the michigan primary care transformation (mipct) project welcome to the 2015 mipct summit!

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The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

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MiPCT Synergy with Blueprint Pillars 3 Vision: MC system that maximized health status through evidence and value-based care delivery MiPCT Population Health Management -Registry skill- building -Role of panel managers -Training specific to each role as well as team-wide sessions MiPCT Pay for Value -Competitive Incentives to Drive Behavior -Commercial G and CPT Code Care Management Billing MiPCT Integration of Care -Patient identification and Engagement -Team-based care focus -Transition coordination MiPCT Structural Transformation -Dashboards; Incorporation of Registry Data -Support for Health IT and Analytics -ADT alerting

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Page 1: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

The Michigan Primary Care Transformation (MiPCT) Project

WELCOME TO THE 2015 MiPCT SUMMIT!

Page 2: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

MiPCT Payers, Patients and Providers

As of March 2015: •1814 providers

▫ 1,577 physicians▫ 237 mid-level providers

•Over 500 care managers•346 PCMH practices•1,158,650 members

  # Patients % Patients

Medicare 186,997 16.1%Medicaid 214,745 18.5%BCBSM 361,802 31.2%BCN 275,316 23.8%Priority 119,990 10.4%Total 1,158,850 100.0%

Page 3: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

MiPCT Synergy with Blueprint Pillars

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Vision: MC system that maximized health status through evidence and value-based care delivery

MiPCT Population

Health Management

-Registry skill-building

-Role of panel managers

-Training specific to each role as well as team-wide sessions

MiPCT Pay for Value

-Competitive Incentives to

Drive Behavior

-Commercial G and CPT Code

Care Management

Billing

MiPCT Integration of

Care

-Patient identification and

Engagement

-Team-based care focus

-Transition coordination

MiPCT Structural

Transformation

-Dashboards; Incorporation of Registry Data

-Support for Health IT and

Analytics

-ADT alerting

Page 4: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

The Michigan Primary Care Transformation (MiPCT) Project

Evaluation and Program Updates8:40-9:10 AM

Page 5: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Evaluation Update

1. Overall Evaluation Results to Date2. Patient Experience Results3. Care Manager Survey Results4. Care Manager Activity5. MiPCT Utilization & Quality Trends

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Page 6: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Overall evaluation results to date•Cost savings for Medicare beneficiaries

▫Caveat: quarter to quarter variation•All-payer utilization, 2011 - 2013

▫Increase in ED rates ▫Moderate decline in hospitalizations

•Patient experience (2015)▫MiPCT Adults generally more positive

than non-MiPCT▫MiPCT parents about the same as non-

MiPCT

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Page 7: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Overall evaluation results to date•Provider/staff survey reveals

satisfaction with Care Management model

•Care Management survey and PO data collection reveal progress on embedment

•Care Manager activity leveling off: 25,000 – 30,000 unique patients per quarter

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Page 8: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

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Page 9: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Methods•Stratified random sample

▫MiPCT and comparison group status▫Payer▫High/very high risk concurrent risk

category•Multi-modal (mail with phone follow-up)•Response rates

▫Medicare▫Medicaid▫Commercial

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Adult survey results: MiPCT

Page 11: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

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Adult survey results: MiPCT

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Child survey results: MiPCT

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Reported occurrenceChild survey results: MiPCT

Page 14: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Analysis•Regression: Generalized Linear Model•IBM SPSS v. 19•Independent Variable: MiPCT status•Controlled for: risk category, payer•Interactions with MiPCT status (e.g., does

MiPCT/PCMH have a different relationship with patient experience for some groups based on):▫High/very high risk score▫Payer type (Medicare, Medicaid, Commercial)

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Page 15: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

* *

*

*

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Adult survey results

* Statistically significant difference

Page 16: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

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Adult survey results

* Statistically significant difference

* **

*

*

*

Page 17: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Child survey results: MiPCT versus comparison groups •MiPCT patients were not significantly different

than other PCMH patients across domains

•MiPCT patients were not significantly different than non-PCMH patients across most domains

▫Exception: MiPCT patient ratings of provider attention to growth and development 11.6% higher

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*

Page 18: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

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Page 19: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

19Average Total Patients in Caseload (at the time of survey):

Page 20: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Protocols20

Page 21: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Team members understand which patients might benefit from care management

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Page 22: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Practice Support

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Page 24: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

PO Quarterly Reporting

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Page 25: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

2011, 2012, & 2013

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Page 26: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Estimated Average MiPCT ED and Inpatient Rates (#/1,000 member years)

NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color.

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Page 27: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Estimated Average MiPCT Diabetes Rates

NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color.

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Page 28: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Estimated Average MiPCT Adult Preventive Rates

NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color.

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Page 29: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Estimated Average MiPCT Peds Preventive Rates

NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color.

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Page 30: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

MiPCT Clinical Update

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The Care Management Resource Center: Helping our Practices to Help Our Patients

Year # CM Trained

2012 2732013 1652014 70

2015 to date

73

  TOTAL 581

• Almost 600 CMs have been trained and supported with continuing education since the MiPCT began

• As health plans (Priority, BCBSM) have expanded the care management benefit beyond MiPCT practices, the CMRC has expanded training sessions (link at: http://mipct.org/care-management-resource-center/ccm-online-registration-page/

CMRC Care Manager Training Growth Over Time

Page 32: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

The Higher the Risk, the More Likely Patients are to Receive CM

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Page 33: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Progress Recap 2015-16 Clinical Focus Areas

•Addressing social determinants of health and overcoming barriers▫Mary Ellen Benzik, Tiger Team Lead▫Toolkit and white paper in development

•Integrating behavioral health▫Kevin Taylor, Tiger Team Lead▫Tiger Team tookit and white paper in development▫Advocacy: proposed CMS collaborative care model▫Coordinating with BCBSM/Priority Health work

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Page 34: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Progress Recap 2015-16 Clinical Focus Areas• Patient registry and data support for population health

▫Registry and EHR User groups being formed for systems most-used by MiPCT practices

▫CMRC site visits to better understand and spread processes highly linked to HEDIS and STAR improvement

• Integrating palliative and end-of-life care▫Advocacy for CMS proposed advance care planning codes▫Ongoing work with Palliative Care subject matter experts

• Addressing appropriateness of care (e.g., Choosing Wisely program, etc.)▫ To launch in 2016

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Page 35: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

CMS Proposed Changes and the MiPCT

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Page 36: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

CMS’ Proposed 2016 Physician Fee Schedule and the MiPCT

Potential Expansion of Comprehensive Primary Care Program (CPC) in 2017 (our “sister” program)

CPC milestones are very similar to the MiPCT

Enhanced patient access and continuity of care,Planned chronic and preventive care, Risk-stratified care management, Patient and caregiver engagement, and Coordination of care across a “medical neighborhood” 

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Page 37: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

2015 MiPCT Steering Committee Comments toCMS: 2017 and Beyond

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CPC Milestone Comparison to MiPCT Activity  CPC Milestone MiPCT

I. Budget Mandatory CM salary and benefit PO reportingII. Care Management for High Risk Patients  MiPCT Multipayer Member List; MDC dashboards with risk score and quality/cost/use measures;

 

Self-management support and patient engagement are an additional 2015-16 focus area for the MiPCT; care managers are required to have self-management and motivational interviewing education, and an all-care-manager half day training in Fall 2015 will provide in-depth training on Brief Action Planning (BAP)

 

Medication reconciliation is a mainstay of care manager training in the MiPCT; Further, the program has partnered with the state information backbone (MiHIN) to add detail on medications to the Admission, Discharge, Transfer (ADT) notifications that the program currently provides when members experience ED, inpatient, home health or SNF admissions or discharges

III. Access and Continuity

24/7 care team access; practices encouraged to achieve PGIP PCMH capability 5.2 for real time access; Project monitors CM sufficiency for an 80% minimum level

IV. Patient Experience

CG-CAHPS survey; Partnered with the Institute for Patient and Family-Centered Care to train MiPCT practices in patient and family advisor programs

V. Quality Improvement MDC registry data collection; webinars, focused learning collaboratives; quarterly learning webinarsVI. Care Coordination Across the Medical Neighborhood

Centralized CM Training and Continuing Education; ADT notifications; Transition of Care and other care guidelines and protocols

VII. Shared Decision Making Potential application to Choosing Wisely focus areaVIII. Participate in Learning Collaborative

MiPCT practices (the PCP, care manager and at least one other practice team member) must satisfy eight practice learning credits per year; Behavioral Health and Social Determinant Tiger Teams; Medication Management competency in CM training

Page 39: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Also Keeping Our Eyes On…..

Potential for CMS to announce implications for MAPCP post 12/3/16 as part of the release of Year 2 and 3 evaluation results

Understanding what is important to each payer group so that we can better service their members – and deliver value that can help to sustain the program in the longer term

The hard work you are doing to service Medicaid, Medicare, BCBSM, Priority Health and BCN patients likely to benefit from Care Management

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Page 40: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

The Michigan Primary Care Transformation (MiPCT) Project

The State Innovation Model and Population Health in Michigan

Elizabeth Hertel, Director of Health Policy Innovation, State of Michigan9:20-10:20 AM

Page 41: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

State Innovation ModelSeptember 16, 2015

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Page 42: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

All Medicare Fee for ServiceFee for Service linked to qualityAlternative payment models

Context: Centers for Medicare and Medicaid Services Payment Reform Targets

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2016

85%

30%

2018

90%

50%

Planned percentage of Medicare FFS payments linked to quality and alternative payment models

*Adapted from Centers for Medicare & Medicaid Services, January 26, 2015

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New York - $99.9 millionOhio - $75 millionMichigan - $70 millionColorado – $65 millionTennessee - $65 millionWashington - $64.9 millionConnecticut - $45 millionIowa - $43.1 millionIdaho - $40 millionDelaware - $35 millionRhode Island - $20 million

Round 2 Model Test States

Round 1 Test States

Page 44: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Michigan State Innovation Model Proposal Overview

• Michigan Blueprint for Health Innovation developed with broad stakeholder engagement in 2013

• Model Test proposal submitted July 2014▫Closely follows Blueprint

• Proposal presentation at Center for Medicare and Medicaid Innovation: October 2014

• $70 Million award announcement: December 2014

• Project begin date: February 1, 2015

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Page 45: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Phased Model Test Wave I Regions

Have all model components and capabilities

Prior experience with pay for value May include Level I and II Accountable

Systems of CareWave II Regions

Have some, but not all, model components and capabilities

Could benefit from additional planning, investment, community convening, before implementation

May include Level I and II Accountable Systems of Care

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Page 46: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Michigan’s Model Test Timeline

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2015

2016

2017

2018

2019-

2020

Page 47: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Michigan’s Blueprint Raises the Bar

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Infrastructure for a Learning Health SystemPolicy

Page 48: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Accountable Systems of Care

▫Physician organizations Cover all of Michigan: both

provider and health system led

Contracting and credentialing support

Practice coaching and quality improvement

Support for patient centered medical home transformation

▫Medicaid managed care

▫Emphasize whole-system transformation, anchored by strong primary care and effective care management

▫Create systems that coordinate care within and beyond health care system (e.g., improved transitions in care)

▫Better leverage health information technology and health information exchange

▫Link with Community Health Innovation Regions for better outcomes

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Page 49: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

State Innovation Model Performance Measures

▫ Drive adoption of a core set of measures▫Align payment and core set of measures

across payers to reduce administrative complexity and provider burden

Michigan State Medical Society has developed a common clinical measure list across several Michigan payers

State Innovation Model Performance Measurement and Recognition Committee will establish additional process and population health measures

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Page 50: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Payment Reform•Align with trend toward payment for

population level performance, moving away from fee-for-service▫Level I: Shared savings (upside risk)▫Level II: Capitation models

•Designed to drive: ▫Consistent delivery of high-quality,

person/family-centered care▫Reductions in low-value care▫Reductions in avoidable acute care utilization

•Provide for investments in community health

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Page 51: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Community Health Innovation Regions

▫Multipurpose collaborative bodies

▫Chartered Value Exchanges

▫Health Improvement Organizations

▫Community Benefit

▫Work together for collective impact on population health:

▫Assess community need▫Define common priorities▫Adopt shared measures of

success▫Pursue mutually reinforcing

strategies towards common priorities

▫Implement systems to coordinate health care, community services, and public health

▫Invest in prevention

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Page 52: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Health Information Exchange/ Health Information Technology

• Key functions of Health Information Exchange in State Innovation Model: ▫Support care coordination within Accountable

Systems of Care and across the health care system ▫Support community linkages to better address social

determinants▫Allow real-time performance monitoring, rapid-cycle

improvement processes▫ Infrastructure components ▫Electronic Medical Record functionality ▫Connection to sub-state Health Information Exchange▫Data aggregator

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Page 53: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

State Innovation Model Target Populations

•Healthy babies•Emergency Department super-

utilization (8+ visits/year)•Multiple chronic conditions

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Page 54: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Medicaid Managed Care Rebid•Managed Care Rebid

▫Request for proposals released May 2015

▫Requires health plan participation in the State Innovation Model

▫Specifically promotes key components of delivery system transformation: Patient-centered medical homes Support for care management Community health workers

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Page 55: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Pre-Implementation Update• Complete

▫ Accountable System of Care and Community Health Innovation Region capacity assessments reviewed

• To Do▫ Region and site selection▫ Develop key program materials for feedback

• Looking ahead▫ Finalize programs▫ Develop operational plans with Model Test

participants▫ Execute agreements with Model Test participants▫ Launch Model Test learning system▫ Implement payment reform

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Implementation Year 1: February 2016 – January 2017

Pre-Implementation: February 2015 – January 2016

Page 57: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Morning Break•Please stay tuned! We’ll be back

shortly after the morning break for in-person attendees

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Page 58: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

The Michigan Primary Care Transformation (MiPCT) Project

Celebrating Best Practices!

10:50-11:50 AM

Page 59: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Celebrating Success in MiPCT Practices!

Page 60: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Practice Awards-Categories•Most Improved – Adult and Family

Medicine•Most Improved – Pediatrics•Diabetic Metric Improvement•Best Overall - Diabetes•Best Overall – Adult and Family

Medicine Practices•Best Overall – Pediatric Practices

Page 61: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Risk Adjustment (for top overall awards)•Purpose

To level the playing field so that practices are recognized for performance, not for the underlying characteristics of their population

•Considerations Health status Demographics Payer mix

Practice average risk score (concurrent)

% Medicare, % Medicaid, % Commercial

Page 62: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Risk Adjustment (continued)•Methods

▫Implemented by MPHI and approved by the Stewardship and Performance Committee

▫Involves comparing how the practice actually performed to how we would have expected it to perform if we knew nothing other than these population characteristics

•Application ▫Best overall adult, diabetes and pediatric

awards▫Not applied to award categories for most

improved

Page 63: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Best Overall – Adult and Family Practices – Risk Adjusted*

•Composite score based on practices’ rankings in the following MDC Measures, risk adjusted by MPHI:

▫Inpatient Admissions▫ED Visits per 1000 Patients▫PCS ED Visits▫Acute ACSC Admission Rate▫Chronic ACSC Admission Rate▫Diabetes Overall

Page 64: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Most Improved – Adult and Family

•Greatest difference in Overall Ranking between baseline (calendar year 2011) and current measurement period as of the April, 2015 release (claims incurred October, 2013 – September, 2014). For example, a practice that moved from rank 200 to rank 100 would count as “more improved” than one that moved from rank 50 to rank 1.

Page 65: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Diabetes Overall - Risk Adjusted*

•Composite score based on practices’ rankings in the following MDC Clinical (non-supplemented) measures; composite (not components) are risk adjusted by MPHI:

▫Diabetes Eye Exam▫Diabetes HbA1c▫Diabetes LDL-C▫Diabetes Nephropathy

Page 66: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Diabetes Metric Improvement

•Greatest percent difference in Diabetes Overall Score between baseline (calendar year 2011) and current measurement period (claims incurred October, 2013 – September, 2014) for all non-Pediatric practices.

•Note that for this measure we are looking at improvement in Score NOT improvement in Rank.

Page 67: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Best Overall – Pediatric Practices - Risk Adjusted*

•Pediatric Practices are defined as those where >= 85% of attributed patients (based on current measurement period patient attribution) are <= 21 years of age.

•Note that in cases where we filter to include only “pediatric” patients we will use <18 as the cutoff age for Pediatrics. This only comes into play where MPHI has requested demographic data be filtered by age for risk adjustment. All MDC measures have age limits built into their calculations (e.g. Well Child visits for different age groups only look at members in those age groups, Adult ACSC utilization measures only look at members >= 18)

•Composite score based on pediatric practices’ rankings for the following MDC Measures, risk adjusted by MPHI:

▫ Pediatric Inpatient Visit Rate with Previous Asthma Diagnosis▫ Pediatric ED Visit Rate with Previous Asthma Diagnosis▫ Pediatric Preventive Overall

Page 68: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Most Improved – Pediatric

•Greatest change in ranking between baseline and current measurement period. See Most Improved – Adult and Family description for change in measurements period definitions.

Page 69: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

The 2015 Winning Practices!

Page 70: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Best Overall – Adult and Family Medicine Practices

•Marquette Internal Medicine Pediatric Associates

•Fenton Medical Center, P.C.•Jane Castillo, MD•Dhiraj Bedi, DO•Lifetime Family Care, PLLC /A Division of Michigan Healthcare Professionals PC

Page 71: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Winning Category: Best Overall- Adult and FamilyPractice Name: Lifetime Family Care

• WHAT MADE A DIFFERENCE (Process Change, etc.):   ▫ Daily morning all-team huddle the first fifteen minutes of

each day (identify who is complex, etc.)▫ Scheduling chronic patients on the day that the Care

Manager is in the office▫ Active use of Welcentive registry – one FT staff member

enters data, identifies gaps in care for team, patients who have not been in with chronic illness, etc.

▫ Drop-down shortcuts and information codes in EHR▫ Having a “start” physician in Dr. Keu

• HINTS FOR OTHER PRACTICES▫ Document policy and enforce it – don’t let it exist just on

paper▫ Use screening toolkit in the EHR▫ Agreement on protocols among physicians in practice

 

Page 72: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Lifetime Family Care: Our Patient/Provider MOU

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Lifetime Family Care: Our Patient/Provider MOU, cont.

Page 74: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Most Improved – Adult and Family Medicine

•E. Ann Arbor Med-Peds•Rivertown Internal Medicine and Pediatrics

•Campustowne Family Medicine•Grand Rapids Internal Medicine and Pediatrics

•Alpine Internal Medicine and Pediatrics

Page 75: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Winning Category: Most Improved – Adult and Family PracticePractice Name: Rivertown Internal Medicine and Pediatrics

• WHAT MADE A DIFFERENCE (Process Change, etc.):   ▫Daily huddles to discuss potential patients for

Care Management▫Daily meetings between Care Manager and

Doctors to discuss cases following Care Management visits.

▫Daily review of hospital discharge list to identify patients to call regarding their transition of care.

• HINTS FOR OTHER PRACTICES▫Flexibility is key to working with and meeting the

needs of the team. 

Page 76: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Winning Category: Most Improved – Adult and Family PracticePractice Name: Campustowne Family MedicineWHAT MADE A DIFFERENCE :   •Re-checking BP’s.  Added a reminder on the cuffs. Placed colored magnets on the door if BP needed to be rechecked.•Performed time studies from check-in to check-out to determine how much time was needed to fulfill Health Maintenance items.•Carried Pocket-buddies with PCMH requirements as a reminder.

HINTS FOR OTHER PRACTICES:•Perform continuous process improvement through use of PDSA (Plan, Study, Do, Act).

Page 77: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Winning Category: Most Improved – Adult and Family PracticePractice Name: Grand Rapids Internal Medicine and PediatricsWHAT MADE A DIFFERENCE :  

▫Physician and staff engagement. ▫Motivational Interviewing skills.  ▫Engagement with community services and

specialists.   ▫Coordinating care for the high-risk pediatric

population. The practice has developed a notebook and tool for parents and educated MAs to have them readily available.

HINTS FOR OTHER PRACTICES▫Care conference as a team approach with PCP,

APP and primary MA. 

Page 78: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Winning Category: Most Improved Adult and Family Practice Practice Name: Alpine IM/FM/PEDs

• WHAT MADE A DIFFERENCE (Process Change, etc.): ▫ We embraced a culture of change, collaboration, team work,

dedication and commitment in putting our patients first. ▫ We developed workflows as a team, and discussed gaps and

barriers that could improve our process daily during team huddles.

▫ We empowered our front line staff. ▫ We utilized all areas of our care team to their fullest clinical

scope including our NP’s, PA’s, Care Managers, MA’s and Providers.

▫ We created standard work, and tracked our teams success by auditing, planning, studying and developing action plans that we could implement

Page 79: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Winning Category: Most Improved Adult and Family Practice Practice Name: Alpine IM/FM/PEDs, cont.

•HINTS FOR OTHER PRACTICES▫Build trust within your team. Celebrate

the small wins. Huddle daily. Empower your front line staff- when you do, they will do great things.

Page 80: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Diabetes Overall

• Family Tree Medical Associates

•St Johns Professional Associates

•SMG DeWitt•Grand Blanc Family Medicine•Jane Castillo, MD

Page 81: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

Winning Category: Diabetes Overall Practice Name: Family Tree Medical Associates

• WHAT MADE A DIFFERENCE (Process Change, etc.):   ▫TEAM- Working together is essential to have a

successful workflow and show results. The most important member of the team is the patientTOOLS- Creating the appropriate tools within EHR to support the work with each patient

▫TIME- Establishing the right attitude as individuals working within our practice including the providers

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Know YOUR Population

We have our MiPCT patients flagged in our

system

Winning Category: Diabetes Overall Practice Name: Family Tree Medical Assoc., cont.

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Population Management at the Point of Care

The MiPCT patients flagged in our system show up yellow on

the clinical and provider schedule

Winning Category: Diabetes Overall Practice Name: Family Tree Medical Assoc., cont.

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HINTS FOR OTHER PRACTICESMaximize each team member’s strengths

▫It helps the team have a positive perspective

▫This will allow openness to work on the challenging aspects and make improvements

Celebrate success no matter how small 

Winning Category: Diabetes Overall Practice Name: Family Tree Medical Assoc., cont.

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Winning Category: Best Overall Diabetes and Most Improved Diabetes Practice Name: SMG- St.Johns

• WHAT MADE A DIFFERENCE:   ▫ Education of physicians, staff, and care managers▫ Implementation of care management▫ Improved physician engagement▫ Patient reminder calls▫ Flagging charts and calling patients regarding gaps in care▫ Personal Action Toward Health (PATH) Workshops

• HINTS FOR OTHER PRACTICES▫ Be persistent and cultivate physician involvement▫ Utilize all members of the team▫ Make use of reports/registries to identify gaps in care▫ Re-evaluate processes frequently and make changes as needed 

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Winning Category: Best Overall DiabetesPractice Name: Sparrow Medical Group - Dewitt

 •What Made a Difference?

▫ Leadership Entrust a team member with individual process responsibility

(e.g. registry lead; batch letter and reminders lead; etc.) Provide resources and monitor progress Single Point Ownership

▫ Work Registries to Identify Gaps in Care Performed by Medical Assistant, not Care Manager

▫ Communication with Patient and Patient Follow Up▫ Support of RN Care Facilitator (RNCF) ▫ Educate, Communicate and Provide Resources to Patient and

Staff

•Hints for Other Practices:▫ Trust Your Team▫ Own It!

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Winning Category: Diabetes OverallPractice Name: SMG DeWitt, cont.

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Diabetes Metric Improvement•Cherry Street Health Center•SMG Holt•St Johns Professional Associates

•Premier Family Physicians•New Day Family Medicine

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Winning Category: Most Improved DiabetesPractice Name: Cherry Health•WHAT MADE A DIFFERENCE: Workflow

Redesign ▫Chart Prep/Standing Orders▫Team Huddles▫Expanded Care Teams (CHW, CDE, MiPCT

CM)▫Self-Management Goals▫Internal/External/Community Referrals

•HINTS FOR OTHER PRACTICES▫Identify Champions

 

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Winning Category: Most Improved DiabetesPractice Name: Cherry Health

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Winning Category: Most Improved DiabetesPractice Name: SMG HOLT• WHAT MADE A DIFFERENCE

▫Strong caregiver/Provider engagement/Teamwork-running patient registries/working patient lists: letters, e-mails, phone calls for follow through care/planned visits

▫New practice-new patients (first time receiving healthcare)

• HINTS FOR OTHER PRACTICES▫Use appt notes/snapshot notes (identify gaps)▫Educate staff on disease mgmt/processes-

provide better patient education/interaction 

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•In addition to engaged providers and empowered staff – we also support this team with our RN Care Facilitator (MiPCT CM).

•We work on recognizing what we track and why. Then we spend time educating the staff which further opens the door to better communication with patients and having more comfortable conversations/patient interactions!

Winning Category: Most Improved DiabetesPractice Name: SMG HOLT, cont.

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•E.g., process maps, tools, etc.

Winning Category: Most Improved DiabetesPractice Name: SMG HOLT, cont.

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Winning Category: Most Improved-Diabetes Practice Name: New Day• WHAT MADE A DIFFERENCE:   ▫ A Flexible and “Eager to Adopt New Things” Culture -- The team

takes care to make sure that everyone has “bought in” to a proposed change

▫ “Whole Practice Team” (coach, CM, physician, front desk lead) meets twice a month to go over their performance on measures, discuss gaps in care, etc.) and uses IHP online registry

▫ Sustaining the Gains of the IHP Diabetes Collaboratives – Integrated successes into the practice workflow as expectations, and have spread the approach to asthma, hypertension

▫ Diabetic Eye Exam Excellence– Practice initiates and faxes the referral to the ophthalmologist. Two weeks later they follow up with the ophthalmologist and follow up if the patient has not gone using a referral tracking form they developed

▫ In-Office Diabetic AIC Testing – The practice has its own machine and can give the patient instantaneous testing and results

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Winning Category: Most Improved-Diabetes Practice Name: New Day, cont.•HINTS FOR OTHER PRACTICES

▫Everyone must be vested in a change (if the front desk, MA, etc. is not “bought in”, the change won’t work)

▫Develop trust in your team –everyone is busy and needs a team that they can trust

▫Incorporate prompts as cues – for example, when a chronic disease patient visits, the appointment system labels as a chronic disease visit, prompting the team to see if they need tests, etc.

 

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Best Overall – Pediatric Practices •Pediatric Specialists of Bloomfield Hills PC

•Pediatric Consultants of Troy PC

•Joseph B. Luna, M.D., P.C.•Cereal City Pediatrics PC•Moazami Pediatrics

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Winning Category: Best Overall Pediatric PracticePractice Names: Cereal City Pediatric and Moazami PediatricWHAT MADE A DIFFERENCE •A Focus on Training

▫ The entire office (including front office) participated in in-service with an asthma educator; have also had in-services from an Asthma Allergy Center on injections

▫ Physicians conducted an in service with the nursing staff on identifying respiratory distress. Now, the content of the in service has been included as part of the new hire training process.

•Useful Standard Tools and Processes ▫ In 2012, a cough protocol/algorithm for the front desk and triage was created to

screen phone calls and prioritize appointments. The office also purchased a spirometer and had the supplier conduct an in service on proper use.

▫ Annual well visits with an asthma action plan is required for all medication refills and notes for medication usage at school for patients with asthma.

▫ Medication follow-up appointment is required for patients w/frequent refills.▫ Asthma patients are tracked and flagged in PCC and Gaps in Care reports and

the office has a designated Asthma Champion.

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Winning Category: Best Overall Pediatric PracticePractice Names: Cereal City Pediatric and Moazami PediatricWHAT MADE A DIFFERENCE, cont.

▫ Priority calls are placed to patients with asthma when flu vaccine arrives, along with other high risk patients before reminder calls are conducted for the healthy.

▫ Refills are monitored for compliance.

•Attention to Patient Education▫ Patient Asthma Education folders are given to patients with a new asthma

diagnosis. ▫ Individual care management education sessions are conducted to teach

patients how to use a spacer, inhaler, or nebulizer.

HINTS FOR OTHER PRACTICES▫ Take time for training and incorporate processes and useful tools as aids to

guide your work ▫ Watch for patterns (which patients are requesting frequent refills, are there

repeating situations that cause rework, etc.) and act on them

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Most Improved – Pediatric

•Pediatric Consultants of Troy PC•CHC Fort Gratiot•Forest Hills Pediatric Associates PC

•Briarwood Center For Women Children and Young Adults

•Pediatric Care of Lansing

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Winning Category: Most Improved – Pediatric PracticePractice Name: Forest Hills Pediatrics • WHAT MADE A DIFFERENCE (Process Change,

etc.):   ▫Care Plan created with built in triggers for recall▫Phone calls within two days of all ED visits▫Recheck with educator after every asthma flare

• HINTS FOR OTHER PRACTICES▫Never assume patients remember what you told

them last time! Keep educating and empowering them to manage their own medications.

 

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Forest Hill – Care Plan Management

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A Round of Applause for ALL Our 2015 Winners

….And Your Practice Could be Recognized in 2016!

Page 104: The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

THANK YOU FOR ATTENDING THE SUMMIT! • Please complete your online Summit Evaluation by

September 29 at: http://mipct.org/2015-summit-prework-webinars/2015-mipct-regional-annual-summit-evaluation-links/

(the link will also be emailed to attendees after the summit)

• Lunch is in the room next door. Please enjoy! Care Managers, remember to be in your designated rooms by 1pm to start the afternoon session! For those of you not involved in afternoon training, feel free to enjoy the beautiful gardens until they close at 5pm today.

• Remember that all morning summit material is posted at mipctdemo.org!

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