The Michigan Primary Care Transformation (MiPCT) Project - Webinar #3Complex Care Manager Training and Care Management Documentation Updates

MiPCT TeamDecember 9, 2011

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Agenda

• Introduction• Complex Care Management Training

Update• Care Management Documentation and

Reporting

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MiPCT Complex Care Manager Training

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CCM Train the Trainer Model• Proposed model for first group of CCMs

▫ 4 Master Trainers (3 open positions)▫ 16 CCM Clinical Leads ▫ Employed by the PO/Practice

Exception – One Master Trainer position filled by Marie Beisel MiCMRC Project Manager

• CCM Master Trainer and CCM Clinical Leads▫ Complete Complex Care Manager Fundamentals course with

Geisinger faculty (may require two waves of on-site training)▫ 3 weeks on site in PA

One week didactic Two weeks partnered with a Geisinger Care Manager

▫ Training in MI, mentoring by Geisinger faculty• CCM Master Trainer additionally completes curriculum

for train the trainer model

*Model is designed for year one MiPCT intervention phase

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MiPCT Leadership

Team

CCM Master Trainer

4 CCM Clinical Leads

CCM Master Trainer

4 CCM Clinical Leads

CCM Master Trainer

4 CCM Clinical Leads

CCM Master Trainer

4 CCM Clinical Leads

MiPCT Complex Care Manager Train the Trainer Program

Complex Care Manager Clinical Lead• Completes Complex Care Manager Fundamentals course at

Geisinger ▫ 3 weeks on site in PA▫ supplemental training in MI

• Preceptor for CCMs in a defined region, has reduced patient caseload

• Leads small group discussions, facilitates networking, sharing best practices

• Contributes to ongoing CCM curriculum development by assisting Master Trainers with CCM education, workflow support, and resources

• Collaborates with CCM Master Trainer, MiPCT leadership, MiPCT clinical subcommittee to assess CCM interventions

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Complex Care Manager Clinical Lead

Sample of key preferred qualifications• Current MI License: RN, NP, PA• 3 to 5 years experience

▫ some adult medicine ▫ setting: home health agency, primary care practice, skilled nursing

facility, hospital medical-surgical unit

• Preceptor experience - working with licensed clinical staff

• Demonstrated ability to create and support a learning environment that is characterized by mutual respect, constructive feedback, and conflict resolution

• Knowledge of chronic conditions and prevention ▫ evidence-based guidelines

• Excellent communication, interpersonal, teaching and facilitation skills

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Master Trainer Complex Care Manager Role• Completes Complex Care Manager Fundamentals course and a Train the

Trainer program with Geisinger faculty ▫ 3 weeks on site in PA ▫ also training in MI

• Oversight of four Complex Care Manager (CCM) Clinical Leads

• Does not have a patient caseload

• Leadership role in providing CCM professional development through mentoring, coaching and education

• Gathers data, populates and analyzes specified CCM activity reports for region

• Collaborates with MiPCT leadership and MiPCT clinical subcommittee to assess, study, and refine CCM training and interventions as needed

• Presents educational offerings for CCMs in small group setting as well as a statewide audience

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Complex Care Manager Master TrainerSample of key preferred qualifications

• Current MI License: RN, NP, PA

• 5 years experience ▫ some adult medicine ▫ setting: home health agency, primary care practice, skilled nursing facility, hospital medical-

surgical unit

• 2 years experience ▫ clinical manager - preferred▫ clinical program development, implementation, monitoring, evaluation - preferred

• Demonstrated ability to create and support a learning environment that is characterized by mutual respect, constructive feedback, and conflict resolution

• Excellent communication, interpersonal, teaching and facilitation skills

• Excellent teaching, presentation, and facilitation skills

• Demonstrated ability to effectively develop educational resources, tools, processes

Training Timeline•CCM Master Trainers and Clinical Leads

▫1-2 waves, likely February for first wave•Subsequent training plans

▫Michigan-based training waves▫Progress from Geisinger-led to combination

of taped webinars and Master-Trainer led sessions

▫Regionally based▫Having four Master Trainers will allow

more flexibility with timing and geography

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Next steps• Additional details on CCM Master Trainer and

clinical leads sent out by December 15▫ Position description details▫ MiPCT salary subsidization amount for each role▫ Definition of selection process

• PO/PHO responses requested by December 22▫ Letter of interest for CCM clinical lead position▫ Letter of interest for CCM Master Trainer position▫ Submit letter of interest to Marie Beisel at

mbeisel@umich.edu• Positions for first Geisinger trip identified by

January 15▫ Anticipated travel date is early February▫ Timing of second wave likely early March

• MiPCT team to finalize contract details with Geisinger by 12/31

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Care Management

Documentation

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Current state•No ideal single source solution for EHR

documentation, registry functionality and care management support▫Integration costly, cumbersome▫Difficult to mimic manual processes with HIT

solutions▫Recognized problem across the country

•Care managers need tools to support workflow

•Supervisors need a way to track productivity

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Basic HIT Functions: Support Care Manager’s work • Create and maintain a list of active patients

• Generate a Patient Tickler List▫ patients scheduled for Care Manager (CM) follow up

visit▫ ideally includes past and future CM visits

• Document Patient Care management visits using a template▫ Common diagnoses▫ Common follow up

Self management goal setting▫ Transitions of care

• Create and maintain individualized patient care plan by Complex Care Managers

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Advanced HIT Functions: Support Care Manager’s work• Access to information

such as: view of patient includes: diagnoses, care giver, PCP, insurance, demographics, care manager and health team member visit schedule, assessments, referrals, patient goals, medications, lab results

• Protocols• Ability to generate Care

Manager activity reports

• Compatibility with care manager’s work flow

• Notification - patient’s appointment with PCP, ER visit, hospitalization

• Assessments ( Functionality, PH Q 9, . .) completed and tracked - longitudinal view

• Patient worksheet: history of goals, assessments, care manager encounters past and future

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MiPCT Required Care Manager Reports• Care Manager Activity Reports

▫ Number of Care Manager encounters at practice location per Care Manager, by payer

• Frequency of reporting – TBD, likely quarterly

• Purpose of reports▫ Provide accountability to payers, demonstrate value ▫ Allow PO and MiPCT leadership to see where

practices are having difficulty with implementation/integration

Ways to accomplish varying levels of Care Management functions •EHR

▫customization▫built in care management feature (rare)

•Registry ▫customization▫built in care management feature (rare)

•Care Management Software▫not integrated▫integrated

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Options for Care Management Documentation and Reporting •PO develops solution – works with

practices

•Common MiPCT solution▫Not required, but option for those

interested▫Care management software options

reviewed by MiPCT team ▫Two possible options

Care Team Connect OHSU Care Management Plus

▫Cost to PO/PHO/practice negotiated by MiPCT

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Care Team Connect•Currently in use or in negotiations with

several MiPCT PO/PHOs•Highly customizable

▫Accept MiPCT data feeds ▫Risk stratification▫Specific protocols for clinical situations▫Connect multiple team members▫Can interface with registry/EHR at

additional cost•Will generate claims for G codes/CPT

codes•Will create MiPCT activity reports

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Care Management Plus•Low cost, web-based product•Provides basic care management support

▫Active patient list▫Tickler lists▫Activity reporting

•Some customization possible▫Templates▫Interface with practice management

system, EHR

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What is the best solution for you?• PO/Practice will need to assess current HIT

capability for care managers• Can PO/practice report the required MiPCT

activity?• Will the HIT in the practice currently provide

the basic functions needed to support the care manager workflow?• If yes, can PO/Practice add support such as

customized documentation templates?• If no, how will PO/Practice address this?

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Next steps•Assessment of MiPCT PO/PHO capabilities

▫Best practice webinar?▫Common solutions for same EHRs?▫Have something that works? We’d like to

hear from you!•Demonstrations from software vendors

▫Care Team Connect, Care Management Plus▫If PO/PHO has care management software

product they would like MiPCT to assess, please contact Marie Beisel at mbeisel@umich.edu

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Questions and Discussion

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