Michigan Primary Care Transformation

Demonstration Project

November 28, 2012 Webinar

Webinars

Remaining webinars for this year cancelled

Webinars will begin again in January 2013

Best practices will be presented at the webinars

Any team member may provide “best practice”

2

MiPCT Meeting

Wednesday, December 12, 2012

6:00pm

American Polish Cultural Center

2975 East Maple Road

Troy, Michigan

3

Year One Comments

Quality means doing it right when no one is

looking

Quality is never an accident; it is always the result

of high intention, sincere effort, intelligent

direction and skillful execution; it represents the

wise choice of many alternatives

4

Year One Comment

“Measurement is the first step that leads to

control and eventually to improvement. If you

can’t measure something, you can’t understand it.

If you can’t understand it, you can’t control it. If

you can’t control it, you can’t improve it.”

5

Reaching End of Year One

Status of 2012 metric attainment

• Surveys provided to practice teams at December 12 meeting

• Surveys based on metrics outlined by MiPCT Committee

Assess integration of care management

Review tasks and capabilities

6

Practice Assessments

Number of complex cases

Number of moderate cases

7

Practice Assessments

SNF/LTC criteria

Able to demonstrate or verbalize the criteria for

each setting

8

Practice Assessments

Palliative Care/Symptom management

Able to identify resources available to the patient

9

Practice Assessments

Practice Guidelines and Protocols

Utilizes and demonstrates understanding of

practice guidelines/protocols

10

Practice Assessments

Exacerbation plan is in place

Patient and family education established; rescue

kits; written instructions

11

Practice Assessments

Accurately stratifies patients based on risk

Demonstrates stratification process to focus on

patients of highest risk

12

Practice Assessment Findings

There is very strong physician management at this

practice.

Care manager is used in a very limited capacity

and primarily in a disease management or patient

teaching capacity.

Physicians do their own medication reconciliation

for their patients as they feel others will make

errors.

13

Practice Assessment Findings

TOC is really only involved in calling patients for

follow up appointments

This was previously done by clerical staff

14

Practice Assessment Findings

Physicians state that they manage their own

complex patients

Care manager spends a great deal of time on

documentation which takes away from the already

limited time with patients. She is not functioning

as a complex care manager and is very limited

even in a disease management capacity

15

How Can You Help Care Manager

Educate staff on the role of the case management

especially in regards to receiving information on

the most complex (not just the diabetic patient or

the "high maintenance" patient)

16

Feedback Loop

Establish plan for monthly meetings or incorporate

the care manager role into existing meetings with

the following agenda items

• review metrics (ER visit volume, inpatient admission volume, care manager caseload, medication reconciliation saves etc.)

• care management success stories

• problem cases where alternate interventions can be discussed

• practice processes to support and promote care management.

17

Care Management Reporting

The care management activity reporting

requirements have been finalized and will be

incorporated into the Quarterly Report beginning

in the first quarter of 2013

18

Care Management Reporting

Number of Care Manager face-to-face encounters

(by Care Manager, by practice, by primary payer)

Number of Care Manager telephone or electronic

encounters by Care Manager, by practice, by

primary payer

Number of unique patients by Care Manager, by

practice, by primary payer

Did referral to outside agency occur

19

Community Care Team Enhancements

Community Care Teams

• Community Care Travel Team

• Community Care Permanent Team

Bill Porter, RN: Community Care Clinical Lead

Erica Ross: Community Care Operations Lead

Dave Johnson, MSW: Behavior Health Consultant

Lori Zeman, PhD: Behavior Health Expert

20

Community Care Team Enhancements

Erica Ross: Community Care Operations Lead

MNO Care Managers assignments and schedule

Monitor care manager assignments at practice sites

Working with Bill Porter and practice team to

determine appropriateness of care manager

assignments

Create and oversee satisfaction surveys and meet

with practice teams and physicians to include them in

pertinent assessments of care managers

21

Community Care Team Enhancements

Erica Ross: Community Care Operations Lead

Review overall productivity statistics of care

managers

Review statistics of care managers employed by

practices

Review requests from practice units for additional

assistance with various activities

22

Upcoming Events

Mackinac Learning Collaborative IV

• December 5, 2012

• Kevin Taylor, MD and Lori Zeman, PhD co chair

• Topic focused on integrated, collaborative or co-located behavior health

• Currently behavior health specialists are integrated into several adult and pediatric practice

• Hoping 100% participation from MiPCT Teams

Mini Learning Collaboratives

23

Open Discussion

24

Merry Christmas

25