Mipct 05 15_2013

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Mipct 05 15_2013

  1. 1. Michigan Primary Care Transformation Demonstration ProjectMay 15, 2013Webinar
  2. 2. Congratulations: URAC Accreditation! Hampton Medical Center• Bruce Johnson, DO: Board Certified in Internal Medicine and Geriatrics; American Medical Directors Association as a Certified Medical Director of Long Term Care Facilities• Susan Tam, DO: Board Certified in Family Medicine• Christie Schunemann, NP: Board Certified Family Nurse Practitioner• Cyndi Jones• Janet Johnson, Office Manager• Dawn Carroll, RN, Hybrid Care Manager2
  3. 3. Sequestration President Obama signed an order that imposes across‐the‐board Federal spending reductions (also known as sequestration) for Federal payments effective as of April 2013.  Congress did not take action to avert this, monthly payments to practices and POs are reduced by 2% beginning April 1, 2013 and this will continue until there is resolution about the Federal budget and Federal deficit. 3
  4. 4. Metrics Year Three Committee review of proposed Year Three Metrics  Metrics submitted to Clinical Sub‐committee All proposed process and clinical outcome metrics approved by Steering Committee 4
  5. 5. Pay for Performance Year End 2012 Not available Fund release date is unknown5
  6. 6. Sharing Activities: Teams6
  7. 7. Spotlighting Practices May 30 Detroit Branch Federal Reserve Bank 8:30am‐12 noon National speaker Volunteers?7
  8. 8. Physician Engagement PCP involvement with care managers PCP involvement with care team Number of patients referred by PCP8
  9. 9. Team Learning Events June 6, 2013  (9am‐3pm) June 8, 2013  (9am‐3pm) June 13, 2013 (4pm‐8pm) Teams participating in Learning Collaborative Compulsory attendance of practice team members Required component of MiPCT practices9
  10. 10. Best Practices for Care Coordination/Management Implement self management, coaching and support with patient/family Implement effective medication management plan Manage care setting transitions• Having a timely, comprehensive response to care setting transitions (esp. from hospitals and skilled nursing facilities) 
  11. 11. Care Manager Training Complex to be online after testing is complete Moderate various opportunities11
  12. 12. ReflectionDon’t talk, just act.  Don’t say, just do.  Don’t promise, just prove.12
  13. 13. June: 20 Days Ultimate Challenge 20 new Blue Cross patients enrolled 10 new Blue Care Network patients enrolled 20 new Medicare/Medicaid patients enrolled ~ 50 new patients 13
  14. 14. Refresher:What is Care Coordination? “A person‐centered, assessment based, interdisciplinary approach to integrating health care and social support services in a cost‐effective manner in which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an evidence‐based process which typically involves a designated lead care coordinator.”
  15. 15. Refresher:What is the Problem? Most health care dollars are spent on a small percentage of beneficiaries Those with complex chronic conditions Causes of high utilization and costs: Deviations from evidence‐based care Poor communication among primary providers, specialists, health and community providers, patients, and families Failure to catch problems early Failure to address psychosocial issues Lack of coordinated, longitudinal management Ineffective transitional management
  16. 16. What is Effective Care Coordination? Intervention with rigorous evidence that:• Improves outcomes• Reduces total health care expenditures for participating beneficiaries• Improved satisfaction or clinical indicators not sufficient• Net savings require reduced hospitalizations
  17. 17. Promising Interventions New care coordination and care management interventions being used by care managers• Transitional care interventions • Care Transitions Intervention (Coleman)• Transitional Care Model (Naylor)• Enhanced Discharge Planning Program – RUSH (Perry)
  18. 18. Promising Interventions Other promising care coordination and care management interventions are emerging• Comprehensive Care Management  ‐ Medicare/ Duals• Guided Care (Boult)• GRACE (Counsell)• Care Management Plus (Dorr)• MCCD: Best Practice Sites (Brown)
  19. 19. Promising Interventions However, promising care coordination and care management interventions are emerging Comprehensive Care Management – Medicaid/ Duals Integrated Care Management (Douglas) Community Based Chronic Care Management (Lessler) Hospital to Home (Raven) Health Care Management Program (Reconnu & Herndon)
  20. 20. What Distinguishes Successful Models? MODEL SYNTHESIS LITERATURE REVIEWTargeting • Patients with select chronic conditions includingco-occurring serious mental health diagnoses andsubstance abuse• Those who were hospitalized in previous year orat time of enrollment• Program targeting to identify thepopulation who can most benefitfrom a given interventionIntervention • Conduct comprehensive in-home initialassessment• Develop a mutually agreed upon “action plan”with goal• Frequent face-to-face contact (home, office) withpatients (~1/month)• Baseline and ongoingassessment of health and socialneeds• Multidisciplinary approach toallow providers to address aspectrum of health and socialservice needs• Flexible provision of services andservice intensityPrimary careprovider• Strong rapport with primary careprovider/specialist/hospital/family/caregiver• Face-to-face contact through co-location, regularhospital rounds, contact with hospitalist•Assign all of a physician’s patients to the samecare manager when possible• Enhanced communication amongproviders, frequently including theprimary care physician
  21. 21. What Distinguishes Successful Models? MODEL SYNTHESIS LITERATURE REVIEWPatientEducation• Providing a strong, evidence based patient education/coaching intervention for managing health, symptoms, medications• Evidence‐based protocols to assess health and social condition and develop care planTraining • Initial comprehensive training of CareManagers and Care Teams• Performance feedback to CareManagers and Care Teams• At least 15 percent of articles included for review report specialized training for service providers as intervention componentCommunity link • Coordinate communication among physicians, health/community providers and patient/family• Connection to existing community health and supportive services
  22. 22. Best Practices for Care Coordination/Management Follow evidence based practices/guidelines for care management Address psychosocial issues• Staff with experts in social supports and community resources for patients with those needs Being a communications facilitator• Care managers actively facilitate communications among providers and between the patient and the providers
  23. 23. Open Discussion23

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