1. Integrating Care Managers within Practices MiPCT Team May 17, 2012

2. Agenda MiPCT Complex Care Management Training Update Geisinger evidence-based tools for CCMs, HCMs CCMs, HCMs – getting started MiPCT POs and Practices ▫Integration of CCMs, HCMs, MCMs into practice MiPCT support for POs and Practices

3. MiPCT CCM Training Update

4. MiPCT Complex Care Management Training Update CCM and HCM Training - 5 day course First 3 training sessions ▫Geisinger faculty, MiPCT Master Trainers To date 3 training sessions completed ▫4/23/12 – 4/27/12 New Hudson ▫4/30/12 – 5/4/12 Grand Rapids ▫5/7/12-5/11/12 Ann Arbor MiPCT CCMs/HCMs trained to date = 73

5. Complex Care Management Training Dates 6/4-8, 2012 Grand Rapids 6/4-8, 2012 New Hudson 6/18-22, 2012 Lansing 6/18-22, 2012 Madison Heights 7/9-13, 2012 Lansing 7/16-20, 2012 Okemos/Marquette (virtual) 8/20-24, 2012 Lansing

6. MiPCT Complex Care Management- Geisinger Partnership Background ▫Train the trainer program for the MiPCT CCM course ▫Certification  Master Trainers, Clinical Leads ▫Geisinger ProvenHealth Navigator Model  Evidence based tools  Standardized interventions based on Geisinger ProvenHealth Navigator model

7. MiPCT Complex Care Management Curriculum Day 1: Begins with MiPCT 101 Days 1,2,3 Geisinger ProvenHealth Navigator (PHN) model Standards of Practice for Case Management Patient population stratification Risk segmentation Right care, right place, right time: criteria based level of care determination Metrics Concept of Medical Home Population based case management Need to know targeted conditions Heart Failure COPD Population based care Path PHN 5 step case management model PHN Time management Medical Home meeting

8. MiPCT Complex Care Management Curriculum Days 4, 5 MiPCT BCBSM PGIP PCMH Identification of high risk MiPCT eligible patients Transitions of care Medication reconciliation Evidence - based care Chronic conditions Specific assessment tools Health Plan Payment Policy BCBSM, BCN, Medicare Advantage Medical Neighborhood Complex Care Manager documentation tools Teamwork SWOT Case Studies Complex care manager – a day in the life and getting started

9. Geisinger Evidence Based Tools For CCMs, HCMs

10. Geisinger Evidence-based Tools Geisinger Standard Case management tools To be used by MiPCT CCMs and HCMs Licensed tools Includes ▫CCM patient visit documentation tools ▫Self Management Action Plans ▫Care Manager Care Path CCM HCMs trained on tools during CCM course ▫receives hard copy of tools

11. Geisinger Evidence Based Tools CCM patient visit documentation tools ▫Comprehensive Patient Assessment (i.e. G9001) ▫Return visit note ▫Post discharge note (i.e. transition of care)

12. Geisinger Evidence-based Tools 10 Self Management Action Plans SMAPs -clinical topic specific Example of Heart Failure SMAP ▫BP monitoring schedule, BP goal ▫Patient education  Monitoring symptoms ▫Action plan (ex. eating right plan, daily weight, medications) ▫Who to call, when to call

14. Geisinger Evidence-based Tools SMAPs After surgery Asthma Case Management (general) COPD HF Diabetes HF HTN Osteoporosis Stop Tobacco Use UTI

15. Geisinger Complex Care manager Licensed Tools for MiPCT FAQ - specifies basic legal requirements PO Attestation letter ▫MiPCT POs need to sign attestation letter ▫Return signed attestation letter to MiPCTdemo@michigan.gov User agreement – micmrc.org ▫CCMs and HCMs  complete the MiPCT CCM course  will receive a username and ID, to access Geisinger tools on micmrc.org

16. PO, Practice Role - Use of Geisinger tools Review Geisinger tools with clinical leaders, CCMs, HCMs If you have an EMR ▫with care management documentation template  compare your current complex care management documentation templates to the Geisinger documentation tools  add fields to EMR documentation templates as needed to incorporate Geisinger content ▫with out care management documentation template  use Geisinger documentation tools If you have a paper medical record ▫MiPCT team will form a work group to develop usable paper tool version of the Geisinger documentation templates  timeline: by 5/24/12 recruit participants, work group meets following week

17. Geisinger Complex Care manager Licensed Tools for MiPCT Distribution of tools ▫CCMs and HCMs  access electronic version of tools via password protected micmrc.org web site ▫POs  first sign attestation letter  provide request for Geisinger tools via mipctdemo@michigan.gov and identify PO contact information  PO and practice - business need to know information

18. CCMs, HCMs – Getting Started

19. Initial Focus Areas for CCMs and HCMs Build Complex patient caseload Transitions of care  Post hospital discharge  Transition from one setting to another – ex. SNF to home Care coordination Medication reconciliation Build/expand the Medical Neighborhood

20. CCMs, HCMs - Screening Complex Care Management Referrals High Risk, high demand ▫MiPCT patient lists ▫PCP, RN, health care team referrals Chronically ill – multiple chronic conditions or poorly controlled Medically complex High utilizer of health system ▫ER visits, hospitalizations Frail/Elderly “Cringe Factor”

21. CCMs and HCMs Daily Work Prioritizing daily work - complex patient case load ▫Review MiPCT eligible patient list with PCP ▫MiPCT eligible complex patient with PCP visit today ▫Transitions of care  from one setting to another  hospital discharge patient list ▫Referrals ▫Follow up on patients in caseload Reminder - focus on MiPCT eligible patients

22. Care Manager Integration into the Practice Role of the PO, Practice Leadership, and MiPCT

23. Practice Leadership – Integration of Care Management Identify a physician champion Practice leadership, physician champion, CCM HCM MCM ▫Identify consistent MiPCT care management goals ▫Assess current processes ▫Redesign processes as needed

24. Practice Leadership – Integration of Care Management ▫Provide education regarding MiPCT and care management for all staff ▫Team members roles  define and communicate how each member contributes to care management ▫Introduction CCM, HCM, MCM to team members  if transitioning from clinic RN role to MiPCT care manager role; communicate Care Manager role responsibilities and expectations with team members

25. Practice Leadership - Integration of CCM, HCM, MCM into Practice Support communication, team building, and education ▫CCM, HCM, MCM schedule appointment with each Physician to discuss role ▫Team meetings ▫Staff meetings ▫Physician meetings ▫Meet with practice leadership ▫1:1 meetings with key members of the health care team

26. PO and Practice: Integration of CCM HCM MCM into Practice Basic ▫Work space ▫Phone ▫Providing the MiPCT attribution members list for CCMs, HCMs Advanced ▫Medical Home meeting  Multidisciplinary – representation of team members  Discuss Care management case studies  Data, Process improvements

27. How MiPCT can help Work with POs to address hospital barriers (timely discharge notifications, etc.) Provide resources and framework for enhancing team functioning ▫Support Learning Collaboratives, Lean workshops, other team based learning ▫More to come – soon! Care Management Resource Center MiPCT Care Manager regional infrastructure

28. Getting Started – Introducing Complex Care Management to the Practice What is your experience? What has worked? What has not worked? Ideas to try...