1. The Michigan Primary Care Transformation (MiPCT) Project
Succeeding in 2014: What it Will Take

2. MiPCT Team-Based Care Recap16
MiPCT Team-Based Care Recap

3. MiPCT Team-Based Care Evergreen” Themes16
MiPCT Team-Based Care Evergreen” Themes
Care managers work in close proximity to PCP team
In PCP office as much as possible
Work with PCP team to meet their needs
Regular communication via huddles, medical meetings, etc.
Ensure Care Management coverage
Focus on MiPCT patients (across participating payers)
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

4. Success = Improvements in Population Health + Cost + Patient Experience

5. Reduction in Unnecessary and Non-Value-Added Costs
How do we make a dent in cost?
-Preventing unnecessary ED and inpatient visits by providing care upstream before a crisis
- Making sure your patients know about your extended access and how to reach you after hours
- Using resources more wisely 5

6. 2014 Priorities Target the Right Patients
Combine data with clinical judgment
Introduce palliative care opportunities when appropriate
Diabetes Management
Expanded Access
Make sure patients know how to contact the practice’s 24/7 access

7. MiPCT: Beyond 2014…

8. Preparing for Sustainability
Physician Organizations have made a significant investment in care management
Working hard for payers to support the model financially
We need your help!

9. CMS – Looking for Solutions (desperately)
Areas of promise – what we’re doing!
Good directional signs
CMS Quarterly Payment Proposal (for 2015)
Commercial Payer Sustainability Statement
Potential for Demo Extension
Question on the table - Can primary care redefine care delivery?
This is our best (last?) chance to provide the answer
If successful, can lead to new funding models

10. How can YOU help shape the future?

11. It’s Time to Put on Your Cape!

12. Thank You!