MiPCT T eam December 9, 2011

1. The Michigan Primary Care Transformation (MiPCT) Project - Webinar #3Complex Care Manager Training and Care Management Documentation Updates MiPCT Team December 9, 2011

2. Agenda • Introduction • Complex Care Management Training Update • Care Management Documentation and Reporting

3. MiPCT Complex Care Manager Training

4. CCM Train the Trainer Model • Proposed model for first group of CCMs • 4 Master Trainers (3 open positions) • 16 CCM Clinical Leads • Employed by the PO/Practice • Exception – One Master Trainer position filled by Marie Beisel MiCMRC Project Manager • CCM Master Trainer and CCM Clinical Leads • Complete Complex Care Manager Fundamentals course with Geisinger faculty (may require two waves of on-site training) • 3 weeks on site in PA • One week didactic • Two weeks partnered with a Geisinger Care Manager • Training in MI, mentoring by Geisinger faculty • CCM Master Trainer additionally completes curriculum for train the trainer model *Model is designed for year one MiPCT intervention phase

5. MiPCT Complex Care Manager Train the Trainer Program

6. Complex Care Manager Clinical Lead • Completes Complex Care Manager Fundamentals course at Geisinger • 3 weeks on site in PA • supplemental training in MI • Preceptor for CCMs in a defined region, has reduced patient caseload • Leads small group discussions, facilitates networking, sharing best practices • Contributes to ongoing CCM curriculum development by assisting Master Trainers with CCM education, workflow support, and resources • Collaborates with CCM Master Trainer, MiPCT leadership, MiPCT clinical subcommittee to assess CCM interventions

7. Sample of key preferred qualifications • Current MI License: RN, NP, PA • 3 to 5 years experience • some adult medicine • setting: home health agency, primary care practice, skilled nursing facility, hospital medical-surgical unit • Preceptor experience - working with licensed clinical staff • Demonstrated ability to create and support a learning environment that is characterized by mutual respect, constructive feedback, and conflict resolution • Knowledge of chronic conditions and prevention • evidence-based guidelines • Excellent communication, interpersonal, teaching and facilitation skills Complex Care Manager Clinical Lead

8. Completes Complex Care Manager Fundamentals course and a Train the Trainer program with Geisinger faculty • 3 weeks on site in PA • also training in MI • Oversight of four Complex Care Manager (CCM) Clinical Leads • Does not have a patient caseload • Leadership role in providing CCM professional development through mentoring, coaching and education • Gathers data, populates and analyzes specified CCM activity reports for region • Collaborates with MiPCT leadership and MiPCT clinical subcommittee to assess, study, and refine CCM training and interventions as needed • Presents educational offerings for CCMs in small group setting as well as a statewide audience Master Trainer Complex Care Manager Role

9. Sample of key preferred qualifications • Current MI License: RN, NP, PA • 5 years experience • some adult medicine • setting: home health agency, primary care practice, skilled nursing facility, hospital medical-surgical unit • 2 years experience • clinical manager - preferred • clinical program development, implementation, monitoring, evaluation - preferred • Demonstrated ability to create and support a learning environment that is characterized by mutual respect, constructive feedback, and conflict resolution • Excellent communication, interpersonal, teaching and facilitation skills • Excellent teaching, presentation, and facilitation skills • Demonstrated ability to effectively develop educational resources, tools, processes Complex Care Manager Master Trainer

10. Training Timeline • CCM Master Trainers and Clinical Leads • 1-2 waves, likely February for first wave • Subsequent training plans • Michigan-based training waves • Progress from Geisinger-led to combination of taped webinars and Master-Trainer led sessions • Regionally based • Having four Master Trainers will allow more flexibility with timing and geography

11. Next steps • Additional details on CCM Master Trainer and clinical leads sent out by December 15 • Position description details • MiPCT salary subsidization amount for each role • Definition of selection process • PO/PHO responses requested by December 22 • Letter of interest for CCM clinical lead position • Letter of interest for CCM Master Trainer position • Submit letter of interest to Marie Beisel at mbeisel@umich.edu • Positions for first Geisinger trip identified by January 15 • Anticipated travel date is early February • Timing of second wave likely early March • MiPCT team to finalize contract details with Geisinger by 12/31

12. Care Management Documentation

13. Current state • No ideal single source solution for EHR documentation, registry functionality and care management support • Integration costly, cumbersome • Difficult to mimic manual processes with HIT solutions • Recognized problem across the country • Care managers need tools to support workflow • Supervisors need a way to track productivity

14. Basic HIT Functions: Support Care Manager’s work • Create and maintain a list of active patients • Generate a Patient Tickler List • patients scheduled for Care Manager (CM) follow up visit • ideally includes past and future CM visits • Document Patient Care management visits using a template • Common diagnoses • Common follow up • Self management goal setting • Transitions of care • Create and maintain individualized patient care plan by Complex Care Managers

15. Advanced HIT Functions: Support Care Manager’s work • Access to information such as: view of patient includes: diagnoses, care giver, PCP, insurance, demographics, care manager and health team member visit schedule, assessments, referrals, patient goals, medications, lab results • Protocols • Ability to generate Care Manager activity reports • Compatibility with care manager’s work flow • Notification - patient’s appointment with PCP, ER visit, hospitalization • Assessments ( Functionality, PH Q 9, . .) completed and tracked - longitudinal view • Patient worksheet: history of goals, assessments, care manager encounters past and future

16. MiPCT Required Care Manager Reports • Care Manager Activity Reports • Number of Care Manager encounters at practice location per Care Manager, by payer • Frequency of reporting – TBD, likely quarterly • Purpose of reports • Provide accountability to payers, demonstrate value • Allow PO and MiPCT leadership to see where practices are having difficulty with implementation/integration

17. Ways to accomplish varying levels of Care Management functions • EHR • customization • built in care management feature (rare) • Registry • customization • built in care management feature (rare) • Care Management Software • not integrated • integrated

18. Options for Care Management Documentation and Reporting • PO develops solution – works with practices • Common MiPCT solution • Not required, but option for those interested • Care management software options reviewed by MiPCT team • Two possible options • Care Team Connect • OHSU Care Management Plus • Cost to PO/PHO/practice negotiated by MiPCT

19. Care Team Connect • Currently in use or in negotiations with several MiPCT PO/PHOs • Highly customizable • Accept MiPCT data feeds • Risk stratification • Specific protocols for clinical situations • Connect multiple team members • Can interface with registry/EHR at additional cost • Will generate claims for G codes/CPT codes • Will create MiPCT activity reports

20. Care Management Plus • Low cost, web-based product • Provides basic care management support • Active patient list • Tickler lists • Activity reporting • Some customization possible • Templates • Interface with practice management system, EHR

21. What is the best solution for you? • PO/Practice will need to assess current HIT capability for care managers • Can PO/practice report the required MiPCT activity? • Will the HIT in the practice currently provide the basic functions needed to support the care manager workflow? • If yes, can PO/Practice add support such as customized documentation templates? • If no, how will PO/Practice address this?

22. Next steps • Assessment of MiPCT PO/PHO capabilities • Best practice webinar? • Common solutions for same EHRs? • Have something that works? We’d like to hear from you! • Demonstrations from software vendors • Care Team Connect, Care Management Plus • If PO/PHO has care management software product they would like MiPCT to assess, please contact Marie Beisel at mbeisel@umich.edu

23. Questions and Discussion