1. The Michigan Primary Care Transformation (MiPCT) Project WELCOME TO THE 2015 MiPCT SUMMIT!

2. MiPCT Payers, Patients and Providers As of March 2015: 1814 providers ▫1,577 physicians ▫237 mid-level providers Over 500 care managers 346 PCMH practices 1,158,650 members # Patients% Patients Medicare186,99716.1% Medicaid214,74518.5% BCBSM361,80231.2% BCN275,31623.8% Priority119,99010.4% Total1,158,850100.0%

3. MiPCT Synergy with Blueprint Pillars 3 Vision: MC system that maximized health status through evidence and value-based care delivery MiPCT Population Health Management -Registry skill- building -Role of panel managers -Training specific to each role as well as team-wide sessions MiPCT Pay for Value -Competitive Incentives to Drive Behavior -Commercial G and CPT Code Care Management Billing MiPCT Integration of Care -Patient identification and Engagement -Team-based care focus -Transition coordination MiPCT Structural Transformation -Dashboards; Incorporation of Registry Data -Support for Health IT and Analytics -ADT alerting

4. The Michigan Primary Care Transformation (MiPCT) Project Evaluation and Program Updates 8:40-9:10 AM

5. Evaluation Update 1.Overall Evaluation Results to Date 2.Patient Experience Results 3.Care Manager Survey Results 4.Care Manager Activity 5.MiPCT Utilization & Quality Trends 5

6. Overall evaluation results to date Cost savings for Medicare beneficiaries ▫Caveat: quarter to quarter variation All-payer utilization, 2011 - 2013 ▫Increase in ED rates ▫Moderate decline in hospitalizations Patient experience (2015) ▫MiPCT Adults generally more positive than non-MiPCT ▫MiPCT parents about the same as non-MiPCT 6

7. Overall evaluation results to date Provider/staff survey reveals satisfaction with Care Management model Care Management survey and PO data collection reveal progress on embedment Care Manager activity leveling off: 25,000 – 30,000 unique patients per quarter 7

8. 8

9. Methods Stratified random sample ▫MiPCT and comparison group status ▫Payer ▫High/very high risk concurrent risk category Multi-modal (mail with phone follow-up) Response rates ▫Medicare ▫Medicaid ▫Commercial 9

10. 10 Adult survey results: MiPCT

11. 11 Adult survey results: MiPCT

12. 12 Child survey results: MiPCT

13. 13 Reported occurrence Child survey results: MiPCT

14. Analysis Regression: Generalized Linear Model IBM SPSS v. 19 Independent Variable: MiPCT status Controlled for: risk category, payer Interactions with MiPCT status (e.g., does MiPCT/PCMH have a different relationship with patient experience for some groups based on): ▫High/very high risk score ▫Payer type (Medicare, Medicaid, Commercial) 14

15. * * * * 15 Adult survey results * Statistically significant difference

16. 16 Adult survey results * Statistically significant difference * * * * * *

17. Child survey results: MiPCT versus comparison groups MiPCT patients were not significantly different than other PCMH patients across domains MiPCT patients were not significantly different than non-PCMH patients across most domains ▫Exception: MiPCT patient ratings of provider attention to growth and development 11.6% higher 17 *

18. 18

19. 19 Average Total Patients in Caseload (at the time of survey) :

20. Protocols 20

21. Team members understand which patients might benefit from care management 21

22. Practice Support 22

23. 23

24. PO Quarterly Reporting 24

25. 2011, 2012, & 2013 25

26. Estimated Average MiPCT ED and Inpatient Rates (#/1,000 member years) NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color. 26

27. Estimated Average MiPCT Diabetes Rates NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color. 27

28. Estimated Average MiPCT Adult Preventive Rates NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color. 28

29. Estimated Average MiPCT Peds Preventive Rates NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color. 29

30. MiPCT Clinical Update 30

31. 31 The Care Management Resource Center: Helping our Practices to Help Our Patients Year# CM Trained 2012273 2013165 201470 2015 to date73 TOTAL581 Almost 600 CMs have been trained and supported with continuing education since the MiPCT began As health plans (Priority, BCBSM) have expanded the care management benefit beyond MiPCT practices, the CMRC has expanded training sessions (link at: http://mipct.org/care- management-resource- center/ccm-online-registration- page/ http://mipct.org/care- management-resource- center/ccm-online-registration- page/ CMRC Care Manager Training Growth Over Time

32. The Higher the Risk, the More Likely Patients are to Receive CM 32

33. Progress Recap 2015-16 Clinical Focus Areas Addressing social determinants of health and overcoming barriers ▫Mary Ellen Benzik, Tiger Team Lead ▫Toolkit and white paper in development Integrating behavioral health ▫Kevin Taylor, Tiger Team Lead ▫Tiger Team tookit and white paper in development ▫Advocacy: proposed CMS collaborative care model ▫Coordinating with BCBSM/Priority Health work 33

34. Progress Recap 2015-16 Clinical Focus Areas Patient registry and data support for population health ▫Registry and EHR User groups being formed for systems most-used by MiPCT practices ▫CMRC site visits to better understand and spread processes highly linked to HEDIS and STAR improvement Integrating palliative and end-of-life care ▫Advocacy for CMS proposed advance care planning codes ▫Ongoing work with Palliative Care subject matter experts Addressing appropriateness of care (e.g., Choosing Wisely program, etc.) ▫To launch in 2016 34

35. CMS Proposed Changes and the MiPCT 35

36. CMS’ Proposed 2016 Physician Fee Schedule and the MiPCT  Potential Expansion of Comprehensive Primary Care Program (CPC) in 2017 (our “sister” program)  CPC milestones are very similar to the MiPCT  Enhanced patient access and continuity of care,  Planned chronic and preventive care,  Risk-stratified care management,  Patient and caregiver engagement, and  Coordination of care across a “medical neighborhood” 36

37. 2015 MiPCT Steering Committee Comments to CMS: 2017 and Beyond 37

38. 38 CPC Milestone Comparison to MiPCT Activity CPC MilestoneMiPCT I. BudgetMandatory CM salary and benefit PO reporting II. Care Management for High Risk Patients MiPCT Multipayer Member List; MDC dashboards with risk score and quality/cost/use measures; Self-management support and patient engagement are an additional 2015-16 focus area for the MiPCT; care managers are required to have self-management and motivational interviewing education, and an all-care-manager half day training in Fall 2015 will provide in-depth training on Brief Action Planning (BAP) Medication reconciliation is a mainstay of care manager training in the MiPCT; Further, the program has partnered with the state information backbone (MiHIN) to add detail on medications to the Admission, Discharge, Transfer (ADT) notifications that the program currently provides when members experience ED, inpatient, home health or SNF admissions or discharges III. Access and Continuity 24/7 care team access; practices encouraged to achieve PGIP PCMH capability 5.2 for real time access; Project monitors CM sufficiency for an 80% minimum level IV. Patient Experience CG-CAHPS survey; Partnered with the Institute for Patient and Family-Centered Care to train MiPCT practices in patient and family advisor programs V. Quality ImprovementMDC registry data collection; webinars, focused learning collaboratives; quarterly learning webinars VI. Care Coordination Across the Medical NeighborhoodCentralized CM Training and Continuing Education; ADT notifications; Transition of Care and other care guidelines and protocols VII. Shared Decision MakingPotential application to Choosing Wisely focus area VIII. Participate in Learning Collaborative MiPCT practices (the PCP, care manager and at least one other practice team member) must satisfy eight practice learning credits per year; Behavioral Health and Social Determinant Tiger Teams; Medication Management competency in CM training

39. Also Keeping Our Eyes On…..  Potential for CMS to announce implications for MAPCP post 12/3/16 as part of the release of Year 2 and 3 evaluation results  Understanding what is important to each payer group so that we can better service their members – and deliver value that can help to sustain the program in the longer term  The hard work you are doing to service Medicaid, Medicare, BCBSM, Priority Health and BCN patients likely to benefit from Care Management 39

40. The Michigan Primary Care Transformation (MiPCT) Project The State Innovation Model and Population Health in Michigan Elizabeth Hertel, Director of Health Policy Innovation, State of Michigan 9:20-10:20 AM

41. State Innovation Model September 16, 2015 41

42. All Medicare Fee for Service Fee for Service linked to quality Alternative payment models Context: Centers for Medicare and Medicaid Services Payment Reform Targets 42 2016 85% 30% 2018 90% 50% Planned percentage of Medicare FFS payments linked to quality and alternative payment models *Adapted from Centers for Medicare & Medicaid Services, January 26, 2015Centers for Medicare & Medicaid Services, January 26, 2015

43. 43 New York - $99.9 million Ohio - $75 million Michigan - $70 million Colorado – $65 million Tennessee - $65 million Washington - $64.9 million Connecticut - $45 million Iowa - $43.1 million Idaho - $40 million Delaware - $35 million Rhode Island - $20 million Round 2 Model Test States Round 1 Test States

44. Michigan State Innovation Model Proposal Overview Michigan Blueprint for Health Innovation developed with broad stakeholder engagement in 2013 Model Test proposal submitted July 2014 ▫Closely follows Blueprint Proposal presentation at Center for Medicare and Medicaid Innovation: October 2014 $70 Million award announcement: December 2014 Project begin date: February 1, 2015 44

45. Phased Model Test Wave I Regions  Have all model components and capabilities  Prior experience with pay for value  May include Level I and II Accountable Systems of Care Wave II Regions  Have some, but not all, model components and capabilities  Could benefit from additional planning, investment, community convening, before implementation  May include Level I and II Accountable Systems of Care 45

46. Michigan’s Model Test Timeline Pre- Implementation Model Test: Wave I Model Test: Waves I and II Model Test and spread State-wide dissemination 46 2015 2016 2017 2018 2019 - 2020

47. Michigan’s Blueprint Raises the Bar 47 Patient Centered Medical Home + Systems of Care Patient Centered Medical Home + Accountable Systems of Care + Population health capacity + Payment reform Infrastructure for a Learning Health System Policy

48. Accountable Systems of Care ▫Physician organizations  Cover all of Michigan: both provider and health system led  Contracting and credentialing support  Practice coaching and quality improvement  Support for patient centered medical home transformation ▫Medicaid managed care ▫Emphasize whole-system transformation, anchored by strong primary care and effective care management ▫Create systems that coordinate care within and beyond health care system (e.g., improved transitions in care) ▫Better leverage health information technology and health information exchange ▫Link with Community Health Innovation Regions for better outcomes ▫Emphasize whole-system transformation, anchored by strong primary care and effective care management ▫Create systems that coordinate care within and beyond health care system (e.g., improved transitions in care) ▫Better leverage health information technology and health information exchange ▫Link with Community Health Innovation Regions for better outcomes 48

49. State Innovation Model Performance Measures ▫Drive adoption of a core set of measures ▫Align payment and core set of measures across payers to reduce administrative complexity and provider burden  Michigan State Medical Society has developed a common clinical measure list across several Michigan payers  State Innovation Model Performance Measurement and Recognition Committee will establish additional process and population health measures 49

50. Payment Reform Align with trend toward payment for population level performance, moving away from fee-for-service ▫Level I: Shared savings (upside risk) ▫Level II: Capitation models Designed to drive: ▫Consistent delivery of high-quality, person/family-centered care ▫Reductions in low-value care ▫Reductions in avoidable acute care utilization Provide for investments in community health 50

51. Community Health Innovation Regions ▫Multipurpose collaborative bodies ▫Chartered Value Exchanges ▫Health Improvement Organizations ▫Community Benefit ▫Work together for collective impact on population health: ▫Assess community need ▫Define common priorities ▫Adopt shared measures of success ▫Pursue mutually reinforcing strategies towards common priorities ▫Implement systems to coordinate health care, community services, and public health ▫Invest in prevention ▫Work together for collective impact on population health: ▫Assess community need ▫Define common priorities ▫Adopt shared measures of success ▫Pursue mutually reinforcing strategies towards common priorities ▫Implement systems to coordinate health care, community services, and public health ▫Invest in prevention 51

52. Health Information Exchange/ Health Information Technology Key functions of Health Information Exchange in State Innovation Model: ▫Support care coordination within Accountable Systems of Care and across the health care system ▫Support community linkages to better address social determinants ▫Allow real-time performance monitoring, rapid-cycle improvement processes ▫Infrastructure components ▫Electronic Medical Record functionality ▫Connection to sub-state Health Information Exchange ▫Data aggregator 52

53. State Innovation Model Target Populations Healthy babies Emergency Department super-utilization (8+ visits/year) Multiple chronic conditions 53

54. Medicaid Managed Care Rebid Managed Care Rebid ▫Request for proposals released May 2015 ▫Requires health plan participation in the State Innovation Model ▫Specifically promotes key components of delivery system transformation:  Patient-centered medical homes  Support for care management  Community health workers 54

55. Pre-Implementation Update Complete ▫Accountable System of Care and Community Health Innovation Region capacity assessments reviewed To Do ▫Region and site selection ▫Develop key program materials for feedback Looking ahead ▫Finalize programs ▫Develop operational plans with Model Test participants ▫Execute agreements with Model Test participants ▫Launch Model Test learning system ▫Implement payment reform 55

56. 56 Quarter 1 (Feb - April) Hiring and orientation Tool and model development Stakeholder engagement plan Quarter 2 (May - July) ASC capacity assessment CHIR capacity assessment Continued model development Timeline development MDHHS workgroups launched Quarter 3 (Aug - Oct) Develop CMS Operational Plan Convening: Performance Measurement and Recognition Committee Quarter 4 (Nov - Jan) Regional selection announced Program policy public comment period CMS Operational Plan submitted Quarter 1 (Feb - April) ASCs and CHIRs submit operational plans and requests for funding Participation agreements signed Collaborative learning networks launch Quarter 2 (May - July) CHIRs undertake strategic planning for population health ASCs, MHPs, and MDHHS test administrative information systems Quarter 3 (Aug - Oct) ASCs and MHPs sign contracts to begin October 1, including: Shared savings Pregnancy bundle Partial and global capitation options Quarter 4 (Nov - Jan) Michigan completes Population Health Improvement Plan Implementation Year 1: February 2016 – January 2017 Pre-Implementation: February 2015 – January 2016

57. Morning Break Please stay tuned! We’ll be back shortly after the morning break for in-person attendees 57

58. The Michigan Primary Care Transformation (MiPCT) Project Celebrating Best Practices! 10:50-11:50 AM

59. Celebrating Success in MiPCT Practices!

60. Practice Awards-Categories Most Improved – Adult and Family Medicine Most Improved – Pediatrics Diabetic Metric Improvement Best Overall - Diabetes Best Overall – Adult and Family Medicine Practices Best Overall – Pediatric Practices

61. Risk Adjustment (for top overall awards) Purpose To level the playing field so that practices are recognized for performance, not for the underlying characteristics of their population Considerations  Health status  Demographics  Payer mix Practice average risk score (concurrent) % Medicare, % Medicaid, % Commercial

62. Risk Adjustment (continued) Methods ▫Implemented by MPHI and approved by the Stewardship and Performance Committee ▫Involves comparing how the practice actually performed to how we would have expected it to perform if we knew nothing other than these population characteristics Application ▫Best overall adult, diabetes and pediatric awards ▫Not applied to award categories for most improved

63. Best Overall – Adult and Family Practices – Risk Adjusted* Composite score based on practices’ rankings in the following MDC Measures, risk adjusted by MPHI: ▫Inpatient Admissions ▫ED Visits per 1000 Patients ▫PCS ED Visits ▫Acute ACSC Admission Rate ▫Chronic ACSC Admission Rate ▫Diabetes Overall

64. Most Improved – Adult and Family Greatest difference in Overall Ranking between baseline (calendar year 2011) and current measurement period as of the April, 2015 release (claims incurred October, 2013 – September, 2014). For example, a practice that moved from rank 200 to rank 100 would count as “more improved” than one that moved from rank 50 to rank 1.

65. Diabetes Overall - Risk Adjusted* Composite score based on practices’ rankings in the following MDC Clinical (non-supplemented) measures; composite (not components) are risk adjusted by MPHI: ▫Diabetes Eye Exam ▫Diabetes HbA1c ▫Diabetes LDL-C ▫Diabetes Nephropathy

66. Diabetes Metric Improvement Greatest percent difference in Diabetes Overall Score between baseline (calendar year 2011) and current measurement period (claims incurred October, 2013 – September, 2014) for all non- Pediatric practices. Note that for this measure we are looking at improvement in Score NOT improvement in Rank.

67. Best Overall – Pediatric Practices - Risk Adjusted* Pediatric Practices are defined as those where >= 85% of attributed patients (based on current measurement period patient attribution) are <= 21 years of age. Note that in cases where we filter to include only “pediatric” patients we will use = 18) Composite score based on pediatric practices’ rankings for the following MDC Measures, risk adjusted by MPHI: ▫Pediatric Inpatient Visit Rate with Previous Asthma Diagnosis ▫Pediatric ED Visit Rate with Previous Asthma Diagnosis ▫Pediatric Preventive Overall

68. Most Improved – Pediatric Greatest change in ranking between baseline and current measurement period. See Most Improved – Adult and Family description for change in measurements period definitions.

69. The 2015 Winning Practices!

70. Best Overall – Adult and Family Medicine Practices Marquette Internal Medicine Pediatric Associates Fenton Medical Center, P.C. Jane Castillo, MD Dhiraj Bedi, DO Lifetime Family Care, PLLC /A Division of Michigan Healthcare Professionals PC

71. Winning Category: Best Overall- Adult and Family Practice Name: Lifetime Family Care WHAT MADE A DIFFERENCE (Process Change, etc.): ▫Daily morning all-team huddle the first fifteen minutes of each day (identify who is complex, etc.) ▫Scheduling chronic patients on the day that the Care Manager is in the office ▫Active use of Welcentive registry – one FT staff member enters data, identifies gaps in care for team, patients who have not been in with chronic illness, etc. ▫Drop-down shortcuts and information codes in EHR ▫Having a “start” physician in Dr. Keu HINTS FOR OTHER PRACTICES ▫Document policy and enforce it – don’t let it exist just on paper ▫Use screening toolkit in the EHR ▫Agreement on protocols among physicians in practice

72. Lifetime Family Care: Our Patient/Provider MOU

73. Lifetime Family Care: Our Patient/Provider MOU, cont.

74. Most Improved – Adult and Family Medicine E. Ann Arbor Med-Peds Rivertown Internal Medicine and Pediatrics Campustowne Family Medicine Grand Rapids Internal Medicine and Pediatrics Alpine Internal Medicine and Pediatrics

75. Winning Category: Most Improved – Adult and Family Practice Practice Name: Rivertown Internal Medicine and Pediatrics WHAT MADE A DIFFERENCE (Process Change, etc.): ▫Daily huddles to discuss potential patients for Care Management ▫Daily meetings between Care Manager and Doctors to discuss cases following Care Management visits. ▫Daily review of hospital discharge list to identify patients to call regarding their transition of care. HINTS FOR OTHER PRACTICES ▫Flexibility is key to working with and meeting the needs of the team.

76. Winning Category: Most Improved – Adult and Family Practice Practice Name: Campustowne Family Medicine WHAT MADE A DIFFERENCE : Re-checking BP’s. Added a reminder on the cuffs. Placed colored magnets on the door if BP needed to be rechecked. Performed time studies from check-in to check-out to determine how much time was needed to fulfill Health Maintenance items. Carried Pocket-buddies with PCMH requirements as a reminder. HINTS FOR OTHER PRACTICES: Perform continuous process improvement through use of PDSA (Plan, Study, Do, Act).

77. Winning Category: Most Improved – Adult and Family Practice Practice Name: Grand Rapids Internal Medicine and Pediatrics WHAT MADE A DIFFERENCE : ▫Physician and staff engagement. ▫Motivational Interviewing skills. ▫Engagement with community services and specialists. ▫Coordinating care for the high-risk pediatric population. The practice has developed a notebook and tool for parents and educated MAs to have them readily available. HINTS FOR OTHER PRACTICES ▫Care conference as a team approach with PCP, APP and primary MA.

78. Winning Category: Most Improved Adult and Family Practice Practice Name: Alpine IM/FM/PEDs WHAT MADE A DIFFERENCE (Process Change, etc.): ▫We embraced a culture of change, collaboration, team work, dedication and commitment in putting our patients first. ▫We developed workflows as a team, and discussed gaps and barriers that could improve our process daily during team huddles. ▫We empowered our front line staff. ▫We utilized all areas of our care team to their fullest clinical scope including our NP’s, PA’s, Care Managers, MA’s and Providers. ▫We created standard work, and tracked our teams success by auditing, planning, studying and developing action plans that we could implement

79. Winning Category: Most Improved Adult and Family Practice Practice Name: Alpine IM/FM/PEDs, cont. HINTS FOR OTHER PRACTICES ▫Build trust within your team. Celebrate the small wins. Huddle daily. Empower your front line staff- when you do, they will do great things.

80. Diabetes Overall Family Tree Medical Associates St Johns Professional Associates SMG DeWitt Grand Blanc Family Medicine Jane Castillo, MD

81. Winning Category: Diabetes Overall Practice Name: Family Tree Medical Associates WHAT MADE A DIFFERENCE (Process Change, etc.): ▫TEAM- Working together is essential to have a successful workflow and show results. The most important member of the team is the patient TOOLS- Creating the appropriate tools within EHR to support the work with each patient ▫TIME- Establishing the right attitude as individuals working within our practice including the providers

82. Know YOUR Population We have our MiPCT patients flagged in our system Winning Category: Diabetes Overall Practice Name: Family Tree Medical Assoc., cont.

83. Population Management at the Point of Care The MiPCT patients flagged in our system show up yellow on the clinical and provider schedule Winning Category: Diabetes Overall Practice Name: Family Tree Medical Assoc., cont.

84. HINTS FOR OTHER PRACTICES Maximize each team member’s strengths ▫It helps the team have a positive perspective ▫This will allow openness to work on the challenging aspects and make improvements Celebrate success no matter how small Winning Category: Diabetes Overall Practice Name: Family Tree Medical Assoc., cont.

85. Winning Category: Best Overall Diabetes and Most Improved Diabetes Practice Name : SMG- St.Johns WHAT MADE A DIFFERENCE: ▫Education of physicians, staff, and care managers ▫Implementation of care management ▫Improved physician engagement ▫Patient reminder calls ▫Flagging charts and calling patients regarding gaps in care ▫Personal Action Toward Health (PATH) Workshops HINTS FOR OTHER PRACTICES ▫Be persistent and cultivate physician involvement ▫Utilize all members of the team ▫Make use of reports/registries to identify gaps in care ▫Re-evaluate processes frequently and make changes as needed

86. Winning Category: Best Overall Diabetes Practice Name: Sparrow Medical Group - Dewitt What Made a Difference? ▫Leadership  Entrust a team member with individual process responsibility (e.g. registry lead; batch letter and reminders lead; etc.)  Provide resources and monitor progress  Single Point Ownership ▫Work Registries to Identify Gaps in Care  Performed by Medical Assistant, not Care Manager ▫Communication with Patient and Patient Follow Up ▫Support of RN Care Facilitator (RNCF) ▫Educate, Communicate and Provide Resources to Patient and Staff Hints for Other Practices: ▫Trust Your Team ▫Own It!

87. Winning Category: Diabetes Overall Practice Name: SMG DeWitt, cont.

88. Diabetes Metric Improvement Cherry Street Health Center SMG Holt St Johns Professional Associates Premier Family Physicians New Day Family Medicine

89. Winning Category: Most Improved Diabetes Practice Name: Cherry Health WHAT MADE A DIFFERENCE: Workflow Redesign ▫Chart Prep/Standing Orders ▫Team Huddles ▫Expanded Care Teams (CHW, CDE, MiPCT CM) ▫Self-Management Goals ▫Internal/External/Community Referrals HINTS FOR OTHER PRACTICES ▫Identify Champions

91. Winning Category: Most Improved Diabetes Practice Name: Cherry Health

92. Winning Category: Most Improved Diabetes Practice Name: SMG HOLT WHAT MADE A DIFFERENCE ▫Strong caregiver/Provider engagement/Teamwork- running patient registries/working patient lists: letters, e-mails, phone calls for follow through care/planned visits ▫New practice-new patients (first time receiving healthcare) HINTS FOR OTHER PRACTICES ▫Use appt notes/snapshot notes (identify gaps) ▫Educate staff on disease mgmt/processes-provide better patient education/interaction

93. In addition to engaged providers and empowered staff – we also support this team with our RN Care Facilitator (MiPCT CM). We work on recognizing what we track and why. Then we spend time educating the staff which further opens the door to better communication with patients and having more comfortable conversations/patient interactions! Winning Category: Most Improved Diabetes Practice Name: SMG HOLT, cont.

94. E.g., process maps, tools, etc. Winning Category: Most Improved Diabetes Practice Name: SMG HOLT, cont.

95. Winning Category: Most Improved-Diabetes Practice Name: New Day WHAT MADE A DIFFERENCE: ▫A Flexible and “Eager to Adopt New Things” Culture -- The team takes care to make sure that everyone has “bought in” to a proposed change ▫“Whole Practice Team” (coach, CM, physician, front desk lead) meets twice a month to go over their performance on measures, discuss gaps in care, etc.) and uses IHP online registry ▫Sustaining the Gains of the IHP Diabetes Collaboratives – Integrated successes into the practice workflow as expectations, and have spread the approach to asthma, hypertension ▫Diabetic Eye Exam Excellence– Practice initiates and faxes the referral to the ophthalmologist. Two weeks later they follow up with the ophthalmologist and follow up if the patient has not gone using a referral tracking form they developed ▫In-Office Diabetic AIC Testing – The practice has its own machine and can give the patient instantaneous testing and results

96. Winning Category: Most Improved-Diabetes Practice Name: New Day, cont. HINTS FOR OTHER PRACTICES ▫Everyone must be vested in a change (if the front desk, MA, etc. is not “bought in”, the change won’t work) ▫Develop trust in your team –everyone is busy and needs a team that they can trust ▫Incorporate prompts as cues – for example, when a chronic disease patient visits, the appointment system labels as a chronic disease visit, prompting the team to see if they need tests, etc.

97. Best Overall – Pediatric Practices Pediatric Specialists of Bloomfield Hills PC Pediatric Consultants of Troy PC Joseph B. Luna, M.D., P.C. Cereal City Pediatrics PC Moazami Pediatrics

98. Winning Category: Best Overall Pediatric Practice Practice Names: Cereal City Pediatric and Moazami Pediatric WHAT MADE A DIFFERENCE A Focus on Training ▫The entire office (including front office) participated in in-service with an asthma educator; have also had in-services from an Asthma Allergy Center on injections ▫Physicians conducted an in service with the nursing staff on identifying respiratory distress. Now, the content of the in service has been included as part of the new hire training process. Useful Standard Tools and Processes ▫In 2012, a cough protocol/algorithm for the front desk and triage was created to screen phone calls and prioritize appointments. The office also purchased a spirometer and had the supplier conduct an in service on proper use. ▫Annual well visits with an asthma action plan is required for all medication refills and notes for medication usage at school for patients with asthma. ▫Medication follow-up appointment is required for patients w/frequent refills. ▫Asthma patients are tracked and flagged in PCC and Gaps in Care reports and the office has a designated Asthma Champion.

99. Winning Category: Best Overall Pediatric Practice Practice Names: Cereal City Pediatric and Moazami Pediatric WHAT MADE A DIFFERENCE, cont. ▫Priority calls are placed to patients with asthma when flu vaccine arrives, along with other high risk patients before reminder calls are conducted for the healthy. ▫Refills are monitored for compliance. Attention to Patient Education ▫Patient Asthma Education folders are given to patients with a new asthma diagnosis. ▫Individual care management education sessions are conducted to teach patients how to use a spacer, inhaler, or nebulizer. HINTS FOR OTHER PRACTICES ▫Take time for training and incorporate processes and useful tools as aids to guide your work ▫Watch for patterns (which patients are requesting frequent refills, are there repeating situations that cause rework, etc.) and act on them

100. Most Improved – Pediatric Pediatric Consultants of Troy PC CHC Fort Gratiot Forest Hills Pediatric Associates PC Briarwood Center For Women Children and Young Adults Pediatric Care of Lansing

101. Winning Category: Most Improved – Pediatric Practice Practice Name: Forest Hills Pediatrics WHAT MADE A DIFFERENCE (Process Change, etc.): ▫Care Plan created with built in triggers for recall ▫Phone calls within two days of all ED visits ▫Recheck with educator after every asthma flare HINTS FOR OTHER PRACTICES ▫Never assume patients remember what you told them last time! Keep educating and empowering them to manage their own medications.

102. Forest Hill – Care Plan Management

103. A Round of Applause for ALL Our 2015 Winners ….And Your Practice Could be Recognized in 2016!

104. THANK YOU FOR ATTENDING THE SUMMIT! Please complete your online Summit Evaluation by September 29 at: http://mipct.org/2015-summit-prework- webinars/2015-mipct-regional-annual-summit-evaluation-links/ (the link will also be emailed to attendees after the summit) http://mipct.org/2015-summit-prework- webinars/2015-mipct-regional-annual-summit-evaluation-links/ Lunch is in the room next door. Please enjoy! Care Managers, remember to be in your designated rooms by 1pm to start the afternoon session! For those of you not involved in afternoon training, feel free to enjoy the beautiful gardens until they close at 5pm today. Remember that all morning summit material is posted at mipctdemo.org! 104