Integrated Health Partners PHO located in Battle Creek, MI Partnership between Calhoun County Physicians Organization and Bronson Battle Creek Hospital 170 affiliated physicians, including 34 specialty areas

Care Management Model 11 Practices 4 Complex Care Managers - 1 CCM embedded in each practice with exception of OMG-MIFM, Olivet and Tekonsha - 2 Hybrids Moderate Care Managers employed by practice 2 Hospitals in Calhoun County participating: Bronson Battle Creek Oaklawn Hospital

Oaklawn Medical Group: Marshall Internal and Family Medicine, Olivet Family Practice, Tekonsha Family Practice Located in Marshall, Olivet, and Tekonsha 7 physicians, 6 midlevel providers, including certified diabetes educator MIPCT population of 5138 patients Trivia

OMG-MIFM, Tekonsha and Olivet Providers Dr. Jose Valle MIPCT Physician Champion

Care Managers Renee Leslie, RN, BS, CCM Complex Care Manager Integrated Health Partners Jane Ruhl, RN, BSN Complex Care Manager Integrated Health Partners Tami Starks, LPN Moderate Care Manager OMG-MIFM Dee Pennington, LPN Moderate Care Manager OMG-MIFM

OMG-MIFM, Tekonsha and Olivet Statistics 21,268 patients in MIPCT OMG-MIFM, Olivet Family Practice and Tekonsha Family Practice have 5138 patients eligible for care management Largest practice participating in MIPCT in Calhoun County Level of patient engagement increased from 3.78% in April to 5.48% in July, 2013

It takes a village to raise a child, it takes teamwork for care management to be successful in a practice

Moderate Care Managers target and engage patients using the following tools Community Resource Sheet Registry – Gaps in Care Emergency Room Reports BCBSM List

Community Resource Guide

IHP Registry Progress Note

Insert registry sheet

Emergency Reports Insert emergency action plan

BCBSM List

Complex Care Managers Target and Engage Patients Inpatient admissions Provider’s daily schedule Referrals

Inpatient Admissions Two hospitals in Calhoun County, Oaklawn Hospital in Marshall, MI and Bronson Battle Creek Daily access inpatient admission information Identify MIPCT PCP and patient

MiPCT list starts with 81 columns Our IT Analyst reduces this to 9 columns Pertinent information is loaded into CTC

Criteria for Identifying a Patient for Care/Case Management 1. Unscheduled Inpatient admission* Moderate: 2 admissions in 90 days Complex: 2 admissions in 30 days  2. ED Visits: 2 visits in 30 days 2> visits in 30 days 3. Poly-pharmacy 5> medications 4. Diagnosis: more than 2 comorbidities complex medical diagnoses and psychological diagnosis*

5. Psycho-social/depression screen: Criteria for Identifying a Patient for Care/Case Management (continued) 5. Psycho-social/depression screen: PHQ-2, PHQ-9 Moderate: 5 or more symptoms, score 15-19* Complex: Score 20>*   6. Age: -over 85 -under 50 with readmission -peds under age 2 7. More than 6 visits to PCP within 1 year* *criteria that in itself can trigger referral to care/case management

Providers Daily Schedule Print providers daily schedule Identify patients in MIPCT Discuss with provider any identified needs

Referrals Providers Office staff Hospital case managers Home Care Community Agencies

Patient Story