The Michigan Primary Care Transformation (MiPCT) Project - Webinar #3 Complex Care Manager Training and Care Management Documentation Updates MiPCT Team December 9, 2011

Agenda Introduction Complex Care Management Training Update Care Management Documentation and Reporting

MiPCT Complex Care Manager Training

CCM Train the Trainer Model Proposed model for first group of CCMs 4 Master Trainers (3 open positions) 16 CCM Clinical Leads Employed by the PO/Practice Exception – One Master Trainer position filled by Marie Beisel MiCMRC Project Manager CCM Master Trainer and CCM Clinical Leads Complete Complex Care Manager Fundamentals course with Geisinger faculty (may require two waves of on-site training) 3 weeks on site in PA One week didactic Two weeks partnered with a Geisinger Care Manager Training in MI, mentoring by Geisinger faculty CCM Master Trainer additionally completes curriculum for train the trainer model *Model is designed for year one MiPCT intervention phase

MiPCT Complex Care Manager Train the Trainer Program MiPCT Leadership Team CCM Master Trainer 4 CCM Clinical Leads

Complex Care Manager Clinical Lead Completes Complex Care Manager Fundamentals course at Geisinger 3 weeks on site in PA supplemental training in MI Preceptor for CCMs in a defined region, has reduced patient caseload Leads small group discussions, facilitates networking, sharing best practices Contributes to ongoing CCM curriculum development by assisting Master Trainers with CCM education, workflow support, and resources Collaborates with CCM Master Trainer, MiPCT leadership, MiPCT clinical subcommittee to assess CCM interventions

Complex Care Manager Clinical Lead Sample of key preferred qualifications Current MI License: RN, NP, PA 3 to 5 years experience some adult medicine setting: home health agency, primary care practice, skilled nursing facility, hospital medical-surgical unit Preceptor experience - working with licensed clinical staff Demonstrated ability to create and support a learning environment that is characterized by mutual respect, constructive feedback, and conflict resolution Knowledge of chronic conditions and prevention evidence-based guidelines Excellent communication, interpersonal, teaching and facilitation skills

Master Trainer Complex Care Manager Role Completes Complex Care Manager Fundamentals course and a Train the Trainer program with Geisinger faculty 3 weeks on site in PA also training in MI Oversight of four Complex Care Manager (CCM) Clinical Leads Does not have a patient caseload Leadership role in providing CCM professional development through mentoring, coaching and education Gathers data, populates and analyzes specified CCM activity reports for region Collaborates with MiPCT leadership and MiPCT clinical subcommittee to assess, study, and refine CCM training and interventions as needed Presents educational offerings for CCMs in small group setting as well as a statewide audience

Complex Care Manager Master Trainer Sample of key preferred qualifications Current MI License: RN, NP, PA 5 years experience some adult medicine setting: home health agency, primary care practice, skilled nursing facility, hospital medical-surgical unit 2 years experience clinical manager - preferred clinical program development, implementation, monitoring, evaluation - preferred Demonstrated ability to create and support a learning environment that is characterized by mutual respect, constructive feedback, and conflict resolution Excellent communication, interpersonal, teaching and facilitation skills Excellent teaching, presentation, and facilitation skills Demonstrated ability to effectively develop educational resources, tools, processes

Training Timeline CCM Master Trainers and Clinical Leads 1-2 waves, likely February for first wave Subsequent training plans Michigan-based training waves Progress from Geisinger-led to combination of taped webinars and Master-Trainer led sessions Regionally based Having four Master Trainers will allow more flexibility with timing and geography

Next steps Additional details on CCM Master Trainer and clinical leads sent out by December 15 Position description details MiPCT salary subsidization amount for each role Definition of selection process PO/PHO responses requested by December 22 Letter of interest for CCM clinical lead position Letter of interest for CCM Master Trainer position Submit letter of interest to Marie Beisel at mbeisel@umich.edu Positions for first Geisinger trip identified by January 15 Anticipated travel date is early February Timing of second wave likely early March MiPCT team to finalize contract details with Geisinger by 12/31

Care Management Documentation

Current state No ideal single source solution for EHR documentation, registry functionality and care management support Integration costly, cumbersome Difficult to mimic manual processes with HIT solutions Recognized problem across the country Care managers need tools to support workflow Supervisors need a way to track productivity

Basic HIT Functions: Support Care Manager’s work Create and maintain a list of active patients Generate a Patient Tickler List patients scheduled for Care Manager (CM) follow up visit ideally includes past and future CM visits Document Patient Care management visits using a template Common diagnoses Common follow up Self management goal setting Transitions of care Create and maintain individualized patient care plan by Complex Care Managers

Advanced HIT Functions: Support Care Manager’s work Access to information such as: view of patient includes: diagnoses, care giver, PCP, insurance, demographics, care manager and health team member visit schedule, assessments, referrals, patient goals, medications, lab results Protocols Ability to generate Care Manager activity reports Compatibility with care manager’s work flow Notification - patient’s appointment with PCP, ER visit, hospitalization Assessments ( Functionality, PH Q 9, . .) completed and tracked - longitudinal view Patient worksheet: history of goals, assessments, care manager encounters past and future

MiPCT Required Care Manager Reports Care Manager Activity Reports Number of Care Manager encounters at practice location per Care Manager, by payer Frequency of reporting – TBD, likely quarterly Purpose of reports Provide accountability to payers, demonstrate value Allow PO and MiPCT leadership to see where practices are having difficulty with implementation/integration

Ways to accomplish varying levels of Care Management functions EHR customization built in care management feature (rare) Registry built in care management feature (rare) Care Management Software not integrated integrated

Options for Care Management Documentation and Reporting PO develops solution – works with practices Common MiPCT solution Not required, but option for those interested Care management software options reviewed by MiPCT team Two possible options Care Team Connect OHSU Care Management Plus Cost to PO/PHO/practice negotiated by MiPCT Findings and considerations Care management software vendors varying functionality lack of defined standards few products designed for ambulatory care setting Good news vendor products can support care manager’s work flow and will improve efficiencies

Care Team Connect Currently in use or in negotiations with several MiPCT PO/PHOs Highly customizable Accept MiPCT data feeds Risk stratification Specific protocols for clinical situations Connect multiple team members Can interface with registry/EHR at additional cost Will generate claims for G codes/CPT codes Will create MiPCT activity reports

Care Management Plus Low cost, web-based product Provides basic care management support Active patient list Tickler lists Activity reporting Some customization possible Templates Interface with practice management system, EHR

What is the best solution for you? PO/Practice will need to assess current HIT capability for care managers Can PO/practice report the required MiPCT activity? Will the HIT in the practice currently provide the basic functions needed to support the care manager workflow? If yes, can PO/Practice add support such as customized documentation templates? If no, how will PO/Practice address this?

Next steps Assessment of MiPCT PO/PHO capabilities Best practice webinar? Common solutions for same EHRs? Have something that works? We’d like to hear from you! Demonstrations from software vendors Care Team Connect, Care Management Plus If PO/PHO has care management software product they would like MiPCT to assess, please contact Marie Beisel at mbeisel@umich.edu

Questions and Discussion