The Michigan Primary Care Transformation (MiPCT) Project Learning Collaborative Information Session Webinar July 31, 2012

MiPCT Success to Date Launch meetings attended by 600 participants Trained over 230 Complex Care Managers Continued training of Moderate Care Managers Payments flowing Beginning of data sharing WAY TO GO

“Embedment” Verb – the act of effectively embedding care managers in primary care practices Critical to the success of MiPCT

What does Effective Embedded Care Management Look Like in Your Day ??? Team huddle kicks the day off CCM meets with post transition patient in the office – reconciles med list, reassesses home needs – connects with community agency for the VNS services MCM follows up on registry, and call backs. Indentifies patient that sugar is out of control , confers with CCM regarding protocol ,and works with front desk to bring patient in sooner for provider visit Doctor stays on schedule Patients get better care Everyone goes home happy!

Learning Collaboratives

Identify Change Concepts Learning Collaboratives Participants Engage Select Topic Planning Group Identify Change Concepts Prework LS 1 P S A D LS 3 LS 2 Supports E-mail Visits Web-site Phone Assessments Senior Leader Reports Outcomes Congress (6-12 months time frame) Embedment of Care managers in primary care practices Late Fall 2012 Starting now

Framework for MiCPT Embedded Care Management Collaborative 3 one day sessions, 2 months apart Monthly learning collaborative call for team participants Collaborative teams include representation for all aspects of the office team Monthly webinar calls for other office staff not involved in the collaborative sessions Monthly reporting on process measures related to model elements Team level meetings ~ 1 hour a month 4 waves of regionally based collaboratives Start monthly beginning in November, 2012

Waves of MiPCT Collaboratives Wave One begins November 2012 Wave Two begins early December 2012 Wave Three begins January 2013 Wave Four begins February 2013

Medication Reconciliation, Quality Improvement Strategy, Care Management Embedment Model PRACTICE TRANSFORMATION CARE MANAGEMENT TRANSFORMATION Transitions of Care, Medication Reconciliation, Advanced Directives Quality Improvement Strategy, Build Teams, Define Roles

Quality Improvement Strategy, Care Management Embedment Model PRACTICE TRANSFORMATION Quality Improvement Strategy, Build Teams, Define Roles

Meetings for Quality Improvement

Sometimes gathering data can bring new and surprising knowledge!

Too Many Men on the Field?

Impact of Practice Transformation Physician Organizations /Practices Offers expertise on team development to sustain change Ability to sustain change by redesigning how your team works together Decrease the chaos Improve the satisfaction for the team delivering care management care.

Impact of Practice Transformation Care Managers Ability to build case load more effectively with the team Increased understanding of the care managers role in the team Decrease the chaos Improved satisfaction with the delivery of care

Medication Reconciliation, Care Management Embedment Model CARE MANAGEMENT TRANSFORMATION Transitions of Care, Medication Reconciliation, Advanced Directives

Impact of Transition of Care Enhanced communication across the care system, With seamless handoffs Recognition of the importance of the patient’s health experience Addresses and prevents the patient from “falling through the cracks”

Impact of Medication Reconciliation Medication list will be accurate and complete at hospital transitions. Patients will be actively engaged to ensure the medication list is correct at all care provider encounters Decreased chaos for the care team Decreased medication side effects and complications for the patient

Impact of Advanced Directives Directives will be discussed with the patients. When obtained, they will be identified and accessible by the care team Patient wants and desires are honored across the care system Unwanted care and costs are avoided

Impact of Care Delivery Transformation Patients Improved engagement in their care Improved patient satisfaction - “they really do care about me” Less chaos Less frustration

Medication Reconciliation, Quality Improvement Strategy, Care Management Embedment Model PRACTICE TRANSFORMATION CARE MANAGEMENT TRANSFORMATION Process Measures 1. 2. 3. 4. Process Measures 1. 2. 3. 4. Transitions of Care, Medication Reconciliation, Advanced Directives Quality Improvement Strategy, Build Teams, Define Roles

Care Management Embedment Model PRACTICE TRANSFORMATION CARE MANAGEMENT TRANSFORMATION Process Measures 1. 2. 3. 4. Process Measures 1. 2. 3. 4. Transitions of Care, Medication Reconciliation, Advanced Directives Quality Improvement Strategy, Build Teams, Define Roles OUTCOMES Reduced Hospitalizations for Ambulatory Care Sensitive Conditions Reduced Emergency Department Visits Reduced Avoidable Readmissions

What does Effective Embedded Care Management Look Like in Your Day ??? Team huddle kicks the day off CCM meets with post transition patient in the office – reconciles med list, reassesses home needs – connects with community agency for the VNS services MCM follows up on registry, and call backs. Indentifies patient that sugar is out of control , confers with CCM regarding protocol ,and works with front desk to bring patient in sooner for provider visit Doctor stays on schedule Patients get better care Everyone goes home happy!

Come Join Us !! Register your practice team at: https://jodyooo.wufoo.com/forms/mipct-learning-collaborative-team-application/ Dates will begin in November CME and CEU will be available Unique learning experience that helps you know that your not alone How can we help you recruit practices for this opportunity ?

Thank You!