The Michigan Primary Care Transformation (MiPCT) Project

1. 1 The Michigan Primary Care Transformation (MiPCT) Project Care Management: MiPCT Tiers 3 and 4

2. 2 What is Care Management? The Center for Health Care Strategies definition: “Programs [that] apply systems, science, incentives, and information to improve medical practice and assist consumers and their support system to become engaged in a collaborative process designed to manage medical/social/mental health conditions more effectively. The goal of care management is to achieve an optimal level of wellness and improve coordination of care while providing cost effective, non-duplicative services.”

3. 3 OK… WHAT is care management??

4. 4

5. 5 Care Management Models (example) • Complex care managers (Tier 4) • 1 per 5,000 MiPCT patients (active cases ~ 150) • Target: patients with multiple co-morbidities and/or high utilization • Goal: coordinate care, maximize function • Care managers (Tier 3) • 1 per 5,000 MiPCT patients (work with ~ 10%) • Target: patients with moderate complexity illness • Goal: mitigate risk factors, optimize chronic conditions, provide self-management support

6. Targeting the Efforts of MiPCT 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

7. 7 Care Management: Basic Principles • Care manager is a member of the PCMH team • Close partnership with patient’s physician • Help patients achieve health goals • Coordinate care, provide follow up between visits • Who can be an MiPCT care manager? • Complex care manager: Registered Nurse, Social Worker (MSW), Nurse Practitioner, Physician Assistant • Other team members can also provide care management services: Pharmacist, Registered Dietician, Certified Diabetes Educator, etc.

8. Goal #1: Avoid Bad Outcomes

9. Goal #2: Avoid Unnecessary Care

10. 10 Models for MiPCT Care Managers

11. 11 Role Comparison: Moderate Risk Care Manager (MiPCT Tier 3), Complex Care Manager (MiPCT Tier 4)

12. 12 Functions of a Care Manager • Partners with practice leadership team to integrate care management • Assesses healthcare, educational, and psychosocial needs of patient/family • Provides self management support • focus is typically on lifestyle and behavior change • Provides patient/family education • with teach back • Implements evidence-based care • chronic disease protocols and guidelines • Assists with transitions between settings • includes medication reconciliation • Assists with advance directives

13. 13 Additional Functions: Complex Care Manager Role • Conducts comprehensive patient assessments (Functional status, fall risk, depression, etc.) • initial and periodically, over time • Creates/maintains individualized, longitudinal plan of care • Implements evidence-based care based on chronic disease protocols and guidelines • intervene early during acute exacerbations • analyze complex data sets • monitor patient/family response

14. 14 Hybrid Care Manager Model Definition of hybrid model: one individual who fills both Complex Care Manager (CCM) and Moderate Risk Care Manager (MCM) role • Use only for special circumstances • Practices with significantly fewer that 5,000 MiPCT attributed patients • Practice that serve primarily pediatric patients and have fewer complex patients • Individual filling both roles must complete the MCM and CCM training requirements • Hybrid model will be evaluated during first year of intervention; continued if successful

15. 15 Features of Successful Care Management Models • Close collaboration between care manager and PCP • High level of “in-person” contact between care manager and patient • Close attention to transitions of care • “Handoffs” are where many errors occur • Need timely information on hospital/SNF discharges • Medication reconciliation is regularly performed • Need access to patient record/EHR • Assess adherence to medication regimens • Target patients at high risk for hospitalization

16. 16 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 Complex Care Management coverage • Manage high-complexity, high-cost patients • Patients selected based on risk score plus PCP input • Focus on evidence-based interventions • Medication reconciliation • Care transitions • In-person contact with patients whenever possible • Comprehensive care plan for complex patients

17. 17 Funding for Care Management

18. 18 MiPCT Care Management Funding • Two sources of care management funding: • Per Member Per Month payments • Funding not directly tied to encounters • Paid on a monthly basis • $4.50 PMPM – Medicare patients • $3.00 PMPM – Medicaid patients • G codes and CPT codes • Encounter-based payments for services • Blue Cross Blue Shield of Michigan • Blue Care Network

19. 19 G Codes/CPT codes • BCBSM/BCN replacement for T-codes • Encounter-based reimbursement for care management services provided by non-physicians • Advantages over T-codes • Patients will not receive a bill for services if not a covered benefit under employer group plan • Allow mechanism for POs/PHOs to bill for services • Specific codes and reimbursement details are available at www.mipctdemo.org (webinar #6)

20. BCBSM/BCN Billing Codes *Net of Incentive amount, plus E/M uplift 20

21. Self-Management SupportMarch 13th, 2012 Kevin Taylor MD, MS Associate Medical Director MiPCT

22. The Impact of Improving Patients’ Self-Management “Improving patient self-management of chronic diseases would have a far greater impact on the health of the population than any improvement in specific medical treatments.” World Health Organization, 2003

23. Self-Management Support Institute of Medicine definition: • “the systematic provision of education and supportive interventions to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support.” • IOM, Priority Areas for National Action: Transforming Health Care Quality 2003.

26. Self-Management Support • Series of techniques or tools that encourage patients to choose healthy behaviors • Collaborative Decision Making (a fundamental shift in the patient-caregiver relationship)

27. Techniques or Tools • Engage Patients By ConnectingThem To Their Data • Patient care notebook • Graphic display of information • Patient entry of data • Blood Pressure, Blood sugar graphs • CHF TeleScale • Patient Visit Summaries • Patient Instruction or Prescription Sheet

29. Collaborative Decision Making:Setting Action Plans • Begin with your patient’s interests • Believe that your patient is motivated to live a long, healthy life • Help your patient determine exactly what they might want to change • Identify and respect ambivalence 4. Develop a reasonable, detailed action plan

30. Unachievable Action Plans • Unclear • “I’m supposed to start exercising.” • Unrealistic • “My doctor told me to lose 10 lbs before the next visit.” • “Taking care of my diabetes means I’m supposed to eat perfectly and never cheat.”

31. Achievable Action Plans • Patients and the care team work together to set general goals for treatment that are important to the patients. • With the help of the care team, patients create a care plan or specific action plan for their own self-care. • Patients and the care team review the plan periodically to ensure that it is effective in reaching the desired goals.

33. Is what I told you to do clear? Doctor Patient Is Clear Information All That Patients Need for Good Self-Management?

34. Information Giving Only • Didactic patient education does not improve health-related behaviors or clinical outcomes • Diabetes (Diabetes Care 24(3);561-87 • Asthma (Kaiser Permanente June 2003) • Arthritis (JAMA 288 (19);2469-75

35. Collaborative Decision Making • Significant association between improved information giving, more participatory decision making, enhanced self-efficacy, healthier behaviors and better outcomes in patients with diabetes. Heisler et al. J Gen Intern. Med. 17 (4);243-52)

36. Self-Management Support Video • http://www.youtube.com/watch?v=Nb0Kikgieng

37. 42 MiPCT Care Manager Training and Infrastructure

38. 43 MiPCT Complex Care Manager Train the Trainer Program

39. 44 Current Statistics: Complex Care Manager Train the Trainer Model • 4 Master Trainers • Adult CCM • 13 Clinical Leads • Pediatric Care Managers • 3 Pediatric Clinical Leads • 2 open positions • In development – Pediatric Curriculum and Care Manager job description • Physician Lead: Dr. Jane Turner (MSU)

40. 45 Master Trainer Complex Care Manager Role • Oversight of 3-4 Complex Care Manager (CCM) Clinical Leads • Does not have a patient caseload • Leadership role in providing CCM professional development • mentoring, coaching and education • Gathers data, populates and analyzes specified CCM activity reports for region • Collaborates with MiPCT leadership and MiPCT clinical subcommittee to assess, study, and refine CCM training and interventions as needed • Presents educational offerings for CCMs in small group setting as well as a statewide audience

41. 46 Complex Care Manager (CCM) Clinical Lead Role • Preceptor for CCMs in a defined region, has reduced patient caseload • Leads small group discussions, facilitates networking, sharing best practices • Contributes to ongoing CCM curriculum development by assisting Master Trainers with CCM education, workflow support, and resources • Collaborates with CCM Master Trainer, MiPCT leadership, MiPCT clinical subcommittee to assess CCM interventions

42. 47 Adult CCM Master Trainers, Clinical Leads Attend Geisinger Training • First wave 2/6/12 – 2/24/12: • 3 Master Trainers, 6 Clinical Leads • Second wave 3/5 – 3/23: • 1 Master Trainer, 5 Clinical Leads • Both waves take place in Pennsylvania

43. 48 MiPCT Adult Clinical Leads and Master Trainers

44. 49 MiPCT Adult CCM Training - Michigan Roll out To Be Held Regionally in Michigan: • April 23, 2012 – New Hudson • April 30, 2012 – Grand Rapids • May 7, 2012 – Ann Arbor • June 2012 and thereafter monthly or as needed based on demand Required training for Adult MiPCT Complex Care Managers (CCM) and Hybrid Care Managers (HCMs)

45. 50 Training plan: Complex/Hybrid Care Managers One-week Michigan MiPCT didactic training • Three days - Complex Care Management Fundamentals, based on Geisinger model • Two days - MiPCT curriculum • MiPCT approved self-management support training • (see list on www.mipctdemo.org) • On-going learning • Precepting: with local Clinical Lead (CL) • Case Study sessions: led by CL • Webinars: continuing education on special topics

46. 51 Training plan: Moderate-Risk Care Managers • MiPCT approved self-management support (SMS) training (www.mipctdemo.org) • Additional suggested topics as defined by MiPCT clinical subcommittee (www.mipctdemo.org) • Many MiPCT-approved SMS training programs also include these additional topics • Ongoing education through MiPCT-sponsored webinars

47. 52 Michigan Care Management Resource Center • UMHS/BCBSM collaboration • Goal is to help disseminate effective, evidence-based care management models throughout Michigan • Initial focus is MiPCT practices -available to all Michigan PO/PHOs /practices • Web-based resource for templates, tools, evidence-based information • Webinars, workshops and mentoring in care management • Personalized care management consultation service

48. 53 Getting Started

49. 54 Getting Started- Orientation suggestions for Care Managers • Complete an MiPCT-approved self management training program • Complete Orientation - guided by PO/Practice Leadership • MiPCT Care Manager orientation outline • Content developed by MiPCT Clinical Leads • In progress - orientation checklist • Development by Master Trainers • Available by April 1

50. 54 Getting Started- Orientation suggestions for Care Managers • Become familiar with role and responsibilities of health care team members • Navigating the Medical neighborhood • Develop relationships: ex. Inpatient case managers, Home Health Agencies, Behavioral health resources, - Meet and establish relationship with team • Review the Clinical Guidelines used by PO/Practice • Identify/learn HIT used by Practice • EMR • Registry (required by the end of 2012) • Care management documentation (note: may be a work-in-progress)