CCPP Module 11, Section 5: Prioritization and Follow-Up Strategies
MODULE 11: PATIENT IDENTIFICATION AND RISK STRATIFICATION

Section 11.5: Prioritization and Follow-Up Strategies

From Air Traffic Controller to Clinical Quarterback: The Science of Managing a High-Risk Patient Panel.

SECTION 11.5

Prioritization and Follow-Up Strategies

Develop effective strategies for managing a panel of high-risk patients, including how to prioritize outreach and establish appropriate follow-up intervals.

11.5.1 The “Why”: The Impossibility of Treating Everyone, All the Time

You have successfully navigated the foundational stages of building your collaborative practice. You have identified your target populations, mastered the data analytics to stratify them by risk, and developed robust workflows for enrollment and care coordination. Your efforts have been fruitful, and you now face a new, high-quality problem: you have a panel of 200, 300, or even 500 high-risk, high-need patients who are all officially under your care. And your calendar has only 40 hours in a week. The immediate, crushing realization is that you cannot provide intensive, hands-on management to every patient, every single day. To attempt to do so is a recipe for professional burnout and clinical ineffectiveness.

This is the moment where you must transition from a clinical practitioner who reacts to the needs of one patient at a time to a panel manager who proactively allocates resources across an entire population. The core challenge of panel management is a classic economic problem: you have a scarce resource (your time and clinical expertise) that you must distribute in a way that produces the greatest possible value (improved patient outcomes, reduced hospitalizations, lower costs). A reactive, “first-come, first-served” or “squeaky wheel gets the grease” approach is guaranteed to fail. It will lead you to spend an inordinate amount of time on stable but demanding patients while your highest-risk, quietly deteriorating patients fall through the cracks.

Therefore, the development of a systematic, data-driven, and ethically sound strategy for prioritization and follow-up is not a “nice to have” skill; it is the single most important operational determinant of your long-term success and sustainability. Prioritization is the science of determining which patient needs your attention right now. Your follow-up strategy is the science of determining how long you can safely wait before checking in on everyone else. Mastering this dynamic interplay is the key to preventing patient harm, maximizing your clinical impact, and proving your value to the healthcare system. It is the defining skill that separates a good clinical pharmacist from a great population health pharmacist.

Pharmacist Analogy: The Monday Morning Queue

Imagine it’s 9 AM on the Monday after a long holiday weekend. You walk into your pharmacy, and the situation is chaotic. The electronic prescription queue has 300 new scripts. The voicemail is full. Six patients are already waiting in line to pick up. A nursing home is on hold, needing an urgent antibiotic. This is your unmanaged patient panel.

The Ineffective Pharmacist’s Approach (Reactive): You start at the top of the electronic queue and begin typing the prescriptions in the order they arrived. While you’re processing a routine refill for vitamin D, the nursing home hangs up, the patient waiting for their post-op pain medication gets frustrated and leaves, and a critical drug interaction on script #250 goes unnoticed until it’s too late. You are treating everyone equally, and as a result, you are failing your highest-need patients.

The Master Pharmacist’s Approach (Prioritization & Triage): You ignore the chronological order of the queue. Your brain instantly goes into triage mode.

  1. Priority 1 (Urgent/Acute): You immediately scan the queue for “waiters,” antibiotics, and post-hospital discharge pain medications. You put the nursing home’s call to the front of the line. These are your “sickest” patients who need help now.
  2. Priority 2 (High-Risk/Complex): Next, you scan for high-risk medications that require your cognitive expertise—a new warfarin order, a complex chemotherapy regimen, a patient on more than 15 medications. These require your focused attention before they can be safely dispensed.
  3. Priority 3 (Routine/Stable): The routine refills for lisinopril, metformin, and atorvastatin are left for last. They are important, but not urgent. You delegate the filling of these to your trusted technicians to be completed throughout the day.

This triage process is the essence of panel management. You used your clinical judgment to stratify a chaotic workload into tiers of urgency and complexity, and then you allocated your personal effort to the highest-priority tasks first. An effective panel management strategy is simply applying this same logic not to a queue of prescriptions, but to a panel of human beings.

11.5.2 A Multi-Factorial Framework for Patient Prioritization

Effective prioritization is not based on a single data point. A patient is not “high priority” simply because they have a high risk score or because their A1c is elevated. True prioritization is a multi-dimensional assessment that blends quantitative data with qualitative clinical judgment. To create a robust and defensible system, you should evaluate each patient on your panel through at least four distinct lenses: Clinical Acuity, Risk Score, Engagement Level, and Impactability.

By scoring patients across these domains, you can create a composite prioritization score that provides a much more nuanced and accurate picture of who needs your immediate attention.

The Four Lenses of Patient Prioritization

1. Clinical Acuity

How sick is the patient right now? This lens focuses on recent events and unstable clinical markers.

2. Risk Score

What is the patient’s future probability of a negative outcome (e.g., hospitalization, death)?

3. Engagement Level

How willing and able is the patient to partner with you in their care? Are they receptive or resistant?

4. “Impactability”

Is there a clear, actionable medication-related problem that you, the pharmacist, can solve?

Masterclass Table: Operationalizing the Prioritization Framework
Prioritization Lens High Priority Indicators (Patient needs attention THIS WEEK) Medium Priority Indicators (Patient needs attention THIS MONTH) Low Priority Indicators (Patient can be monitored)
1. Clinical Acuity
  • Hospital discharge within the last 7 days.
  • ED visit within the last 72 hours.
  • Critically abnormal lab value (e.g., K+ > 5.5, INR > 5).
  • Initiation of a new high-risk medication (e.g., insulin, warfarin, DOAC).
  • Persistently uncontrolled markers despite therapy (e.g., BP > 160 systolic, A1c > 9%).
  • Recent medication change initiated by another provider.
  • Upcoming specialist appointment requiring medication review.
  • Stable on current regimen.
  • Clinical markers at or near goal.
  • No acute events in the past 6 months.
2. Risk Score
  • LACE+ score > 10 (High risk for 30-day readmission).
  • In the top 5% of a predictive model for cost or mortality.
  • CHA₂DS₂-VASc ≥ 4 with no anticoagulation.
  • LACE+ score 5-9.
  • In the top 6-20% of a predictive model.
  • Multiple chronic conditions but not yet flagged by predictive models.
  • LACE+ score < 5.
  • In the bottom 50% of a predictive model.
  • Few or well-managed chronic conditions.
3. Engagement Level
  • Newly enrolled and highly motivated patient.
  • Patient who has personally reached out with a question or concern.
  • Recently discharged patient who is overwhelmed and asking for help.
  • Consistently attends scheduled appointments but is a passive participant.
  • Agrees to changes but has poor follow-through.
  • Reliable but requires frequent prompting.
  • Has missed the last 2 scheduled appointments (“no-show”).
  • Does not respond to portal messages or phone calls.
  • Has explicitly declined further services (“stable, leave me alone”).
4. “Impactability”
  • A clear gap in guideline-directed medical therapy (e.g., HFrEF patient not on an ARNI or SGLT2i).
  • Severe cost-related non-adherence for a critical medication.
  • Polypharmacy with multiple high-risk medications and a clear opportunity for de-prescribing.
  • Patient requires titration of existing medications to reach goal.
  • Adherence barriers are present but not critical (e.g., complex regimen, forgetfulness).
  • Needs routine monitoring for safety and efficacy.
  • Patient is already on an optimized, guideline-directed regimen.
  • Primary barriers are non-pharmacological (e.g., purely surgical or social issues).
  • Patient has already been through extensive medication optimization with limited success (maximum tolerated medical therapy).
The Daily Huddle: Your Prioritization Power Tool

One of the most effective ways to operationalize this framework is to start your day with a 15-minute “panel huddle.” Block off the first 15 minutes of your schedule to do nothing but review your panel and set your priorities for the day. Use your EHR dashboard or a custom registry to review:

  1. New Discharges: Any of your paneled patients discharged in the last 24-48 hours? These are your #1 priority for outreach.
  2. New Referrals: Any new pharmacist consults or referrals? These are your next priority.
  3. Critical Lab Alerts: Any flagged lab results? Address these immediately.
  4. Your “Top 5”: Based on the multi-factor framework, who are the 5 patients on your panel who absolutely need a touchpoint today or this week? Put them on a list and ensure you have a plan for each.

This disciplined daily routine prevents the “tyranny of the urgent” (responding only to what’s in your inbox) and forces you to proactively manage your highest-risk patients.

11.5.3 Designing Your Follow-Up Strategy: The Cadence of Care

Once you have prioritized your outreach, the next critical element is to establish a rational and sustainable cadence for patient follow-up. A “one-size-fits-all” approach (e.g., “I’ll follow up with everyone in one month”) is just as inefficient as a lack of prioritization. The appropriate follow-up interval is a clinical decision based on two key factors: the patient’s clinical stability and the pharmacokinetic/pharmacodynamic properties of the intervention you performed.

For example, the follow-up required after starting insulin is vastly different from the follow-up required after switching a patient to a lower-cost statin. The former requires close monitoring within days; the latter can be safely re-evaluated in months. Your follow-up strategy should be a dynamic, patient-specific plan, not a rigid, arbitrary schedule.

Masterclass Table: The Follow-Up Cadence Matrix
Patient/Intervention Category Description Recommended Follow-Up Interval & Method Clinical Rationale & Pharmacist’s Goal
Tier 1: Acute/High-Intensity Patients who are acutely ill, recently discharged from the hospital, or have had a major change to a high-risk medication. 1-3 Days (Phone Call)
7-14 Days (Telehealth/In-Person Visit)		 Rationale: The highest risk for adverse events and readmission is in the immediate post-discharge period. Starting medications like insulin or warfarin requires very close monitoring to prevent severe hypoglycemia or bleeding.
Goal: Confirm medication access, assess for immediate side effects, ensure understanding of the new regimen, and “catch” any post-discharge problems before they escalate to an ED visit.
Tier 2: Titration/Optimization Patients who are clinically stable but not yet at their therapeutic goal. You are actively titrating medications to achieve a specific target (e.g., BP, A1c). 2-4 Weeks (Phone Call, Portal Message, or Visit) Rationale: The time to see the full effect of a dose change for many chronic medications (e.g., antihypertensives, antidepressants) is typically 2-4 weeks. Following up sooner is often too early to assess efficacy, and waiting longer delays reaching the therapeutic goal.
Goal: Assess tolerance of the new dose, check updated lab/home monitoring data, and make a decision on the next titration step.
Tier 3: Stable/Monitoring Patients who are at their clinical goal and stable on their current regimen. They have demonstrated good adherence and self-management skills. 3-6 Months (Visit or “As Needed”) Rationale: Once a patient is stable and at goal, the intensity of follow-up can be safely reduced. Routine monitoring is still required for long-term safety and efficacy, but frequent check-ins are unnecessary and can be a poor use of resources.
Goal: Routine safety monitoring (e.g., annual renal function check for ACEi), reassessment of adherence, and screening for any new medication-related problems.
Tier 4: Graduate/Maintenance Patients who have been stable for an extended period (>1 year), have met all therapeutic goals, and have “graduated” from active CMM. Annual Check-in or PRN Rationale: Your panel must have a “way out” to make room for new high-risk patients. Graduating stable patients is a sign of a successful intervention.
Goal: Perform an annual comprehensive medication review to ensure no new issues have arisen, but otherwise empower the patient to manage their stable regimen and reach out to you only if a problem occurs.

11.5.4 The Sustainable Workflow: Structuring Your Time for Panel Management

Having a brilliant strategy for prioritization and follow-up is meaningless without a structured workflow that allows you to execute it. You must be the master of your own schedule, deliberately blocking time for the different types of work required for effective panel management. If your calendar is filled back-to-back with 30-minute follow-up visits, you will have no time for the crucial, proactive work of reviewing your panel, conducting outreach to high-risk patients, or coordinating care with providers. A sustainable CMM schedule is a carefully designed mosaic of different activity types.

The “Ideal” Panel Manager’s Weekly Template

While every practice is different, a highly effective weekly template might look something like this. The key is the concept of “theme days” or “blocked time” to ensure all types of work get done.

Time Block Monday Tuesday Wednesday Thursday Friday
8:00 – 9:00 AM Panel Huddle & Prioritization (Review dashboards, discharges, labs, plan the day)
9:00 – 12:00 PM New Patient Enrollment Visits (Longer, scheduled appointments) Follow-Up Visits (Scheduled telehealth/in-person) New Patient Enrollment Visits Follow-Up Visits Acute Outreach Block (Post-discharge calls, urgent follow-ups)
12:00 – 1:00 PM Lunch & Team Meetings
1:00 – 4:00 PM Follow-Up Visits “Asynchronous” Work (EHR messages, PA requests, provider coordination) Follow-Up Visits “Asynchronous” Work Admin & Catch-Up (Documentation, close open charts)
4:00 – 5:00 PM Chart Prep & Plan for Tomorrow
Protect Your Asynchronous Time

The most common mistake new panel managers make is allowing their scheduled patient visits to fill their entire day. This leaves no time for the critical “in-between” work of care coordination, documentation, and provider communication. You must fiercely protect your administrative and asynchronous work blocks. These are not “free time”; they are essential for the safe and effective functioning of your service. Work with your scheduler to ensure these blocks are respected and not double-booked with patient appointments.