Integrating Care Managers to Enhance Complex Care Management in Practice Teams

1. Integrating Care Managers within Practices MiPCT Team May 17, 2012

2. Agenda • MiPCT Complex Care Management Training Update • Geisinger evidence-based tools for CCMs, HCMs • CCMs, HCMs – getting started • MiPCT POs and Practices • Integration of CCMs, HCMs, MCMs into practice • MiPCT support for POs and Practices

3. MiPCT CCM Training Update

4. MiPCT Complex Care Management Training Update • CCM and HCM Training - 5 day course • First 3 training sessions • Geisinger faculty, MiPCT Master Trainers • To date 3 training sessions completed • 4/23/12 – 4/27/12 New Hudson • 4/30/12 – 5/4/12 Grand Rapids • 5/7/12-5/11/12 Ann Arbor • MiPCT CCMs/HCMs trained to date = 73

5. Complex Care Management Training Dates • 6/4-8, 2012 Grand Rapids • 6/4-8, 2012 New Hudson • 6/18-22, 2012 Lansing • 6/18-22, 2012 Madison Heights • 7/9-13, 2012 Lansing • 7/16-20, 2012 Okemos/Marquette (virtual) • 8/20-24, 2012 Lansing

6. MiPCT Complex Care Management- Geisinger Partnership • Background • Train the trainer program for the MiPCT CCM course • Certification • Master Trainers, Clinical Leads • Geisinger ProvenHealth Navigator Model • Evidence based tools • Standardized interventions based on Geisinger ProvenHealth Navigator model

7. MiPCT Complex Care Management Curriculum Day 1: Begins with MiPCT 101 Days 1,2,3 Geisinger ProvenHealth Navigator (PHN) model • Standards of Practice for Case Management • Patient population stratification • Risk segmentation • Right care, right place, right time: criteria based level of care determination • Metrics • Concept of Medical Home • Population based case management • Need to know targeted conditions • Heart Failure • COPD • Population based care Path • PHN 5 step case management model • PHN Time management • Medical Home meeting

8. MiPCT Complex Care Management Curriculum Days 4, 5 MiPCT • BCBSM PGIP PCMH • Identification of high risk MiPCT eligible patients • Transitions of care • Medication reconciliation • Evidence - based care • Chronic conditions • Specific assessment tools • Health Plan Payment Policy BCBSM, BCN, Medicare Advantage • Medical Neighborhood • Complex Care Manager documentation tools • Teamwork • SWOT • Case Studies • Complex care manager – a day in the life and getting started

9. Geisinger Evidence Based Tools For CCMs, HCMs

10. Geisinger Evidence-based Tools Geisinger Standard Case management tools • To be used by MiPCT CCMs and HCMs • Licensed tools • Includes • CCM patient visit documentation tools • Self Management Action Plans • Care Manager Care Path • CCM HCMs trained on tools during CCM course • receives hard copy of tools

11. Geisinger Evidence Based Tools • CCM patient visit documentation tools • Comprehensive Patient Assessment (i.e. G9001) • Return visit note • Post discharge note (i.e. transition of care)

12. Geisinger Evidence-based Tools • 10 Self Management Action Plans • SMAPs -clinical topic specific • Example of Heart Failure SMAP • BP monitoring schedule, BP goal • Patient education • Monitoring symptoms • Action plan (ex. eating right plan, daily weight, medications) • Who to call, when to call

14. Geisinger Evidence-based Tools SMAPs • After surgery • Asthma • Case Management (general) • COPD • HF Diabetes • HF • HTN • Osteoporosis • Stop Tobacco Use • UTI

15. Geisinger Complex Care manager Licensed Tools for MiPCT • FAQ - specifies basic legal requirements • PO Attestation letter • MiPCT POs need to sign attestation letter • Return signed attestation letter to MiPCTdemo@michigan.gov • User agreement – micmrc.org • CCMs and HCMs • complete the MiPCT CCM course • will receive a username and ID, to access Geisinger tools on micmrc.org

16. PO, Practice Role - Use of Geisinger tools • Review Geisinger tools with clinical leaders, CCMs, HCMs • If you have an EMR • with care management documentation template • compare your current complex care management documentation templates to the Geisinger documentation tools • add fields to EMR documentation templates as needed to incorporate Geisinger content • with out care management documentation template • use Geisinger documentation tools • If you have a paper medical record • MiPCT team will form a work group to develop usable paper tool version of the Geisinger documentation templates • timeline: by 5/24/12 recruit participants, work group meets following week

17. Geisinger Complex Care manager Licensed Tools for MiPCT • Distribution of tools • CCMs and HCMs • access electronic version of tools via password protected micmrc.org web site • POs • first sign attestation letter • provide request for Geisinger tools via mipctdemo@michigan.gov and identify PO contact information • PO and practice - business need to know information

18. CCMs, HCMs – Getting Started

19. Initial Focus Areas for CCMs and HCMs • Build Complex patient caseload • Transitions of care • Post hospital discharge • Transition from one setting to another – ex. SNF to home • Care coordination • Medication reconciliation • Build/expand the Medical Neighborhood

20. CCMs, HCMs - Screening Complex Care Management Referrals • High Risk, high demand • MiPCT patient lists • PCP, RN, health care team referrals • Chronically ill – multiple chronic conditions or poorly controlled • Medically complex • High utilizer of health system • ER visits, hospitalizations • Frail/Elderly • “Cringe Factor”

21. CCMs and HCMs Daily Work • Prioritizing daily work - complex patient case load • Review MiPCT eligible patient list with PCP • MiPCT eligible complex patient with PCP visit today • Transitions of care • from one setting to another • hospital discharge patient list • Referrals • Follow up on patients in caseload • Reminder - focus on MiPCT eligible patients

22. Care Manager Integration into the Practice Role of the PO, Practice Leadership, and MiPCT

23. Practice Leadership – Integration of Care Management • Identify a physician champion • Practice leadership, physician champion, CCM HCM MCM • Identify consistent MiPCT care management goals • Assess current processes • Redesign processes as needed

24. Practice Leadership – Integration of Care Management • Provide education regarding MiPCT and care management for all staff • Team members roles • define and communicate how each member contributes to care management • Introduction CCM, HCM, MCM to team members • if transitioning from clinic RN role to MiPCT care manager role; communicate Care Manager role responsibilities and expectations with team members

25. Practice Leadership - Integration of CCM, HCM, MCM into Practice • Support communication, team building, and education • CCM, HCM, MCM schedule appointment with each Physician to discuss role • Team meetings • Staff meetings • Physician meetings • Meet with practice leadership • 1:1 meetings with key members of the health care team

26. PO and Practice: Integration of CCM HCM MCM into Practice • Basic • Work space • Phone • Providing the MiPCT attribution members list for CCMs, HCMs • Advanced • Medical Home meeting • Multidisciplinary – representation of team members • Discuss Care management case studies • Data, Process improvements

27. How MiPCT can help • Work with POs to address hospital barriers (timely discharge notifications, etc.) • Provide resources and framework for enhancing team functioning • Support Learning Collaboratives, Lean workshops, other team based learning • More to come – soon! • Care Management Resource Center • MiPCT Care Manager regional infrastructure

28. Getting Started – Introducing Complex Care Management to the Practice • What is your experience? • What has worked? • What has not worked? Ideas to try. . .