Care Management News
January 13, 2015
Today’s Topics
2

Learning events

Maintenance of Certification

How IHI views MNO care management activities

Learning Community

What’s new
Training
3

Who Should Register? MNO PCPs and members of
the practice team

Prerequisites: Knowledge of medical terminology
and anatomy

Clock Hours: 10 (Note: 10 clock hours accounts
only for time spent in the online or in-person
course, proficiency exam and not study time. Study
time will vary widely per individual.)

Course Length: To be completed within a 3-month
period or less
Training
4

Certificate of Completion: Yes

Testing: A one-hour wrap up session followed by
a one hour competency exam is required

Course Material: Workbooks and study guides
available after registration
Why Attend
5

Identify conventions and guidelines used in coding

Describe signs, symptoms and ill-defined
conditions

Explain rule out versus probable, possible,
differential, suspected terms relating to diagnosis
Why Attend
6

Explain CMS STAR ratings

Illustrate how CMS STAR ratings are measured

Identify the CMS STAR ratings data sources

Demonstrate a strategy to improve STAR ratings

Illustrate coding chronic illness conditions using
Medicare’s guidelines for correct coding

Show the CMS Risk Adjustment Model and the
HCC Categories (Hierarchical Condition Categories)
Why Attend
7

Show examples of appropriate documentation and
coding

Describe common documentation inadequacies

Illustrate how to correctly incorporate the Chronic
Care Management (CCM) codes

Identify a successful patient-centered care plan
document

Explain transition care management codes
Cohort A: Instructor Led - Classroom
8

Wednesday, February 4
6:00pm-8:00pm

Wednesday, February 11
6:00pm-8:00pm

Wednesday, February 18
6:00pm-8:00pm

Wednesday, February 25
6:00pm-8:00pm
Cohort B: Instructor Led - Classroom
9

Thursday, March 5
6:00pm-8:00pm

Thursday, March 12
6:00pm-8:00pm

Thursday, March 19
6:00pm-8:00pm

Thursday, March 26
6:00pm-8:00pm
Cohort C: Instructor Led - Classroom
10

Monday, April 13
6:00pm-8:00pm

Monday, April 20
6:00pm-8:00pm

Monday, April 27
6:00pm-8:00pm

Monday, May 4
6:00pm-8:00pm
Full Day: Instructor Led - Classroom
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
Wednesday, February 4
8:30am-4:30pm

Saturday, February 7
8:30am-4:30pm

Wednesday, February 11
8:30am-4:30pm

Wednesday, February 18
8:30am-4:30pm

Saturday, March 7
8:30am-4:30pm

Saturday, March 14
8:30am-4:30pm

Saturday, April 18
8:30am-4:30pm

Monday, April 20
8:30am-4:30pm
Mandatory Wrap Up and
Competency Exam
12

Thursday, April 16, 2015
9:00am-11:00am
6:00pm-8:00pm

Saturday, April 18, 2015
9:00am-11:00am
10:00am-12noon

Thursday, May 14, 2015
9:00am-11:00am
6:00pm-8:00pm

Saturday, May 16, 2015
9:00am-11:00am
10:00am-12noon

Tuesday, June 15, 2015
9:00am-11:00am
6:00pm-8:00pm
Other Approaches
13

On demand

On-demand interactive

Self paced learning
Why Attend Training
14

Contractual Agreement

Documentation training

Coding

Preparation for ICD-10
A Guide For Caring For the Elderly
15

Two day training for team members

Certificate upon completion

Membership in learning community

First training in May
Maintenance of Certification
16

Part IV module, ABMSF AF4Q Greater Detroit Area
Health Council (GHAHC), was added to each
Physician Portfolio

All MNO PCPs who successfully completed MLC III
were awarded the CMEs for MOC – Part IV
MOC - Part IV and MLC
17

A payment is required to complete the process.

Within the Physician Portfolio, you will see a
Pending Payment link on the Modules Page under
the modules listed in-progress. Click the "Pending
Payment" link will permit you to make this
payment online.

Until payment has been made credit will not be
awarded.
BCBSM, IHI and MNO

Target population
• Medicare Advantage members with at least 6
chronic conditions who are attributed to a physician
organization that is providing high intensity care
model
18
BCBSM, IHI and MNO

Target population’s core challenges
• Psychosocial needs
• Mental health needs that are unmet
• Polypharmacy
• Managing 6+ chronic conditions
• Geo location
• Lack of practice and PCP buy-in
19
BCBSM, IHI and MNO

Integrated Care Team
• Community-based multi-disciplinary care team with
heavy emphasis on psychosocial support
• Integrated care team coordinates with dozens of
Primary Care Physicians in the community
• PCPs sit outside the Integrated Care Team
20
MNO Team

Nurse Practitioner
• Oversees HICM including developing policies and
procedures
• Provides medical interventions as needed
• Makes home visits, including doing initial
assessment with social worker when needed

Geriatrician
• Assess interdisciplinary team activities
• Reviews cases
• Advises team on assessments
MNO Team

Registered Nurse
• Assigned to Primary Care Provider to serve a panel
of patients
• Does outreach to PCPs to recruit patients
• Assists in patient recruitment
• Provides home visits
• Navigates care with patient/caregiver/family
• Interacts with hospitalist, home care agency, DME
• PCMH –N activities
MNO Team

Psychologist (PhD)
• Supervises the masters level behavioral health
providers
• Oversees psychosocial assessments
• Provides home visits when necessary
Clinical Psychologist
24

Consults with the team around care plans as each
patient is reviewed in the weekly huddle

Leads learning modules related to behavioral health
factors (eg. depression, dementia, caregiver burden,
chronic pain... and adds BH perspective to other
modules)

Participates in the development of policies and
procedures and clinical protocols from a BH
perspective
Behavioral Health Care Management

BH CM goes beyond assessment, care planning,
and linking to community resources
• Provides brief behavioral health, evidencebased interventions shown to be helpful with
geriatric patients
• Facilitates self-management support of mental
health and physical health symptoms through
motivational interviewing, patient education, and
brief action planning
25
Behavioral Health Care Management

Other kinds of interventions include
• brief problem solving therapy
• teaching relaxation techniques
• supportive counseling to caregivers
• brief cognitive-behavior therapy
26
MNO Care Team

Social Workers
• Perform initial assessment with nurse practitioner or
RN
• Co-create care plans with patient and other care team
members
• Link patients to community resources
MNO Care Team

Dietitian and/or Certified Diabetes Educator
• Co-create meal plans with patients/caregivers
• Access community resources for patients and their
caregivers
• Teach care team

Pharmacist
• Provide medication education, management and
reconciliation
• Meet with Primary Care Physicians
• Teach care team
28
MNO Care Team

Medical Assistants
• Provide back-up support and complete paperwork

Health Coaches: Certified Exercise Specialists
• Trained in wellness, health, and injury prevention as
well as health coaching
• Design exercise programs in the home
29
MNO Care Team

Primary Care Physicians
• Provides primary care in various communities
• Assesses care plans
• Communicates with Integrated Care Team via
Protected Time
MNO Care Team coordinates with over
80 Primary Care Physicians
30
MNO Care Team

Caregiver/Family members
• Interact directly with the care team
• Partner in creating and carrying out the care plan
31
What Else…

Central Training and Education Hub: Comprised of
Nurse Practitioner, Registered Nurse, Pharmacist
and Psychologist
Provide training
Lead team in a 4 hour weekly meting
Assess team competency
Lead Quality Improvement activities
Develop and share PDSAs
32
MNO Care Team Support

IT Support
• Data capture
• Maintain central electronic health record
• Create templates
• Repository
33
MNO Care Team Support

Coding and Billing
• Interacts with payer
• Coders and Billers
• Revenue Cycle Consultant
• Run reports on documentation completion by the
team
• Advise on ways that team can increase efficiency
34
What We’ve Learned So Far
35

Behavioral health is the key component of the care
team

Relationship between Primary Care Physicians (PCPs)
and patients is very significant

Collaborating with PCPs requires finding the key
person in each PCP office
What We’ve Learned So Far
36

Learning how PCP and practice team prefer to
communicate, and using technology to
communicate in real time (secure text & email)

PCPs are very responsive to Integrated Care Team
including making same-day appointments available
to Integrated Care Team patients
What’s New
37

SIM Grant

Innovation Grant

Clinical Team
Open Discussion
38