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

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

3. MiPCT Complex Care Manager Training

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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
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

12. Care Management Documentation

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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?

22. 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

23. Questions and Discussion