1. MiPCT Embedded Case management Barriers to developing an embedded Case Management program

2. Presenters: Della Slavsky RN, BSN MiPCT Clinical Lead, UP Health Plan Mary Beth Carstens RN, BSN MiPCT Complex Case Manager, UP Health Plan Angela Tebby, LPN MiCPT Moderate Case Manager, UP Health Plan

3. Barriers to Developing Embedded Case Management Case Managers (CM)new to practice Staff roles needed to be defined Integration of CM position into practice Goals needed to be identified Processes needed to be developed

4. Barriers to Developing Embedded Case Management continued MiPCT project in early development Gradual roll out of MiPCT required Complex Case Management Training Moderate Care Management Training required MiPCT Patient List issues BCBS Billing issues

5. Where we began… Moderate care management ◦ Gaps in care – using the MiPCT list ◦ Diabetic population ◦ Heart Failure Transitions of Care ◦ Inpatient follow up ◦ Emergency Department follow up

6. Moderate Care Management, Diabetic population HbA1C over 8.0 Name/InsuranceHbA1C Results Date lab drawn Office Visit scheduled Call date John/BCBS14.34/24/12No5/14/13 Sharon/BCBS12.51/13/12No5/14/13 Jack/Medicare11.78/1/11No5/14/13 Lisa/Medicaid10.55/26/125/22/13 Alexis/Med Adv9.72/23/128/2/13 Wilho/Medicare12.310/5/11No5/14/13

7. Transition of Care Process Identified Barriers No ED list was being sent to office IP list was sometimes sent to the office No one was “in charge” of the list when it was sent In short, there was no consistent and timely process for TOC follow up

8. Focus on TOC Barriers Fishbone Barrier analysis completed Interventions devised and completed Success

9. Transition of Care Fishbone Barrier Analysis

10. Barrier 1- No ED list provided to Practice Opportunity: Obtain timely and consistent ED notification list to practice Interventions: Call Facility ED Manager Call Facility IT Department Outcome: Success, a daily ED list sent to practice

11. Barrier 2 – IP list notification not consistent Opportunity: Obtain timely and consistent IP lists sent to practice Interventions: Met with hospitalist providers to discuss program PO Medical director sent letter to Facility Medical director Practice office contracted with Facility to gain read only access to information systems for IP list of admits and discharges Outcome: Success, a timely and consistent IP admit and dc list obtained at practice

12. Barrier 3 - No Process for Follow-up with ED & IP Opportunity: Improve process for notification of ED and IP admits and discharges Interventions: Met with staff to develop a process Process improvements made to current process Outcome: Success, we now have a consistent and timely process within the office for follow up with IP and ED admits and discharges

13. MiPCT Case Management Transitions of Care Process Purpose: To foster structured and coordinated care between health care settings to ensure the quality and safety of patient care when there is a transition from one health care setting to another. Process: Case Manager (CM) receives Emergency Department list each morning and assesses for MiPCT eligible members The CM logs into Facility Information system to check hospital inpatient and discharge patient list Patient is on the MiPCT list Review discharge information (summary, medications, instructions) ◦ If discharge information has not been sent, CM will fax request/call for it Contact patient per phone 24-48 hours after discharge ◦ Review reason for phone call ◦ Assess how patient is doing that day ◦ Medication reconciliation (first phone call and as needed). Request patient to bring ALL meds to next appointment for visual confirmation of medications ◦ Ensure follow up visits/tests are scheduled; if not, assist member as needed ◦ Assess caregiver support needs ◦ Coordinate ancillary services (home health, DME, transportation, pharmacy needs) or contact existing services to provide timely, complete and accurate information between entities as appropriate ◦ Provide education to patient related to signs and symptoms to report to PCP office ◦ Follow up phone call to assess ongoing CM needs, patient condition, self management goals as needed ◦ Track follow up visits and/or tests to ensure they are completed ◦ Meet with patient at follow up visit, as feasible Patient is NOT on MiPCT list Refer to PCP staff nurse for follow up