The Michigan Primary Care Transformation (MiPCT) Project

1. The Michigan Primary Care Transformation (MiPCT) Project Overview and Transition of Care Lessons Learned to Date Marie Beisel MSN, RN, CPHQ

2. Disclosure • I have no conflict of interest to declare • I do not have any relevant financial relationships with any commercial interests

3. Objectives • Describe the Michigan Primary Care Transformation (MiPCT Clinical Model • Identify three patient centered medical home care management components associated with positive outcomes • Explain the MiPCT transition of care and lessons learned to date

4. CMS Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration • Centers for Medicare & Medicaid Services is exploring the role of the PCMH in improving US health care • Participating in state-based PCMH demonstrations • CMS Demo Stipulations • Must include Commercial, Medicaid, Medicare patients • Must be budget neutral over 3 years of project • Must improve cost, quality, and patient experience • 8 states selected for participation, including Michigan • Michigan start date: January 1, 2012

5. MAPCP Demo: Participating States • Maine 22 practices  42 (year 3) • Michigan 410 practices • Minnesota 159 practices  340 (year 3) • New York 35 practices • North Carolina 54 practices • Pennsylvania 78 practices • Rhode Island 13 practices • Vermont 110 practices  220 (year 3) _____________________________________________ • TOTAL 881 practices  1,192 (year 3)

6. Michigan: Selected health statistics • 45th (of 50 states) in coronary heart disease deaths • 41rd in percent of obese adults • 34th in infant mortality rate • 34th in percent of adults who smoke • 34th in overall cancer death rate • 20th in percent of adults who exercise regularly • 12th in adults receiving colon cancer screening • 5th in childhood immunization rate Source: Comparison of Michigan Critical Health Indicators and Healthy People 2010 Targets, Michigan Department of Community Health, May 2011

7. The Vision for a Multi-Payer Model • Use the CMS Multi-Payer Advanced Primary Care Practice demo as a catalyst to redesign MI primary care • Multiple payers will fund a common clinical model • Allows global primary care transformation efforts • Support development of evidence-based care models • Create a model that can be broadly disseminated • Facilitate measurable, significant improvements in population health for our Michigan residents • Bend the current (non-sustainable) cost curve • Contribute to national models for primary care redesign • Form a strong foundation for successful ACO models

8. CMS Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration • CMS award notification: November 16, 2010 • 8 states selected for participation, including Michigan • Start date: January 1, 2012 • Includes Commercial, Medicaid and Medicare patients • Financial stipulations • Must be budget neutral over 3 years of project • Expect improvements in cost, quality, and patient experience

9. MiPCT Practice Participation Criteria • PCMH-designated in 2010, and maintain PGIP or NCQA designation over the 3-year demonstration • Part of a participating PO/PHO/IPA • Agree to work on the four selected focus initiatives: • Care Management • Self-Management Support • Care Coordination • Linkage to Community Services

10. Participating Provider and Payer PartnersAs of September 2012 • *Choice of a 01/01/12 or 04/01/12 start dates; 6 Additional Practices joining in 01/2013. • * Medicaid Managed care • **BCBSM commercial, BCBSM Medicare Advantage

12. MiPCT Clinical Model:Optimizing Patient Engagement, Improving Population Health

13. Managing Populations: Stratified Approach to Patient Care and Care Management IV. Most complex(e.g., Homeless,Schizophrenia) <1% of population Caseload 15-40 III. ComplexComplex illnessMultiple Chronic DiseaseOther issues (cognitive, frail elderly, social, financial) 3-5% of population Caseload 50-200 50% of populationCaseload~1000 II. Mild-moderate illnessWell-compensated multiple diseases Single disease I. Healthy Population

15. MiPCT PO/Practice Expectations • Care management • Performed for appropriate high and moderate risk individuals • Population management • Registry functionality by end of year 1 • Proactive patient outreach • Point of care alerts for services due • Access improvement • 24/7 access to clinician • 30% same-day access • Extended hours

16. Success = Improvements in Population Health + Cost + Patient Experience

17. Role Comparison: Moderate Risk Care Manager, Complex Care Manager

18. Evidence-Based Review:PCMH Care Management Components Associated With Positive Outcomes • Care delivery by multidisciplinary teams • Care delivery in collaboration with physician’s office • Attention to care transitions • Medication reconciliation • In-person visits along with telephonic encounters • Patient selection important - risk stratification plus physician input important to successful interventions

19. MiPCT Care Management Priorities • Care managers work in close proximity to PCP team • In PCP office as much as possible • Work with PCP team to meet their needs • Evidence supports this model as superior to vendor-based • Ensure Care Management coverage • 2 Care Manager per 5000 MiPCT patients • Focus on evidence-based interventions • Medication reconciliation • Care transitions • In-person contact with patients whenever possible • Comprehensive care plan for complex patients

20. MiPCT Clinical Resources • Care Manager Development • Care Management Resource Center - Web-based resource for care managers and POs • National and local evidence-based training models • Care management implementation guide • Team Development • Facilitated learning opportunities for practice teams • Examples: Learning Collaboratives, webinars and seminars • Physician Engagement • “Town hall” meetings to be scheduled • Profile success of physician/care manager partnerships

21. MiPCT Care Manager Training Details • Complex care manager training • Partnership with Geisinger Health System • Clinical leads: three weeks in Pennsylvania • One week didactic training • Two week preceptorship • Care managers: • One week didactic training in MI, ongoing webinars/support • Moderate care manager training • Chronic care model, self-management support • MiPCT-approved programs identified throughout state

22. Year One MiPCT – Statewide Care Management Progress to Date • In 2012 over 350 Care Managers (CMs) hired and completed required training • Building infrastructure in partnership with POs • CM Work station at office practice location • CM Documentation tools • Process to bill for CM visits • Ongoing Care Manager training, coaching, mentoring • Patient education materials

23. Year One MiPCT – Statewide Care Management Progress to date • Building Infrastructure cont. • Delivery of Care Management at the practice level • Staff members roles defined • PCP referrals to Care Manager • Communication- PCP, CM, staff members • Building volume of G code and CPT codes submitted • Care Managers are building caseloads • Started with transitions of care for HCM, CCM Expand to enroll complex and moderate patients

24. Care Management Delivery by the Practice Planned patient care i.e. huddles, processes, work flow, policies PCMH meetings monthly, action plan, follow up PO and Practice Leadership Care Manager and PCP partnership Patient Office staff – defined roles and responsibilities Information technology, support

25. 2013 Priorities • Care managers fully integrated into practices • Target PCMH interventions to patients from all participating payers • Distribute multi-payer lists and Data dashboard reports • Bill G-codes/CPT codes on BCBSM/BCN patients • Use registry for proactive population management • Focus on efficient and effective health care • Avoid unnecessary services/hospitalizations • Assess practice utilization patterns • Ensure adequate clinic access to meet demands

26. MiPCT Team and PO Leaders Work Together to Define Care Management Activity • Define standard work • Gather and share examples of standard work developed by POs and practices • CCM Responsibilities with detailed description of processes and action step, available end of March • Conduct “go sees” – ongoing by Master Trainers, Clinical Leads • Gather and share best practice processes, resources, tools, staff job descriptions • Continue to identify gaps – assist with developing solutions

27. MiPCT Transition of Care Intervention • Care Manager conducts Transition of Care follow up phone call within 24-48 hours post hospital discharge • Then weekly x 4 – phone visit • Address: • Medication reconciliation • Follow up - PCP appt., specialist appt., tests • Social support • Assessment – barriers • Red flags • Access to PCP office – “how to”

28. MiPCT TOC Lessons Learned Primary Care Practice • Across the state practices continue to partner with hospitals to receive the discharge notification • Notification to Primary care practices of hospital discharge varies widely: • not occurring consistently • Fax • Electronic ADT • Some MiPCT POs/practices are using IT resources to link the ADT to the MiPCT patient list – notifies Care Manager and practice real time • It is ALL about relationships • Care Managers, Practice Leaders and Physician Organization Leaders initiate communication across the continuum • Hospitals – Discharge Planners, Care Managers • Skilled Nursing Facilities • Home Health Agencies • Health Plan Care Managers

29. MiPCT Transition of Care (TOC) Workgroup • Areas identified to address • High Volume of TOC • Some care managers have high volume of patients discharged from the hospital • Not able to consistently call every patient within 24-48 hrs. post hospitalization • Challenges • balancing patient caseload: TOC, following up on new referrals, and managing caseload • Some care managers are part time and/or support multiple practices • Outcome of TOC work group: recommendation to risk stratify patients discharged from the hospital, continue work to define practice team members responsibilities

30. www.micmrc.org

31. www.mipctdemo.org

32. Contact InformationMarie Beisel MSN, RN, CPHQmbeisel@umich.eduOffice phone: 734 998-8519