1. MICMT Complex Care Management Course
Introduction
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2. Welcome! HOUSE KEEPING Location of bathrooms etc.
Facilitators introduce themselves

3. Group Activity Introductions Your name Your discipline
Your practice location
How long have you been in your role
Have participants get into groups and take turns answering the question aloud.
Also during this time, have participants fill out tent cards with their name, discipline and amount of time in their role.
Have an example tent card ready to show. Ex: Sarah Fraley, LMSW Social Worker, 2 years

4. Question What’s Most important for You to learn today
Record answers on dry erase board or hanging paper.
Attend to these questions throughout the day.

5. Learning Objective
Describe Michigan Institute for Care management and Transformation goals and resources available for physician office team members
Direct participants to notecards on tables to use for questions that come up throughout the day.
Collect the first bunch at lunch and address during the 2nd half of the day
Review the rest of the cards during the last break of the day

6. Competencies
I identify patients and populations appropriate for care management utilizing available clinical data and a risk score if available.
I collaborate/coordinate care with the PCP and member of the PCP practice team to improve the health of the population of patients attributed to the PCP, as measured by the outcomes measures of demonstration programs the practice participates in: CPC+, SIM, PDCM, Priority Health.
I apply the key steps of the evidence based Care Management 5 step process  (referrals, screen, enroll, management, and case close) for patients on Care Management Services to assess, plan, and manage patients and caseload.

7. Competencies Cont.
I use transition of care patient follow-up information to assess and plan care management services
I am applying the key steps of the evidence based 5 step process for patients on Care Management services to assess, plan, and manage patient and case load
I incorporate identified SDOH needs into the patient’s plan of care and care interventions and conduct follow-up on needs, goals and outcomes.
I build and balance case load and services across the team to optimize care, billing codes and create sustainability  of the care management program and services .

8. Michigan Institute for Care Management and Transformation (MICMT)
Who we are:
Partnership between University of Michigan and BCBSM Physician Group Incentive Program
Goal of MICMT:
To help expand the adoption of and access to multidisciplinary care teams providing care management to populations served by the physician community in order to improve care coordination and outcomes for patients with complex illness, emerging risk, and transitions of care
MICMT will comprehensively support the work of care team members in primary care setting: SW, RNs, Pharm D and assist with providing training and guidance/best practice dissemination to the care team
And provide a mechanism for data collection and analysis about care management around the state. We are a collaboration between Michigan Medicine and BCBSM

9. MICMT Team Members Pharmacist Hai Mi Choe, PharmD Executive Director
Marie Beisel, MSN, RN, CCM, CPHQ
Administrative Manager Senior Healthcare
Alicia Majcher, MHSA
Administrative Director of Care Management
Julie Geyer, BBA
Senior Project Manager
Sandy Becker, MA
Data Analyst
Judy Avie, BSN, M.Ed. IT, RN
Program Manager
Sarah Fraley, LMSW, ACSW
Project Manager
Scott Johnson, BBA, MSA, RN
Project Manager
Sarah Fraley, LMSW, ACSW
Betty Rakowski, BSN, RN, MA Ed
Curriculum Designer
Nicole Rockey, PharmD
Pharmacist
Cindy Stevens
Administrative Assistant Sr.
Julie Wolf

10. MICMT Care Manager Resources
Statewide Live and Recorded Webinars
One webinar per month
Care Management Connection Newsletter
eLearning Modules
Care Management 101
Care Management/ Team Based Success Stories
Best Practice Sharing
Tools
Quality
Michigan Care Management Resource Center website

11. MICMT Complex Care Management In-Person Course Curriculum
Care Management Delivery in the Primary Care Setting
Team Based Care
5 Step Process
Financial Aspects of a Care Manager’s Day
Transitions of Care in the Primary Care Setting
Comprehensive Assessment and Care Plan
Social Determinants of Health

12. Successful completion of the MICMT CMC
Completion of self-study modules through MICMT website
Post test grade of 80% or better
Completion of 1 day, in person training
Post test grade of 80% or better TBD
Completion of CM course evaluation, (sent to your address)
External trainer may alter self-study

14. Care Management in the Primary Care Setting – The Michigan Landscape
/31/ Michigan Primary Care Transformation demonstration (MiPCT)
1/1/2015 Centers for Medicare & Medicaid Services (CMS): Chronic Care Management Services
2015 and ongoing: Michigan Health plans have Care Management programs for practices who meet criteria
1/1/17: Michigan State Innovation Model and the Comprehensive Primary Care Plus models of care

15. Care Management Programs
Michigan Care Management Programs for Practices who meet Criteria:
State Innovation Model (SIM)
Comprehensive Primary Care Plus (CPC+)
BCBSM Provider Delivered Care Management (PDCM)
Priority Health Care Management

16. Activity Care Management Introduction Activity
Share your example from self-study:

17. Contact Us
General Questions/Inquiries: MiCMRC Complex Care Management Course Questions/Inquiries:

18. MiCMRC CCM Course Reference Guide
MiCMRC Recorded Webinars…………….……………………………………………..8
Michigan Care Management Resource Center Website…………………….13