The Michigan Primary Care Transformation (MiPCT) Project

1. The Michigan Primary Care Transformation (MiPCT) Project 2013 Annual Summit Sharing Care Management Best Practice & Building the Care Manager Caseload

2. Objectives • Recognize the key elements of care management practice embedment • Describe best practice steps and tools to identify patients for care management • Identify successes, barriers and solutions to building and managing the care manager’s caseload

3. Care Management Embedment • Clearly defined roles for each staff member • Care Manager is an integral part of the PCP practiceteam • Care Manager is integrated in the delivery of care by the practice • Care Model • Redesign how care is delivered • Ex. Pre-visit planning, huddles, team based care, care manager’s schedule is visible by the staff

4. Care Management Delivery by the Practice Planned patient care i.e. huddles, processes, work flow, policies PCMH meetings monthly, action plan, follow up PO and Practice Leadership Care Manager and PCP partnership Patient Office staff – defined roles and responsibilities Information technology, support

5. Identify Target Patient Population for Care Management . . . • High Risk • MiPCT patient list • Risk scores • Frequent hospitalizations • Frequent ED visits • Multiple chronic conditions • Frail elderly • PCP and staff referrals • Peds with special needs • ECF/sub acute rehab • PCP/ practice staff input and referral • Moderate Risk • MiPCT patient list • Newly diagnosed chronic condition • Poorly controlled chronic condition • Lifestyle and behavior change • Obesity • Prevention • PCP/ practice staff input and referral

6. What do I know about my Practice’s Patient Population? What Data is Available? MiPCT Michigan Data Collaborative: • Patient acuity • Risk scores • Prevalence of chronic conditions for your practice • Quality Metrics • Primary Care Sensitive ED visits • Inpatient hospitalizations Practice Data: • Practice’s Registry Data • Quality Indicator metrics • Trending and benchmark data • Patient acuity • Risk scores • Other?

7. Reports View PO Report Tab You can view, sort, print, and export the data in these reports • You can view the following reports that are specific to your PO: • IP Detail Report (Most Recent 6 Months) • IP Summary Report (Most Recent 6 Months) • ED Summary Report (Most Recent 6 Months) • ED Detail Report (Most Recent 6 Months)

8. How are we doing? • Where are we with care manager’s building patient caseload? • Is the g/cpt-code utilization increasing? • What should the patient caseload be for a full time care manager?

9. 2013 PO Report – 1st & 2nd Quarter Care Manager Activities

10. 2013 2nd Quarter PO Report – Care Manager Activities

11. MiPCT Benchmark* for Care Manager Caseload Care manager’s patient caseload – 2nd Quarter PO Data

12. What Have We Learned So Far? • Referral form for care manager • Front staff identifies potential MiPCT patients in advance of patient visit • PCP and care manager shared visit • Leverage IT - ability to identify patient is enrolled in care management and care manager contact info • Care manager addresses gaps in care • patient enrolled in CM or • patient identified as having gaps in care during office visit • Triggers for identification of patients

13. Sharing Best Practice – What is working? Case Load Development Process – It Takes a TEAM

14. West Front Primary Care -

15. YOUR Voice Heard!

16. New Ideas to Consider

17. Moving Forward Ideas to move our state to MiPCT success • What is working? • Challenges to address?

18. Share YOUR Best Practice • Complete a Best Practice template! • Next Steps: • MiPCT team follows up to create workflow documents and distribution or • If practice work flow is documented. . .“will you share you work flow?”

19. Questions and Answers