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(1)

Michigan Primary Care

Transformation: Effective

Implementation of Care

Management in the Primary Care

Setting

Marie Beisel, MSN, RN, CPHQ Mary Ellen Benzik, MD

(2)

Objectives

Describe the components of the MiPCT

demonstration and how it works

Identify care management strategies used in

MiPCT that are successful and lessons learned

(3)

How We Will Meet Objectives

First 20 min

▫ Overview, key challenges and key learnings - on

integrating care management

Interactive Group Activity:

▫ Divide into early, developing or advanced in your

journey

▫ 10 min to brainstorm challenges you are facing; then

pick two challenges the group is most interested in

▫ 10 min share solutions / brainstorm solutions for the

challenges

▫ 20 min for report out of each group - have some one

be the recorder for each group

(4)

CMS Multi-Payer

Advanced Primary Care Practice (MAPCP)

Demonstration Project

(5)

CMS Multi-Payer Advanced Primary Care

Practice (MAPCP) Demonstration

2012-2014

Centers for Medicare & Medicaid Services is

participating in state-based PCMH demonstrations

▫ Assessing effect of different payment models

CMS Demo Stipulations

▫ Must include Commercial, Medicaid, Medicare patients

▫ Must be budget neutral over 3 years of project

▫ Must improve cost, quality, and patient experience

8 states selected for participation, Michigan is largest

with approximately 50% of MAPCP practices

▫ Michigan Primary Care Transformation (MiPCT)

▫ Michigan start date:

January 1, 2012

(6)

MiPCT Demonstration Timeline

1/1/12 12/31/14 Post-Demo MiPCT Original Demonstration Period Demonstration Two Year CMS Extension 12/31/16

GOAL: To sustain our gains (effective, efficient

team-based care with embedded Care Managers)

(7)

Practice Participation Criteria

PCMH-designated in 2010, and maintain PGIP or

NCQA PCMH designation over the 3-year

demonstration as Part of a participating

PO/PHO/IPA

Agree to work on the four selected focus initiatives:

o

Care Management

o

Self-Management Support

o

Care Coordination

o

Linkage to Community Services

(8)

The Vision for a Multi-Payer Model

Use the CMS Multi-Payer Advanced Primary Care

Practice demo as a catalyst to redesign MI primary care

▫ Multiple payers will fund a common clinical model

▫ Allows global primary care transformation efforts

▫ Support development of evidence-based care models

Create a model that can be broadly disseminated

▫ Facilitate measurable, significant improvements in

population health for our Michigan residents

▫ Bend the current (non-sustainable) cost curve

▫ Contribute to national models for primary care redesign

(9)

MAPCP Demo: Participating States in 2014

Maine

70 practices 122,420 patients

Michigan

358 practices 1,109,926 patients

Minnesota **

282 practices 1,013,545 patients

New York

41 practices

99,019 patients

North Carolina

47 practices 83,553 patients

Pennsylvania ** 51 practices 163,670 patients

Rhode Island

16 practices 57,676 patients

Vermont

123 practices 272,324 patients

____________________________________________

TOTAL

988 practices

2,922,151 patients

(10)

IV. Most complex (e.g., Homeless, Schizophrenia) III. Complex Complex illness Multiple Chronic Disease Other issues (cognitive, frail

elderly, social, financial)

II. Mild-moderate illness

Well-compensated multiple diseases Single disease I. Healthy Population <1% of population Caseload 15-40 3-5% of population Caseload 50-200 50% of population Caseload~1000

Managing Populations:

Stratified approach to patient care and

care management

(11)

Health IT

- Registry / EHR registry functionality * - Care management documentation * - E-prescribing (optional)

- Patient portal (advanced/optional) - Community portal/HIE (adv/optional) - Home monitoring (advanced/optional)

Patient Access

- 24/7 access to decision-maker *

- 30% open access slots * - Extended hours *

- Group visits (advanced/optional) - Electronic visits (advanced/optional)

Infrastructure Support

- PO/PHO and practice determine optimal balance of shared support - Patient risk assessment

- Population stratification - Clinical metrics reporting

*denotes requirement by end of year 1

PCMH Services PCMH Infrastructure

Complex Care Management

Functional Tier 4

All Tier 1-2-3 services plus:

 Home care team

 Comprehensive care plan  Palliative and end-of life care

Care Management

Functional Tier 3

All Tier 1-2 services plus:

 Planned visits to optimize chronic conditions  Self-management support  Patient education  Advance directives Transition Care Functional Tier 2

All Tier 1 services plus:

 Notification of admit/discharge  PCP and/or specialist follow-up  Medication reconciliation

Navigating the Medical Neighborhood

Functional Tier 1

 Optimize relationships with specialists and hospitals  Coordinate referrals and tests  Link to community resources

Prepared Proactive Healthcare Team

Engaging, Informing and Activating Patients

Michigan Primary Care Transformation Project

Advancing Population Management

(12)

MiPCT PO/Practice Expectations

Care management

▫ Performed for appropriate high and moderate risk

individuals

Population management

▫ Proactive patient outreach

▫ Point of care alerts for services due

▫ Patient registry functionality by end of year one

Access improvement

▫ 24/7 access to clinician

▫ 30% same-day access

▫ Extended hours

(13)

Quality and Experience of Care Metrics:

MI and National Evaluations are Different, with common elements

National

Diabetes care:

LDL-C screening

HbA1c testing

Retinal eye examination

Medical attention for nephropathy

All 4 diabetes tests

None of the 4 diabetes tests

Ischemic Vascular Disease:

Total lipid panel test

Patient experience (CAHPS)

Michigan

Diabetes

Asthma

Hypertension

Cardiovascular

Obesity

Adult preventive care

Child preventive care

Childhood lead screening

(Medicaid)

Patient experience (CAHPS)

(14)

How will CMS define success?

14

The tie to budget neutrality and ROI

(15)

Evaluation Details

Statistical analysis of the effect of care

management, care transitions, community

linkages, IT, patient access on quantifiable

outcomes, using:

▫ Claims data

▫ Clinical quality indicators

▫ Patient survey on experience of care

▫ Provider/clinic staff survey on work life satisfaction

Key interviews and feedback gathering from

(16)

Strategies for achieving…

SHORT TERM SAVINGS

• High-risk patient intensive care management

• 24/7 clinical decision maker access to prevent unnecessary ED utilization and inpatient

admissions

• Baseline data analysis for

utilization outliers and focused root cause analysis

• Educate on evidence-based approaches to care (e.g., Heart Failure, COPD, Transitions of Care)

LONG TERM SAVINGS

• Focus on all “tiers” of patient population

• Recognize and reward

performance on intermediate markers of chronic conditions to prevent long-term

complications (BP in diabetes, etc.)

• Focus on primary prevention/screening

• Work to build self-sustaining healthy communities

(17)

Practice Participation Criteria

PCMH-designated in 2010, and maintain PGIP or

NCQA designation during demonstration

Part of a participating PO/PHO/IPA

Agree to work on the four selected focus initiatives:

o

Care Management

o

Self-Management Support

o

Care Coordination

(18)

MiPCT Payers, Patients and Providers

As of March 2015:

• 1814 providers

▫ 1,577 physicians

▫ 237 mid-level providers

Over 500 care managers

• 346 PCMH practices • 1,158,650 members # Patients % Patients Medicare 186,997 16.1% Medicaid 214,745 18.5% BCBSM 361,802 31.2% BCN 275,316 23.8% Priority 119,990 10.4% Total 1,158,850 100.0%

(19)

What is Care Management?

“Programs [that] apply systems, science, incentives, and

information to improve medical practice and assist

consumers and their support system to become engaged in a

collaborative process designed to manage

medical/social/mental health conditions more effectively.

The goals of care management:

achieve an optimal level of wellness

improve coordination of care

provide cost effective, non-duplicative services

(20)

Care Management Continuum:

Ramsay, Rebecca (2011). Implementing Effective Clinical Care Management; Building Care Management Capacity within a Transforming Primary Care System, Care Oregon (PowerPoint slides). Retrieved from

http://www.chcact.org/resources/SNMHI_EffectiveClinicalCare.pdf

shttp://www.chcact.org/resources/SNMHI_EffectiveClinicalCare.pdfay, Rebecca (2011). Implementing Effective Clinical Care Management; Building Care Management Capacity within a Transforming Primary Care System, Care Oregon (PowerPoint

(21)

MiPCT Care Management Priorities

Care managers work in close proximity to PCP team

In PCP office as much as possible

Work with PCP team to meet their needs

Evidence supports this model as superior to vendor-based

Ensure Complex Care Management coverage

Manage high-complexity, high-cost patients

Patients selected based on risk score plus PCP input

Focus on evidence-based interventions

Medication reconciliation

Care transitions

In-person contact with patients whenever possible

Comprehensive care plan for complex patients

(22)

Getting Started – MiPCT Implementation Guide

Michigan Primary Care Transformation (MiPCT) Implementation Guide I. Background

a. MiPCT Orientation

The Michigan Primary Care Transformation Project (MiPCT) is a demonstration project testing the value of the patient centered medical home (PCMH) model. This model expands access to primary care while improving care coordination. This model has been increasingly important given the rise in multiple chronic diseases and the dramatic increase in health care costs. The traditional model of health care delivery, with 15-minute in-person

appointments and disconnected primary care physicians and specialists, is not working for patients or their doctors.

MiPCT addresses the shortcomings in the current system by providing funding to primary care physicians to hire care managers and implement all payor all patient registries to track and follow up with patients, especially those with multiple chronic diseases. In addition, MiPCT pays physicians to expand office hours and offer same day appointments. Finally, MiPCT rewards physicians for improving their patients’ health and avoiding unnecessary emergency department visits and hospitalizations.

MiPCT was developed in November 2010 after Michigan was selected by the Center for Medicare and Medicaid Services (CMS) as one of eight states to participate in the CMS Multi-Payer Advanced Primary Care Practice Demonstration. Michigan has the largest demonstration project in the country, reaching approximately 1.2 million patients served by 1,600 providers in almost 500 practices. All of the insurance companies and physician organizations in Michigan have been invited to participate.

Care Management:

• What is it? • Who does it?

• How does it fit in a Primary Care Practice? • Staffing Models – which

one works for MY practice?

• Care Manager Job Descriptions

(23)

MiPCT Care Manager Required Training

MiPCT Complex and Hybrid Care Manager

training

Complex Care Management Course:

Blended learning activity – 2 day in person” didactic

training

CMRC approved Self Management program

Moderate Care Manager training

Chronic care model, self-management support

MiPCT-approved programs identified throughout

state

(24)

MiPCT Transition of Care Intervention

Care Manager conducts Transition of Care follow up

phone call within 24-48 hours post hospital discharge

Then weekly x 4 – phone visit

Address:

▫ Medication reconciliation

▫ Follow up - PCP appt., specialist appt., tests

▫ Social support

▫ Assessment – barriers

▫ Red flags

▫ Care coordination

▫ Inform patient/caregiver

(25)

MiPCT TOC Lessons Learned - Primary Care

Practice (PCP)

Notification to PCP of patient admit/hospital ▫ In 2011, hospital discharge notification at PCP office varied widely, inconsistent ▫ Progress to date: patient admit/hospital discharge notification to PCP practice reported by POs is

significantly more prevalent ▫ Examples of notifications:

 Fax discharge summary  Electronic notification  MiPCT Care Manager has

access to hospital EMR

Leveraging IT resources:

▫ Some MiPCT POs/practices provide electronic notification directly to the MiPCT Care Manager/PCP practice

 MiPCT patient list with alert of patient admit/ER visit for the subset of hospitals within their own health system

 Add ADT info here

In progress. . .

▫ Develop system level process: Communication between hospital discharge planner and MiPCT care manager upon admission, preparation for discharge, time of discharge

(26)

MiPCT Care Manager Curriculum

Ongoing

 Webinars – statewide

 Best Practice, chronic conditions, process, project updates

 Two per month first 2 years, now 1 to 2 per month

 Conference Calls – regional/specialty

 Facilitated by Master Trainer

 Care Manager sharing peer to peer, interactive

MiPCT Practice Flash Newsletter - monthly

 Complex Care Management Course offered monthly

 > 500 Care Managers trained

 Care Management Best Practice Work Group - Care Manager, PO

 Michigan Care Management Resource Center website

(27)

Michigan Care Management Resource

Center – micmrc.org

BCBSM/UMHS collaboration

Initial focus is MiPCT practices, but available to all PGIP

POs/PHOs/practices

Web-based resource for templates, tools, evidence-based

information, care manager job descriptions, etc.

Webinars, workshops and mentoring in care management

Personalized care management consultation service

Goal is to help disseminate effective, evidence-based care

management models throughout Michigan

(28)

MiPCT Team Based Care Management

Delivery

(29)

Planned patient care i.e.

huddles, processes, work flow, policies

Care Manager and PCP partnership

Office staff – defined roles and

responsibilities Information

technology, support Patient

Care Management Delivery by the Practice TEAM

PO and Practice Leadership PCMH meetings monthly, action plan, follow up

(30)

How Do We Identify MiPCT Care

Management Success in Michigan?

(31)

MiPCT Care Manager Case review and

Practice Assessment

Care Manager Case reviews • completed by Clinical Leads

using a standard MiPCT evaluation tool.

• Findings provide data

regarding progress and areas requiring improvement for both the PO/practice and MiPCT.

• PO’s, practices and Care

managers identified for Best Practice Work group.

MiPCT Practice Assessment

• Practice assessment identifies infrastructure associated with practices with high

HEDIS/Quality metrics

• Practice assessment data used by both the PO/practice and MiPCT to identify progress made and existing barriers.

(32)

MiPCT Care Management Best Practice

Work Group – Background

• Care management activity across the state is varied.

• Care management best practices do exist and it will be beneficial to gather and analyze these best practice activities via a MiPCT work group to identify models and improvement processes.

• Work Group Participants

▫ Invitation based on performance criteria of CM encounter data, MiPCT quality and utilization metrics for Adult population

 PO Leaders  Care Managers  Clinical Leads  Physician(s)

(33)

Individual

Care

Manager: CM

Role, CM

Skill, Patient

Acuity

System

Factors,

Practice

Embedment

Individual Care Manager (CM): How does the care manager complete daily work?

System Factors:

Leadership, Infrastructure & Practice embedment

(34)

Key: Share Care Management Best

Practice

MiPCT Summit Conferences-October 2015

MiPCT statewide Pediatric Conference Fall 2015

Shared Care Management Best Practice learning on

Michigan Care Management Resource Center

website

MiPCT Care Management educational webinars and

conferences

MiPCT Newsletter: Publish success stories

▫ Started with Care Manager success stories

▫ New for 2015: Team based success stories and PO

level success stories

(35)

Lessons Learned

Transition of Care – a good place to start

Identification of target population

Investing early in team based care development

▫ Educate PCP and team members about care

management

▫ Support and training for care managers

Defining Care Manager role - work flows

Key to success: Physician champion and Practice

(36)

Lessons Learned

• Importance of Convener (Physician Organization) engagement,

resources, and leadership.

• Importance of engaging, educating and motivating physicians.

• Recognize and address the challenges of care management integration into practices. It takes time

• Minimize administrative burden as much as possible by aligning demonstration data requirements with other existing initiatives as feasible.

• Recognize that technology can be both a barrier and a benefit: resolve IT issues such as how to manage monthly patient lists and document care plans early in the process.

(37)

Lessons Learned

(cont.)

• Do conduct targeted Care Manager training based on project goals, discussions with clinical leadership and care manager feedback, both initially and ongoing.

• Do rely on PCP and team input as well as claims data and risk scores to select patients for care management.

• Avoid engaging patients who no longer need care management. A guideline for discharging patients from care management creates standardized approach and provides a tool for care managers to guide decision making.

(38)
(39)

References

• http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

• G. F. Anderson and P. S. Hussey, Multinational Comparisons of Health Systems Data 2004, The Commonwealth Fund, October 2004. OECD data.

Ramsay, Rebecca (2011). Implementing Effective Clinical Care Management; Building Care Management Capacity within a Transforming Primary Care System, Care Oregon (PowerPoint

slides). Retrieved from http://www.chcact.org/resources/SNMHI_EffectiveClinicalCare.pdf

shttp://www.chcact.org/resources/SNMHI_EffectiveClinicalCare.pdfay, Rebecca (2011

• Capturing the Head, Hearts and Hands of People to Effect Change. The Road to Commitment. Roland Loup and Ron Kellar, DO Journal, Fall 2005.

• Neil J. Baker, MD. Adaptive Change Challenges and Hemodynamics of Change. IHI work shop. April 2013.

(40)

Let’s Talk!

Quickly move to designated early Early, developing or advanced Break off in groups of 5-7

(41)

Let’s Talk

For 10 min – identify challenges

▫ Describe the current challenges you are facing in

your organization related to integrating care

management

▫ Pick one or two that you want to discuss as a

group

(42)

Let’s Talk

For 10 min – identify potential solutions

▫ Share solutions that you may have for that

challenge

(43)

Let’s Talk

For 20 min – group learning

Challenges Solutions

Early

Developing Advanced

(44)

Thank you

Marie Beisel

mbeisel@umich.edu

Micmrc-requests@med.umich.edu

Mary Ellen Benzik

References

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