Integrated Health Partners

1. Integrated Health Partners • PHO located in Battle Creek, MI • Partnership between Calhoun County Physicians Organization and Bronson Battle Creek Hospital • 170 affiliated physicians, including 34 specialty areas

2. Care Management Model • 11 Practices • 4 Complex Care Managers - 1 CCM embedded in each practice with exception of OMG-MIFM, Olivet and Tekonsha - 2 Hybrids • Moderate Care Managers employed by practice • 2 Hospitals in Calhoun County participating: • Bronson Battle Creek • Oaklawn Hospital

3. Oaklawn Medical Group: Marshall Internal and Family Medicine, Olivet Family Practice, Tekonsha Family Practice • Located in Marshall, Olivet, and Tekonsha • 7 physicians, 6 midlevel providers, including certified diabetes educator • MIPCT population of 5138 patients • Trivia

4. OMG-MIFM, Tekonsha and Olivet Providers Dr. Jose Valle MIPCT Physician Champion

5. Care Managers Jane Ruhl, RN, BSN Complex Care Manager Integrated Health Partners Renee Leslie, RN, BS, CCM Complex Care Manager Integrated Health Partners Tami Starks, LPN Moderate Care Manager OMG-MIFM Dee Pennington, LPN Moderate Care Manager OMG-MIFM

6. OMG-MIFM, Tekonsha and Olivet Statistics • 21,268 patients in MIPCT • OMG-MIFM, Olivet Family Practice and Tekonsha Family Practice have 5138 patients eligible for care management • Largest practice participating in MIPCT in Calhoun County • Level of patient engagement increased from 3.78% in April to 5.48% in July, 2013

7. It takes a village to raise a child, it takes teamwork for care management to be successful in a practice

9. Moderate Care Managers target and engage patients using the following tools • Community Resource Sheet • Registry – Gaps in Care • Emergency Room Reports • BCBSM List

10. CommunityResource Guide

11. IHP Registry Progress Note

12. Insert registry sheet

13. Emergency Reports • Insert emergency action plan

14. BCBSM List

15. Complex Care Managers Target and Engage Patients • Inpatient admissions • Provider’s daily schedule • Referrals

16. Inpatient Admissions Two hospitals in Calhoun County, Oaklawn Hospital in Marshall, MI and Bronson Battle Creek • Daily access inpatient admission information • Identify MIPCT PCP and patient

17. MiPCT list starts with 81 columns • Our IT Analyst reduces this to 9 columns • Pertinent information is loaded into CTC

18. Criteria for Identifying a Patient for Care/Case Management • 1. Unscheduled Inpatient admission* • Moderate: • 2 admissions in 90 days • Complex: • 2 admissions in 30 days  • 2. ED Visits: • Moderate: • 2 visits in 30 days • Complex: • 2> visits in 30 days • 3. Poly-pharmacy 5> medications • 4. Diagnosis: • Moderate: • more than 2 comorbidities • Complex: • complex medical diagnoses and psychological diagnosis*

19. Criteria for Identifying a Patient for Care/Case Management (continued) • 5. Psycho-social/depression screen: • PHQ-2, PHQ-9 • Moderate: • 5 or more symptoms, score 15-19* • Complex: • Score 20>* • 6. Age: • -over 85 • -under 50 with readmission • -peds under age 2 • 7. More than 6 visits to PCP within 1 year* *criteria that in itself can trigger referral to care/case management

20. Providers Daily Schedule • Print providers daily schedule • Identify patients in MIPCT • Discuss with provider any identified needs

21. Referrals • Providers • Office staff • Hospital case managers • Home Care • Community Agencies

22. Patient Story