1. MiPCT Launch Tier 1 and Tier 2 Mary Ellen Benzik,MD Associate Medical Director MiPCT

2. I wear many hats – Family Physician Medical Director of Integrated Health Partners Active participant in the BCBSM PDCM Associate Medical Director MiPCT

3. Significance of a Demonstration Project  When successful – may lead to direct redesign of CMS/Medicare funding without congressional confirmation  Awesome opportunity to impact the future of primary care in the country  Ability to improve the quality of care for our patients  “Do what we have always wanted to do”

4. Critical Areas  Self-management support  Community resources  Care transitions  Care coordination

5. Requires System Change Not Superman

7. Care Management MiPCT Framework Complex Care Management Functional Tier 4 All Tier 1-2-3 services plus:  Comprehensive care plan  Home visits  Palliative and end-of life care P O P U L A T I O N Care Management Functional Tier 3 All Tier 1-2 services plus:  Planned visits  Self-management support  Patient education  Optimize chronic conditions  Advance directives Navigating the Medical Neighborhood Functional Tier 1 Health IT - Registry / EHR registry functionality - Care management documentation - E-prescribing - Patient portal (optional) - Community portal/HIE (optional) Patient Access - 24/7 access to decision-maker - 30% open access slots - Extended hours - Group visits (optional) - Electronic visits (optional) Infrastructure Support - PO/PHO and practice determine optimal balance of shared support - Patient risk assessment - Population stratification - Clinical metrics reporting  Optimize relationships with specialists and hospitals  Coordinate referrals and tests  Link to community resources 7-12-11 PCMH ServicesPCMH Infrastructure Transition Care Functional Tier 2 All Tier 1 services plus:  Notification of admit/discharge  PCP and/or specialist follow-up  Medication reconciliation Prepared Proactive Healthcare Team providing evidence-based, person-centered care Person side Population side

8. Population health one person at a time

9. Care Management Conceptual Framework Complex Care Management Functional Tier 4 All Tier 1-2-3 services plus:  Comprehensive care plan  Home visits  Palliative and end-of life care P O P U L A T I O N Care Management Functional Tier 3 All Tier 1-2 services plus:  Planned visits  Self-management support  Patient education  Optimize chronic conditions  Advance directives Navigating the Medical Neighborhood Functional Tier 1 Health IT - Registry / EHR registry functionality - Care management documentation - E-prescribing - Patient portal (optional) - Community portal/HIE (optional) Patient Access - 24/7 access to decision-maker - 30% open access slots - Extended hours - Group visits (optional) - Electronic visits (optional) Infrastructure Support - PO/PHO and practice determine optimal balance of shared support - Patient risk assessment - Population stratification - Clinical metrics reporting  Optimize relationships with specialists and hospitals  Coordinate referrals and tests  Link to community resources 7-12-11 PCMH ServicesPCMH Infrastructure Transition Care Functional Tier 2 All Tier 1 services plus:  Notification of admit/discharge  PCP and/or specialist follow-up  Medication reconciliation Prepared Proactive Healthcare Team providing evidence-based, person-centered care

10. Care Management Conceptual Framework Complex Care Management Functional Tier 4 All Tier 1-2-3 services plus:  Comprehensive care plan  Home visits  Palliative and end-of life care P O P U L A T I O N Care Management Functional Tier 3 All Tier 1-2 services plus:  Planned visits  Self-management support  Patient education  Optimize chronic conditions  Advance directives Navigating the Medical Neighborhood Functional Tier 1 Health IT - Registry / EHR registry functionality - Care management documentation - E-prescribing - Patient portal (optional) - Community portal/HIE (optional) Patient Access - 24/7 access to decision-maker - 30% open access slots - Extended hours - Group visits (optional) - Electronic visits (optional) Infrastructure Support - PO/PHO and practice determine optimal balance of shared support - Patient risk assessment - Population stratification - Clinical metrics reporting  Optimize relationships with specialists and hospitals  Coordinate referrals and tests  Link to community resources 7-12-11 PCMH ServicesPCMH Infrastructure Transition Care Functional Tier 2 All Tier 1 services plus:  Notification of admit/discharge  PCP and/or specialist follow-up  Medication reconciliation Prepared Proactive Healthcare Team providing evidence-based, person-centered care

11. SWOT sheet Navigating the medical Neighborhood StrengthWeaknessOpportunityThreat Relationship with MD/hosp Coordination Referrals Coordination tests Link to community Resources

12. Navigating the Medical Neighborhood  Optimize relationships with specialists and hospitals  Coordinate referrals and tests  Link to community resources

13. http://www.improvingchroniccare.org The Care Coordination Model

14. PCMH in the Neighborhood  Accountability ◦ Know who your patients are (registry) ◦ Track referrals and test results  http://www.improvingchroniccare.org/downloads/3_referral_tr acking_guide.pdf http://www.improvingchroniccare.org/downloads/3_referral_tr acking_guide.pdf  Patient Support ◦ Identification of patient medical, logistic, insurance needs ◦ Motivational interviewing ◦ Transition of care ◦ Identification of barriers

15. Connecting to the Neighborhood  Relationships and Agreements ◦ Community Agencies ◦ Hospitals / Emergency rooms ◦ Specialist ◦ http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/ 1483/PCMH_Tools%20&%20Resources_v2 http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/ 1483/PCMH_Tools%20&%20Resources_v2 ◦ http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__ home/1483 http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__ home/1483  Connectivity ◦ http://www.improvingchroniccare.org/index.php?p=Connectivity &s=415 http://www.improvingchroniccare.org/index.php?p=Connectivity &s=415 ◦ Case examples of three area solutions

16. It’s all about relationships More than just a handshake

17. Concept of Compacts Establishes specific agreements and expectations related to : Transitions of Care Access Collaborative Care Management Patient Communications Great definitions Templates for all of these four areas

18. SWOT analysis Table conversation Report out

19. Care Management Conceptual Framework Complex Care Management Functional Tier 4 All Tier 1-2-3 services plus:  Comprehensive care plan  Home visits  Palliative and end-of life care P O P U L A T I O N Care Management Functional Tier 3 All Tier 1-2 services plus:  Planned visits  Self-management support  Patient education  Optimize chronic conditions  Advance directives Navigating the Medical Neighborhood Functional Tier 1 Health IT - Registry / EHR registry functionality - Care management documentation - E-prescribing - Patient portal (optional) - Community portal/HIE (optional) Patient Access - 24/7 access to decision-maker - 30% open access slots - Extended hours - Group visits (optional) - Electronic visits (optional) Infrastructure Support - PO/PHO and practice determine optimal balance of shared support - Patient risk assessment - Population stratification - Clinical metrics reporting  Optimize relationships with specialists and hospitals  Coordinate referrals and tests  Link to community resources 7-12-11 PCMH ServicesPCMH Infrastructure Transition Care Functional Tier 2 All Tier 1 services plus:  Notification of admit/discharge  PCP and/or specialist follow-up  Medication reconciliation Prepared Proactive Healthcare Team providing evidence-based, person-centered care

20. SWOT sheet Transitions of care StrengthWeaknessOpportunityThreat Notification of: Admissions Discharges Emergency room

21. SWOT sheet Transitions of care StrengthWeaknessOpportunityThreat PCP Follow up Specialist Follow up Medication Reconciliation

22. Transitions of Care

23.  Notifications of admissions, discharges, ER visits

24. Transition of care  The Post-Hospital Follow-Up Visit: A Physician Checklist to Reduce Readmissions  Eric A. Coleman, MD Read more: http://www.chcf.org/publications/2010/10/the- post-hospital-follow-up-visit-a-physician- checklist#ixzz1omLp27nz http://www.chcf.org/publications/2010/10/the- post-hospital-follow-up-visit-a-physician- checklist#ixzz1omLp27nz

25. Transition of care – Check list for post hospital follow up Prior to visit Review discharge summary Clarify outstanding questions with send physician Reminder call to patient or family care giver Stress the importance of the visit and address any barriers Remind to bring medication list, medications both otc and rxd Provide instructions on seeking after hours care both emergent and nonemergent Coordinate care with home health or care managers if necessary

26. Transition of care – Check list for post hospital follow up During the Visit Ask the patient to explain: His/her goal for the visit What factors they believed led to admission/er visit What medications they are taking and on what schedule Perform medication reconciliation with attention to pre- hospital regiment Determine the need to Adjust meds Follow up on any outstanding tests Do monitoring or testing Discuss advanced directives Discuss future treatments (POLST)

27. Transition of care – Check list for post hospital follow up During the visit (continued) Collaborate with patient on self management support ; perform teach back Explain warning signs and how to respond ; have patient teach back Provide instruction on how to seek after hours care both emergent and nonemergent

28. Transition of care – Check list for post hospital follow up At the Conclusion of the Visit Print reconciled and dated medication list and provide a copy to the patient, family care giver, home health nurse, and case manager (if applicable) Communicate changes in the care plan to family care givers, health care nurses, and care managers Consider skill home health care and other supportive services Ensure the next appt is made as appropriate

29. Medication Reconciliation Insanity: doing the same thing over and over again and expecting different results. Albert Einstein Albert Einstein

30. Tools for medication reconciliation More than you can count - in all different sizes and colors!!

31. Which is the Correct List The one the patient states they are taking

32. The Correct List  In home assessment  Asking “how do you take your medications”  Not “do you take X in Y way”  Bag review  …………………  ………………………..

33. So – why can’t we get it right?? Guhad A, Farris KB, Batra P, Benzik ME. Community health partners perceptions of problems with medication reconciliation. Ongoing research.

34. Engaging Patient Educating patients on issue related to safety and medication Community partners to work with patients on medication Personal Health Record

35. How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations

36. SWOT analysis Table conversation Report out

37. Challenges for Care Management

38. Thanks Mary Ellen Benzik, MD mebstork@aol.com Cell 269-580-7738 Office 269- 245- 3850