Faces Behind the Health Data

For La Clínica panel managers Adriana Alcala and Ana Flores, data has a face.  “You are taking care of the person, you’re taking care of the community. Not only do we work here, I live ten minutes away, so on the weekend or at church, I am literally seeing people in the community,” says Alcala.

Panel managers play a key role in helping the community to access preventative services at their local health center. “What I like to say is that I help the providers take better care of their patients.  Sometimes some patients fall out of care.  It’s our job to bring them back.”  Panel managers reach out to patients by phone and in person to track progress on specific health issues.  Alcala and Flores manage panels that include hypertension, diabetes, patients on blood thinners and patients with HIV.

Anna Flores points out that medication management also comes with the territory.  “We are making sure patients are taking their meds, whether it’s for blood pressure, diabetes.  They may not understand the bottle directions because they are in English, or they don’t know how to read, or they can’t see, or they misunderstand how often to take them.”

A casual chat with a corner fruit vendor illustrates what panel management looks like in the community health center setting. The vendor pulled Alcala aside to tell her that she had called the health center, but couldn’t get her medicine. Alcala offered to call her when she returned to work.  “I’d rather our patients be able to approach me, than have two weeks go by and then they come back for their blood pressure medicine and blood pressure check and they didn’t start that medication. Or, they don’t ever come back.”

Part of the Care Team

Panel management blends two community health innovations; use of data and the care team model. “We do a lot of things that a medical assistant might not get a chance to do, and we are definitely working at the top of our scope. (La Clínica Chief Medical Officer) Dr. Paul Bayard is an advocate for panel management and making sure that our time is being respected. In the past, it may have been easy just to grab one of the panel managers to work on the floor.  But he sees that panel managers have both administrative things they have to do and a lot of reaching out to patients,” says Alcala.

In the reality of the hectic clinic environment, panel managers take on a role that providers may not have time to tackle with packed schedules. For example, if panel managers see that 60 percent of panel patients have their blood pressure well controlled, they reach out and plan a course of care with the 40 percent who do not.

Data and the Reality of Patients’ Lives

Flores notes how tracking data can motivate both her and the patient. “We get excited, I’ll say, ‘Adriana, look at this patient. At her last visit, her sugar was all over, but now look!’ They usually bring their sugar log and we can look. During the visit we get to motivate the patient – We can do this! So let’s do this plan for two weeks, what do you think? And the patient saying, yeah! Of course! And then coming back in two weeks and seeing beautiful sugar results.”

Alcala is determined to get data “cleaned up” or getting patients identified for services and their health measures moving in the right direction. For example, of 200 patients falling behind their ideal measures, she may discover some of them were identified because they were dental or optical patients and have never been to primary care.

“I like numbers, because they keep us on track. I get excited when our numbers look good, but sometimes all our patients’ blood pressures could be high all day long. But, at the end of the day, when that patient walks out of the door smiling because they had a chance to vent, or we link them to other resources, and they say they’ll come back, then the numbers don’t reflect what an awesome day you had. So that’s the frustrating part of it.  Hopefully, you’ll see results at the next visit, but for that day our blood pressure numbers will look horrible.”

Panel managers understand the broader challenges patients face that may have nothing to do with their bodies.  When getting a patient back into care after a long absence, Alcala and Flores get reacquainted with the patient and learn the patient’s daily struggles, from loss of a parent, housing insecurity, a child with substance abuse disorder, or dealing with immigration issues.

“You got to hear their story.  They got to let it out with you,” says Alcala, “Sometimes we go home tired and sometimes a little emotional. We do have some patients that are dealing with a lot of tough issues. You feel really bad and there’s only so much we can do, but then you wake up and tomorrow’s a new day.”

La Clínica’s panel management efforts continue to pay off.  In the last 15 months, through participation in PHASE, their hypertension blood pressure control rates rose from 62% to 75% control. Their blood pressure control rates for diabetes rose from 73% control to 83% control, among other successes.