scheduled and seen. Practice is not reviewing and updating panel assignments on a regular basis. Practice has assigned all patients to a provider panel and confirmed the assignments with providers and patients. Practice reviews and updates panel assignments on a regular basis.

 Note: numbers are PAT scores


Why is this important?

Empanelment is the process of assigning all patients to a provider and reviewing each provider’s patient load in terms of both number of patients and patient complexity.1 This approach transforms a practice’s care model from treating acute, episodic patient needs (i.e. scheduling patients to the next available provider to treat the current illness at hand) to one of care continuity.1 Each patient is assigned to a specific clinician or care team, taking into account patient and family preferences, designating practice responsibility to every patient.2 This approach supports the Patient-Centered Medical Home model and is considered a “foundational building block of high-performing primary care.”3 Assignment of patients to individual care teams allows for care management over time, ultimately promoting the health of the entire patient population.


Potential Tactics

  • Determine guidelines for panel size and patient complexity per panel
  • Identify a practice manager for risk stratification and panel management
  • Determine panel size according to patient risk and utilization (see Milestone 9)
  • Review and update panel assignments on a regular basis


Tools and Resources


What might this look like in practice?

Tired of the daily struggle to keep up with both scheduled appointments and urgent care needs, physicians at a primary care practice in Athens, Georgia decided it was time to change the way they were managing their patient population. A recent chart review revealed less than 10% of all eligible patients were up to date on recommended screenings. It was impossible to identify every recommended screening for patients given the high-volume and unpredictable schedule as patients were assigned to the next available provider. 

The team set out to define their entire patient population, identify patients who were deceased or had moved, and assign each remaining patient to a physician provider. Throughout the course of three months, each physician and their care team reviewed each of the patients’ medical records on their panel, identifying themes in care gaps (e.g. recommended screenings, follow-up appointments scheduled) and flagging patients to be contacted for check-up appointments who had not been seen in the past three years. After six months of implementing empanelment into the practice, physician-patient relationships were stronger, patients were reporting higher satisfaction scores, and recommended screening for the patient population improved by 30%.



  1. Module 20. Facilitating Panel Management. Content last reviewed May 2013. Agency for Healthcare Research and Quality, Rockville, MD.
  2. Empanelment. Safety Net Medical Home Initiative. Accessed October 17, 2016. Available at:
  3. Grumbach K, Olayiwola N. Patient Empanelment: The Importance of Understanding Who Is at Home in the Medical Home. J Am Board Fam Med. March-April 2016; 28(2):170-172.
  4. Centers for Medicare and Medicaid Services. Transforming Clinical Practice Initiative (TCPI) Change Package: Transforming Clinical Practice Driver Diagram. Change Concept 1.3.1. Version 2.0. Update March 16, 2016.