1. The Michigan Primary Care Transformation (MiPCT) Project: December PGIP Meeting Update MiPCT Team December 2, 2011 1

2. Agenda Introduction MiPCT Participation Care Management Update Funding Update MiPCT Next Quarter Timeline Invitational Launch Meeting Care Manager Practice Integration 2

3. MiPCT Participation Statistics JanuaryApril (yes/tentative) Total POs29332 Practices38770457 Providers1,6281541,782 Patients1,111,290127,9611,239,251

4. MiPCT Care Management Update Self Management Training programs MiPCT Implementation Guide Part 1 Complex Care Manager Training Update 4

5. Self Management and Moderate Risk Care Management (MCM) Training Programs A summary of Self Management and Moderate Risk Care Manager training programs ▫training programs reviewed by MiPCT team Self Management training ▫programs must be MiPCT approved ▫required for all Care Managers 5

6. Self Management Training Program- MiPCT Criteria Self management support – background Motivational Interviewing and/or Empowerment skills Individualized patient assessment Collaborative goal setting Problem solving Systematic follow up, support Minimum 6 hours didactic Opportunity for learner to practice new skills ▫Post didactic - trainer facilitated webinar, conference call, face to face meetings to discuss case studies 6

7. Self Management and Moderate Risk Care Management (MCM) Training Programs MCM and self management training programs “at a glance” Programs vary: some are specific to self management training, a few address both MCM and self management training Program objectives/content Program contact Resources Modality Duration, location Trainer qualifications Certification, CEs Statewide or regional Cost “Self Management and MCM Training Programs" posted: mipctdemo.org 7

8. Self Management and Moderate Risk Care Management (MCM) Training Programs The self management and MCM training document will continue to expand MiPCT will continue to review and add training programs How you can help Contact mbeisel@umich.edu if you have an existing self management or MCM training program you would like reviewed or find another one that you are interested in pursuing 8

9. Self Management Resources Self Management resources – summary document May be used as a supplement to a self management training program Ex. toolkits, videos, modules How you can help Please submit self management resources to mbeisel@umich.edu “Self Management Resources” posted: mipctdemo.org 9

10. MiPCT Implementation Guide – Part I Background Overview of care management Successful components of care management Care Management Model and Staffing  Four models: travel team, integrated, hybrid and central  Description of models  Pros and cons of each model  Steps to identify a care management model that is a good fit  Includes table with potential models to consider based on patient population, CCM & MCM FTE, and practice locations 10

11. MiPCT Implementation Guide – Part I cont. Essential characteristics/skills for Care Manager Strong communication skillsMotivated, self-directed “People” skillsEngagement of patients and providers Critical thinking skills Psychosocial aspects of chronic conditions Patient engagement and activation skills Basic computer skills Negotiating and conflict resolution skills Ref: Geisinger Health Plan, The Medical Home Case Manager, April 2010 Roles - Care Managers, Panel Management Hiring Care Managers 11

12. MiPCT Implementation Guide – Part I cont. Operations Training CCMs, MCMs Integration of care manager into practice setting Team roles Identification of patients for care management “MiPCT Implementation Guide Part I” posted: mipctdemo.org 12

13. MiPCT Implementation Guide – Part II planned – topics G codes Geisinger specific CCM curriculum Care Management Software MiPCT Data reports, Patient Lists Team roles 13

14. Complex Care Manager (CCM) Training MiPCT will provide required training for CCMs ▫Tentative - MiPCT partnership with Geisinger ▫Expect plan to be finalized within 1 - 2 weeks Train the Trainer Model MiPCT Webinar 12/9 3-5 pm ▫ Update CCM training 14

15. MiPCT Training for Complex Care Managers (CCMs ) and Hybrid CMs CCMs and Hybrid Care Managers ▫Mandatory completion of MiPCT CCM training  MiPCT team provides standardized CCM training  CCM training will take place in Michigan Time line -tentative ▫CCM Master Trainers – training occurs Jan/Feb 2012 ▫Group 1 CCM - training occurs (ideally) Feb 2012 ▫Plan rolling training for several months 15

16. Complex Care Manager (CCM) Training CCM train the trainer model 10 – 15 Master CCM Trainers Master Trainers  Located Regionally  Receive training directly from Geisinger Master Trainer role  Preceptor for new MiPCT CCMs  Patient caseload Cost  Some salary subsidized by MiPCT 16

17. MiPCT Clinical Resources MiPCT clinical content temporary location - mipctdemo.org Michigan Care Management Resource Center website - live Jan 2012 micmrc.org will transition MiPCT clinical content from mipctdemo.org to the micmrc.org website - Jan 2012 17

18. Funding Update BCBSM – off-cycle payment for portion of first three months funding will be sent next week (tentative date December 9) ▫Purpose is to “jump-start” care management ▫Balance of first quarter payments will be sent in January PGIP payment, represents $3 PMPM payment BCN – will determine within the next week when they will start G-codes/CPT codes ▫Understand that POs/PHOs/practices need ramp up time to begin G-code billing ▫Committed to paying $3 PMPM until that time 18

19. MiPCT Timeline – next 4 mos. Implementation Plan Part CDue December 8, 2011 MiPCT Webinar: Care Management software, CCM training December 9, 2011 3-5 pm MiPCT Webinar: Financial reporting and Performance Incentive metrics December 14, 2011 3-5 pm Post positions, interview, and hire Care Managers In progress, continue (high priority) Plan training for MCM Care Managers: Select a MiPCT approved self management training program Review MCM general recommended training topics Schedule training programs for MCMs – align with hiring dates MiPCT Invitational Launch MeetingMarch – April 2012 19

20. Michigan Primary Care Transformation Project (MiPCT) Launch Invitational Meeting Supporting Your Success in Partnering with Patients to Improve Care Experience, Outcomes, and Value 20

21. Launch meeting Goal of Meeting ▫To advance our practice unit’s and organization’s capabilities to implement the MiPCT program in their networks.  Provide a motivational kick off to the program  Create network opportunities and best practice sharing  Develop the knowledge and skills necessary for success Multiple Meetings (2 or 3) ▫Located in South, West, North Regions Who should attend ▫1 Representative from each PO/PHO Dates: ▫March-April 2012 21

22. One Day Program Key Note Speaker ▫Motivational MiPCT Overview and Updates Skill Building Session ▫Change management and practice transformation Breakout sessions ▫ Transitions in Care ▫ Medication Reconciliation ▫ Extended Access and Patient Awareness ▫ Patient Advisory Council ▫ Data Collaborative Update ▫ Care Management Resource Center: An In-depth Look Sharing our stories ▫ Our Practice ’ s Best Practice for PCMH ▫ What Do We Do Well? ▫ Identifying Our Opportunities for Improvement 22

23. Care Manager Practice Integration 23

24. Care Management Models ▫Travel Team  Consists of MCM and CCMs that are responsible for a patient caseload at multiple practices ▫Integrated  Consists of MCMs and CCMs that are located on site at the practice ▫Hybrid  The role of the CCM and MCM is filled by one individual ▫Central  The Care Manager is located off-site and supports multiple practices  Care Manager spends at least 50% FTE onsite at practice location  The role of the CCM and MCM may be filled by one individual or may be separate individuals

25. We need to let them into the PCMH !!

26. Let them on the Team – Care Management at the Practice Level

27. Integrating Care Management into Primary Care Care Management Resource Center Experience of the 5 pilot BCBSM PDCM physician organizations ▫Henry Ford ▫U of M ▫Genesys ▫Lakeshore Health Network ▫Integrated Health Partners Participation in learning opportunities in 1 st to 2 nd quarter 2012

28. Questions and Discussion 28