1. The Michigan Primary Care Transformation (MiPCT) Project 2013 Annual Summit Sharing Care Management Best Practice & Building the Care Manager Caseload 1

2. Objectives Recognize the key elements of care management practice embedment Describe best practice steps and tools to identify patients for care management Identify successes, barriers and solutions to building and managing the care manager’s caseload 2

3. Care Management Embedment Clearly defined roles for each staff member Care Manager is an integral part of the PCP practice team Care Manager is integrated in the delivery of care by the practice Care Model ▫Redesign how care is delivered ▫Ex. Pre-visit planning, huddles, team based care, care manager’s schedule is visible by the staff 3

4. 4 Planned patient care i.e. huddles, processes, work flow, policies Care Manager and PCP partnership Office staff – defined roles and responsibilities Information technology, support Patient Care Management Delivery by the Practice PO and Practice Leadership PCMH meetings monthly, action plan, follow up

5. Identify Target Patient Population for Care Management... High Risk ▫MiPCT patient list ▫Risk scores ▫Frequent hospitalizations ▫Frequent ED visits ▫Multiple chronic conditions ▫Frail elderly ▫PCP and staff referrals ▫Peds with special needs ▫ECF/sub acute rehab ▫PCP/ practice staff input and referral Moderate Risk ▫MiPCT patient list ▫Newly diagnosed chronic condition ▫Poorly controlled chronic condition ▫Lifestyle and behavior change ▫Obesity ▫Prevention ▫PCP/ practice staff input and referral 5

6. What Data is Available? MiPCT Michigan Data Collaborative: Patient acuity ▫Risk scores Prevalence of chronic conditions for your practice Quality Metrics Primary Care Sensitive ED visits Inpatient hospitalizations Practice Data: Practice’s Registry Data Quality Indicator metrics Trending and benchmark data Patient acuity ▫Risk scores Other? What do I know about my Practice’s Patient Population? 6

7. 7 View PO Report Tab You can view the following reports that are specific to your PO: IP Detail Report (Most Recent 6 Months) IP Summary Report (Most Recent 6 Months) ED Summary Report (Most Recent 6 Months) ED Detail Report (Most Recent 6 Months) Reports You can view, sort, print, and export the data in these reports

8. How are we doing? Where are we with care manager’s building patient caseload? Is the g/cpt-code utilization increasing? What should the patient caseload be for a full time care manager? 8

9. 2013 PO Report – 1 st & 2 nd Quarter Care Manager Activities 9

10. Complex Care Managers Quartile 25th50th75th90 th Face-Face Encounters/FTE/quarter 223365884 Phone Encounters/FTE/quarter 250101172260 Unique Patients/FTE/quarter 2395388188 Hybrid Care Managers Quartile 25th50th75th90th Face-Face Encounters/FTE/quarter 2174190160 Phone Encounters/FTE/quarter 242106205321 Unique Patients/FTE/quarter 24983148211 Moderate Care Managers Quartile 25th50th75th90th Face-Face Encounters/FTE/quarter 21855106193 Phone Encounters/FTE/quarter 21342113238 Unique Patients/FTE/quarter 23365101184 2013 2 nd Quarter PO Report – Care Manager Activities 10

11. MiPCT Benchmark* for Care Manager Caseload Care manager’s patient caseload – 2 nd Quarter PO Data 11 Care Manager Role 90 th Percentile Qtr 2 face to face encounters/FTE 90 th Percentile QTR 2 phone encounters/FTE Encounters per day = Benchmark* Complex842606 encounters per day Hybrid1603218 encounters per day Moderate1932387 encounters per day

12. What Have We Learned So Far? Referral form for care manager Front staff identifies potential MiPCT patients in advance of patient visit PCP and care manager shared visit Leverage IT - ability to identify patient is enrolled in care management and care manager contact info Care manager addresses gaps in care ▫patient enrolled in CM or ▫patient identified as having gaps in care during office visit Triggers for identification of patients 12

13. Sharing Best Practice – What is working? Case Load Development Process – It Takes a TEAM 13

14. West Front Primary Care - Work FlowPractice /POMiPCT Care Management Webinar  Team Based Care – Balancing a Care Manager Caseload (identification of potential patients, team roles, integration)  Transition of Care West Front Primary Care/ NPO8.17.13 Care Management Using a Quality Improvement Process (identification of potential patients, team roles, integration) Family Tree Medical Associates/ POM 9.18.13  Transitioning Patients Enrolled in Care Management  Physician referral to Care Manager – A warm handoff Lakeshore health Network/ Mercy Primary Care Network n/a Utilizing Registry Report – Addressing HTN and the CM role Henry Ford Medical Groupn/a Building a Care Manager’s Caseload – Team based careHolt Family Practice/McLarenn/a Building Care Management Integration – Practice and PO support Holt Family Practice/McLarenn/a Medical Assistant & Care Manager Role- Population management St. Clair Medical, P.C./ Mercy Community Physicians PHO n/a 14

15. YOUR Voice Heard! 15

16. New Ideas to Consider 16

17. Moving Forward Ideas to move our state to MiPCT success What is working? Challenges to address? 17

18. Share YOUR Best Practice Complete a Best Practice template! Next Steps: ▫MiPCT team follows up to create workflow documents and distribution or ▫If practice work flow is documented...“will you share you work flow?” 18

19. Questions and Answers 19