Mary Ellen Benzik,MD
Associate Medical Director
MiPCT
I wear many hats –
Family Physician
Medical Director of
Integrated Health Partners
Active participant in the BCBSM
PDCM
Associate Medical Director
MiPCT
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When successful – may lead to direct redesign of
CMS/Medicare funding without congressional
confirmation
Awesome opportunity to impact the future of
primary care in the country
Ability to improve the quality of care for our
patients
“Do what we have always wanted to do”
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Self-management support
Community resources
Care transitions
Care coordination
Complex Care
Management
Functional Tier 4
Care Management
Functional Tier 3
Transition Care
Functional Tier 2
Navigating the Medical
Neighborhood
Functional Tier 1
All Tier 1-2-3 services plus:
 Comprehensive care plan
 Home visits
 Palliative and end-of life care
All Tier 1-2 services plus:
 Planned visits
 Self-management support
 Patient education
 Optimize chronic conditions
 Advance directives
All Tier 1 services plus:
 Notification of admit/discharge
 PCP and/or specialist follow-up
 Medication reconciliation
 Optimize relationships with
specialists and hospitals
 Coordinate referrals and tests
 Link to community resources
Prepared Proactive Healthcare Team
providing evidence-based, person-centered care
PCMH Services
P O P U L A T I O N
Care Management
MiPCT Framework
Health IT
- Registry / EHR registry functionality
- Care management documentation
- E-prescribing
- Patient portal (optional)
- Community portal/HIE (optional)
Patient Access
- 24/7 access to decision-maker
- 30% open access slots
- Extended hours
- Group visits (optional)
- Electronic visits (optional)
Infrastructure Support
- PO/PHO and practice determine
optimal balance of shared support
- Patient risk assessment
- Population stratification
- Clinical metrics reporting
PCMH Infrastructure
7-12-11
Care Management
Conceptual Framework
Functional Tier 4
Care Management
Functional Tier 3
Transition Care
Functional Tier 2
Navigating the Medical
Neighborhood
Functional Tier 1
All Tier 1-2-3 services plus:
 Comprehensive care plan
 Home visits
 Palliative and end-of life care
All Tier 1-2 services plus:
 Planned visits
 Self-management support
 Patient education
 Optimize chronic conditions
 Advance directives
All Tier 1 services plus:
 Notification of admit/discharge
 PCP and/or specialist follow-up
 Medication reconciliation
 Optimize relationships with
specialists and hospitals
 Coordinate referrals and tests
 Link to community resources
Prepared Proactive Healthcare Team
providing evidence-based, person-centered care
PCMH Services
P O P U L A T I O N
Complex Care
Management
Health IT
- Registry / EHR registry functionality
- Care management documentation
- E-prescribing
- Patient portal (optional)
- Community portal/HIE (optional)
Patient Access
- 24/7 access to decision-maker
- 30% open access slots
- Extended hours
- Group visits (optional)
- Electronic visits (optional)
Infrastructure Support
- PO/PHO and practice determine
optimal balance of shared support
- Patient risk assessment
- Population stratification
- Clinical metrics reporting
PCMH Infrastructure
7-12-11
Care Management
Conceptual Framework
Functional Tier 4
Care Management
Functional Tier 3
Transition Care
Functional Tier 2
Navigating the Medical
Neighborhood
Functional Tier 1
All Tier 1-2-3 services plus:
 Comprehensive care plan
 Home visits
 Palliative and end-of life care
All Tier 1-2 services plus:
 Planned visits
 Self-management support
 Patient education
 Optimize chronic conditions
 Advance directives
All Tier 1 services plus:
 Notification of admit/discharge
 PCP and/or specialist follow-up
 Medication reconciliation
 Optimize relationships with
specialists and hospitals
 Coordinate referrals and tests
 Link to community resources
Prepared Proactive Healthcare Team
providing evidence-based, person-centered care
PCMH Services
P O P U L A T I O N
Complex Care
Management
Health IT
- Registry / EHR registry functionality
- Care management documentation
- E-prescribing
- Patient portal (optional)
- Community portal/HIE (optional)
Patient Access
- 24/7 access to decision-maker
- 30% open access slots
- Extended hours
- Group visits (optional)
- Electronic visits (optional)
Infrastructure Support
- PO/PHO and practice determine
optimal balance of shared support
- Patient risk assessment
- Population stratification
- Clinical metrics reporting
PCMH Infrastructure
7-12-11
Navigating the
medical
Neighborhood
Relationship with
MD/hosp
Coordination
Referrals
Coordination
tests
Link to
community
Resources
Strength
Weakness
Opportunity
Threat
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Optimize relationships with specialists and
hospitals
Coordinate referrals and tests
Link to community resources
http://www.improvingchroniccare.org
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Accountability
◦ Know who your patients are (registry)
◦ Track referrals and test results
 http://www.improvingchroniccare.org/downloads/3_referral_tr
acking_guide.pdf
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Patient Support
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Identification of patient medical, logistic, insurance needs
Motivational interviewing
Transition of care
Identification of barriers
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Relationships and Agreements
◦ Community Agencies
◦ Hospitals / Emergency rooms
◦ Specialist
◦ http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/
1483/PCMH_Tools%20&%20Resources_v2
◦ http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__
home/1483
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Connectivity
◦ http://www.improvingchroniccare.org/index.php?p=Connectivity
&s=415
◦ Case examples of three area solutions
More than just a handshake
Establishes specific agreements and expectations related to :
Transitions of Care
Access
Collaborative Care Management
Patient Communications
Great definitions
Templates for all of these four areas
Table conversation
Report out
Care Management
Conceptual Framework
Functional Tier 4
Care Management
Functional Tier 3
Transition Care
Functional Tier 2
Navigating the Medical
Neighborhood
Functional Tier 1
All Tier 1-2-3 services plus:
 Comprehensive care plan
 Home visits
 Palliative and end-of life care
All Tier 1-2 services plus:
 Planned visits
 Self-management support
 Patient education
 Optimize chronic conditions
 Advance directives
All Tier 1 services plus:
 Notification of admit/discharge
 PCP and/or specialist follow-up
 Medication reconciliation
 Optimize relationships with
specialists and hospitals
 Coordinate referrals and tests
 Link to community resources
Prepared Proactive Healthcare Team
providing evidence-based, person-centered care
PCMH Services
P O P U L A T I O N
Complex Care
Management
Health IT
- Registry / EHR registry functionality
- Care management documentation
- E-prescribing
- Patient portal (optional)
- Community portal/HIE (optional)
Patient Access
- 24/7 access to decision-maker
- 30% open access slots
- Extended hours
- Group visits (optional)
- Electronic visits (optional)
Infrastructure Support
- PO/PHO and practice determine
optimal balance of shared support
- Patient risk assessment
- Population stratification
- Clinical metrics reporting
PCMH Infrastructure
7-12-11
Transitions of
care
Notification
of:
Admissions
Discharges
Emergency room
Strength
Weakness
Opportunity
Threat
Transitions of
care
PCP
Follow up
Specialist
Follow up
Medication
Reconciliation
Strength
Weakness
Opportunity
Threat
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Notifications of admissions, discharges , ER visits
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The Post-Hospital Follow-Up Visit: A Physician
Checklist to Reduce Readmissions
Eric A. Coleman, MD
Read more:
http://www.chcf.org/publications/2010/10/thepost-hospital-follow-up-visit-a-physicianchecklist#ixzz1omLp27nz
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Prior to visit
• Review discharge summary
• Clarify outstanding questions with send physician
• Reminder call to patient or family care giver
• Stress the importance of the visit and address any barriers
• Remind to bring medication list, medications both otc and rxd
• Provide instructions on seeking after hours care both emergent
and nonemergent
• Coordinate care with home health or care managers if
necessary
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During the Visit
• Ask the patient to explain:
• His/her goal for the visit
• What factors they believed led to admission/er visit
• What medications they are taking and on what schedule
• Perform medication reconciliation with attention to prehospital regiment
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Determine the need to
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Adjust meds
Follow up on any outstanding tests
Do monitoring or testing
Discuss advanced directives
Discuss future treatments (POLST)
During the visit (continued)
• Collaborate with patient on self management
support ; perform teach back
• Explain warning signs and how to respond ; have
patient teach back
• Provide instruction on how to seek after hours care
both emergent and nonemergent
At the Conclusion of the Visit
• Print reconciled and dated medication list and
provide a copy to the patient, family care giver,
home health nurse, and case manager (if
applicable)
• Communicate changes in the care plan to family
care givers, health care nurses, and care managers
• Consider skill home health care and other
supportive services
• Ensure the next appt is made as appropriate
Insanity: doing the same thing over and over again and
expecting different results.
Albert Einstein
More than you can count - in all different sizes and colors!!
The one the patient states they are taking
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In home assessment
Asking “how do you take your medications”
Not “do you take X in Y way”
Bag review
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Guhad A, Farris KB, Batra P,
Benzik ME.
Community health partners
perceptions of problems
with medication reconciliation.
Ongoing research.
Educating patients on issue related to safety and medication
Community partners to work with patients on medication
Personal Health Record
How-to Guide:
Improving Transitions from the Hospital to
the Clinical Office Practice to Reduce Avoidable
Rehospitalizations
Table conversation
Report out
Thanks
Mary Ellen Benzik, MD
mebstork@aol.com
Cell 269-580-7738
Office 269- 245- 3850