Patient-provider relationships are at the heart of Arlington Free Clinic’s care model. However, since nearly all physicians who serve AFC are volunteers, our dedicated team of staff nurse managers serves as the main point of contact for patients, providing personalized, coordinated care.
One way this is done is through empanelment, which means that a patient is “assigned” to a nurse manager in our electronic medical record (Epic) for care coordination. Historically, every patient was automatically empaneled, with about 300 patients per nurse manager. While this approach ensured coverage, there were no set parameters for patient assignment or removal, which created challenges for our nursing team, including inconsistencies in care and difficulty prioritizing patients who might benefit most from close follow-up.
Thanks to generous grant funding from Kaiser Permanente, we are improving our empanelment process to focus on patients who will benefit most from targeted nurse-led care, including those with complex diagnoses, recent emergency room visits or hospitalizations, or patients on high-risk medications. This approach directly addresses social, language, and system barriers and improves care coordination and patient outcomes. It also supports navigation across onsite and offsite services and early identification of high-risk patients to prevent disease progression and avoidable complications. Importantly, patients who are not empaneled will still have direct access to our staff through our nurse of the day and triage phone lines, ensuring no one falls through the cracks.
We are grateful to Kaiser Permanente for this meaningful investment in our nurse-led model of care. These improvements will combine evidence-based population health strategies with the personal touch of our skilled nursing staff, improving access to coordinated care and strengthening the patient-provider relationships that make AFC’s care so impactful.
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