Integrated Health Partners
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Transcript of Integrated Health Partners
Integrated Health Partners
• PHO located in Battle Creek, MI• Partnership between Calhoun County
Physicians Organization and Bronson Battle Creek Hospital
• 170 affiliated physicians, including 34 specialty areas
Care Management Model• 11 Practices • 4 Complex Care Managers - 1 CCM embedded in each practice with
exception of OMG-MIFM, Olivet and Tekonsha - 2 Hybrids• Moderate Care Managers employed by practice• 2 Hospitals in Calhoun County participating: Bronson Battle Creek Oaklawn Hospital
Oaklawn Medical Group: Marshall Internal and Family Medicine, Olivet Family Practice,
Tekonsha Family Practice
• Located in Marshall, Olivet, and Tekonsha• 7 physicians, 6 midlevel providers, including
certified diabetes educator• MIPCT population of 5138 patients • Trivia
OMG-MIFM, Tekonsha and Olivet Providers
Dr. Jose ValleMIPCT Physician Champion
Care Managers
Renee Leslie, RN, BS, CCMComplex Care Manager
Integrated Health Partners
Jane Ruhl, RN, BSNComplex Care Manager
Integrated Health Partners
Tami Starks, LPNModerate Care Manager
OMG-MIFM
Dee Pennington, LPNModerate Care Manager
OMG-MIFM
OMG-MIFM, Tekonsha and Olivet Statistics
• 21,268 patients in MIPCT• OMG-MIFM, Olivet Family Practice and
Tekonsha Family Practice have 5138 patients eligible for care management
• Largest practice participating in MIPCT in Calhoun County
• Level of patient engagement increased from 3.78% in April to 5.48% in July, 2013
It takes a village to raise a child, it takes teamwork for care management to be
successful in a practice
Moderate Care Managers target and engage patients using the following
tools
• Community Resource Sheet• Registry – Gaps in Care• Emergency Room Reports• BCBSM List
CommunityResource
Guide
IHP Registry Progress
Note
Insert registry sheet
Emergency Reports
• Insert emergency action plan
BCBSM List
Complex Care Managers Target and Engage Patients
• Inpatient admissions• Provider’s daily schedule• Referrals
Inpatient Admissions
Two hospitals in Calhoun County, Oaklawn Hospital in Marshall, MI and Bronson Battle Creek• Daily access inpatient admission information• Identify MIPCT PCP and patient
•MiPCT list starts with 81 columns•Our IT Analyst reduces this to 9 columns •Pertinent information is loaded into CTC
Criteria for Identifying a Patient for Care/Case Management
• 1. Unscheduled Inpatient admission*– Moderate: – 2 admissions in 90 days– Complex:– 2 admissions in 30 days
• 2. ED Visits:– Moderate:– 2 visits in 30 days– Complex:– 2> visits in 30 days
• 3. Poly-pharmacy 5> medications• 4. Diagnosis:
– Moderate:– more than 2 comorbidities– Complex:– complex medical diagnoses and psychological diagnosis*
Criteria for Identifying a Patient for Care/Case Management (continued)
• 5. Psycho-social/depression screen:– PHQ-2, PHQ-9– Moderate:– 5 or more symptoms, score 15-19*– Complex:– Score 20>*
• 6. Age:
– -over 85– -under 50 with readmission– -peds under age 2
• 7. More than 6 visits to PCP within 1 year* *criteria that in itself can trigger referral to care/case
management
Providers Daily Schedule
• Print providers daily schedule• Identify patients in MIPCT• Discuss with provider any identified needs
Referrals
• Providers• Office staff• Hospital case managers• Home Care• Community Agencies
Patient Story