In value-based care, panel management is where the promise of population health becomes real in the exam room and in our outreach lists. Panel management means proactively caring for a defined group of patients, using data to identify who needs what, and closing gaps in preventive and chronic care before problems escalate.
For CPP practices, this work starts with a simple question: “Who is actually in our panel, and what do we owe them?” Empanelment, having an accurate list of patients assigned to each provider, is the foundation. When we know our panel, we can stop reacting only to who shows up and begin planning care for those who don’t.
This month, we are asking you to use your panel huddle to shine a spotlight on one critical care gap: annual diabetic retinal exams. Diabetic retinopathy remains a leading cause of adult blindness, yet many patients never make it to a separate eye care appointment. Teleretinal solutions like the Welch Allyn RetinaVue 700 Imager, deployed in primary care, have been shown to dramatically increase documented diabetic retinal exam compliance and close quality gaps.
To support CPP practices in this work, NCMSF is contracting with Baxter to offer RetinaVue diabetic eye cameras to eligible CPP practices. This means more of our teams will be able to complete diabetic eye screenings in the clinic, at the point of care, during routine visits, turning what used to be a referral into a same-day service.
Here’s how to connect your panel huddle directly to this effort:
- Identify your diabetic panel. Use your registry to list patients with diabetes and sort by “overdue for retinal exam.” Flag those patients for outreach and in-reach (catching them when they are already scheduled for another visit).
- Design the workflow. In your huddle, map the steps: who identifies eligible patients, who performs the RetinaVue exam, how results are routed and documented, and how follow-up is managed for abnormal findings.
- Track and learn. Each month, review: How many diabetic patients in our panel received a retinal exam in the last calendar year? How many gaps remain? What barriers did we encounter, and what adjustments can we make?
The panel management emphasized that our VBC Upskilling effort, combined with the RetinaVue camera opportunity through NCMSF and Baxter, gives CPP practices a concrete, high-impact way to protect vision, close care gaps, and improve quality performance, one panel huddle at a time.
If your CPP practice is interested in bringing a RetinaVue diabetic eye camera into your clinic or learning more about eligibility and support for your Value-Based Care contracts, please contact the North Carolina Medical Society Foundation. Our team can help you explore options, understand the workflow, and take the next step toward closing diabetic eye care gaps across your panel.