Care Management and Value-based Care

Improving outcomes and patient satisfaction starts with understanding your patient panel and your patients' risk level so you can create care plans that meet their needs.

This streamlined care approach may also potentially mean additional revenue for your practice as you identify Chronic Care Management codes or payment in value-based care contracts.

Empanelment: Understand Your Patient Population

Empanelment is the process of identifying and assigning active patients to clinicians or care teams to establish and maintain patient-clinician relationships. The process includes:

  • Identifying the ideal panel per clinician
  • Developing initial patient panels per clinician
  • Refining the panels based on clinician input and ideal panel size
  • Ongoing panel management

Your ideal panel may fluctuate over time due to changes both in your practice’s panel as well as your practice’s staffing model.

Why Empaneling Patients Matters in Value-based Care?

Empanelment is the first step to increasing access to care, improving continuity of care, and implementing care coordination, all of which improve health outcomes and reduce costs. Additionally, allowing clinicians to focus on forming meaningful relationships with a specific population of patients ensures that all patients receive optimal care regardless of when their last visit occurred. The process of empaneling patients to a clinician or care team also adds value for all participants involved in care delivery, including the patient.  

A Step Past Empaneling: Risk-Stratified Care Management

Once you understand your patient panel, then you're ready to take the next step: risk-stratified care management (RSCM). RSCM is the process of assigning a health risk status to a patient, and using the patient’s risk status to direct and improve care. The goal of RSCM is to help patients achieve the best health and quality of life possible by preventing chronic disease, stabilizing current chronic conditions, and preventing acceleration to higher-risk categories and higher associated costs.

Identifying a patient's health risk category can help your care team plan, develop, and implement a personalized care plan in collaboration with the patient. For some, the plan may address a need for more robust care coordination with other clinicians, intensive care management, or collaboration with community resources.

Improving Outcomes and Reducing Health Care Costs  

In a practice panel of 1,000 patients, there will likely be close to 200 patients (20%) who could benefit from an increased level of support. This 20% of the population accounts for 80% of the total health care spending in the United States, with the very highest medical costs concentrated in the top 1%.

Efforts to implement RSCM have the added benefit of preparing your practice to succeed in value-based care. Value-based care models require practices to have a method for systematically categorizing and monitoring their patient populations, so that risk-adjusted payments can be made for the additional care and resources the health care team provides to patients with increased risk.

What's Next?

1. Learn how to create patient panels for physicians and care teams with AAFP TIPS™.

2. Download the RSCM Rubric(161 KB PDF) (free to AAFP members) to identify your patients' risk category. Not a member? Purchase the RSCM Rubric.

3. Learn how to position your practice to better respond to the changing health care landscape with the Medical Home Checklist.

Fighting for Family Medicine

The AAFP fights for what family physicians need every day. We are advocating for electronic health record functionality to support family physicians rather than hinder them.

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AAFP TIPS™ Empanelment

Learn about the importance of patient panels and how to create them for physicians and care teams with AAFP TIPS™.

Implement Risk-stratified Care Management

The RSCM Rubric provides a framework to help you identify and assign health risk level, and then create a care plan based on it.

Free to Members

Not a member? Purchase the full-color PDF that can be printed legal- or poster-size for guidance through the RCSM process.


A study, co-authored by Sandra Kamnetz, M.D., demonstrates how empanelment allows practices to determine staffing needs, set compensation, and provide better patient care.

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The Medical Home Checklist

Ready to position your practice to better respond to the changing health care landscape? Learn how to get started.

The Medical Home Checklist

Ready to position your practice to better respond to the changing health care landscape? Learn how to get started.