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MiPCT Launch Tier 1 and Tier 2

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Presentation on theme: "MiPCT Launch Tier 1 and Tier 2"— Presentation transcript:

1 MiPCT Launch Tier 1 and Tier 2
Mary Ellen Benzik,MD Associate Medical Director MiPCT

2 I wear many hats – Family Physician Medical Director of Integrated Health Partners Active participant in the BCBSM PDCM Associate Medical Director MiPCT

3 Significance of a Demonstration Project
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”

4 Critical Areas Self-management support Community resources
Care transitions Care coordination

5 Requires System Change Not Superman

6

7 Care Management MiPCT Framework
PCMH Services Infrastructure Person side Complex Care Management Functional Tier 4 All Tier services plus: Comprehensive care plan Home visits Palliative and end-of life care P O P U L A T I O N Care Management Functional Tier 3 All Tier 1-2 services plus: Planned visits Self-management support Patient education Optimize chronic conditions Advance directives Navigating the Medical Neighborhood Functional Tier 1 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 Optimize relationships with specialists and hospitals Coordinate referrals and tests Link to community resources PCMH Services PCMH Infrastructure Transition Care Functional Tier 2 All Tier 1 services plus: Notification of admit/discharge PCP and/or specialist follow-up Medication reconciliation Prepared Proactive Healthcare Team providing evidence-based, person-centered care Population side 7

8 Population health one person at a time

9 Care Management Conceptual Framework
PCMH Services Infrastructure Complex Care Management Functional Tier 4 All Tier services plus: Comprehensive care plan Home visits Palliative and end-of life care P O P U L A T I O N Care Management Functional Tier 3 All Tier 1-2 services plus: Planned visits Self-management support Patient education Optimize chronic conditions Advance directives Navigating the Medical Neighborhood Functional Tier 1 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 Optimize relationships with specialists and hospitals Coordinate referrals and tests Link to community resources PCMH Services PCMH Infrastructure Transition Care Functional Tier 2 All Tier 1 services plus: Notification of admit/discharge PCP and/or specialist follow-up Medication reconciliation Prepared Proactive Healthcare Team providing evidence-based, person-centered care 9

10 Care Management Conceptual Framework
PCMH Services Infrastructure Complex Care Management Functional Tier 4 All Tier services plus: Comprehensive care plan Home visits Palliative and end-of life care P O P U L A T I O N Care Management Functional Tier 3 All Tier 1-2 services plus: Planned visits Self-management support Patient education Optimize chronic conditions Advance directives Navigating the Medical Neighborhood Functional Tier 1 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 Optimize relationships with specialists and hospitals Coordinate referrals and tests Link to community resources PCMH Services PCMH Infrastructure Transition Care Functional Tier 2 All Tier 1 services plus: Notification of admit/discharge PCP and/or specialist follow-up Medication reconciliation Prepared Proactive Healthcare Team providing evidence-based, person-centered care 10

11 SWOT sheet Strength Weakness Opportunity Threat Navigating the medical
Neighborhood Strength Weakness Opportunity Threat Relationship with MD/hosp Coordination Referrals Coordination tests Link to community Resources

12 Navigating the Medical Neighborhood
Optimize relationships with specialists and hospitals Coordinate referrals and tests Link to community resources

13 The Care Coordination Model
We have to start at the practice level 13

14 PCMH in the Neighborhood
Accountability Know who your patients are (registry) Track referrals and test results acking_guide.pdf Patient Support Identification of patient medical, logistic, insurance needs Motivational interviewing Transition of care Identification of barriers

15 Connecting to the Neighborhood
Relationships and Agreements Community Agencies Hospitals / Emergency rooms Specialist 1483/PCMH_Tools%20&%20Resources_v2 home/1483 Connectivity &s=415 Case examples of three area solutions

16 It’s all about relationships
More than just a handshake

17 Concept of Compacts 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

18 SWOT analysis Table conversation Report out

19 Care Management Conceptual Framework
PCMH Services Infrastructure Complex Care Management Functional Tier 4 All Tier services plus: Comprehensive care plan Home visits Palliative and end-of life care P O P U L A T I O N Care Management Functional Tier 3 All Tier 1-2 services plus: Planned visits Self-management support Patient education Optimize chronic conditions Advance directives Navigating the Medical Neighborhood Functional Tier 1 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 Optimize relationships with specialists and hospitals Coordinate referrals and tests Link to community resources PCMH Services PCMH Infrastructure Transition Care Functional Tier 2 All Tier 1 services plus: Notification of admit/discharge PCP and/or specialist follow-up Medication reconciliation Prepared Proactive Healthcare Team providing evidence-based, person-centered care 19

20 SWOT sheet Strength Weakness Opportunity Threat Notification of:
Transitions of care Strength Weakness Opportunity Threat Notification of: Admissions Discharges Emergency room

21 SWOT sheet Strength Weakness Opportunity Threat PCP Follow up
Transitions of care Strength Weakness Opportunity Threat PCP Follow up Specialist Medication Reconciliation

22 Transitions of Care

23 Transitions of Care Notifications of admissions, discharges , ER visits

24 Transition of care The Post-Hospital Follow-Up Visit: A Physician Checklist to Reduce Readmissions Eric A. Coleman, MD Read more: post-hospital-follow-up-visit-a-physician- checklist#ixzz1omLp27nz

25 Transition of care – Check list for post hospital follow up
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

26 Transition of care – Check list for post hospital follow up
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 pre- hospital regiment Determine the need to Adjust meds Follow up on any outstanding tests Do monitoring or testing Discuss advanced directives Discuss future treatments (POLST)

27 Transition of care – Check list for post hospital follow up
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

28 Transition of care – Check list for post hospital follow up
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

29 Medication Reconciliation
Insanity: doing the same thing over and over again and expecting different results. Albert Einstein

30 Tools for medication reconciliation
More than you can count - in all different sizes and colors!!

31 Which is the Correct List
The one the patient states they are taking

32 The Correct List In home assessment
Asking “how do you take your medications” Not “do you take X in Y way” Bag review ………………… ………………………..

33 So – why can’t we get it right??
Guhad A, Farris KB, Batra P,   Benzik ME.   Community health partners perceptions of problems with medication reconciliation. Ongoing research. 

34 Engaging Patient Educating patients on issue related to safety and medication Community partners to work with patients on medication Personal Health Record

35 How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations

36 SWOT analysis Table conversation Report out

37 Challenges for Care Management
37 37

38 Figure. Proposed “Wedges” Model for US Health Care, With Theoretical Spending Reduction Targets for 6 Categories of Waste The “wedges” model for US health care follows the approach based on the model by Pacala and Socolow.9 The solid black “business as usual” line depicts a current projection of health care spending, which is estimated to grow faster than the gross domestic product (GDP), increasing the percentage of GDP spent on health care; the dashed line depicts a more sustainable level of health care spending growth that matches GDP growth, fixing the percentage of GDP spent on health care at 2011 levels. Between these lines lies the “stabilization triangle”—the reduction in national health care expenditures needed to close the gap. The 6 colored regions filling the triangle show one possible set of spending reduction targets; each region represents health care expenditures as a percentage of GDP that could be eliminated by reduction of spending in that waste category over time. Berwick, D. M. et al. JAMA doi: /jama Copyright restrictions may apply.

39 Furnace Story

40 Thanks Mary Ellen Benzik, MD Cell Office

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