The Michigan Primary Care Transformation (MiPCT) Project: December PGIP Meeting Update

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

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

3. MiPCT Participation Statistics

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

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

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

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

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

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

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

11. MiPCT Implementation Guide – Part I cont. • Roles - Care Managers, Panel Management • Hiring Care Managers

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

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

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

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

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

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

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

19. MiPCT Timeline – next 4 mos.

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

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

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

23. Care ManagerPractice Integration

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 1st to 2nd quarter 2012

28. Questions and Discussion