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. MiPCT Care Manager Update Patient Panel Size Mary Ellen Benzik,MD

3. Not what we had planned ---

4. 2013 PO Report – 1st & 2nd Quarter Care Manager ActivitiesThe Mean increases are statistically significant.

5. Care Manager Volume Quarter 2, 2013

6. Care Management Breakdown-80/20 Rule

7. Simple Math • 1,000,000 patients • 20% = 200,000 patients potentially for care management • 22,234 in one quarter • Potentially over 100,000 patient encounters a year at the current pace

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

9. But this is NOT About NUMBERS

10. Care Manager Survey Results Physician Interaction • Care Managers reported working with an average of 8.4 physicians • On average, 83% of these physicians referred patients

11. Care Manager Survey Results

12. Care Manager Survey Results • The physician(s) I work with support the concepts of the MiPCT care management team.

13. Care Manager Survey Results • Physicians are available on a daily basis to address questions related to management of MiPCT patients.

14. Care Manager Survey Results • Physicians understand and are actively involved in population management

15. Does Anybody Achieve Target CaseLoads? Yes!

16. How Do The Best Performing Practices Do It? • Front office staff screen member lists, confirm current eligibility, identify gaps in care, etc. • Office, PO and Nursing management support team-based care • Backfilling occurs • Physicians partner with the Care Manager and refer patients • Team meets regularly as a team to discuss successes and opportunities for improvement

17. Today is about Solutions

18. Henry Ford Medical Group (HFMG) MiPCT HTN Initiative Juliann Testy RN, BSN Henry Ford Health System

19. New Initiative for HFMG: Measure Up, Pressure Down Campaign Sponsored by AMGF

20. Case Managers and Diabetes Care Team Educators have BP related program goals as part of their Performance Management process- Disease management & RN BP re-check visit process • As self-management site champions, support staff with skill application following interactive self-management workshops for Medical Assistants and RNs • Developed collaborative protocols with Home Health Care: Telehealth Home Monitoring Process; calibration of BP cuffs • Pharm D’s share tips on medication reconciliation issue recognition CMs Participate in Blood Pressure Campaign80% BP Control Target by 2015

21. Campaign targets final gap in diabetes care • Uses Registry & Epic to link meaningful info to Providers • Bumped against MiPCT Attribution for Team Care • Site/Physician based by component • Identifies active point person/program • Eligibility status • Identifies patients with poor BP Control and more… New “Gimme 5” CampaignHelps Manage MiPCT Population

22. “Gimme 5” Campaign: A Twist on Diabetes Population Management

23. Group Work – Care Management Processes

24. Group Work

25. Report Out