WEBINAR #1: FUNDING MODEL, CARE MANAGEMENT MODELS AND IMPLEMENTATION PLAN NOVEMBER 3, 2011 Michigan Primary Care Transformation Project

Agenda MiPCT funding  Payment amounts  Timing of distribution  BCBSM/BCN care coordination payments MiPCT Care Managers  Overview of roles, job descriptions and training  Staffing models for your PO/PHO Part C Implementation Plan  Section 1: Care management contacts and staffing  Section 2: Activities for MiPCT functional tiers  Section 3: Care coordination and incentive payments 2

MiPCT Funding

Payment Amounts 4 PayerCare Coordination Payment Practice Transformation Payment Performance Incentive Payment Medicare$4.50 PMPM$2.00 PMPM$3.00 PMPM (variable) Medicaid Managed Care $3.00 PMPM$1.50 PMPM$3.00 PMPM (variable) BCBSMEncounter based G-codes 10% E/M uplift (not new money) Existing PGIP incentives (not new money) BCNEncounter based G-codes $1.50 PMPM for FFS contracts only Difference between $3.00 and current pool

Funding/Distribution by Payer Medicare  Care coordination payment ($4.50 PMPM)  Paid monthly  Flows to PO/PHO  First payment expected January 2012  One month’s payment held for complex care manager training yr 1  Practice transformation payment ($2.00 PMPM)  Paid monthly  Flows to practice  First payment expected January 2012  Performance incentive payment ($3.00 PMPM average)  Paid semi-annually  Flows to PO/PHO  First payment expected July

Funding/Distribution by Payer Medicaid  Care coordination payment ($3.00 PMPM)  Paid quarterly  Flows to PO/PHO  First payment expected March 2012  One month’s payment held for complex care manager training year 1  Practice transformation payment ($1.50 PMPM)  Paid quarterly  Flows to practice  First payment expected March 2012  Performance incentive payment ($3.00 PMPM average)  Paid semi-annually  Flows to PO/PHO  First payment expected July

Funding/Distribution by Payer BCBSM  Care coordination payment (G-codes, CPT codes)  Encounter-based payments  Flows to entity who files the claim  First G-code payments expected April 2012  First quarter’s payments will be paid PMPM in late Nov 2011  Practice transformation payment  Existing 10% E/M uplift  No changes in amount/flow – NOT NEW MONEY  Performance incentive payment (Existing PGIP payment)  Paid semi-annually  No changes in amount/flow – NOT NEW MONEY 7

Funding/Distribution by Payer BCN  Care coordination payment (G-codes, CPT codes)  Encounter-based payments  Flows to entity who files the claim  First G-code payments expected January 2012 (still TBD)  Practice transformation payment ($1.50 PMPM)  Paid monthly (tentative) ONLY TO FFS CONTRACTS  Flows to practice  First payment expected January 2012  Performance incentive payment ($1.20 PMPM average)  Paid semi-annually (tentative)  $1.20 amount incremental to existing PRP/PAYG payments  Flows to PO/PHO (tentative)  First payment expected July

Care Management Funding Sources Two sources of care management funding:  PMPM payments – “guaranteed” 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 9

BCBSM/BCN Care Coordination Payments G codes  G9001: Coordinated care fee – initiation rate (all inclusive)  G9002: Coordinated care fee – maintenance rate CPT codes  98961: Group education (2-4 patients)  98962: Group education (5-8 patients)  98966: Telephone assessment/medical discussion (5-10 min)  98967: Telephone assessment/medical discussion (11-20 min)  98968: Telephone assessment/medical discussion (21+ min) More details to be provided on next webinar 10

MiPCT Funding Spreadsheets Distributed to each PO/PHO Contents  Sheet 1: Information tab  Sheet 2: PO/PHO funding summary  Sheet 3: Funding detail by practice  Includes number of care managers funded by practice Moderate risk care managers Complex care managers  Allows customization of care manager salary/benefits 11

OVERVIEW OF ROLES, JOB DESCRIPTIONS, TRAINING MiPCT Care Managers

Role Comparison: Moderate Risk Care Manager, Complex Care Manager Moderate Risk Care Manager (MCM)Complex Care Manager (CCM) Patient Population 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. Patient Caseload Caseload 500 (approx active patients); one MCM per 5,000 patients. Caseload 150 (approx active patients); one CCM per 5,000 patients. Focus of Care Management Proactive, population management. Work with patients to optimize control of chronic conditions and prevent/minimize long term complications. Targeted interventions to avoid hospitalization, ER visits. Ensure standard of care, coordinate care across settings, help patients understand options. Duration of Care Management Typically a series of 1 to 6 visitsFrequency of visits high at times, duration of months 13

Hybrid Care Manager Model Definition of hybrid model: one individual who fills both Complex Care Manager (CCM) and Moderate Risk Care Manager (MCM) role  Considered only for special circumstances  practices with significantly fewer that 5,000 MiPCT attributed patients  Practice that serve primarily pediatric patients and have fewer complex patients  Individual filling both roles must complete the MCM and CCM training requirements  Hybrid model will be evaluated during first year of intervention; continued if successful 14

Complex Care Manager Role 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 on building capacity of patient/family for self care Provides patient/family education  with teach back, sustain over time Implements evidence-based care, chronic disease protocols and guidelines  intervene early during acute exacerbations  analyze complex data sets  monitor patient/family response Creates/maintains individualized plan of care 15

Complex Care Manager Role cont. Coordination of care  Specialists, hospitals, community resources, etc. Transitions of care Assists with advance directives, palliative care, hospice and other end of life coordination 16

Complex Care Manager Job Description Sample of key required qualifications* Current MI License: RN, MSW, NP, PA 3 years experience  adult medicine and pediatric patients (as applicable to practice)  setting: 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 * note: see CCM job description for complete details 17

Complex Care Manager Training MiPCT and Care Management Resource Center will provide training - required  standardized interventions and tools  evidence based  if practice currently has a complex care program in place, MiPCT team will review MiPCT to partner with Geisinger for CCM training (potential)  train the trainer model Self Management Support training – required More details on CCM training will be provided in the next webinar 18

Moderate Risk Care Manager Role Partners with practice leadership team to integrate care management Assesses healthcare, educational, and psychosocial needs of patient/family Provides self management support  focus is 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 19

Moderate Risk Care Manager Job Description Sample of key required qualifications* Current MI License: RN, MSW, NP, PA, LPN, RD, Pharmacist 2 years experience  adult medicine and pediatric patients (as applicable to practice)  setting: home health agency, primary care practice, skilled nursing facility, hospital medical-surgical unit Knowledge of chronic conditions  evidence-based guidelines, prevention... Excellent assessment, triage skills Excellent communication and facilitation skills *note: see MCM job description for complete details 20

Moderate Risk Care Manager Training Core Curriculum: three areas of focus  Self Management Support training - required  General training topics - suggested Important for building MCM’s knowledge base and skills Topics may be refined based on individualized needs of the practice  MiPCT training – required MCM Training responsibility shared  MiPCT and Care Management Resource Center + POs/PHOs/IPAs, practices 21

Moderate Risk Care Manager Training: Who arranges/provides training? MCM Training topicShared by MiPCT and PO/PHO/IPA/ practice MiPCT team PO/PHO/ IPA, Practice Self management support training – required, arranged by the PO/PHO/IPA, practice x General, suggested topics x - subset of the general topics x MiPCT training topics - required x 22

Moderate Risk Care Manager Training General Topics - sample Chronic Care ModelBasic care management tools, concepts PCMH overviewDeveloping competence in managing chronic conditions (DM, Asthma, CAD, HF, COPD, HTN, Depression) Role of the Moderate Risk Care ManagerTransition of care, coordination of care, medication reconciliation, health literacy, cultural competency, advance directives * (MiPCT team and PO/PHO/IPA, practices - provide training) Identifying psychosocial issues and barriers Criteria to identify/refer to CCM 23

Moderate Risk Care Manager Training MiPCT Topics - sample Orientation to PCMH and MiPCT G code billing Participation in Michigan Care Management Consortium Measurement and reporting Integration into PCMH designated practices Transition of care, coordination of care, medication reconciliation, health literacy, cultural competency, advance directives * (MiPCT team and PO/PHO/IPA, practices - provide training) Care management documentation 24

HOW MANY DO YOU NEED? WHERE WILL YOU PUT THEM? MiPCT Care Managers

Care Management Priorities Care managers work in close proximity to PCP team  In PCP office as much as possible  When designing model, work with PCP team to meet their needs Ensure Complex Care Management coverage  1:5000 for adult population  1:2500 if using hybrid model Focus on evidence-based interventions  Medication reconciliation  Care transitions  In-person contact with patients whenever possible  Comprehensive care plan for complex patients 26

Designing a Model for your PO/PHO Consider on-site care managers (CCM and MCM) for sites with 5,000 or more beneficiaries Sites with 2,500-5,000 beneficiaries  Options (examples, other scenarios possible)  on-site CCM, “travel team” for moderate risk patients  On-site MCM, CCM shared among 2-3 practices  On-site “hybrid” care manager, plus non-licensed care coordinator Sites with < 2,500 beneficiaries  Both CCM and MCM roles shared among 2-3 sites Case studies and implementation guide on the way Contact MIPCTDEMO.michigan.gov for free consultation 27

Contact Information: Care Management Marie Beisel MSN, RN, CPHQ UMHS Project Manager, Care Management Resource Center e mail: office phone: Jean Malouin MD, MPH Medical Director, Michigan Primary Care Transformation Project e mail: Office phone:

OVERVIEW AND GENERAL INSTRUCTIONS Implementation Plan Part C

Instructions for completing form Work with participating practices to develop responses for each section on the form Return completed form to Amanda First at by December 1, 2011 Completed forms will be reviewed and feedback provided by December 15, 2011 POs/PHOs needing assistance should contact MiPCT at 30

Section 1: Care Management Contacts/Staffing Identify lead MiPCT care management contact for each practice Care management staffing  Describe how care management will be staffed for each participating practice  Describe tools/processes to integrate care managers into practice Describe plans for training care managers  Complex care managers (MiPCT program)  Hybrid care managers (use MiPCT complex care training)  Moderate risk care managers (menu of options)  Specify if consultation desired 31

Section 2: Activities for MiPCT Functional Tiers Describe current and planned activities for each of the MiPCT functional tiers:  Navigating the medical neighborhood  Care Transitions  Care Management  Complex Care Management 32

Section 3: Care Coordination and Incentive Payments Describe how care coordination funding will be distributed between PO/PHO and practice Describe how incentive payments will be distributed between the PO/PHO and practice (Information required by CMS)  Percentage of incentive payments to be retained by PO/PHO  Services provided by PO/PHO 33

Questions ? 34