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The Michigan Primary Care Transformation (MiPCT) Project. Succeeding in 2014: What it Will Take. 16. MiPCT Team-Based Care Recap. 16. MiPCT Team-Based Care Evergreen” Themes. Care managers work in close proximity to PCP team In PCP office as much as possible
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The Michigan Primary Care Transformation (MiPCT) Project Succeeding in 2014: What it Will Take
16 MiPCT Team-Based Care Recap
16 MiPCT Team-Based Care Evergreen” Themes • Care managers work in close proximity to PCP team • In PCP office as much as possible • Work with PCP team to meet their needs • Regular communication via huddles, medical meetings, etc. • Ensure Care Management coverage • Focus on MiPCT patients (across participating payers) • Manage high-complexity, high-cost patients • Patients selected based on risk score plus PCP input • Focus on evidence-based interventions • Medication reconciliation • Care transitions • In-person contact with patients whenever possible • Comprehensive care plan for complex patients
Success = Improvements in Population Health + Cost + Patient Experience
Reduction in Unnecessary and Non-Value-Added Costs How do we make a dent in cost? -Preventing unnecessary ED and inpatient visits by providing care upstream before a crisis - Making sure your patients know about your extended access and how to reach you after hours - Using resources more wisely 5
2014 Priorities • Target the Right Patients • Combine data with clinical judgment • Introduce palliative care opportunities when appropriate • Diabetes Management • Expanded Access • Make sure patients know how to contact the practice’s 24/7 access
Preparing for Sustainability • Physician Organizations have made a significant investment in care management • Working hard for payers to support the model financially • We need your help!
CMS – Looking for Solutions(desperately) • Areas of promise – what we’re doing! • Good directional signs • CMS Quarterly Payment Proposal (for 2015) • Commercial Payer Sustainability Statement • Potential for Demo Extension • Question on the table - Can primary care redefine care delivery? • This is our best (last?) chance to provide the answer • If successful, can lead to new funding models
