Michigan Primary Care Transformation
Demonstration Project
November 28, 2012 Webinar
Webinars
Remaining webinars for this year cancelled
Webinars will begin again in January 2013
Best practices will be presented at the webinars
Any team member may provide “best practice”
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MiPCT Meeting
Wednesday, December 12, 2012
6:00pm
American Polish Cultural Center
2975 East Maple Road
Troy, Michigan
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Year One Comments
Quality means doing it right when no one is
looking
Quality is never an accident; it is always the result
of high intention, sincere effort, intelligent
direction and skillful execution; it represents the
wise choice of many alternatives
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Year One Comment
“Measurement is the first step that leads to
control and eventually to improvement. If you
can’t measure something, you can’t understand it.
If you can’t understand it, you can’t control it. If
you can’t control it, you can’t improve it.”
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Reaching End of Year One
Status of 2012 metric attainment
• Surveys provided to practice teams at December 12 meeting
• Surveys based on metrics outlined by MiPCT Committee
Assess integration of care management
Review tasks and capabilities
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Practice Assessments
Number of complex cases
Number of moderate cases
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Practice Assessments
SNF/LTC criteria
Able to demonstrate or verbalize the criteria for
each setting
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Practice Assessments
Palliative Care/Symptom management
Able to identify resources available to the patient
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Practice Assessments
Practice Guidelines and Protocols
Utilizes and demonstrates understanding of
practice guidelines/protocols
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Practice Assessments
Exacerbation plan is in place
Patient and family education established; rescue
kits; written instructions
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Practice Assessments
Accurately stratifies patients based on risk
Demonstrates stratification process to focus on
patients of highest risk
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Practice Assessment Findings
There is very strong physician management at this
practice.
Care manager is used in a very limited capacity
and primarily in a disease management or patient
teaching capacity.
Physicians do their own medication reconciliation
for their patients as they feel others will make
errors.
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Practice Assessment Findings
TOC is really only involved in calling patients for
follow up appointments
This was previously done by clerical staff
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Practice Assessment Findings
Physicians state that they manage their own
complex patients
Care manager spends a great deal of time on
documentation which takes away from the already
limited time with patients. She is not functioning
as a complex care manager and is very limited
even in a disease management capacity
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How Can You Help Care Manager
Educate staff on the role of the case management
especially in regards to receiving information on
the most complex (not just the diabetic patient or
the "high maintenance" patient)
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Feedback Loop
Establish plan for monthly meetings or incorporate
the care manager role into existing meetings with
the following agenda items
• review metrics (ER visit volume, inpatient admission volume, care manager caseload, medication reconciliation saves etc.)
• care management success stories
• problem cases where alternate interventions can be discussed
• practice processes to support and promote care management.
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Care Management Reporting
The care management activity reporting
requirements have been finalized and will be
incorporated into the Quarterly Report beginning
in the first quarter of 2013
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Care Management Reporting
Number of Care Manager face-to-face encounters
(by Care Manager, by practice, by primary payer)
Number of Care Manager telephone or electronic
encounters by Care Manager, by practice, by
primary payer
Number of unique patients by Care Manager, by
practice, by primary payer
Did referral to outside agency occur
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Community Care Team Enhancements
Community Care Teams
• Community Care Travel Team
• Community Care Permanent Team
Bill Porter, RN: Community Care Clinical Lead
Erica Ross: Community Care Operations Lead
Dave Johnson, MSW: Behavior Health Consultant
Lori Zeman, PhD: Behavior Health Expert
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Community Care Team Enhancements
Erica Ross: Community Care Operations Lead
MNO Care Managers assignments and schedule
Monitor care manager assignments at practice sites
Working with Bill Porter and practice team to
determine appropriateness of care manager
assignments
Create and oversee satisfaction surveys and meet
with practice teams and physicians to include them in
pertinent assessments of care managers
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Community Care Team Enhancements
Erica Ross: Community Care Operations Lead
Review overall productivity statistics of care
managers
Review statistics of care managers employed by
practices
Review requests from practice units for additional
assistance with various activities
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Upcoming Events
Mackinac Learning Collaborative IV
• December 5, 2012
• Kevin Taylor, MD and Lori Zeman, PhD co chair
• Topic focused on integrated, collaborative or co-located behavior health
• Currently behavior health specialists are integrated into several adult and pediatric practice
• Hoping 100% participation from MiPCT Teams
Mini Learning Collaboratives
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Open Discussion
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Merry Christmas
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