1. 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

2. 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

3. 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

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

5. 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

6. 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

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

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

10. Community Resource Guide

11. IHP Registry Progress Note

12. Insert registry sheet

13. Emergency Reports
Insert emergency action plan

14. BCBSM List

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

16. 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

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

18. 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*

19. 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

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

21. Referrals Providers Office staff Hospital case managers Home Care
Community Agencies

22. Patient Story