1. The Michigan Primary Care Transformation (MiPCT) Project 2013 Annual Summit Sharing Care Management Best Practice & Building the Care Manager Caseload 1

2. MiPCT Care Manager Update Patient Panel Size Mary Ellen Benzik,MD

3. 3 Not what we had planned ---

4. 2013 PO Report – 1 st & 2 nd Quarter Care Manager Activities The Mean increases are statistically significant. 4

5. Care Manager Volume Quarter 2, 2013 Encounters Unique Patients Face to Face Phone Total15,25032,70922,237 Per CM FTE 6311282 5

6. Care Management Breakdown- 80/20 Rule Complex Well Moderate

7. Simple Math 1,000,000 patients 20% = 200,000 patients potentially for care management 22,234 in one quarter Potentially over 100,000 patient encounters a year at the current pace

8. MiPCT Benchmark* for Care Manager Caseload Care manager’s patient caseload – 2 nd Quarter PO Data 8 Care Manager Role 90 th Percentile Qtr 2 face to face/FTE 90 th Percentile QTR 2 Phone encounters/FTE Encounters per day = Benchmark* Complex842606 encounters per day Hybrid1603218 encounters per day Moderate1932387 encounters per day

9. But this is NOT About NUMBERS

10. Care Manager Survey Results Care Managers reported working with an average of 8.4 physicians On average, 83% of these physicians referred patients 10 Physician Interaction

11. Care Manager Survey Results 11

12. Care Manager Survey Results The physician(s) I work with support the concepts of the MiPCT care management team. 12 Strongly Disagree DisagreeNeither Agree nor Disagree AgreeStrongly Agree

13. Care Manager Survey Results Physicians are available on a daily basis to address questions related to management of MiPCT patients. 13 NeverRarelySometimesFrequentlyAlways

14. Care Manager Survey Results Physicians understand and are actively involved in population management 14 NeverRarelySometimesFrequentlyAlways

15. Does Anybody Achieve Target CaseLoads? Yes!

16. How Do The Best Performing Practices Do It? Front office staff screen member lists, confirm current eligibility, identify gaps in care, etc. Office, PO and Nursing management support team-based care Backfilling occurs Physicians partner with the Care Manager and refer patients Team meets regularly as a team to discuss successes and opportunities for improvement

17. Today is about Solutions Sharing Best Processes Engaging your care team Letting go of patients when appropriate

18. Henry Ford Medical Group (HFMG) MiPCT HTN Initiative Juliann Testy RN, BSN Henry Ford Health System

19. New Initiative for HFMG: Measure Up, Pressure Down Campaign S ponsored by AMGF

20. CMs Participate in Blood Pressure Campaign 80% BP Control Target by 2015 Case Managers and Diabetes Care Team Educators have BP related program goals as part of their Performance Management process- Disease management & RN BP re-check visit process As self-management site champions, support staff with skill application following interactive self-management workshops for Medical Assistants and RNs Developed collaborative protocols with Home Health Care: Telehealth Home Monitoring Process; calibration of BP cuffs Pharm D’s share tips on medication reconciliation issue recognition

21. New “Gimme 5” Campaign Helps Manage MiPCT Population Campaign targets final gap in diabetes care Uses Registry & Epic to link meaningful info to Providers Bumped against MiPCT Attribution for Team Care ◦Site/Physician based by component ◦Identifies active point person/program ◦Eligibility status ◦Identifies patients with poor BP Control and more… 21

22. “Gimme 5” Campaign: A Twist on Diabetes Population Management 22

24. Group Work DescriptionTitle of Work Flow A. Team Based Care – Care Manager Patient Engagement using HTN Registry Henry Ford Health System – MIPCT Eligible HTN Registry B. Building Care Manager Caseload – PO, Health System, Practice Support McLaren Holt Family Practice: Building Care Management Integration Process C. Team Based Care – Care Manager Daily Work Processes McLaren Holt Family Practice: Team Based Care D. Care Manager Processes – Case Closure Lakeshore Health Network/Mercy Health Primary Care Network: Transitioning Care Management Patients E. Team Based Care – Care Manager Daily Work Processes Lakeshore Health Network/Mercy Health Primary Care Network Care Manager Warm Handoff F. Team Based Care – Care Manager Daily Work Processes (includes case closure) West Front Primary Care: Care Manager Work flow

25. Report Out