Post on 15-Dec-2015
transcript
The Michigan Primary Care Transformation (MiPCT) Project
Overview and Transition of Care Lessons Learned to Date
Marie Beisel MSN, RN, CPHQ
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Disclosure• I have no conflict of interest to declare
• I do not have any relevant financial relationships with any commercial interests
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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
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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
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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)
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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
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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
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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
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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:oCare Managemento Self-Management SupportoCare Coordinationo Linkage to Community Services
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Participating Provider and Payer PartnersAs of September 2012
# Practices* # POs # Physicians # Payers
387 Practices 36 POs 1650 Physicians
4 (Medicaid*, Medicare,
BCBSM**, BCN)
*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
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IV. Most complex
(e.g., Homeless,Schizophrenia)
III. ComplexComplex illness
Multiple Chronic DiseaseOther issues (cognitive, frail
elderly, social, financial)
II. Mild-moderate illnessWell-compensated multiple diseases
Single disease
I. Healthy Population
<1% of population Caseload 15-40
3-5% of population Caseload 50-200
50% of populationCaseload~1000
Managing Populations: Stratified Approach to Patient Care and
Care Management
Health IT- Registry / EHR registry functionality * - Care management documentation *- E-prescribing (optional)- Patient portal (advanced/optional)- Community portal/HIE (adv/optional)- Home monitoring (advanced/optional)
Patient Access- 24/7 access to decision-maker * - 30% open access slots *- Extended hours *- Group visits (advanced/optional)- Electronic visits (advanced/optional)
Infrastructure Support- PO/PHO and practice determine
optimal balance of shared support - Patient risk assessment - Population stratification - Clinical metrics reporting
*denotes requirement by end of year 1
PCMH Services PCMH Infrastructure
Complex CareManagementFunctional Tier 4
All Tier 1-2-3 services plus: Home care team Comprehensive care plan Palliative and end-of life care
Care Management
Functional Tier 3
All Tier 1-2 services plus: Planned visits to optimize
chronic conditions Self-management support Patient education Advance directives
Transition Care
Functional Tier 2
All Tier 1 services plus: Notification of admit/discharge PCP and/or specialist follow-up Medication reconciliation
Navigating the Medical Neighborhood
Functional Tier 1
Optimize relationships withspecialists and hospitals
Coordinate referrals and tests Link to community resources
Prepared Proactive Healthcare TeamEngaging, Informing and Activating Patients
Michigan Primary Care Transformation Project Advancing Population Management
P O P U L A T I O N M A N A G E M E N T
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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
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Role Comparison: Moderate Risk Care Manager, Complex Care Manager
Moderate Risk Care Manager (MCM)
Complex Care Manager (CCM)
Patient Population
Moderate risk patients identified by registry, PCP referral for proactive and
population management.
High risk patients identified by PCP referral and input, risk
stratification, patient MiPCT list.
Patient Caseload
Caseload 500 (approx. 90 - 100 active patients); one MCM per 5,000
patients.
Caseload 150 (approx. 30 - 50 active patients); one CCM per
5,000 patients.
Focus of Care
Management
Proactive, population management. Work with patients to optimize control
of chronic conditions and prevent/minimize long term
complications.
Targeted interventions to avoid hospitalization, ER visits. Ensure standard of care, coordinate care
across settings, help patients understand options.
Duration of Care
Management
Typically a series of 1 to 6 visitsFrequency of visits high at times,
duration of months
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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
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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
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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
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
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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
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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
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Planned patient care i.e. huddles, processes, work flow, policies
Care Manager and PCP
partnership
Office staff – defined roles
and responsibilities
Information technology,
support
Patient
Care Management Delivery by the Practice
PO and Practice Leadership
PCMH meetings monthly, action plan,
follow up
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
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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
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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”
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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
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
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Contact InformationMarie Beisel MSN, RN, CPHQ
mbeisel@umich.eduOffice phone: 734 998-8519