The Michigan Primary Care Transformation (MiPCT) Project: December PGIP Meeting Update

MiPCT TeamDecember 2, 2011

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Agenda

• Introduction• MiPCT Participation• Care Management Update• Funding Update• MiPCT Next Quarter Timeline• Invitational Launch Meeting• Care Manager Practice Integration

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MiPCT Participation StatisticsJanuary April

(yes/tentative)

Total

POs 29 3 32

Practices 387 70 457

Providers 1,628 154 1,782

Patients 1,111,290 127,961 1,239,251

MiPCT Care Management Update• Self Management Training programs

• MiPCT Implementation Guide Part 1

• Complex Care Manager Training Update

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Self Management and Moderate Risk Care Management (MCM) Training Programs

A summary of Self Management and Moderate Risk Care Manager training programs

▫ training programs reviewed by MiPCT team

Self Management training ▫ programs must be MiPCT approved▫ required for all Care Managers

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Self Management Training Program- MiPCT Criteria•Self management support – background•Motivational Interviewing and/or

Empowerment skills•Individualized patient assessment•Collaborative goal setting•Problem solving•Systematic follow up, support•Minimum 6 hours didactic •Opportunity for learner to practice new

skills▫Post didactic - trainer facilitated webinar,

conference call, face to face meetings to discuss case studies

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Self Management and Moderate Risk Care Management (MCM) Training Programs MCM and self management training programs “at a glance”

Programs vary: some are specific to self management training, a few address both MCM and self management training

• Program objectives/content • Program contact • Resources • Modality • Duration, location • Trainer qualifications• Certification, CEs• Statewide or regional• Cost

“Self Management and MCM Training Programs" posted: mipctdemo.org

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Self Management and Moderate Risk Care Management (MCM) Training Programs

• The self management and MCM training document will continue to expand • MiPCT will continue to review and add training

programs

• How you can help• Contact mbeisel@umich.edu

• if you have an existing self management or MCM training program you would like reviewed or

• find another one that you are interested in pursuing

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Self Management Resources

• Self Management resources – summary document• May be used as a supplement to a self management

training program• Ex. toolkits, videos, modules

• How you can help• Please submit self management resources to

mbeisel@umich.edu

“Self Management Resources” posted: mipctdemo.org

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MiPCT Implementation Guide – Part I• Background

• Overview of care management• Successful components of care management

• Care Management Model and Staffing Four models: travel team, integrated, hybrid and central

Description of models Pros and cons of each model

Steps to identify a care management model that is a good fit

Includes table with potential models to consider based on patient population, CCM & MCM FTE, and practice locations

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MiPCT Implementation Guide – Part I cont.

Essential characteristics/skills for Care Manager

 

Strong communication skills Motivated, self-directed

“People” skills Engagement of patients and providers

Critical thinking skills Psychosocial aspects of chronic conditions

Patient engagement and activation skills Basic computer skills

Negotiating and conflict resolution skills

Ref: Geisinger Health Plan, The Medical Home Case Manager, April 2010 

• Roles - Care Managers, Panel Management

• Hiring Care Managers

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MiPCT Implementation Guide – Part I cont.Operations• Training CCMs, MCMs

• Integration of care manager into practice setting

• Team roles

• Identification of patients for care management

“MiPCT Implementation Guide Part I” posted: mipctdemo.org

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MiPCT Implementation Guide – Part II planned – topics •G codes•Geisinger specific CCM curriculum •Care Management Software•MiPCT Data reports, Patient Lists•Team roles

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Complex Care Manager (CCM) Training•MiPCT will provide required training for

CCMs ▫Tentative - MiPCT partnership with

Geisinger▫Expect plan to be finalized within 1 - 2

weeks•Train the Trainer Model•MiPCT Webinar 12/9 3-5 pm

▫ Update CCM training

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MiPCT Training for Complex Care Managers (CCMs ) and Hybrid CMs

•CCMs and Hybrid Care Managers▫Mandatory completion of MiPCT CCM

training MiPCT team provides standardized CCM

training CCM training will take place in Michigan

•Time line -tentative▫CCM Master Trainers – training occurs

Jan/Feb 2012▫Group 1 CCM - training occurs (ideally) Feb

2012▫Plan rolling training for several months

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Complex Care Manager (CCM) Training• CCM train the trainer model

• 10 – 15 Master CCM Trainers• Master Trainers

Located Regionally Receive training directly from Geisinger

• Master Trainer role Preceptor for new MiPCT CCMs Patient caseload

• Cost Some salary subsidized by MiPCT

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MiPCT Clinical Resources• MiPCT clinical content

• temporary location - mipctdemo.org• Michigan Care Management Resource

Center website - live Jan 2012• micmrc.org• will transition MiPCT clinical content from

mipctdemo.org to the micmrc.org website - Jan 2012

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Funding Update

•BCBSM – off-cycle payment for portion of first three months funding will be sent next week (tentative date December 9)▫ Purpose is to “jump-start” care management▫ Balance of first quarter payments will be sent in January

PGIP payment, represents $3 PMPM payment•BCN – will determine within the next

week when they will start G-codes/CPT codes▫ Understand that POs/PHOs/practices need ramp up time

to begin G-code billing▫ Committed to paying $3 PMPM until that time

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MiPCT Timeline – next 4 mos.

Implementation Plan Part C Due December 8, 2011MiPCT Webinar: Care Management software, CCM training

December 9, 2011 3-5 pm

MiPCT Webinar: Financial reporting and Performance Incentive metrics

December 14, 2011 3-5 pm

Post positions, interview, and hire Care Managers

In progress, continue (high priority)

Plan training for MCM Care Managers: • Select a MiPCT approved self

management training program

• Review MCM general recommended training topics

Schedule training programs for MCMs – align with hiring dates

MiPCT Invitational Launch Meeting

March – April 2012

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Michigan Primary Care Transformation Project (MiPCT) Launch Invitational Meeting

Supporting Your Success in Partnering with Patients to Improve Care Experience,

Outcomes, and Value

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Launch meeting• Goal of Meeting

▫To advance our practice unit’s and organization’s capabilities to implement the MiPCT program in their networks. Provide a motivational kick off to the

program Create network opportunities and best

practice sharing Develop the knowledge and skills necessary

for success• Multiple Meetings (2 or 3)

▫Located in South, West, North Regions• Who should attend

▫1 Representative from each PO/PHO • Dates:

▫March-April 2012

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One Day Program• Key Note Speaker

▫ Motivational• MiPCT Overview and Updates• Skill Building Session

▫ Change management and practice transformation• Breakout sessions

▫ Transitions in Care▫ Medication Reconciliation▫ Extended Access and Patient Awareness▫ Patient Advisory Council▫ Data Collaborative Update▫ Care Management Resource Center: An In-depth Look

• Sharing our stories ▫ Our Practice’s Best Practice for PCMH▫ What Do We Do Well?▫ Identifying Our Opportunities for Improvement

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Care ManagerPractice Integration

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Care Management Models ▫Travel Team

Consists of MCM and CCMs that are responsible for a patient caseload at multiple practices

▫Integrated Consists of MCMs and CCMs that are located on

site at the practice ▫Hybrid

The role of the CCM and MCM is filled by one individual

▫Central The Care Manager is located off-site and

supports multiple practices Care Manager spends at least 50% FTE onsite at

practice location The role of the CCM and MCM may be filled by

one individual or may be separate individuals

We need to let them into the PCMH !!

Let them on the Team – Care Management at the Practice Level

Integrating Care Management into Primary Care

•Care Management Resource Center •Experience of the 5 pilot BCBSM PDCM

physician organizations ▫Henry Ford ▫U of M ▫Genesys ▫Lakeshore Health Network ▫Integrated Health Partners

•Participation in learning opportunities in 1st to 2nd quarter 2012

Questions and Discussion

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