1. The Michigan Primary Care Transformation (MiPCT) Project
Overview and Transition of Care Lessons Learned to Date
Marie Beisel MSN, RN, CPHQ

2. Disclosure I have no conflict of interest to declare
I do not have any relevant financial relationships with any commercial interests

3. Objectives
Describe the Michigan Primary Care Transformation (MiPCT Clinical Model
Identify three patient centered medical home care management components associated with positive outcomes
Explain the MiPCT transition of care and lessons learned to date

4. CMS Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration
Centers for Medicare & Medicaid Services is exploring the role of the PCMH in improving US health care
Participating in state-based PCMH demonstrations
CMS Demo Stipulations
Must include Commercial, Medicaid, Medicare patients
Must be budget neutral over 3 years of project
Must improve cost, quality, and patient experience
8 states selected for participation, including Michigan
Michigan start date: January 1, 2012

5. MAPCP Demo: Participating States
Maine practices  (year 3)
Michigan practices
Minnesota 159 practices  (year 3)
New York practices
North Carolina practices
Pennsylvania practices
Rhode Island practices
Vermont practices  (year 3)
_____________________________________________
TOTAL practices  1,192 (year 3)

6. Michigan: Selected health statistics
45th (of 50 states) in coronary heart disease deaths
41rd in percent of obese adults
34th in infant mortality rate
34th in percent of adults who smoke
34th in overall cancer death rate
20th in percent of adults who exercise regularly
12th in adults receiving colon cancer screening
5th in childhood immunization rate
Source: Comparison of Michigan Critical Health Indicators and Healthy People Targets, Michigan Department of Community Health, May 2011

7. The Vision for a Multi-Payer Model
Use the CMS Multi-Payer Advanced Primary Care Practice demo as a catalyst to redesign MI primary care
Multiple payers will fund a common clinical model
Allows global primary care transformation efforts
Support development of evidence-based care models
Create a model that can be broadly disseminated
Facilitate measurable, significant improvements in population health for our Michigan residents
Bend the current (non-sustainable) cost curve
Contribute to national models for primary care redesign
Form a strong foundation for successful ACO models

8. CMS Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration
CMS award notification: November 16, 2010
8 states selected for participation, including Michigan
Start date: January 1, 2012
Includes Commercial, Medicaid and Medicare patients
Financial stipulations
Must be budget neutral over 3 years of project
Expect improvements in cost, quality, and patient experience

9. MiPCT Practice Participation Criteria
PCMH-designated in 2010, and maintain PGIP or NCQA designation over the 3-year demonstration
Part of a participating PO/PHO/IPA
Agree to work on the four selected focus initiatives:
Care Management
Self-Management Support
Care Coordination
Linkage to Community Services

10. Participating Provider and Payer Partners As of September 2012
# Practices*
# POs
# Physicians
# Payers
387 Practices
36 POs
1650 Physicians
4 (Medicaid*, Medicare, BCBSM**, BCN)
*Choice of a 01/01/12 or 04/01/12 start dates; 6 Additional Practices joining in 01/2013.
* Medicaid Managed care
**BCBSM commercial, BCBSM Medicare Advantage

12. MiPCT Clinical Model: Optimizing Patient Engagement, Improving Population Health

13. Managing Populations: Stratified Approach to Patient Care and
IV. Most complex (e.g., Homeless, Schizophrenia)
III. Complex Complex illness Multiple Chronic Disease Other issues (cognitive, frail elderly, social, financial)
II. Mild-moderate illness Well-compensated multiple diseases
Single disease
I. Healthy Population
<1% of population Caseload 15-40
3-5% of population Caseload
50% of population Caseload~1000
Managing Populations:
Stratified Approach to Patient Care and
Care Management

15. MiPCT PO/Practice Expectations
Care management
Performed for appropriate high and moderate risk individuals
Population management
Registry functionality by end of year 1
Proactive patient outreach
Point of care alerts for services due
Access improvement
24/7 access to clinician
30% same-day access
Extended hours

16. Success = Improvements in Population Health + Cost + Patient Experience
Statistical analysis of the effect of work completed by the MiPCT practices: care management, care transitions, community linkages, IT, patient access on quantifiable outcomes, using:
Claims data
Clinical quality indicators
Utilization
Hospital readmission rate within 30 days
Primary Care treatable ED rate
Hospitalization rate - ambulatory care sensitive conditions
Reference: MiPCT Clinical Metrics updated resource tab

17. Role Comparison: Moderate Risk Care Manager, Complex Care Manager
Moderate Risk Care Manager (MCM)
Complex Care Manager
(CCM)
Patient Population
Moderate risk patients identified by registry, PCP referral for proactive and population management.
High risk patients identified by PCP referral and input, risk stratification, patient MiPCT list.
Patient Caseload
Caseload 500 (approx active patients); one MCM per 5,000 patients.
Caseload 150 (approx active patients); one CCM per 5,000 patients.
Focus of Care Management
Proactive, population management. Work with patients to optimize control of chronic conditions and prevent/minimize long term complications.
Targeted interventions to avoid hospitalization, ER visits. Ensure standard of care, coordinate care across settings, help patients understand options.
Duration of Care Management
Typically a series of 1 to 6 visits
Frequency of visits high at times, duration of months

18. Evidence-Based Review: PCMH Care Management Components Associated With Positive Outcomes
Care delivery by multidisciplinary teams
Care delivery in collaboration with physician’s office
Attention to care transitions
Medication reconciliation
In-person visits along with telephonic encounters
Patient selection important - risk stratification plus physician input important to successful interventions

19. MiPCT Care Management Priorities
Care managers work in close proximity to PCP team
In PCP office as much as possible
Work with PCP team to meet their needs
Evidence supports this model as superior to vendor-based
Ensure Care Management coverage
2 Care Manager per 5000 MiPCT patients
Focus on evidence-based interventions
Medication reconciliation
Care transitions
In-person contact with patients whenever possible
Comprehensive care plan for complex patients

20. MiPCT Clinical Resources
Care Manager Development
Care Management Resource Center - Web-based resource for care managers and POs
National and local evidence-based training models
Care management implementation guide
Team Development
Facilitated learning opportunities for practice teams
Examples: Learning Collaboratives, webinars and seminars
Physician Engagement
“Town hall” meetings to be scheduled
Profile success of physician/care manager partnerships

21. MiPCT Care Manager Training Details
Complex care manager training
Partnership with Geisinger Health System
Clinical leads: three weeks in Pennsylvania
One week didactic training
Two week preceptorship
Care managers:
One week didactic training in MI, ongoing webinars/support
Moderate care manager training
Chronic care model, self-management support
MiPCT-approved programs identified throughout state

22. Year One MiPCT – Statewide Care Management Progress to Date
In 2012 over 350 Care Managers (CMs) hired and completed required training
Building infrastructure in partnership with POs
CM Work station at office practice location
CM Documentation tools
Process to bill for CM visits
Ongoing Care Manager training, coaching, mentoring
Patient education materials

23. Year One MiPCT – Statewide Care Management Progress to date
Building Infrastructure cont.
Delivery of Care Management at the practice level
Staff members roles defined
PCP referrals to Care Manager
Communication- PCP, CM, staff members
Building volume of G code and CPT codes submitted
Care Managers are building caseloads
Started with transitions of care for HCM, CCM Expand to enroll complex and moderate patients

24. Care Management Delivery by the Practice
PCMH meetings monthly, action plan, follow up
PO and Practice Leadership
Care Manager and PCP partnership
Patient
Office staff – defined roles and responsibilities
Information technology, support
Planned patient care i.e. huddles, processes, work flow, policies

25. 2013 Priorities Care managers fully integrated into practices
Target PCMH interventions to patients from all participating payers
Distribute multi-payer lists and Data dashboard reports
Bill G-codes/CPT codes on BCBSM/BCN patients
Use registry for proactive population management
Focus on efficient and effective health care
Avoid unnecessary services/hospitalizations
Assess practice utilization patterns
Ensure adequate clinic access to meet demands

26. MiPCT Team and PO Leaders Work Together to Define Care Management Activity
Define standard work
Gather and share examples of standard work developed by POs and practices
CCM Responsibilities with detailed description of processes and action step, available end of March
Conduct “go sees” – ongoing by Master Trainers, Clinical Leads
Gather and share best practice processes, resources, tools, staff job descriptions
Continue to identify gaps – assist with developing solutions

27. MiPCT Transition of Care Intervention
Care Manager conducts Transition of Care follow up phone call within hours post hospital discharge
Then weekly x 4 – phone visit
Address:
Medication reconciliation
Follow up - PCP appt., specialist appt., tests
Social support
Assessment – barriers
Red flags
Access to PCP office – “how to”

28. MiPCT TOC Lessons Learned Primary Care Practice
Across the state practices continue to partner with hospitals to receive the discharge notification
Notification to Primary care practices of hospital discharge varies widely:
not occurring consistently
Fax
Electronic ADT
Some MiPCT POs/practices are using IT resources to link the ADT to the MiPCT patient list – notifies Care Manager and practice real time
It is ALL about relationships
Care Managers, Practice Leaders and Physician Organization Leaders initiate communication across the continuum
Hospitals – Discharge Planners, Care Managers
Skilled Nursing Facilities
Home Health Agencies
Health Plan Care Managers

29. MiPCT Transition of Care (TOC) Workgroup
Areas identified to address
High Volume of TOC
Some care managers have high volume of patients discharged from the hospital
Not able to consistently call every patient within hrs. post hospitalization
Challenges
balancing patient caseload: TOC, following up on new referrals, and managing caseload
Some care managers are part time and/or support multiple practices
Outcome of TOC work group: recommendation to risk stratify patients discharged from the hospital, continue work to define practice team members responsibilities
Some care managers are including ER follow up phone visits
Evidence based tool to stratify patients at high risk for hospital re-admission
tool can be used in ambulatory care setting
Care Manager is able to collect the data elements for the tool by reviewing the patient’s hospital discharge summary
ease of use, time to complete - supports efficiency

30.
Michigan Care Management Resource Center web site
Public section
Job Descriptions CCM, MCM
MiPCT Implementation Guide
Evidence based interventions, tools
Private section for CCMs, HCMs
CCMs and HCMs will receive User ID and Password upon completion of the MiPCT CCM course
Contains Geisinger licensed tools

32. Contact Information Marie Beisel MSN, RN, CPHQ Office phone: