This document summarizes a webinar for the Michigan Primary Care Transformation Demonstration Project. It announces that remaining webinars for 2012 are cancelled but will resume in January 2013. It also announces an upcoming meeting on December 12, 2012 to assess metrics and care management integration from the first year of the project. Various assessments of practice care management capabilities and findings from assessments are discussed.

1. Michigan Primary Care
Transformation
Demonstration Project
November 28, 2012
Webinar

2. Webinars
 Remaining webinars for this year cancelled
 Webinars will begin again in January 2013
 Best practices will be presented at the webinars
 Any team member may provide “best practice”
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3. MiPCT Meeting
Wednesday, December 12, 2012
6:00pm
American Polish Cultural Center
2975 East Maple Road
Troy, Michigan
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4. Year One Comments
 Quality means doing it right when no one is
looking
 Quality is never an accident; it is always the result
of high intention, sincere effort, intelligent
direction and skillful execution; it represents the
wise choice of many alternatives
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5. Year One Comment
 “Measurement is the first step that leads to
control and eventually to improvement. If you
can’t measure something, you can’t understand it.
If you can’t understand it, you can’t control it. If
you can’t control it, you can’t improve it.”
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6. Reaching End of Year One
 Status of 2012 metric attainment
• Surveys provided to practice teams at December 12
meeting
• Surveys based on metrics outlined by MiPCT
Committee
 Assess integration of care management
 Review tasks and capabilities
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7. Practice Assessments
 Number of complex cases
 Number of moderate cases
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8. Practice Assessments
 SNF/LTC criteria
 Able to demonstrate or verbalize the criteria for
each setting
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9. Practice Assessments
 Palliative Care/Symptom management
 Able to identify resources available to the patient
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10. Practice Assessments
 Practice Guidelines and Protocols
 Utilizes and demonstrates understanding of
practice guidelines/protocols
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11. Practice Assessments
 Exacerbation plan is in place
 Patient and family education established; rescue
kits; written instructions
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12. Practice Assessments
 Accurately stratifies patients based on risk
 Demonstrates stratification process to focus on
patients of highest risk
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13. Practice Assessment Findings
 There is very strong physician management at this
practice.
 Care manager is used in a very limited capacity
and primarily in a disease management or patient
teaching capacity.
 Physicians do their own medication reconciliation
for their patients as they feel others will make
errors.
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14. Practice Assessment Findings
 TOC is really only involved in calling patients for
follow up appointments
 This was previously done by clerical staff
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15. Practice Assessment Findings
 Physicians state that they manage their own
complex patients
 Care manager spends a great deal of time on
documentation which takes away from the already
limited time with patients. She is not functioning
as a complex care manager and is very limited
even in a disease management capacity
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16. How Can You Help Care Manager
 Educate staff on the role of the case management
especially in regards to receiving information on
the most complex (not just the diabetic patient or
the "high maintenance" patient)
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17. Feedback Loop
 Establish plan for monthly meetings or incorporate
the care manager role into existing meetings with
the following agenda items
• review metrics (ER visit volume, inpatient admission
volume, care manager caseload, medication
reconciliation saves etc.)
• care management success stories
• problem cases where alternate interventions can be
discussed
• practice processes to support and promote care
management.
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18. Care Management Reporting
 The care management activity reporting
requirements have been finalized and will be
incorporated into the Quarterly Report beginning
in the first quarter of 2013
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19. Care Management Reporting
 Number of Care Manager face-to-face encounters
(by Care Manager, by practice, by primary payer)
 Number of Care Manager telephone or electronic
encounters by Care Manager, by practice, by
primary payer
 Number of unique patients by Care Manager, by
practice, by primary payer
 Did referral to outside agency occur
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20. Community Care Team
Enhancements
 Community Care Teams
• Community Care Travel Team
• Community Care Permanent Team
 Bill Porter, RN: Community Care Clinical Lead
 Erica Ross: Community Care Operations Lead
 Dave Johnson, MSW: Behavior Health Consultant
 Lori Zeman, PhD: Behavior Health Expert
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21. Community Care Team
Enhancements
 Erica Ross: Community Care Operations Lead
 MNO Care Managers assignments and schedule
 Monitor care manager assignments at practice sites
 Working with Bill Porter and practice team to
determine appropriateness of care manager
assignments
 Create and oversee satisfaction surveys and meet
with practice teams and physicians to include them in
pertinent assessments of care managers
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22. Community Care Team
Enhancements
 Erica Ross: Community Care Operations Lead
 Review overall productivity statistics of care
managers
 Review statistics of care managers employed by
practices
 Review requests from practice units for additional
assistance with various activities
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23. Upcoming Events
 Mackinac Learning Collaborative IV
• December 5, 2012
• Kevin Taylor, MD and Lori Zeman, PhD co chair
• Topic focused on integrated, collaborative or co-
located behavior health
• Currently behavior health specialists are integrated
into several adult and pediatric practice
• Hoping 100% participation from MiPCT Teams
 Mini Learning Collaboratives
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24. Open Discussion
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25. Merry Christmas
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