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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MiPCT Clinical Model:Optimizing Patient Engagement, Improving Population Health

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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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Success = Improvements in Population Health + Cost + Patient Experience

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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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www.micmrc.org

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www.mipctdemo.org

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Contact InformationMarie Beisel MSN, RN, CPHQ

mbeisel@umich.eduOffice phone: 734 998-8519