Practice based care management many paths to chronic disease care
1 / 20

Practice-Based Care Management: Many Paths to Chronic Disease Care - PowerPoint PPT Presentation

  • Uploaded on

Practice-Based Care Management: Many Paths to Chronic Disease Care. Jodi Summers Holtrop, PhD, MCHES, Michigan State University Department of Family Medicine. Care Management Delivery Models. Provider-Delivered Care Management Pilot ( PDCM Pilot ).

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Practice-Based Care Management: Many Paths to Chronic Disease Care' - gabby

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Practice based care management many paths to chronic disease care
Practice-Based Care Management: Many Paths to Chronic Disease Care

Jodi Summers Holtrop, PhD, MCHES,

Michigan State University Department of Family Medicine

Provider delivered care management pilot pdcm pilot
Provider-Delivered Care Management Pilot Disease Care(PDCM Pilot)

  • Collaborative project between Blue Cross Blue Shield of Michigan (BCBSM) and 5 state Physician Organizations (POs)

  • Focus on Chronic Disease Care Management

  • $2M over 2 year Pilot

  • Goals:

  • To support chronic care management within primary care physician practices

  • Increase the percentage of BCBSM disease management cases managed by primary care physician practices

Provider delivered care management grant pdcm ahrq study
Provider-Delivered Care Management Grant Disease Care(PDCM AHRQ Study)

  • Assess the PDCM pilot

  • 3 year $1.8 grant from AHRQ


Compare patient outcomes among those offered PDCM versus health plan delivered care management

Describe the implementation of PDCM

Describe practice environments and contexts of chronic care delivery, and identify implementation, PO, and practice features associated with improved outcomes

Pdcm ahrq study convergent mixed methods model
PDCM AHRQ Study: Convergent Mixed Methods Model


Compare PDCM to HPDCM

Does CM participation

→ improve clinical outcomes?

→ reduce utilization/cost?

  • Patient Outcomes:

  • Engagement

  • Clinical results

  • Utilization

Does a higher quality CM program and more integration lead to better outcomes? Which outcomes?

  • Within PDCM:

  • CM Program Quality

  • CM Integration in practice

  • Normalization of CM

  • Practice Environment

Are practice environment and normalization of CM mediators?

Pdcm pilot monthly data flow process
PDCM Pilot Monthly data flow process Methods Model



  • Confirm member is patient of pilot PCP

  • Confirm patient has chronic condition

  • Confirm ability to provide CM if needed

  • Decide to accept / not accept

  • Create member list

  • Member ID

  • Name

  • Date of birth

  • Gender

  • Risk score

  • High cost flags

  • Chronic disease flags

  • 12-month IP, ED counts

  • BCBSM CM/DM case status

  • New member flag

  • Lost eligibility flag (drop)

  • Previous month PO responses

  • Member list return file

  • Member ID

  • Acceptance status

  • Accept date

  • Reason for no accept

  • Chronic disease(s)

  • Acceptance end date

  • Acceptance end reason

  • Activity files

  • Encounters

  • Goals

Compare pdcm to health plan delivered care management hpdcm
Compare PDCM to Health Plan Delivered Care Management (HPDCM)



Number of patients having CM outreach attempt


62 – 82%

Targeted =

Number of patients accepted

Number of patients having CM encounter

Engaged =



Number of patients having CM outreach attempt

Point: PDCM engagement rates appear to be higher than HPDCM

Note – still completing PDCM individual PO CM only rates; HPDCM rates are for the overall, not matched, populations

Care management features
Care Management Features (HPDCM)

  • Program Quality

    • Patient access

    • CMgr qualifications and personal attributes

    • Staff CM training

    • Resources for staff and patients

    • Program duration, dosage, features and length of visit

  • Integration in Practice

    • Practice staff participation in CM

    • CM team use

    • Location of CMgr visits with patients

    • CMgr visit documentation

    • Incentives and barriers for CM use

Practice based care management many paths to chronic disease care

Analysis of PO and Practice Care Management Features, Integration and Context

Immersion crystalization analysis

Emergent themes ACROSS practices/PO’s

Quotations pulled by quotes

Reconciliation meeting for all practices within PO model – team and coders

Coders review summary documents, add comments/quotes

All transcripts for each practice assigned and coded by one of three coders

Reconciliation meeting across PO’s – team and coders

Audio files sent for transcription

  • Practice visit – 2 team members

  • Interviews

  • Observations

  • Complete summary documents (both)

  • Quality

  • Integration

  • NPT/implementation

  • Lead RA:

  • Practice summary (internal)

  • Practice report and task diagram

  • Resources

  • Observation guide

2 team members reconcile scores and notes

  • Completed summary documents

  • Quality

  • Integration

  • NPT

  • Practice summary

Revised summary documents v.1

Revised summary documents v.2

Revised summary documents v.3 – Key features WITHIN practices/PO

Practice report sent to practice for member checking; modifications made

Care management models within pdcm
Care Management Models: Within PDCM Centralization at PO

Point: Within PDCM there is variation in practice integration

  • In 5 PO’s, 8 “models” of delivery – 2 distinct types

  • Integration: centralized → practice-based

    • One PO very centralized; more like health plan

    • Three PO’s two different models happening

    • Two PO’s highly integrated

  • Within practice-based models

    • Full-time C Mgr as practice team member only doing CM

    • Full-time nurse doing CM 1 day per week as part of job (included in job description of all practice nurses)

    • Travel model with panel manager and C Mgr (panel manager in practice; C Mgr 1-3 days per week at practice)

How people talk about integration
How people talk about Integration Centralization at PO

Point: Integration feels different than centralized to the participants

Interviewer: If you would do anything to improve the CM program, what would it be?

  • Centralized models

    • C Mgr: Increase referrals of patients to the CM, like pulling teeth to get referrals

    • Provider: C Mgr is a resource we can refer to

  • Integrated models

    • C Mgr: Hire more C Mgr’s. We have so many patients with needs and can’t keep up with the existing number of C Mgr’s

    • Provider: Hire more C Mgrs. The CM is part of our team and how we practice care

Program quality
Program Quality Centralization at PO

Point: Most PDCM programs were of high quality with a few exceptions


  • MA delivered programs without much training

  • Not delivering motivational interviewing, rather telling patient what to do in one or a few brief calls

  • When restricted to only BCBSM patients on “lists” tended to work differently (out of patient flow, lacking provider selection of patient) rather than as team concept with this being just part of your care

  • Co-pays were reported to result in patient refusal of CM as compared to programs charging no patient co-pay or billing

    • Issues were the patient not knowing what the co-pay will be or wanting to pay it once they knew. Patients did not want to answer the phone for CM calls fearing they would get a bill

Program quality and integration
Program Quality and Integration Centralization at PO

Point: Lack of either quality or integration limits program use and likely effectiveness

  • Even if highly integrated, can it overcome problems of poor quality? PROBABLY NOT

    • Poorly trained or not properly credentialed C Mgr lacks cultural credibility and trust from team

    • Lack of time and support to do CM means it doesn’t happen

  • Even if your program is of high quality, can it overcome barriers of lack of integration? PROBABLY NOT

    • Hard to reach patients only by phone out of scope of normal care

    • C Mgr not known as practice team member

    • Lack of day to day huddles and ad hoc communication about patients (providers often don’t read EMR notes)

    • Providers and practice members forget to refer; an extra step

Summary Centralization at PO

  • Patients appear to participate in PDCM at higher rates than health plan care management

  • Typical community, non-research directed primary care practices can implement CM

  • PDCM program quality is generally high

  • PDCM integration in practice is highly variable

  • More CM integration appears to equal more team use of CM and we think CM participation

To be continued
To be continued… Centralization at PO

  • Results are PRELIMINARY

  • Ongoing work includes

    • Verifying target population and specific practice and PO CM engagement rates

    • Gathering data on clinical values, claims

    • Analyzing emergent themes across practices

  • Further analysis

    • “Recipe” for successful care management – qualitative comparative analysis

Research team
Research Team Centralization at PO

  • Michigan State University

    • Jodi Holtrop, Zhehui Luo, Qiaoling Chen, Laurie Fitzpatrick

  • University of Michigan

    • Gretchen Piatt, Lee Green (now U Alberta), Georges Potworowski (now SUNY Albany), Mike Fetters, Jean Malouin, Trudy Adler, Amy Kowalk

  • Altarum Institute

    • Rachelle May-Gentile, Anya Day, Brad Hinks, Lauren Wendel, Kristen Werner

  • Blue Cross Blue Shield of Michigan

    • Margaret Mason, Lisa Rajt, Min Tao, Ann Emeott, Guipeng Liu, Hsiu-Ching Chang, Darline El Reda

  • Physician Organizations

    • Ruth Clark, Mary Ellen Benzik, Cecilia Sauter, Jen Bailey, Cathy Heiman, Cara Seguin

Practice based care management many paths to chronic disease care

THANK YOU! Centralization at PO