MICMT Complex Care Management Course

1. MICMT Complex Care Management Course Introduction

2. Welcome! HOUSEKEEPING – Review Folder and Agenda

3. Group Activity 1 Introductions • Your name • Your discipline • Your practice location • How long have you been in your role

4. Group Activity 2 Question What’s Mostimportant for You to learn today?

5. Learning Objective • Describe Michigan Institute for Care Management and Transformation goals and resources available for physician office team members • Also. . . for Your Information: Michigan Care Management Resource Center joined the newly formed MICMT – January 1, 2019 • As we evolve, you will see both MICMT and MiCMRC branding and logos on many resources • We are under construction and ask for your patience!

6. Michigan Institute for Care Management and Transformation (MICMT) • Who we are: • Partnership between University of Michigan and BCBSM Physician Group Incentive Program • Goal of MICMT: • To help expand the adoption of and access to multidisciplinary care teams providing care management to populations served by the physician community in order to improve care coordination and outcomes for patients with complex illness, emerging risk, and transitions of care

7. MICMT Team Members • Hae Mi Choe, PharmD • Executive Director • Marie Beisel, MSN, RN, CCM, CPHQ • Administrative Manager Senior Healthcare • Alicia Majcher, MHSA • Operations Director • Julie Geyer, BBA • Senior Project Manager • Sandy Becker, MA • Data Analyst • Judy Avie, BSN, M.Ed. IT, RN • Program Manager • Sarah Fraley, LMSW, ACSW • Project Manager • Scott Johnson, BBA, MSA, RN • Project Manager • Sarah Fraley, LMSW, ACSW • Project Manager • Betty Rakowski, BSN, RN, MA Ed • Curriculum Designer • Nicole Rockey, PharmD • Pharmacist • Cindy Stevens • Administrative Assistant Sr. • Julie Wolf • Administrative Assistant Sr.

8. MICMT Care Management Resources Statewide Live and Recorded Webinars Billing resources Topics Pages - ex. Team Based Care, Chronic Conditions, Palliative Care, SDOH, Behavioral Health eLearning Modules Care Management 101 Care Management/ Team Based Success Stories and Best Practice Sharing Tools Quality MICMT Complex Care Management Course offeredmonthly Michigan Care Management Resource Center website www.micmrc.org

9. Competencies • I identify patients and populations appropriate for care management utilizing available clinical data and a risk score if available. • I apply the key steps of the evidence based Care Management 5 step process  (referrals, screen, enroll, management, and case closure) for patients on Care Management Services to assess, identify problems, plan, monitor and manage patients and caseload. • I collaborate/coordinate care with the PCP and members of the PCP practice team to improve the health of the population of patients attributed to the PCP, as measured by the outcomes of demonstration programs the practice participates in: CPC+, SIM, PDCM, Priority Health. • I incorporate identified SDOH needs into the patient’s plan of care, interventions and conduct follow-up on needs, goals and outcomes. • I build and balance case load and services across the team to optimize care, billing codes and create sustainability of the care management program and services.

10. MICMT Complex Care Management In-Person Course Curriculum: Introduction Paradigm Shift 5 Step Process Team Based Care Sustainability and Billing Case Studies

11. MICMT Statewide Complex Care Management course Post Test and Evaluation

12. MICMT Statewide CCM Course Post Test and Evaluation Successful completion of CCM course includes: • Complete the course • Complete the Michigan Institute for Care Management and Transformation (MICMT) Statewide CCM Post Test and the MICMT Statewide course evaluation. • Achieve a passing score on the Post Test of 80% or greater. • If needed, you may retake the Post Test. • You will need approximately 45 minutes to complete the Post Test and the evaluation.

13. MICMT Statewide Complex Care Management (CCM) Course Post Test and Evaluation Logistics: • The MICMT Statewide CCM Post Test and evaluation is web based • A web link to the CCM Post Test and evaluation will be sent to you via the e-mail you provided during registration • Test Scoring • occurs real-time when you submit your responses. You will receive Pass/Fail notification prior to closing the test • upon achieving a Passing test score, you will continue on to the evaluation. • Lastly, an e-mail is sent to you with notification of MICMT Statewide CCM Course Post Test “Pass” status For questions regarding the MICMT Statewide CCM course Post test and evaluation, contact: micmt-requests@med.umich.edu

15. Care Management Programs Michigan Care Management Programs for Practices who meet Criteria to Participate: • State Innovation Model (SIM) • http://www.michigan.gov/mdhhs/0,5885,7-339-71551_2945_64491---,00.html • Comprehensive Primary Care Plus (CPC+) • https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus • BCBSM Provider Delivered Care Management (PDCM) • http://www.bcbsm.com/providers/value-partnerships/physician-group-incentive-prog/models-of-care.html • Priority Health Care Management • Log in online at priorityhealth.com/provider. You’ll find care management information and more in Procedures & Services > Medical/Surgical Services > Care Management. Here, you’ll also find a link to Priority Health’s printable Expanded Services Contracted Billable Codes listing.

16. Care Management Introduction Activity 3

17. micmt-requests@med.umich.edu Contact Us

18. MICMT CCM Course Reference Guide MiCMRC Recorded Webinars Michigan Care Management Resource Center Website