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The Michigan Primary Care Transformation
(MiPCT) Project - Webinar #3
Complex Care Manager Training and Care
Management Documentation Updates
MiPCT Team
December 9, 2011
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Agenda
• Introduction
• Complex Care Management Training Update
• Care Management Documentation and
Reporting
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MiPCT Complex Care Manager
Training
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CCM Train the Trainer Model
• Proposed model for first group of CCMs
▫ 4 Master Trainers (3 open positions)
▫ 16 CCM Clinical Leads
▫ Employed by the PO/Practice
 Exception – One Master Trainer position filled by Marie Beisel MiCMRC
Project Manager
• CCM Master Trainer and CCM Clinical Leads
▫ Complete Complex Care Manager Fundamentals course with Geisinger
faculty (may require two waves of on-site training)
▫ 3 weeks on site in PA
 One week didactic
 Two weeks partnered with a Geisinger Care Manager
▫ Training in MI, mentoring by Geisinger faculty
• CCM Master Trainer additionally completes curriculum for train
the trainer model
*Model is designed for year one MiPCT intervention phase
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MiPCT Complex Care Manager
Train the Trainer Program
MiPCT
Leadership
Team
CCM Master
Trainer
4 CCM Clinical
Leads
CCM Master
Trainer
4 CCM Clinical
Leads
CCM Master
Trainer
4 CCM Clinical
Leads
CCM Master
Trainer
4 CCM Clinical
Leads
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Complex Care Manager Clinical Lead
• Completes Complex Care Manager Fundamentals course at Geisinger
▫ 3 weeks on site in PA
▫ supplemental training in MI
• Preceptor for CCMs in a defined region, has reduced patient caseload
• Leads small group discussions, facilitates networking, sharing best
practices
• Contributes to ongoing CCM curriculum development by assisting
Master Trainers with CCM education, workflow support, and resources
• Collaborates with CCM Master Trainer, MiPCT leadership, MiPCT
clinical subcommittee to assess CCM interventions
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Complex Care Manager Clinical Lead
Sample of key preferred qualifications
• Current MI License: RN, NP, PA
• 3 to 5 years experience
▫ some adult medicine
▫ setting: home health agency, primary care practice, skilled nursing facility,
hospital medical-surgical unit
• Preceptor experience - working with licensed clinical staff
• Demonstrated ability to create and support a learning environment that is
characterized by mutual respect, constructive feedback, and conflict
resolution
• Knowledge of chronic conditions and prevention
▫ evidence-based guidelines
• Excellent communication, interpersonal, teaching and facilitation skills
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Master Trainer Complex Care Manager Role
• Completes Complex Care Manager Fundamentals course and a Train the
Trainer program with Geisinger faculty
▫ 3 weeks on site in PA
▫ also training in MI
• Oversight of four Complex Care Manager (CCM) Clinical Leads
• Does not have a patient caseload
• Leadership role in providing CCM professional development through
mentoring, coaching and education
• Gathers data, populates and analyzes specified CCM activity reports for
region
• Collaborates with MiPCT leadership and MiPCT clinical subcommittee to
assess, study, and refine CCM training and interventions as needed
• Presents educational offerings for CCMs in small group setting as well as a
statewide audience
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Complex Care Manager Master Trainer
Sample of key preferred qualifications
• Current MI License: RN, NP, PA
• 5 years experience
▫ some adult medicine
▫ setting: home health agency, primary care practice, skilled nursing facility, hospital
medical-surgical unit
• 2 years experience
▫ clinical manager - preferred
▫ clinical program development, implementation, monitoring, evaluation - preferred
• Demonstrated ability to create and support a learning environment that is
characterized by mutual respect, constructive feedback, and conflict resolution
• Excellent communication, interpersonal, teaching and facilitation skills
• Excellent teaching, presentation, and facilitation skills
• Demonstrated ability to effectively develop educational resources, tools, processes
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Training Timeline
• CCM Master Trainers and Clinical Leads
▫ 1-2 waves, likely February for first wave
• Subsequent training plans
▫ Michigan-based training waves
▫ Progress from Geisinger-led to combination of
taped webinars and Master-Trainer led sessions
▫ Regionally based
▫ Having four Master Trainers will allow more
flexibility with timing and geography
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Next steps
• Additional details on CCM Master Trainer and clinical
leads sent out by December 15
▫ Position description details
▫ MiPCT salary subsidization amount for each role
▫ Definition of selection process
• PO/PHO responses requested by December 22
▫ Letter of interest for CCM clinical lead position
▫ Letter of interest for CCM Master Trainer position
▫ Submit letter of interest to Marie Beisel at mbeisel@umich.edu
• Positions for first Geisinger trip identified by January 15
▫ Anticipated travel date is early February
▫ Timing of second wave likely early March
• MiPCT team to finalize contract details with Geisinger by 12/31
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Care Management
Documentation
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Current state
• No ideal single source solution for EHR
documentation, registry functionality and care
management support
▫ Integration costly, cumbersome
▫ Difficult to mimic manual processes with HIT
solutions
▫ Recognized problem across the country
• Care managers need tools to support workflow
• Supervisors need a way to track productivity
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Basic HIT Functions: Support Care
Manager’s work
• Create and maintain a list of active patients
• Generate a Patient Tickler List
▫ patients scheduled for Care Manager (CM) follow up visit
▫ ideally includes past and future CM visits
• Document Patient Care management visits using a template
▫ Common diagnoses
▫ Common follow up
 Self management goal setting
▫ Transitions of care
• Create and maintain individualized patient care plan by Complex
Care Managers
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Advanced HIT Functions: Support
Care Manager’s work
• Access to information such as:
view of patient includes:
diagnoses, care giver, PCP,
insurance, demographics, care
manager and health team
member visit schedule,
assessments, referrals, patient
goals, medications, lab results
• Protocols
• Ability to generate Care
Manager activity reports
• Compatibility with care
manager’s work flow
• Notification - patient’s
appointment with PCP, ER
visit, hospitalization
• Assessments ( Functionality,
PH Q 9, . .) completed and
tracked - longitudinal view
• Patient worksheet: history of
goals, assessments, care
manager encounters past and
future
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MiPCT Required Care Manager
Reports
• Care Manager Activity Reports
▫ Number of Care Manager encounters at practice location
per Care Manager, by payer
• Frequency of reporting – TBD, likely quarterly
• Purpose of reports
▫ Provide accountability to payers, demonstrate value
▫ Allow PO and MiPCT leadership to see where practices are
having difficulty with implementation/integration
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Ways to accomplish varying levels
of Care Management functions
• EHR
▫ customization
▫ built in care management feature (rare)
• Registry
▫ customization
▫ built in care management feature (rare)
• Care Management Software
▫ not integrated
▫ integrated
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Options for Care Management
Documentation and Reporting
• PO develops solution – works with practices
• Common MiPCT solution
▫ Not required, but option for those interested
▫ Care management software options reviewed by
MiPCT team
▫ Two possible options
 Care Team Connect
 OHSU Care Management Plus
▫ Cost to PO/PHO/practice negotiated by MiPCT
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Care Team Connect
• Currently in use or in negotiations with several
MiPCT PO/PHOs
• Highly customizable
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▫
▫
▫
▫
Accept MiPCT data feeds
Risk stratification
Specific protocols for clinical situations
Connect multiple team members
Can interface with registry/EHR at additional cost
• Will generate claims for G codes/CPT codes
• Will create MiPCT activity reports
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Care Management Plus
• Low cost, web-based product
• Provides basic care management support
▫ Active patient list
▫ Tickler lists
▫ Activity reporting
• Some customization possible
▫ Templates
▫ Interface with practice management system, EHR
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What is the best solution for you?
• PO/Practice will need to assess current HIT
capability for care managers
• Can PO/practice report the required MiPCT activity?
• Will the HIT in the practice currently provide the basic
functions needed to support the care manager
workflow?
• If yes, can PO/Practice add support such as customized
documentation templates?
• If no, how will PO/Practice address this?
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Next steps
• Assessment of MiPCT PO/PHO capabilities
▫ Best practice webinar?
▫ Common solutions for same EHRs?
▫ Have something that works? We’d like to hear
from you!
• Demonstrations from software vendors
▫ Care Team Connect, Care Management Plus
▫ If PO/PHO has care management software product
they would like MiPCT to assess, please contact
Marie Beisel at mbeisel@umich.edu
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Questions and Discussion