Integrating Care Managers within Practices MiPCT Team May 17, 2012 Agenda • MiPCT Complex Care Management Training Update • Geisinger evidence-based tools for CCMs, HCMs • CCMs, HCMs – getting started • MiPCT POs and Practices ▫ Integration of CCMs, HCMs, MCMs into practice • MiPCT support for POs and Practices MiPCT CCM Training Update MiPCT Complex Care Management Training Update • CCM and HCM Training - 5 day course • First 3 training sessions ▫ Geisinger faculty, MiPCT Master Trainers • To date 3 training sessions completed ▫ 4/23/12 – 4/27/12 New Hudson ▫ 4/30/12 – 5/4/12 Grand Rapids ▫ 5/7/12-5/11/12 Ann Arbor • MiPCT CCMs/HCMs trained to date = 73 Complex Care Management Training Dates • • • • • • • 6/4-8, 2012 6/4-8, 2012 6/18-22, 2012 6/18-22, 2012 7/9-13, 2012 7/16-20, 2012 8/20-24, 2012 Grand Rapids New Hudson Lansing Madison Heights Lansing Okemos/Marquette (virtual) Lansing MiPCT Complex Care ManagementGeisinger Partnership • Background ▫ Train the trainer program for the MiPCT CCM course ▫ Certification Master Trainers, Clinical Leads ▫ Geisinger ProvenHealth Navigator Model Evidence based tools Standardized interventions based on Geisinger ProvenHealth Navigator model MiPCT Complex Care Management Curriculum Day 1: Begins with MiPCT 101 Days 1,2,3 Geisinger ProvenHealth Navigator (PHN) model • Standards of Practice for Case Management • Patient population stratification • Risk segmentation • Right care, right place, right time: criteria based level of care determination • Metrics • Concept of Medical Home • Population based case management • Need to know targeted conditions • Heart Failure • COPD • Population based care Path • PHN 5 step case management model • PHN Time management • Medical Home meeting MiPCT Complex Care Management Curriculum Days 4, 5 MiPCT • BCBSM PGIP PCMH • Identification of high risk MiPCT eligible patients • Transitions of care • Medication reconciliation • Evidence - based care • Chronic conditions • Specific assessment tools • Health Plan Payment Policy BCBSM, BCN, Medicare Advantage • Medical Neighborhood • Complex Care Manager documentation tools • Teamwork • SWOT • Case Studies • Complex care manager – a day in the life and getting started Geisinger Evidence Based Tools For CCMs, HCMs Geisinger Evidence-based Tools Geisinger Standard Case management tools • To be used by MiPCT CCMs and HCMs • Licensed tools • Includes ▫ CCM patient visit documentation tools ▫ Self Management Action Plans ▫ Care Manager Care Path • CCM HCMs trained on tools during CCM course ▫ receives hard copy of tools Geisinger Evidence Based Tools • CCM patient visit documentation tools ▫ Comprehensive Patient Assessment (i.e. G9001) ▫ Return visit note ▫ Post discharge note (i.e. transition of care) Geisinger Evidence-based Tools • 10 Self Management Action Plans • SMAPs -clinical topic specific • Example of Heart Failure SMAP ▫ BP monitoring schedule, BP goal ▫ Patient education Monitoring symptoms ▫ Action plan (ex. eating right plan, daily weight, medications) ▫ Who to call, when to call Geisinger Evidence-based Tools SMAPs • • • • • After surgery Asthma Case Management (general) COPD HF Diabetes • • • • • HF HTN Osteoporosis Stop Tobacco Use UTI Geisinger Complex Care manager Licensed Tools for MiPCT • FAQ - specifies basic legal requirements • PO Attestation letter ▫ MiPCT POs need to sign attestation letter ▫ Return signed attestation letter to MiPCTdemo@michigan.gov • User agreement – micmrc.org ▫ CCMs and HCMs complete the MiPCT CCM course will receive a username and ID, to access Geisinger tools on micmrc.org PO, Practice Role - Use of Geisinger tools • Review Geisinger tools with clinical leaders, CCMs, HCMs • If you have an EMR ▫ with care management documentation template compare your current complex care management documentation templates to the Geisinger documentation tools add fields to EMR documentation templates as needed to incorporate Geisinger content ▫ with out care management documentation template use Geisinger documentation tools • If you have a paper medical record ▫ MiPCT team will form a work group to develop usable paper tool version of the Geisinger documentation templates timeline: by 5/24/12 recruit participants, work group meets following week Geisinger Complex Care manager Licensed Tools for MiPCT • Distribution of tools ▫ CCMs and HCMs access electronic version of tools via password protected micmrc.org web site ▫ POs first sign attestation letter provide request for Geisinger tools via mipctdemo@michigan.gov and identify PO contact information PO and practice - business need to know information CCMs, HCMs – Getting Started Initial Focus Areas for CCMs and HCMs • Build Complex patient caseload • Transitions of care Post hospital discharge Transition from one setting to another – ex. SNF to home • Care coordination • Medication reconciliation • Build/expand the Medical Neighborhood CCMs, HCMs - Screening Complex Care Management Referrals • High Risk, high demand ▫ MiPCT patient lists ▫ PCP, RN, health care team referrals • Chronically ill – multiple chronic conditions or poorly controlled • Medically complex • High utilizer of health system ▫ ER visits, hospitalizations • Frail/Elderly • “Cringe Factor” CCMs and HCMs Daily Work • Prioritizing daily work - complex patient case load ▫ Review MiPCT eligible patient list with PCP ▫ MiPCT eligible complex patient with PCP visit today ▫ Transitions of care from one setting to another hospital discharge patient list ▫ Referrals ▫ Follow up on patients in caseload • Reminder - focus on MiPCT eligible patients Care Manager Integration into the Practice Role of the PO, Practice Leadership, and MiPCT Practice Leadership – Integration of Care Management • Identify a physician champion • Practice leadership, physician champion, CCM HCM MCM ▫ Identify consistent MiPCT care management goals ▫ Assess current processes ▫ Redesign processes as needed Practice Leadership – Integration of Care Management ▫ Provide education regarding MiPCT and care management for all staff ▫ Team members roles define and communicate how each member contributes to care management ▫ Introduction CCM, HCM, MCM to team members if transitioning from clinic RN role to MiPCT care manager role; communicate Care Manager role responsibilities and expectations with team members Practice Leadership - Integration of CCM, HCM, MCM into Practice • Support communication, team building, and education ▫ CCM, HCM, MCM schedule appointment with each Physician to discuss role ▫ Team meetings ▫ Staff meetings ▫ Physician meetings ▫ Meet with practice leadership ▫ 1:1 meetings with key members of the health care team PO and Practice: Integration of CCM HCM MCM into Practice • Basic ▫ Work space ▫ Phone ▫ Providing the MiPCT attribution members list for CCMs, HCMs • Advanced ▫ Medical Home meeting Multidisciplinary – representation of team members Discuss Care management case studies Data, Process improvements How MiPCT can help • Work with POs to address hospital barriers (timely discharge notifications, etc.) • Provide resources and framework for enhancing team functioning ▫ Support Learning Collaboratives, Lean workshops, other team based learning ▫ More to come – soon! • Care Management Resource Center • MiPCT Care Manager regional infrastructure Getting Started – Introducing Complex Care Management to the Practice • What is your experience? • What has worked? • What has not worked? Ideas to try. . .