MiPCT Embedded Case management

1. MiPCT Embedded Case management Barriers to developing an embedded Case Management program

2. Presenters: • Della Slavsky RN, BSN MiPCT Clinical Lead, UP Health Plan • Mary Beth Carstens RN, BSN MiPCT Complex Case Manager, UP Health Plan • Angela Tebby, LPN MiCPT Moderate Case Manager, UP Health Plan

3. Barriers to Developing Embedded Case Management • Case Managers (CM)new to practice • Staff roles needed to be defined • Integration of CM position into practice • Goals needed to be identified • Processes needed to be developed

4. Barriers to Developing Embedded Case Management continued MiPCT project in early development • Gradual roll out of MiPCT required Complex Case Management Training • Moderate Care Management Training required • MiPCT Patient List issues • BCBS Billing issues

5. Where we began… • Moderate care management • Gaps in care – using the MiPCT list • Diabetic population • Heart Failure • Transitions of Care • Inpatient follow up • Emergency Department follow up

6. Moderate Care Management, Diabetic population HbA1C over 8.0

7. Transition of Care Process Identified Barriers • No ED list was being sent to office • IP list was sometimes sent to the office • No one was “in charge” of the list when it was sent • In short, there was no consistent and timely process for TOC follow up

8. Focus on TOC Barriers • Fishbone Barrier analysis completed • Interventions devised and completed • Success

9. Transition of Care Fishbone Barrier Analysis

10. Barrier 1- No ED list provided to Practice Opportunity: • Obtain timely and consistent ED notification list to practice Interventions: • Call Facility ED Manager • Call Facility IT Department Outcome: • Success, a daily ED list sent to practice

11. Barrier 2 – IP list notification not consistent Opportunity: • Obtain timely and consistent IP lists sent to practice Interventions: • Met with hospitalist providers to discuss program • PO Medical director sent letter to Facility Medical director • Practice office contracted with Facility to gain read only access to information systems for IP list of admits and discharges Outcome: • Success, a timely and consistent IP admit and dc list obtained at practice

12. Barrier 3 - No Process for Follow-up with ED & IP Opportunity: • Improve process for notification of ED and IP admits and discharges Interventions: • Met with staff to develop a process • Process improvements made to current process Outcome: • Success, we now have a consistent and timely process within the office for follow up with IP and ED admits and discharges

13. MiPCT Case Management Transitions of Care Process Purpose: To foster structured and coordinated care between health care settings to ensure the quality and safety of patient care when there is a transition from one health care setting to another. Process: • Case Manager (CM) receives Emergency Department list each morning and assesses for MiPCT eligible members • The CM logs into Facility Information system to check hospital inpatient and discharge patient list Patient is on the MiPCT list • Review discharge information (summary, medications, instructions) • If discharge information has not been sent, CM will fax request/call for it • Contact patient per phone 24-48 hours after discharge • Review reason for phone call • Assess how patient is doing that day • Medication reconciliation (first phone call and as needed). Request patient to bring ALL meds to next appointment for visual confirmation of medications • Ensure follow up visits/tests are scheduled; if not, assist member as needed • Assess caregiver support needs • Coordinate ancillary services (home health, DME, transportation, pharmacy needs) or contact existing services to provide timely, complete and accurate information between entities as appropriate • Provide education to patient related to signs and symptoms to report to PCP office • Follow up phone call to assess ongoing CM needs, patient condition, self management goals as needed • Track follow up visits and/or tests to ensure they are completed • Meet with patient at follow up visit, as feasible Patient is NOT on MiPCT list • Refer to PCP staff nurse for follow up