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Michigan Primary Care Transformation Demonstration Project May 15, 2013 Webinar

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Page 1: Mipct 05 15_2013

Michigan Primary Care Transformation 

Demonstration Project

May 15, 2013Webinar

Page 2: Mipct 05 15_2013

Congratulations: URAC Accreditation!

Hampton Medical Center• Bruce Johnson, DO: Board Certified in Internal Medicine and Geriatrics; American Medical Directors Association as a Certified Medical Director of Long Term Care Facilities

• Susan Tam, DO: Board Certified in Family Medicine• Christie Schunemann, NP: Board Certified Family Nurse Practitioner

• Cyndi Jones• Janet Johnson, Office Manager• Dawn Carroll, RN, Hybrid Care Manager

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Page 3: Mipct 05 15_2013

Sequestration

President Obama signed an order that imposes across‐the‐board Federal spending reductions (also known as sequestration) for Federal payments effective as of April 2013. 

Congress did not take action to avert this, monthly payments to practices and POs are reduced by 2% beginning April 1, 2013 and this will continue until there is resolution about the Federal budget and Federal deficit. 

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Page 4: Mipct 05 15_2013

Metrics Year Three

Committee review of proposed Year Three Metrics 

Metrics submitted to Clinical Sub‐committee

All proposed process and clinical outcome metrics approved by Steering Committee 

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Page 5: Mipct 05 15_2013

Pay for Performance Year End 2012

Not available

Fund release date is unknown

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Page 6: Mipct 05 15_2013

Sharing Activities: Teams

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Spotlighting Practices

May 30

Detroit Branch Federal Reserve Bank

8:30am‐12 noon

National speaker

Volunteers?

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Page 8: Mipct 05 15_2013

Physician Engagement

PCP involvement with care managers

PCP involvement with care team

Number of patients referred by PCP

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Page 9: Mipct 05 15_2013

Team Learning Events

June 6, 2013  (9am‐3pm)

June 8, 2013  (9am‐3pm)

June 13, 2013 (4pm‐8pm) Teams participating in Learning Collaborative

Compulsory attendance of practice team members

Required component of MiPCT practices

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Page 10: Mipct 05 15_2013

Best Practices for Care Coordination/Management

Implement self management, coaching and support with patient/family

Implement effective medication management plan

Manage care setting transitions

• Having a timely, comprehensive response to care setting transitions (esp. from hospitals and skilled nursing facilities) 

Page 11: Mipct 05 15_2013

Care Manager Training

Complex to be online after testing is complete

Moderate various opportunities

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Page 12: Mipct 05 15_2013

Reflection

Don’t talk, just act.  

Don’t say, just do.  

Don’t promise, just prove.

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June: 20 Days Ultimate Challenge

20 new Blue Cross patients enrolled

10 new Blue Care Network patients enrolled

20 new Medicare/Medicaid patients enrolled

~ 50 new patients 

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Page 14: Mipct 05 15_2013

Refresher:What is Care Coordination?

“A person‐centered, assessment based, interdisciplinary approach to integrating health care and social support services in a cost‐effective manner in which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an evidence‐based process which typically involves a designated lead care coordinator.”

Page 15: Mipct 05 15_2013

Refresher:What is the Problem?

Most health care dollars are spent on a small percentage of beneficiaries Those with complex chronic conditions

Causes of high utilization and costs: Deviations from evidence‐based care Poor communication among primary providers, specialists, health and community providers, patients, and families

Failure to catch problems early Failure to address psychosocial issues Lack of coordinated, longitudinal management Ineffective transitional management

Page 16: Mipct 05 15_2013

What is Effective Care Coordination?

Intervention with rigorous evidence that:

• Improves outcomes

• Reduces total health care expenditures for participating beneficiaries

• Improved satisfaction or clinical indicators not sufficient

• Net savings require reduced hospitalizations

Page 17: Mipct 05 15_2013

Promising Interventions

New care coordination and care management interventions being used by care managers

• Transitional care interventions • Care Transitions Intervention (Coleman)

• Transitional Care Model (Naylor)

• Enhanced Discharge Planning Program – RUSH (Perry)

Page 18: Mipct 05 15_2013

Promising Interventions

Other promising care coordination and care management interventions are emerging

• Comprehensive Care Management  ‐Medicare/ Duals

• Guided Care (Boult)

• GRACE (Counsell)

• Care Management Plus (Dorr)

• MCCD: Best Practice Sites (Brown)

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Promising Interventions

However, promising care coordination and care management interventions are emerging Comprehensive Care Management – Medicaid/ 

Duals

Integrated Care Management (Douglas)

Community Based Chronic Care Management (Lessler)

Hospital to Home (Raven)

Health Care Management Program (Reconnu & Herndon)

Page 20: Mipct 05 15_2013

What Distinguishes Successful Models? 

MODEL SYNTHESIS LITERATURE REVIEWTargeting • Patients with select chronic conditions including

co-occurring serious mental health diagnoses and substance abuse• Those who were hospitalized in previous year or at time of enrollment

• Program targeting to identify the population who can most benefit from a given intervention

Intervention • Conduct comprehensive in-home initial assessment • Develop a mutually agreed upon “action plan” with goal• Frequent face-to-face contact (home, office) with patients (~1/month)

• Baseline and ongoing assessment of health and social needs• Multidisciplinary approach to allow providers to address a spectrum of health and social service needs• Flexible provision of services and service intensity

Primary care provider

• Strong rapport with primary careprovider/specialist/hospital/family/caregiver• Face-to-face contact through co-location, regular hospital rounds, contact with hospitalist•Assign all of a physician’s patients to the same care manager when possible

• Enhanced communication among providers, frequently including the primary care physician

Page 21: Mipct 05 15_2013

What Distinguishes Successful Models? 

MODEL SYNTHESIS LITERATURE REVIEW

PatientEducation

• Providing a strong, evidence based patient education/coaching intervention for managing health, symptoms, medications

• Evidence‐based protocols to assess health and social condition and develop care plan

Training • Initial comprehensive training of CareManagers and Care Teams• Performance feedback to CareManagers and Care Teams

• At least 15 percent of articles included for review report specialized training for service providers as intervention component

Community link • Coordinate communication among physicians, health/community providers and patient/family

• Connection to existing community health and supportive services

Page 22: Mipct 05 15_2013

Best Practices for Care Coordination/Management

Follow evidence based practices/guidelines for care management

Address psychosocial issues• Staff with experts in social supports and community resources for patients with those needs

Being a communications facilitator• Care managers actively facilitate communications among providers and between the patient and the providers

Page 23: Mipct 05 15_2013

Open Discussion

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