Michigan Primary Care Transformation (MiPCT) Implementation Guide
I. Background a. MiPCT Orientation
The Michigan Primary Care Transformation Project (MiPCT) is a demonstration project testing the value of the patient centered medical home (PCMH) model. This model expands access to primary care while improving care coordination. This model has been increasingly important given the rise in multiple chronic diseases and the dramatic increase in health care costs. The traditional model of health care delivery, with 15-minute in-person appointments and disconnected primary care physicians and specialists, is not working for patients or their doctors.
MiPCT addresses the shortcomings in the current system by providing funding to primary care physicians to hire care managers and implement all payor all patient registries to track and follow up with patients, especially those with multiple chronic diseases.
In addition, MiPCT pays physicians to expand office hours and offer same day appointments. Finally,
MiPCT rewards physicians for improving their patients’ health and avoiding unnecessary emergency department visits and hospitalizations.
MiPCT was developed in November 2010 after Michigan was selected by the Center for Medicare and
Medicaid Services (CMS) as one of eight states to participate in the CMS Multi-Payer Advanced Primary
Care Practice Demonstration. Michigan has the largest demonstration project in the country, reaching approximately 1.2 million patients served by 1,600 providers in almost 500 practices. All of the insurance companies and physician organizations in Michigan have been invited to participate.
Focus areas include:
 Care Management
 Self-Management Support
 Care Coordination
 Linkages to Community Services
MiPCT and the Michigan Care Management Resource Center (MiCMRC) will provide assistance and support to physicians and their practices by providing training for care managers, facilitating care management integration into practices and hosting team-based learning activities. For questions regarding the MiCMRC please contact Marie Beisel at mbeisel@umich.edu
.
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b. What is Care Management?
Definition: (Center for Healthcare Strategies, 2007)
“Activities that assist patients and their support systems to manage medical and psychosocial problems with the aim of improving care health and reducing the need for expensive medical services.”
Goals of Care Management:
1.
Improve patient’s functional health status
2.
Enhance coordination of care
3.
Eliminate duplication of services
4.
Reduce the need for unnecessary, costly medical services
Primary Care: Moderate Risk Care Management, Complex Care Management and Panel Management
Facilitated by MiPCT team and Care Management Resource Center, POs/PHOs and practices will develop processes to provide coordinated, patient centered care. The care management interventions are focused on patients with mild to moderate chronic disease and patients that have high complexity, high cost, and/or high utilizers of the health care system. Additionally, panel management supports systematic processes to follow up with patients to ensure evidence based preventive services, and tests are ordered and completed (see figure 1).
Ramsay, Rebecca (2011). Implementing Effective Clinical Care Management; Building Care Management Capacity within a Transforming
Primary Care System, Care Oregon (PowerPoint slides). Retrieved from http://qhmedicalhome.org/safety-net/evidencebasedcare.cfm#Guide
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Moderate Risk Care Management
POs/PHOs and/or practices, with assistance from MiPCT and the Care Management Resource Center, will develop processes and train personnel to help patients with mild-moderate illness manage their chronic conditions, and help patients at risk for developing chronic conditions minimize these risks.
Role of MiPCT Moderate Risk Care managers: a. Use registry for population identification and proactive patient management b. Provide care based on evidence-based practice guidelines c. Use collaborative practice models that include the primary care physician and other care team providers d. Provide patient self-management support (may also involve other team members) e. Work with patients to optimize control of their chronic conditions and prevent long-term complications f. Assist in transitions between settings g. Provide patient education with teach back to ensure understanding
Complex Care Management
POs/PHOs and/or practices, with assistance from MiPCT and the Care Management Resource Center, will develop processes and train personnel to provide coordinated, non-duplicative care for highcomplexity and or/high-utilizing patients.
Role of Complex Care Managers: a.
Use high-risk patient list, augmented by PCP input, for population identification and proactive patient management b.
Create a comprehensive, proactive plan of care c.
Provide care based on evidence-based practice guidelines d.
Use collaborative practice models that include primary care physician and other care team providers e.
Provide patient self-management support f.
Work with patients to optimize control of their chronic conditions, improve functional status, and prevent/minimize long-term complications g.
Provide patient education with teach back to ensure understanding h.
Coordinate care with specialists, hospitals and other community resources i.
Assist with advance directives, palliative care, hospice and other end-of-life care coordination
Please refer to Appendix A for a comparison of MCM and CCM roles.
Panel Management
Role of the Patient Care Coordinator
The role of the Patient Care Coordinator will vary depending on needs of the practice and the defined roles of members of the health care team. Often this role involves follow up and communication with
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patients to ensure patients receive appropriate tests and preventive services as ordered by the primary care physician. Note that this role is not required for MiPCT participating practices, but may serve to enhance the team’s success with population management and care coordination.
The following are examples of activities that may be completed by a Patient Care Coordinator: a. Utilize a registry patient list to identify patients with overdue tests/preventive services b. Generate registry patient lists for health care team members c. Conduct outreach activities, such as patient reminder phone call regarding tests/preventive services due. d. Contribute to self-management support for patients e. Notify health care team members of patients that may benefit from care management f. Assist patients with scheduling appointments including coordination of tests and office visits c. Components of Successful Care Management
As you begin to consider how your PO/PHO and practices will develop or build on current capacity in the area of care management, it is important to review components that are known to contribute to successful care management programs. Based on review of the literature, there are six key components for successful care management programs:
Targeting: The care manager should have access to patient health records and methods for identifying patients at risk for hospitalizations and/or complications from their chronic conditions. For complex care management, this includes access to information about patients who are at risk for high healthcare costs. This allows the care manager to work from a list of patients and ideally consult with the patient’s primary care physician to identify patients that will benefit from care management services.
In-person encounters: Evidence widely supports that the care manager is most effective when there is a significant amount of in person, face to face contact with patients. Other methods of interacting with patients between the face to face visits such as phone calls, e-mails can be utilized. However, the evidence is clear that regular in-person contact results in better outcomes.
Access to timely information on hospital admissions and emergency room visits: Access to hospital admission and emergency room visits, allows the care manager to intervene shortly after these events occur. The care manager can act immediately, by providing transition care interventions. The transition care interventions are aimed at addressing problems, coordinating care and follow up to prevent readmissions.
Close interactions between care managers and primary care practitioners: The care manager should work in close proximity with the primary care physician and be considered an integral part of the patient care team. Care management is optimized when services are provided in collaboration with the primary care physician. An integrated patient centered care plan is key and allows the care manager to offer support with services that meet the goals of the plan.
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Services provided: Care management interventions focus on the interplay of multiple medical issues rather than a single disease state, and emphasize proper use and reconciliation of medications. Social support, access, and coordination of care are also important.
Care Management staff: The care managers need to complete training on how to perform all aspects of care management services. It is critical that care managers have appropriate training and education.
Training in motivational interviewing and patient centered goal setting and tracking is particularly important.
II. Care Management Model and Staffing a. How Many Moderate Risk Care Managers (MCMs) and Complex Care Managers (CCMs) do you need to hire?
The first steps involve reviewing the number of MiPCT patients attributed to your practice and the funding needed to support the salary of a CCM and MCM. Based on ratios used by successful care management programs, MiPCT is recommending the following care manager - patient caseload ratios:
A “Funding Summary Spread Sheet” “which includes information specific for your practice has been sent to your PO/PHO/IPA. The spreadsheet includes practice level funding estimates for care management,
MiPCT beneficiary counts, and number of care managers supported by MiPCT care coordination funding. b. How many care managers will be covered by MiPCT Funding Sources?
There are two sources of care management funding:

PMPM payments – “up-front” funding

G codes and CPT codes – payment for services provided

Depends on appropriate staffing

Funding model based on $3 PMPM equivalent in payments

How much activity is needed to equate to $3 PMPM??
Assumptions:
Hire one care manager for 2,500 patients
Average G-code reimbursement is $60-$65 (fee schedule TDB)
Activity level:
One full time care manager would need to bill 6-7 encounters per work day (48 week year) to equate to $3 PMPM – very feasible c. Selecting a Care Management Model
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Successful care management programs to date have some common key elements: 1) The care manager(s) are located in close proximity to the PCP and 2) The care manager(s) are considered an
integral part of the health care team. Care managers working remotely, in isolation of the team have not been shown to be as effective.
Care Management Models and Staffing
Care Management models and staffing may be thought of in two dimensions.
Care management model – refers to the operational, logistic set up for care management. The care management model defines how care management is “set up” for practices.
Care management staffing – refers to “who does the work”. This has important implications and the patient population for each practice should be closely considered when making decisions about licensure of candidates to fill the CCM and MCM roles (see Appendix B and C: CCM and
MCM Job descriptions).
B. Types of Care Management Models
There are several types of care management models:
Travel team – Consists of MCM and CCMs that are responsible for a patient caseload at multiple practices. A PO/PHO/IPA that has a cluster of practices within a reasonable geographic proximity may benefit from a Care Management travel team. For example if there are 5 practices and across all 5 practices there is a sum of 10,000 MiPCT attributed beneficiaries, the travel team could consist of 2
CCMs and 2 MCMs. Other team members, such as pharmacists, social workers, and dieticians can also serve as valuable members of the health care travel team.
Integrated – Consists of MCMs and CCMs that are located on site at the practice. This model works best when the practice has approximately > 5,000 MiPCT beneficiary volume that allows separate individuals to fill the MCM and CCM roles. In smaller practices, it is also possible to have a single MCM or CCM located on-site full time, while the other care managers and team members are part of a travel team.
Hybrid – With this model, the role of the CCM and MCM is filled by one individual. This model should be considered only for special circumstances as follows: Practices with significantly fewer than 5,000
MiPCT attributed patients or practices that serve primarily pediatric patients and/or have fewer complex patients.
For practices with less than 1,000 MiPCT attributed patients, the hybrid model may take on these functions:

The care manager resides full-time in the practice, but does care management as a portion of his/her overall responsibilities (for example, devoting 1-2 days per week for care management )

The care manager works with multiple practices and spends 1-2 days (for example) per week in each of 2-3 practices.
Central – With this model, the care manager is located off-site and supports multiple practices. The role of the CCM and MCM may be filled by one individual or may be separate individuals. The offsite care
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manager may partner with the on-site Patient Care Coordinator at the practice site. In order to be most effective, the care manager should see patients at the practice location for at least 50% of his/her FTE.
Care Management Models: Table 1
Care Management Model Travel team Integrated Hybrid Central
Model Characteristics:
Location of care manager CCM, MCM has a set schedule and conducts patient visits at multiple practices
Separate MCM and CCM roles filled by same individual or separate individuals
Availability of care managers
– ease of scheduling patients to have face to face and phone visits with care managers
Documentation of care management encounters
Communication with primary care team members
Model pros and cons
Communication/relationships with primary care team members
Efficiency - availability
Set schedule for face to face visits
(care manager is not on site every day)
Potential: care manager may need to learn several registries,
EHRs
Via EHR, secure email, scheduled formal meetings, ad hoc when on site
Con:
Not on site daily, need to develop processes for health care team and patient communication
Comment:
Requires more coordination with
PO
Pro:
CCM and MCM are onsite at the practice
100%
Separate
Fluid, available
100% of schedule
Care manager utilizes the
EHR, registry used at practice
Huddles, team meetings, via
EHR, ad hoc
Care manager is onsite at the practice 100%
Fluid, available
100% of schedule
Care manager utilizes the EHR, registry used at practice
Huddles, team meetings, via
EHR, ad hoc
CCM and MCM are located off site and see patients at practice location 50% of FTE
May be separate or same
Set schedule for face to face visits (care manager is not on site every day)
Potential: care manager may need to learn several registries, EHRs
Via EHR, secure email, scheduled formal meetings, ad hoc when on site
Pro: Promotes optimal communication with PCP, heath care team and relationship building with patients and health care team
Pro: Promotes optimal communication with PCP, heath care team and relationship building with patients and health care team
Con:
Not on site daily, need to develop processes for health care team and patient communication.
Comment: Requires more coordination with PO.
Pro:
Same
Pro: Excellent Pro:
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Efficiency – Access; scheduling phone and or face to face care manager visits
Care Manager billing
Care Manager work station space
Practices that do not have a large volume of MiPCT attributed patients are able to have MCM and
CCM on scheduled dates
Con: Complexity of scheduling, limited face to face access for patients
Excellent availability of care managers since they are
100% on site.
Con: Patient that moves from complex to moderate may prefer to keep working with their CCM
Pro: Access is good. Role of
MCM and CCM are separate.
Able to use scheduling template, and access is good for patients
Need to establish criteria and mechanism for billing so patient visits will be billed to the provider of the service
Comment: Set up requires PO involvement
Needs a flex work station at the practice
(workstation may be used by others on dates care manager is not working at the practice)
Pro: Billing by care manager will use similar process as other providers, but will use G codes
Needs a permanent workstation at the practice availability of care managers since they are
100% on site.
Patient may move from complex to moderate and this model allows patient to keep the same care manager
Pro: Access is good.
Con: Hybrid care manager may have moderate risk patients scheduled and has a crisis with complex patient.
At times will be challenged to juggle both populations.
Pro: Billing by care manager will use similar process as other providers, but will use G codes
May add efficiency for practices with very small number of
MiPCT attributed beneficiaries
For practices with close to 2,500 attributed MiPCT patients, may also provide efficient use of resources
Con: Complexity of scheduling, limited face to face access for patients
Need to establish criteria and mechanism for billing so patient visits will be billed to the provider of the service
Comment: Set up requires PO involvement
Needs a permanent workstation at the practice
Needs a flex work station at the practice
(workstation may be used by others on dates care manager is not working at the practice), also needs a centrally-based workstation
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Selecting a Care Management Model that fits your PO/PHO/Practices
Which care management model is a best fit for your PO/PHO/Practices?
Things to consider:
 Identify patient population needs for each practice (ex. Practice has very low population of patients with multiple chronic conditions)
 Map the geographic location of the practices (are the practices located in close vicinity to each other or far apart?)
 Identify the total number of FTEs funded for CCM and the MCM roles for the PO
 Identify and sort allocated FTEs of CCM and MCM for each practice at your PO
(complete worksheet: Appendix D: Care Management Staffing for PO Practices)
 If you have care management in place, consider how the program will expand to build on the current capacity
 Review the pros and cons of each model (see table 1: Care management model )
 Based on the per practice CCM FTE and MCM FTE, patient population, and geography of practice locations – at a high level identify the possible Care Management models (see table 2)
 Narrow the selection of models to a “few potential models” and review with the physician champion at each practice to gain understanding of provider preferences
 Gain consensus to select a model that is a best fit
B. Steps to Identify the Care Management Model that is a fit for your PO/PHO/Practice
Several factors must be considered to facilitate selection of a Care Management Model. The following steps will help identify the care management model(s) which have potential to be a good match for your situation:
Step 1. For my PO/PHO, how many total Moderate Risk Care Managers and Complex Care Managers can be funded via MiPCT? (This is based on MiPCT attributed beneficiaries - refer to funding table)
___ Total MCMs ___ Total CCMs
Step 2. For each practice in your PO/PHO: a. Determine how many CCM and MCMs are possible. The number of MCM and CCM FTEs for each practice is based on the funding allocated for the MiPCT attributed beneficiaries. (Refer to MiPCT funding table for your PO). Note that there may be a need to adjust these numbers up or down by practice depending on the variable patient complexity at each site. If performing this type of adjustment, please keep in mind that the total number of care managers should approximate that listed in the Funding Spreadsheet. b. Identify and sort allocated CCM and MCM FTEs, using Appendix D: Worksheet: “Care Management
Staffing for PO/PHO Practices”. By completing this work sheet you will have a summary of CCM and
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MCM FTEs associated for each practice in your PO, sorted by FTE. It may also be helpful to include an assessment of practice population complexity (Low, Med, or High) to help with decision-making regarding CCMs and MCMs needed. c. Review and answer questions below (see table 2). This table will help you address patient population needs, CCM and MCM FTE available for each practice, and practice location considerations.
Table 2:
Question/determine practice situation Potential Models to consider based on patient population,
FTE and practice locations
Practices with < 0.5 MCM FTE and < 0.5 CCM FTE Practices are geographically clustered:
Travel team - if several practices have <0.5 MCM FTE and
<0.5 CCM FTE you may be able to form a Travel team to cover several practices
Practices are not geographically clustered: a) Hybrid model - part time employee b) Central model - if several practices have significantly <0.5
MCM FTE and <0.5 CCM FTE c) Central model Phase 1 - start with a CCM
Practices with 0.5 MCM FTE and 0.5 CCM FTE Practices are geographically clustered:
Hybrid or Travel team model
Practices are not geographically clustered:
Hybrid model
Practices with > 0.5 MCM FTE and > 0.5 CCM FTE Model depends on the MCM and CCM FTE allocation and patient population: a) Integrated model - if close to a 1.0 CCM FTE and 1.0 MCM
FTE and patient population has significant number of high risk patients b) Hybrid model - ex. if 0.6 CCM FTE and 0.6 MCM FTE
Practices with 1.0 MCM FTE and 1.0 CCM FTE
Practices with 1.5 MCM FTE and 1.5 CCM FTE and/or pediatric population with small number of high risk patients (i.e. hire a 1.0 FTE individual that performs both the
CCM and MCM role)
Model depends on patient population: a) Integrated model - patient population has significant number of high risk patients b) Hybrid model – pediatric population and/or small number of high risk patients a) Hybrid- consider needs of patient population b) Integrated model plus Travel Team- 1.0 MCM FTE and
1.0 CCM Integrated plus use travel team for the remaining
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0.5 MCM FTE and 0.5 CCM FTE
Practices with > 1.5 MCM FTE and > 1.5 CCM FTE a) Hybrid- consider needs of patient population b) Integrated model plus Travel Team - 1.0 or more MCM
FTE and 1.0 or more CCM Integrated, plus use travel team for the remaining FTEs
Step 3: Review the pros and cons of the potential Care Management models you have identified.
Consider the likelihood of each model and how it would work for your PO/practice. If you determine a model will not work, identify the reason and consider if there are any options /problem solving that may be possible and would result in successful implementation of the model.
Step 4: Share the outcome of your work: Meet with stakeholders and physicians at the practices to discuss each step and the outcome of your work. Ask stakeholder and physicians for feedback regarding strengths and risks of each potential model.
Step 5: Gain consensus – select the care management model. d. Hiring Care Managers
Complex Care Manager (CCM)
CCM - key responsibilities:

Partners with practice leadership team to integrate care management into practice

Completes comprehensive patient assessments – ex. functionality, depression
 initial and periodically, over time

Provides self-management support



 focus is on building capacity of patient/family for self-care
Provides patient/family education
 with teach back, sustains over time

Implements evidence-based care, chronic disease protocols and guidelines intervenes early during acute exacerbations analyzes complex data sets
 monitors patient/family response

Creates/maintains individualized plan of care

Coordination of care
 assists to integrate care when patients need services from other
 providers, institutions, and/or agencies.
Transitions of care, including medication management and reconciliation
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
Assists with advance directives, palliative care, hospice and other end of life coordination
CCM – key qualifications:
 Registered Nurse, Masters of Social Work, Nurse Practitioner, or Physician Assistant license.
 Minimum of 3 years experience in adult and/or pediatric medicine (as applicable to the practice)
 Experience is in the following settings: home health agency, primary care practice, skilled nursing facility, hospital medical – surgical unit
 Ability to manage complex chronic conditions
 Utilize evidence-based guidelines




Critical thinking skills
Excellent assessment and triage skills
Ability to analyze complex data sets
Ability to implement evidence-based interventions and protocols for chronic conditions
 Excellent communication and facilitation skills
See Appendix B: CCM job description
Moderate Risk Care Manager (MCM)
MCM - key responsibilities:

Partners with practice leadership team to integrate care management into practice

Assesses healthcare, educational, and psychosocial needs of patient/family

Provides self-management support with focus typically on lifestyle and behavior change

Provides patient/family education with teach back

Implements evidence-based care – chronic disease protocols and guidelines

Assists with transitions between settings, includes medication reconciliation

Assists with advance directives
MCM - key qualifications of the MCM:
 Registered Nurse, Masters of Social Work, Nurse Practitioner, Physician Assistant, Licensed
Practical Nurse, Registered Dietician, Pharmacist license,
 Minimum of 2 years experience in adult and/or pediatric medicine (as applicable to the practice)
 Experience is in the following settings: home health agency, primary care practice, skilled nursing facility, hospital medical – surgical unit
 Knowledge of chronic conditions
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 Excellent assessment, triage skills
 Excellent communication and facilitation skills
See Appendix C: MCM job description
Selecting a CCM and MCM
A candidate’s years of experience, specialty area, appropriate licensure and background are factors to consider. However, the characteristics of the candidate are also very important. During the interview process assess the candidate for characteristics listed below.
Essential characteristics/skills for Care Manager
Strong communication skills
“People” skills
Critical thinking skills
Patient engagement and activation skills
Negotiating and conflict resolution skills
Motivated, self-directed
Engagement of patients and providers
Psychosocial aspects of chronic conditions
Basic computer skills
Littlewood, D., Sciandra, J. (2010). The Medical Home Case Manager: Profiting from Patient-Centered
Care Coordination. New Jersey, Healthcare Intelligence Network.
III. Operations
a. Training for the Complex Care Manager
Training for the CCMs will be provided by MiPCT team and Care Management Resource Center. The
CCM is required to complete this training, which is evidence based and utilizes standardized tools and interventions. If a PO/PHO/practice currently has a complex care training program in place, the MiPCT team will review the program to assess consistency with MiPCT training objectives. If you wish to have an existing program assessed, please contact Marie Beisel for consultation at mbeisel@umich.edu
.
MiPCT is progressing toward a decision to partner with Geisinger for CCM training. Geisinger, MiPCT, and the Care Management Resource Center will implement a train the trainer model. In addition to the complex care training, the CCM is also required to complete Self-Management Support training. The
Self-Management Support training for the CCMs will be included in their curriculum and this training will be arranged by the MiPCT team. Additional details on this CCM training will be available soon.
b. Training for the Moderate Risk Care Manager
Moderate Risk Care Manager Core Curriculum includes:
1.
Self-Management Support Training: Self-management support training is a mandatory requirement for MCMs and non-licensed personnel who are assisting MCMs with self-management support.
POs/PHOs and/or practices will select and complete a self-management training program which will
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also meet PGIP 11.8 criteria. A summary of approved self-management training programs is posted on the MiPCT website: www.mipctdemo.org. For assistance with selection of self-management training programs, or to request the addition of a program to the approved list, please contact
Marie Beisel at mbeisel@umich.edu
.
2.
General training topics: The MiPCT team has identified general training topics for the MCM role.
Although training in an approved program for self-management support is the only mandatory
MiPCT requirement for MCMs, additional training topics are considered important for building the
MCM’s knowledge base and skills. However, there is an appreciation for individualized needs of the practice. POs/PHOs and/or practices may add and/or refine these topics as they consider and arrange for training based on individualized needs.
3.
MiPCT training: The MiPCT team will provide ongoing training during the demonstration project to support the educational needs of the MCM. The training may include webinars, networking conference calls and informal site visits.
4.
For details of MCM general training topics and MiPCT training, please refer to Appendix E:
Moderate-Risk Care Manager Training.
Moderate Risk Care Managers: Who arranges/provides training?
PO/PHO/
IPA, Practice x
MCM Training topic
Shared by MiPCT and
PO/PHO/IPA/practice
MiPCT team
x
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c. Integration of Care Managers into the practice setting
Once the Care Managers are hired they will need to orient to the practice and complete training specific to their role. This is an opportunity for the practice to have multidisciplinary meetings to identify current state roles of assistive clinical staff. You may find that the assistive clinical staff roles need modifications in order to optimize the team’s efficiency with delivering patient care.
Early in the orientation, it is helpful to have the Care Manager shadow team members. Ongoing, the practice should determine strategies for the Care Manager and team members to communicate. This may include huddles at specific times of the day, team meetings, regularly scheduled staff meetings, and identification of days of the week to touch base with team members. The goal is to have the Care
Manager become an integral member of the team. d. Team Roles
Appendix F provides an illustration of how the roles of care team members can be redesigned to accommodate new duties and responsibilities. Each team member plays a valuable role and should operate at a level that fully utilizes their skills and training. Care managers should work in close partnership with all team members to provide coordinated, non-duplicative patient care. Making this type of coordinated, team-based care run smoothly is not always easy, but it is one of the most important components of successful care management interventions. During the first year of the
MiPCT demonstration, we will provide tools and educational sessions to help you define the roles of all team members, including care managers. We will also provide you with the opportunity to share your success stories and “best practices” on the CMRC web site and in other venues. e. Identification of Patients for Care Management
Moderate Risk Care Manager:
The focus of the Moderate Risk Care Manager is to work with patients to optimize control of chronic conditions and prevent/minimize long term complications. Moderate risk patients may have a newly diagnosed chronic condition, be at a state of readiness to take an active role in managing their chronic condition and/or have a chronic condition that is poorly controlled. Moderate Risk patients are identified by registries and PCP referral to the MCM. Additionally, as members of the health care team interact with patients, team members may also identify potential patients that may benefit from working with the Moderate Risk Care Manager.
Registry reports may include the following fields: patient demographics, PCP, chronic condition diagnosis, pertinent test date and normal/abnormal results, next PCP visit date. The MCM actively reviews the registry reports and identifies patients that have poorly controlled chronic condition and
/or follow up appointment with PCP is needed. The MCM reviews the “potential patients for care
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management” with PCP input to determine which patients will optimally benefit from care management. MCM consultation with the PCP is important: a) initially to identify and plan the care management support and b) also ongoing to deliver a team approach to self-management support, patient education, and treatment plan.
Complex Care Manager:
The focus of the Complex Care Manager is to work with patients with high complexity and/or high utilization of medical care. CCMs will use high risk patient lists, augmented by PCP input, for population identification and patient management. An extensive review of the literature reveals that there is no single best method that emerges as superior for identification of patients that will benefit from intensive care management. Methods used by successful models generally involve some type of initial stratification (based on claims and/or clinical data) augmented by input from the primary care provider and other members of the health care team. Patients may also be identified for complex care management at hospital discharge, underscoring the importance of providing care during transitions.
For MiPCT beneficiaries, the Michigan Data Collaborative (MDC) will be providing bi-monthly lists of high-risk patients. These lists will be determined based on a prospective Diagnostic Cost Grouping
(DCG) risk score derived from historical claims data. The list will also include additional information that may be helpful such as the number of hospitalizations and emergency department visits a patient has had over a given period. Any claims-based risk stratifier has inherent limitations, and PO/PHOs and their practices are encouraged to use additional information that is available (PCP/team input, registry information, pharmacy utilization data, etc.) to augment this high-risk list.
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Appendix A
Michigan Primary Care Transformation Role Comparison: Moderate Risk Care Manager, Complex Care
Manager
2
3
4
Patient Population
Patient Caseload
Focus of Care Management
1 Major Responsibilities
Moderate Risk Care Manager (MCM) Complex Care Manager (CCM)
Moderate risk patients identified by registry, PCP referral for proactive and population management.
High risk patients identified by PCP referral and input, risk stratification, patient MiPCT list.
Caseload 500 (approx. 90 - 100 active patients); one MCM per 5,000 patients.
Caseload 150 (approx. 30 - 50 active patients); one CCM per 5,000 patients.
Proactive, population management. Work with patients to optimize control of chronic conditions and prevent/minimize long term complications.
Assess healthcare, educational, and psychosocial needs of the patient/family. With PCP, assess need to refer to other care team members (CCM, etc.) if indicated.
Targeted interventions to avoid hospitalization,
ER visits. Ensure standard of care, coordinate care across settings, help patients understand options.
Conduct comprehensive patient assessment, initial and periodically over time (such as depression, functionality, health risk assessment, etc.).
1
Provide self-management support - focus is typically on lifestyle and behavior change.
Provide patient/family education with teach back.
Provide self-management support - focus on building capacity of patient/family for self-care.
Provide patient/family education with teach back, sustain over time.
Implement evidence- based care, chronic disease protocols and guidelines; such as medication titration, fluid status monitoring.
2
3
4
5
Implement evidence-based care, chronic disease protocols and guidelines.
Create/maintain individualized plan of care.
Implement systems of care that facilitate close monitoring. Intervene early during acute exacerbations.
5
6
Analyze complex data sets, monitor closely patient/family response to care.
6
7
Assist with transitions between settings. Includes medication reconciliation.
Coordinate care with specialists, hospitals and other community resources. Assist with transitions between settings. Includes medication reconciliation.
7
17

Appendix B
DEPARTMENT OF HUMAN RESOURCES
JOB DESCRIPTION
TITLE: Complex Care Manager
FLSA: Exempt
DEPARTMENT:
LOCATION:
JOB SUMMARY:
Provides care management and care coordination for adult and pediatric patients with complex illness, in the primary care setting, under minimal supervision. In partnership with the primary care practice leadership team, the Complex Care Manager leads care management within the team through process improvement, workflow redesign, providing assistance with training, and delegating to other members of the team. Serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.
Manages a caseload of approximately 150 complex patients; of which 30 to 50 patients are actively followed by complex care manager. Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options. Infrequent, but possibility of home visits.
MAJOR DUTIES AND RESPONSIBILITIES:
1.
Identifies the targeted high risk population within practice site(s) per PCP referral, risk stratification, and patient lists. Includes patients with repeated social and/or health crises.
2.
Assesses over time the health care, educational, and psychosocial needs of the patient/family.
Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.
3.
Collaborates with PCP, patient, and members of the health care team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated.
18

4.
Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.
5.
Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.
6.
Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
7.
Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team. Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, and post-acute care services.
8.
Provides follow-up with patient/family when patient transitions from one setting to another.
Completes timely post-hospital follow-up: Medication reconciliation, PCP or specialist followup appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.
9.
Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
10.
Maintains required documentation for all care management activities.
11.
Works with practice and PO/PHO leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model.
12.
Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.
SKILLS AND ABILITIES:
1.
Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
2.
Demonstrates ability to work autonomously and be directly accountable for practice.
3.
Demonstrates ability to influence and negotiate individual and group decision-making.
19

4.
Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.
5.
Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.
6.
Demonstrates ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.
Required Qualifications:

Current Michigan Registered Nurse, Nurse Practitioner, Physician Assistant or Master of Social
Work License

Three years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting, within the past five years

Knowledge of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education

Critical thinking skills and ability to analyze complex data sets. Ability to manage complex clinical issues utilizing assessment skills and protocols

Excellent assessment and triage skills. Ability to implement evidence base interventions and protocols for chronic conditions

Demonstrates excellent communication--both verbal and written

Excellent interpersonal and facilitation skills

Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities

Time management, priority setting, work delegation and work organization.

General computer knowledge and capability to use computer
Preferred Qualifications:

Bachelor’s degree or higher, in clinical field

Care management experience

Experience as participant in continuous quality improvement

Completion of self-management support training
20

Appendix C
DEPARTMENT OF HUMAN RESOURCES
JOB DESCRIPTION
TITLE: Moderate Risk Care Manager
FLSA: Exempt
DEPARTMENT:
LOCATION:
JOB SUMMARY:
Provides care management and care coordination for adult and pediatric patients with mild to moderate illness, under minimal supervision. In partnership with primary care practice leadership team, the
Moderate Risk Care Manager leads population management within the team through process improvement workflow redesign, providing assistance with training, and delegating to other members of the team. Collaborates with members of the health care team to empower patients to manage their chronic conditions. Assists patients, who are at risk for developing chronic conditions, to minimize these risks. Serves in an expanded health care role to collaborate with PCP and patients to ensure the delivery of quality, efficient, patient centered, and cost-effective healthcare services. Assesses, plans, implements, monitors, and evaluates delivery of individualized patient care with the goal of optimizing the patient’s health status. Provides self-management support and patient education.
Works primarily with moderate risk patients to optimize control of chronic conditions and prevent/minimize long term complications. Manages a caseload of approximately 500 patients; of which 90-100 are actively supported at a time.
MAJOR DUTIES AND RESPONSIBILITIES:
1.
Identifies the targeted population within practice site(s), per PCP referral and registry reports.
2.
Assesses the healthcare, educational, and psychosocial needs of the patient/family.
3.
Collaborates with PCP, patient, and members of the health care team, to assess patient, develop and implement an agreed upon plan.
4.
Provides self-management support and empowers the patient to achieve optimal health and independence
5.
Implements evidence-based care, chronic disease protocols and guidelines. Utilizes registry to identify patients with chronic conditions, and a gap in clinical care. Utilizes patient list to ensure overdue tests/labs are completed, monitors individual patient progress and population management.
21

6.
Coordinates patient care by linking patients to resources; including community resources.
7.
Provides follow up with patient/family when patient transitions from one setting to another.
Completes post hospital discharge calls: Medication reconciliation, PCP or specialist follow up appointment, assesses symptoms, teaches warning signs, coordinates care, reviews discharge instructions, and problem-solves barriers.
8.
Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
9.
Participates in continuous quality improvement to enhance care management in the office setting.
10.
Maintains required documentation for all care management activities.
11.
Works with practice and PO/PHO leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the Patient
Centered Medical Home.
12.
Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.
SKILLS AND ABILITIES:
1.
Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
2.
Understands chronic disease management strategies and is able to implement appropriate protocols and guidelines.
3.
Demonstrates ability to work autonomously and be directly accountable for practice.
4.
Demonstrates ability to influence and negotiate individual and group decision-making.
5.
Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.
6.
Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving and decision-making, priority setting, work delegation and work organization.
Required Qualifications:

Current Michigan Registered Nurse, Nurse Practitioner, Physician Assistant, Licensed Practical
22

Nurse, Master of Social Work, Registered Dietician, or Pharmacist License

Two years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical, within the past five years

Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education

Excellent assessment and triage skills

Demonstrates excellent communication-both verbal and written

Excellent interpersonal and facilitation skills

Ability to affect change, work as a productive and effective team member, to be flexible, and adapt to needs/priorities

Time management, priority setting, work delegation and work organization

General computer knowledge and capability to use computers
Preferred Qualifications:
Bachelor’s degree or higher, in clinical field
Care management experience
Experience as participant in continuous quality improvement
Completion of self-management support training
23

Total Care
Manager FTE
(arrange lowest to highest)
Appendix D
Worksheet: Care Management Staffing for PO/PHO Practices
Practice Name Moderate-
Risk Care
Manager
FTE
Complex
Care
Manager FTE
Practice
Population
Complexity (Low,
Med, High)
24

Appendix E
MiPCT Moderate-Risk Care Manager Training
The MiPCT team has identified a core curriculum for Moderate Risk Care Managers (MCMs). The training for MCMs is a shared responsibility between the MiPCT team, POs/PHOs and/or practices.
POs/PHOs and /or practices will develop processes and arrange training for personnel to help patients with mild-moderate illness manage their chronic conditions, and help patients at risk for developing chronic conditions minimize these risks.
Moderate Risk Care Manager Core Curriculum includes:
1.
Self-Management Support Training: Self-management support training is a mandatory requirement for MCMs and non-licensed personnel who are assisting MCMs with selfmanagement support. POs/PHOs and/or practices will select and complete a self-management training program which meets PGIP 11.8 criteria and include the components listed in Section A, item 3 below. A summary of approved self-management training programs will be posted on the MiPCT website: www.mipctdemo.org
. For assistance with selection of self-management training programs, or to request the addition of a program to the approved list, please contact
Marie Beisel at mbeisel@umich.edu
.
2.
General training topics: The MiPCT team has identified general training topics for the MCM role.
Although training in an approved program for self-management support is the only MiPCT requirement for MCMs, additional training topics are considered important for building the
MCM’s knowledge base and skills. However, there is an appreciation for individualized needs of the practice. POs/PHOs and/or practices may add and/or refine these topics as they consider and arrange for training based on individualized needs. See section A below.
3.
MiPCT training: The MiPCT team will provide ongoing training during the demonstration project to support the educational needs of the MCM. The training may include webinars, networking conference calls and informal site visits. See Section B below.
Section A: Training arranged by PO/PHO and /or practice
Suggested General training topics for Moderate Risk Care Manager
The MiPCT Clinical Steering Committee has identified suggested MCM training topics related to care management. These are general MCM training topics for POs/PHOs and/ or practices to consider when assessing/developing a training program or when assessing an existing regional/national program:
1.
Chronic Care Model
2.
PCMH overview, addressing key areas (MiPCT and Care Management Resource Center will provide training and tools. POs/PHOs/IPAs practices will individualize, develop processes, and implement).

Coordination of care including Transitions of Care
25


Medication reconciliation
3.
Self-management support

Introduction to technique(s)

Setting self-management goals

Interactive practice sessions

Overcoming resistance and barriers

Ongoing follow-up (reinforce techniques, problem solve)
4.
Identifying psychosocial needs and coordinating with community resources and practice team members (include criteria to identify and refer a patient for complex care management).

Psychosocial Issues and Barriers o Transportation o Financial o Food and shelter o Domestic violence o Substance abuse, alcohol abuse o Family roles, caregiver support o Palliative care o Cognitive decline, dementia
5.
Developing competence in managing chronic diseases including DM, Asthma, CAD, HF, COPD, HTN,
Depression

Following Evidence based care/ Clinical guidelines o Protocols o Understanding quality measures

Identifying “Red Flags” – signs &/or symptoms of significant change in clinical condition requiring intervention (if no intervention, likely to lead to negative decline)
6.
Basic care manager concepts and tools

Developing Standardization in Care Management: documentation templates, patient education materials, patient assessment, education pathway, using registry reports

Improving quality and efficiency –introduction to tools, techniques to manage work flow efficiently

Documentation

Coding
7.
Role of the Moderate Risk Care Manager

Identification of patients

Integration into team based care

Specific responsibilities of care manager, complex care manager

Documentation basics (criteria for billing, templates)

Use of HIT/care management software

Teach back technique, visit summary

Data and measurement
Section B: Training to be provided by MiPCT team and Care Management Resource Center
MiPCT training topics (finalized list and schedule to be determined)

Orientation to PCMH model and statewide initiative
26


Participation in Michigan Care Management Consortium to disseminate knowledge, foster shared learning and recognition of best practices

MiPCT team member roles

Integration into PCMH designated practices

Care management documentation options o Templates o Care management software

G-code billing

Care management documentation, measurement, and reporting

Working with MiPCT data reports

Addressing key areas: Transition care, coordination of care, medication reconciliation, health literacy, cultural competency, advance directives

Develop additional training sessions/webinars to reinforce specific MiPCT goals and objectives, and address gaps in general training
27

MODERATE-
RISK CARE
MANAGER
Appendix F
TYPICAL PRIMARY CARE OFFICE
PRIMARY CARE
PHYSICIAN

SPENDS MOST OF TIME
TREATING ACUTE CONDITIONS

LITTLE STANDARDIZATION
ACROSS PATIENTS

SPENDS TIME AFTER HOURS
FOLLOWING UP ON TESTS AND
APPOINTMENTS WITH PATIENTS
REGISTERED
NURSE
MEDICAL
ASSISTANT

MAY NOT ROUTINELY BE PART
OF CARE TEAM

TRIAGES INCOMING PATIENT
CALLS

SPENDS MOST OF TIME ON
ACUTE PATIENT ISSUES

LITTLE TIME DEVOTED TO
PROACTIVE PATIENT MGMT

ROOMS PATIENTS, TAKES VITAL
SIGNS, ASSESS REASON FOR
VISIT

HAS DOWN TIME BETWEEN
VISITS
FRONT DESK
STAFF
COMPLEX CARE
MANAGER

TRIAGES INCOMING PATIENT
CALLS

PROVIDES REMINDER CALLS TO
PATIENTS BEFORE
APPOINTMENTS

MAY NOT ROUTINELY BE PART
OF CARE TEAM

MAY NOT ROUTINELY BE PART
OF CARE TEAM
IN THE MEDICAL HOME

PROACTIVELY PROVIDES
STANDARDIZED CHRONIC, PREVENTIVE
CARE

MANAGES AND LEADS MULTI-LEVEL
CARE TEAM

COORDINATES CARE WITH SPECIALISTS
AND HOSPITALS

PARTICIPATES IN TEAM HUDDLES

HAS PROTECTED TIME TO FOCUS ON
DELIVERING CARE MANAGEMENT FOR
PATIENTS WITH CHRONIC CONDITIONS
(SEE DESCRIPTION BELOW)

PARTICIPATES IN TEAM HUDDLES

THOROUGHLY SCREENS PATIENT
NEEDS AND REVIEWS CHART, LABS,
SELF-MANAGEMENT GOALS IN PRE-
VISIT CHART REVIEW

PERFORMS PRE-PHYSICIAN SERVICES
(FOOT SCREENING), RECORD IN CHART

PARTICIPATES IN TEAM HUDDLES

LIAISES WITH CLINIC NURSE BEFORE
APPOINTMENT TO CHECK FOR
OUTSTANDING PATIENT NEEDS

IDENTIFIES SERVICES DUE THROUGH
REGISTRY AND DISCUSSES PRE-VISIT
TESTS WITH PATIENTS

ENCOURAGES/PROMOTES SELF- MGMT
OF CHRONIC CONDITIONS

CONDUCTS ONE-ON-ONE AND GROUP
PATIENT EDUCATION

MANAGES CHRONIC CONDITIONS
THROUGH PHYSICIAN LED PROTOCOLS

PERFORMS TRANSITION CARE WITH
MEDICATION RECONCILIATION

OVERSEES AND FACILITATES
COORDINATION OF CARE

PARTICIPATES IN TEAM HUDDLES

WORKS WITH PCP AND TEAM TO
IDENTIFY PATIENTS FOR INTENSIVE
CARE MANAGEMENT/COORDINATION

DEVELOPS COMPREHENSIVE CARE
PLAN AND REVIEW WITH
PATIENT/FAMILY

MANAGE CARE TRANSITIONS

RECONCILE MEDICATIONS

ACTS AS LIAISON FOR PRIMARY AND
SPECIALTY CARE TEAM MEMBERS

PARTICIPATES IN TEAM HUDDLES
28

Appendix F
TYPICAL PRIMARY CARE OFFICE

MAY NOT ROUTINELY BE PART
OF CARE TEAM
PATIENT CARE
COORDINATOR
SOCIAL
WORKER

MAY NOT ROUTINELY BE PART
OF CARE TEAM
PHARMACIST
REGISTERED
DIETICIAN
NURSE
PRACTITIONER/
PHYSICIAN
ASSISTANT
LICENSED
PRACTICAL
NURSE

MAY NOT ROUTINELY BE PART
OF CARE TEAM

MAY NOT ROUTINELY BE PART
OF CARE TEAM

MAY NOT ROUTINELY BE PART
OF CARE TEAM

MAY NOT ROUTINELY BE PART
OF CARE TEAM
IN THE MEDICAL HOME

REVIEWS REGISTRY AND IDENTIFIES
GAPS IN CHRONIC AND PREVENTIVE
CARE

NOTIFIES PATIENT OF CARE GAPS AND
COMPLETE LAB/TEST REQUISITIONS

ASSISTS CARE MANAGERS WITH
COORDINATING REFERRALS AND TESTS

DOCUMENTS SERVICES IN REGISTRY

PRODUCES POPULATION REPORTS

LIAISON WITH COMMUNITY
RESOURCES FOR PATIENT HOUSING,
FOOD, TRANSPORATION NEEDS

FACILITATE REFERRALS FOR CHRONIC
SUBSTANCE ABUSE, MENTAL HEALTH
SERVICES, CARE MANAGEMENT

PSYCHOSOCIAL SPRITIAL ASSESSMENT
AND SHORT TERM COUNSELING FOR
ADJUSTMENT TO ILLNESS, GRIEF AND
LOSS, FAMILY ISSUES

FACE TO FACE AND TELEPHONIC
MANAGEMENT TO INTENSIFY AND
OPTIMIZE MEDICATION REGIMENS

ASSESS BARRIERS TO MEDICATION
ADHERENCE

EDUCATE ON INSULIN THERAPY AND
HOME GLUCOSE MONITORING

IDENTIFY FORMULARY ALTERNATIVES

PERFORM NUTRITION ASSESSMENTS

WORK WITH PATIENTS TO DEVELOP
AND IMPLEMENT A NUTRITIONAL PLAN
TO TARGET CHRONIC CONDITIONS

IDENTIFY BARRIERS TO DIET
ADHERENCE

ACTIVELY OWNS PATIENT
MANAGEMENT

LEVERAGED FOR SAME-DAY AND
AFTER-HOURS ACCESS

SEES PATIENTS WITH MINIMAL
SUPERVISION

TELEPHONE MANAGEMENT: FOLLOW
UP ON ITEMS DELEGATED BY PCP OR
RN

MANAGE PRESCRIPTION REFILLS

PERFORM TESTS AND PROCEDURES
(IVS, STRAIGHT CATH, SUTURE
REMOVAL)

ASSIST WITH TRANSITION CARE AND
CARE COORDINATION
29