2016 PO FLASH

MiPCT Logo Final

Information for our POs is published in the MiPCT PO FLASH in an effort to consolidate communications from MiPCT to our POs.   These publications are posted here for your easy reference.  A .pdf link appears on this page, followed by the text version of each issue.  For questions regarding the information in the FLASH, please email mipctdemo@michigan.gov.


December 12, 2016

Looking to 2017:  Closing out the MiPCT Demonstration and Transitioning to the Ongoing Programs

As the close of the demonstration period of the MiPCT comes to an end (on December 31, 2016), and the transition to ongoing programs (e.g., CPC+, SIM PCMH Initiative, etc.) begins on January 1, 2017, we wanted to thank everyone for their tremendously hard work during the demonstration.   We all worked hard and it paid off — Michigan’s performance led the nation in the CMS/RTI evaluation.  The close of the demonstration period brings with it some responsibilities and activities during 2017, however, that are important to remember.   Among them:

  •  The 4Q 2016 PO Quarterly Report will be due on January 31, 2017.  Remember that 80% Care Manager Sufficiency ratio still applies.
  • The 54 and 60 month incentive scoring will be distributed for your review and then paid in 2017.   Information about these will be sent to your MiPCT PO leads as it is available.
  • MiPCT PHI may be retained through December 31, 2017, but effective January 1, 2018, CMS requires it to be destroyed.  Summary or limited data sets may be retained however.    We will work with the MDC on guidance and helpful resources to prepare for the January 2018 deadline and this will also be distributed to your PO leads throughout 2017 so that all are well-prepared.  An attestation of data destruction will also be sent along with timing later in 2017.
  • The mipct.org website will be retained throughout 2017 and refreshed as appropriate.   Resources will continue to be available on it and wrap up activity information will be included as well.  The website will also be refreshed to incorporate a high-level “go-to” tool to help POs and practices easily find summary, key information about the SIM PCMH Initiative and CPC+.

Rather than “goodbye”, we continue our journey together and will support each other as we move forward to make additional progress on primary care transformation and population health.


REMINDER: MiPCT Care Manager Summit 2016 Pre-Work Recorded CE Webinars Close 12/31/16

For those of you who have not already taken advantage of the opportunity to earn up to 7 nursing or social work CE contact hours, the MiPCT Care Manager Summit 2016 Pre-Work recorded webinars will remain available until December 31, 2016. Four of the five webinars are approved for 1.5 CE contact hours and one is approved for 1.0 CE contact hour by both the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing, and by the Michigan Social Work Continuing Education Collaborative.

Please view the five recorded webinars prior to December 31, 2016. The links to the webinars will no longer be available after that date. The recorded webinars are posted on the http://www.mipct.org website on the 2016 Summit Prework Webinars page located under the 2016 MiPCT Annual Summits tab. Questions: micmrc-requests@med.umich.


MiCMRC CARE MANAGER WEBINARS

NEW 2017 MiCMRC CARE MANAGER EDUCATIONAL WEBINARS

Wednesday January 18th 2017 2-3pm

Title: Family Caregiver Health

Presenter: Donna Yadrich, MPA

To register for this webinar: http://micmrc.org/webinars


BCBSM Pharmacy Resources Now Available, May be Helpful for PDCM Practices

New pharmacy resources are available on the PGIP Collaboration site that MiPCT/PDCM care managers may find helpful when working with chronic condition patients.

Resources include an online toolkit published by the U.S. Department of Health and Human Services to educate providers and patients about safe pain management, called www.turnthetiderx.org; as well as the new Toolkits and Fliers section on the left side of the Pharmacy Initiative page, which includes information for physician organizations, patients and providers. Topics include saving money by using generic drugs, the dangers of antibiotic overuse, engaging providers in Collaborative Quality Initiatives, and safely managing patient pain, among others.

To access this information and share it with MiPCT/PDCM care managers, visit the Pharmacy Initiative page on the collaboration site under “Initiatives/Projects/Workgroups.”


 MiCMRC Complex Care Management Course Registration – 2017 Updates

New in 2017 The MiCMRC Complex Care Management (CCM) course:

  • Open to all care managers!
  • Has been updated to include new content!
  • No course fee!
  • Provides Social Work CE’s!

The MiCMRC Complex Care Management course is designed to prepare the healthcare professional for the role of Complex Care Manager. Course content is applicable to all Care Managers in the ambulatory care setting, working with complex patients. The MiCMRC Complex Care Management Course (CCM) curriculum provides the framework for the complex care management role, foundational elements of integration into the ambulatory care setting, and development of complex care management skills.

NEW FOR 2017: No fee for the MiCMRC CCM Course. Also, due to the numerous care management programs in 2017, CMRC is now requiring the PO leader, practice manager or attendee’s direct manager to register the care manager for the Complex Care Management Course. This will facilitate accuracy of completion of the course registration fields and access to longitudinal resources for your staff.

The training format for MiCMRC CCM course consists of: a one-hour introductory live webinar, two days for recorded webinar self-study (consists of approximately 6 hours’ self-study) and two days of in person classroom instruction.

**For High Intensity Care Model Managers (HICM) ONLY- New for 2017, HICM now integrates with the CCM course. HICM participants are required to complete the MiCMRC CCM course and two subsequent HICM self-study modules that provide the additional specific information for the HICM program.

NOTES:   If you have 15 or more non MiPCT Care Managers in your area and would like the MiCMRC team to provide a regional training at your location please submit your request to:   micmrc-requests@med.umich.edu

For questions please contact micmrc-requests@med.umich.edu

Upcoming course dates and course registration close dates:

January 23-26, 2017. Introductory Webinar January 23rd, 2017. Total six-hour self-study modules and post-tests January 23-24th, 2017. In person training January 25-26th, 2017. NOTE: Registration will be available on Thursday December 15th. Please visit micmrc.org for registration links.

January 30- February 2nd, 2017. Introductory Webinar January 30th, 2017. Total six-hour self-study modules and post-tests January 30-January 31, 2017. In person training February 1-2nd, 2017. NOTE: Registration will be available on Thursday December 15th. Please visit micmrc.org for registration links.


Care Manager Success Story 

Submitted by Colleen Jergenson, Otsego Memorial Hospital Medical Group

Dee, a 20-year-old special needs female was referred to care manager Colleen via her primary care physician for uncontrolled diabetes, inconsistently updating her diabetes log, and missing numerous appointments. Dee was currently residing with her father who was responsible for updating her diabetes long, however, her mother had taken on the responsibility of getting Dee to her appointments. During Colleen’s first phone contact with Dee’s mother there were multiple social barriers that came to light: neither parent had a personal vehicle for transportation, Dee’s mother was homeless and unaware of any available assistance, furthermore when not in school, Dee would remain at home alone while her father went to work. During that time her food intake and blood sugars were not being monitored.

As a short-term goal Dee’s father would provide an updated blood sugar log to the provider prior to the appointment. A long-term goal, after Dee’s mother had voiced her concerns over her daughters wellbeing, was the possibility of Dee moving into an adult foster care where she would be provided better care but still be able to be in contact with her parents.

Dee was brought to the next appointment with the help of transportation facilitated by Colleen, however, her father failed to provide the blood sugar log as requested by her physician. Colleen made several attempts to contact Dee’s father but was unsuccessful.

At the end of the appointment Colleen discussed with Dee and her mother the opportunity to attend a special needs camp that Colleen would be volunteering as a camp nurse. Dee was excited at the opportunity to attend the camp. Colleen assisted with getting the application filled out and sent it to Community Mental Health for assistance with funding. In addition, Colleen notified the CMH Family Support coordinator, introduced herself as Dee’s care manager, and stated her willingness to work with the support coordinator regarding Dee’s care.

Dee arrived at camp with much enthusiasm. However in light of her excitement, there were numerous challenges. First, Dee was found to have head lice and needed to be treated prior to activities. Second, it was discovered that her current insulin bottle had been expired four years prior and her testing strips had expired five years prior. Dee’s father was unaware of this and gave permission for Colleen to work with her physician to get new Insulin and testing strips. At the advisement of the camp staff as well as Dee’s primary care provider, Adult Protective Services along with her CMH support worker were contacted.

Following the events at camp, Dee’s current situation was investigated by APS permanent guardianship was approved with placement into an adult foster care home. Colleen reached out to Dee’s new guardian and caregiver to introduce herself as her care manager, to provide contact information, and schedule a follow up appointment with Dee. Diabetic education was provided to Dee and her new caregiver. Since Dee has been appointed a new guardian, she has attended all scheduled appointments. In addition, Dee’s caregiver has been very proactive in her care and eager to learn on how she can better serve Dee.

At her next appointment, Dee’s physician asked how her new home was. Her first response was she loved taking hot showers, having clean clothes every day and was excited to show off her new haircut. In the two weeks since Dee had been in her new home her blood sugars have decreased from 246-355 to 84-192 due to consistency of her diet and checking her blood sugar. Although it was unfortunate Dee had to be removed from her current home environment, it was through the work of Colleen her care manager and the collaboration of others that Dee was able to get back on track with her diabetes management and have a renewed sense of happiness in her life.


From the MI Department of Health and Human Services – Your Public Health Partner

HIV Consultation Program

As a result of the Affordable Care Act and Medicaid expansion, more Michiganders have health coverage than ever before and are seeking out primary care services. As a result, health care professionals in primary care are more likely to encounter patients diagnosed with HIV (or at risk of contracting the virus), than ever before. According to the 2015 Annual Michigan HIV Surveillance Report, there are just over 15,000 individuals living with HIV in Michigan. Many providers may have questions about addressing the health care needs of such individuals. A new consultation program established by the Michigan Department of Health and Human Services, in partnership with Henry Ford Health System, can address questions and help support health care providers in caring for patients living with or at risk for HIV.

The Michigan HIV Consultation Program offers Michigan health care professionals information and guidance regarding:

  • HIV Occupational and Non-Occupational Post-Exposure Prophylaxis (PEP/nPEP)
  • HIV Pre-Exposure Prophylaxis (PrEP)
  • HIV Disease Management
  • HIV Drug Interactions
  • Perinatal HIV treatment

Non-urgent questions can be submitted to www.henryford.com/hiv-consult-program-request and will receive a response in 24-48 hours. For urgent questions, health care professionals should call the 24-hour consultation line at (313) 575-0332. Consultations are provided by a team of knowledgeable doctors and mid-level providers.

Please visit www.michigan.gov/hivstd for information about the State of Michigan’s activities related to prevention, control and surveillance of the human immunodeficiency virus (commonly called HIV), sexually transmitted diseases (also known as STDs), and viral hepatitis (types A, B and C).

You can always find more public health information and resources, including an order form for educational materials for use in primary care, at www.michigan.gov/primarycare.

 


 

 

 

 

 

Behind the Data                                                                                    

By Michigan Data Collaborative

MDC’s Behind the Data section provides high-level information about the data for the MiPCT project in a Q & A format.

Q: Can you explain the purpose MDC’s ED Risk Adjusted Model and how it is calculated?

A: MDC used the following evidence based guideline from the National Committee for Quality Assurance (NCQA) to generate the ED Risk-Adjusted Model: “The National Committee for Quality Assurance investigated the appropriateness of developing this risk adjusted HEDIS measure by building on the existing, unadjusted measure: Ambulatory Care (AMB). Since 1993, the AMB measure has reported the unadjusted emergency department (ED) and outpatient services across health plan members of all ages.” (https://www.ncqa.org/Portals/0/PublicComment/HEDIS2016/4.%20Risk%20Adjusted%20Utilization.pdf)

NCQA test results reveal that risk adjustment is a desirable refinement and demonstrates that a risk adjustment strategy is both accurate and reliable. NCQA’s advisory panels agree that the results support the reliability of the risk adjustment model and that the measures can help identify opportunities for quality improvement.

MDC’s ED Risk Adjusted Model

MDC’s model for risk adjustment includes the relative health, payer, and demographic information of the patient population, allowing for better comparisons of ED use across Provider Organizations (POs). The model reports a risk-adjusted ratio of ED visits during the measurement year (observed) and the predicted probability of ED visits (expected). The model for ED risk adjustment uses Diagnostic Cost Groups developed by Verisk Health, Inc. to assign member level risk scores.

The following three rates are developed for the final evaluation:

  • PO Observed ED Rate – Uses the actual ED visits within the measurement period.
  • PO Expected ED Rate – Uses a two-step model to predict ED visits, which is based on the member’s age, risk score, gender, and payer.
  • The logistic regression estimates the probability of having zero ED visits.
  • The negative binomial regression estimates the probability of ED visits in the measurement year.
  • Overall Observed Rate – Combines all provider organization ED visits.

MDC’s ED Risk-Adjusted Formula

ED risk adjusted = ([PO observed ED rate] / [PO predicted ED rate]) * [overall observed rate]

The ED risk adjusted rate can then be used to compare against the utilization for other providers or MiPCT overall.

SIM / PCMH Initiative – Clinical Data Submission Update Reminder

As we posted in the October FLASH newsletters, POs and Practices continuing with SIM PCMH will send clinical data directly to MiHIN. The MiHIN/SIM team will provide direction regarding how to submit the clinical data in the near future.


 


November 14, 2016

Final MACRA Rule Identifies BCBSM PGIP PCMH as an Acceptable Regional Designation

The final rule for Medicare Access and CHIP Reauthorization Act (MACRA) was recently released by CMS.   It clarifies that regional PCMH programs that meet certain criteria, including BCBSM’s PGIP PCMH designation, qualify as an acceptable designation for MIPS PCMH credit.  Specifically, CMS relayed that:  “We also expand our definition of how CMS will recognize a MIPS eligible clinician or group as being a certified patient-centered medical home or comparable specialty practice to include certification from a national program, regional or state program, private payer or other body that administers patient-centered medical home accreditation.”   The final rule also identified BCBSM PGIP PCMH designation and the Oregon Patient-Centered Primary Care Home program as two examples of acceptable designation programs.


SIM PCMH Initiative Updates

In late October, MDHHS announced the practices eligible for SIM PCMH Initiative participation in 2017.  They are included as an attachment (Selected Practices.pdf).  The applying organization (practice or PO) for each eligible organization was sent a participation agreement to confirm their participation.  Data sharing and MiHIN legal onboarding documents followed.  The participation agreements were due to MDHHS last Friday (e.g.,  postmarked by November 11).    After signed agreements are tabulated, we will then ascertain those that are continuing MiPCT practices, those that are new to the SIM but applied via a PO, and those practices that applied independently.

MDHHS also released a set of G/CPT codes that are to be submitted for eligible Medicaid patients on and after January 1, 2017.  They are included as an attachment (2017 Care Management and Coordination Tracking Codes.pdf) and will also be covered on the November 15 Billing and Coding noon webinar.

 


Reporting of Incentive Distributions

Incentive payments from Medicare and Medicaid that were made to POs through the 42-month incentive payment (January 1, 2015-June 30, 2015) are posted on the web-based quarterly report, https://mipct.mihealth.org/. The Incentive Distribution reports are submitted in addition to the quarterly report, as data becomes available. The reports are accessed in a section below the list of quarterly reports on the Financial Reports page.

To complete each report:

  • Click on Edit to open each report to open the Incentive Distribution section.
  • Enter the amount and date payment was made to each practice.
  • As with the quarterly reports, anyone who has a user account may enter and save the data. However, the person who has the authority to submit the financial report will also be responsible for submitting the Distribution of Incentives.
  • The submitter will complete the steps below.
  • Select the checkbox at the end of the page to indicate the report is ready to submit. The Checkbox is only visible to Submitter.
  • Select the “Submit” button at the end of the page. The Status on the Financial Reports page changes from Draft to Submitted.

The Incentive Distributions can be completed anytime one is listed in Draft status. Please complete them at your earliest convenience.


BCBSM Pharmacy Resources Now Available for PDCM Practices

New pharmacy resources are available on the PGIP Collaboration site that MiPCT/PDCM care managers may find helpful when working with chronic condition patients.

Resources include an online toolkit published by the U.S. Department of Health and Human Services to educate providers and patients about safe pain management, called www.turnthetiderx.org; as well as the new Toolkits and Fliers section on the left side of the Pharmacy Initiative page, which includes information for physician organizations, patients and providers.

Topics include saving money by using generic drugs, the dangers of antibiotic overuse, engaging providers in Collaborative Quality Initiatives, and safely managing patients pain, among others.

To access this information and share it with MiPCT/PDCM care managers, visit the Pharmacy Initiative page on the collaboration site under “Initiatives/Projects/Workgroups.”


Caregiver Stress: Supporting the Caregiver

The term family caregiver and/or informal care giver refers to an unpaid family member, friend, or neighbor who provides care to an individual suffering a chronic condition and needs assistance with various activities such as bathing, eating, dressing or taking medications. When caring for older adults or those with chronic disabilities of all ages, this “informal care” can be substantial in scope, intensity, and duration. Sometimes caregivers are referred to as secondary patients who also need attention and guidance.

A 2015 survey conducted by AARP regarding caregiving in the U.S. showed that approximately 43.5 million adults had provided unpaid care to an adult or child in a twelve-month period. In addition, 60% of caregivers were female, whereas males accounted for 40%. Furthermore, in 2013 it was estimated that caregivers in the U.S. provided 37 billion hours of unpaid care at an estimated cost of 470 billion dollars. On average an informal caregiver devotes 4.3 years to this work. In most cases the care being provided is that of activities of daily living (ADL) or instrumental activities of daily living (IADL). However, this does not always paint a clear picture of unforeseen challenges of providing assistance with such activities, i.e. patients who may have dementia, are resistant to care or have complex medication management.

Most family members feel unprepared to take on the caregiver role, with many having a lack of knowledge of how to deliver appropriate care and receive little guidance from health care professionals. Many are unaware of when community resources may be needed and therefore may not know how to access those resources. Caregivers are patients themselves, with many dealing with physical and mental health issues from their physically and emotionally demanding role as a caregiver. For example, elderly spouses who experience stressful caregiving situations have a 63%higher mortality rate. Caregivers have additional risk for fatigue and sleep disturbances, increased blood pressure, lower immune functioning and an increased risk for cardiovascular disease.

In addition to the increased health risks, caregivers have a difficult time balancing caregiving with other activities such as work or family leisure time, which can lead to increased distress from not being able to participate in those activities. More than half of adult children caring for a parent are employed. They report missed days, interruptions of their work, and reduced productivity. Moreover, those who are unemployed or have lower incomes may experience more distress due to fewer resources to meet the demands.

The Care Manager’s Role

Professional advocacy, can be instrumental in raising awareness of caregiver stress. The care manager plays an important role in supporting the caregiver at risk for physical and emotional harm. Interventions should serve two purposes. First, support the caregiver as a client. In this approach the caregiver is the primary recipient of the education and training which then benefits the patient. Second, utilizing interventions to help the caregiver increase competency and confidence, will lead to providing safe and effective care to the patient, indirectly reducing stress. Research has found that multicomponent interventions rather than single interventions like support groups or education greatly reduce burden.

In some cases, those caring for stroke survivors or patients with dementia found counseling to improve quality of life and reduce depression. Furthermore, many caregivers felt a reduction in burden or distress when receiving socially-supported phone calls that provided some respite from caregiving. Also, home visits and enhanced social support including assistance with respite/day care interventions reduced depression and increased well-being. In addition, a prescriptive program based on research on problem-solving and therapy was developed to empower family members to moderate caregiver stress through the Prepared Caregiver Model which is summarized in the acronym COPE (Creativity, Optimism, Planning, and Expert information). This model teaches caregivers how to design and carry out a plan that focuses on medical and psychosocial issues and are coordinated with care plans of health care professionals.

Caregivers require the knowledge, skills and judgement to carry out the needed tasks of caregiving and having those things help them feel more prepared to deliver care. When providing care one needs to take into account the following dimensions:

  • Nature of the task
  • Frequency of the tasks
  • Hours of care provided each day
  • Skills, knowledge and ability
  • Extent to which tasks can be routine, incorporate into daily schedules
  • Support of other family members.

At a minimum, care managers can recognize and respect a caregiver’s efforts, assess their needs, provide concrete instructions on the specific care they are giving and refer them to other community resources to provide on-going help. This assessment should take place in addition to the patient assessment. Listening skills and the ability to interpret body language and verbal communication are essential competencies when meeting with patients and their family members. Linking caregivers throughout the disease trajectory is critical because many times they are unaware of the support services available

Houts, P. S., Nezu, A. M., Nezu, C. M., & Bucher, J. A. (1996). The prepared family caregiver: a problem-solving approach to family caregiver education. Patient education and counseling, 27(1), 63-73.

Schulz, R. PhD, & Sherwood, P.R. PhD, RN, CNRN. (2008). Physical and mental health effects of family caregiving. American Journal of Nursing. 108(9 Suppl): 23-27.

Care Giving in the U.S. Final Report. (June 2015). AARP. Retrieved from http://www.caregiving.org/wp-content/uploads/2015/05/2015_CaregivingintheUS_Final-Report-June-4_WEB.pdf

Family Caregivers Provide Staggering $470 Billion in Unpaid Care According to AARP Study. (July 2015). Retrieved from http://www.aarp.org/about-aarp/press-center/info-07-2015/family-caregivers-provide-470-billion-in-unpaid-care-aarp-study.html

Reinhard SC, Given B, Petlick NH, et al. Supporting Family Caregivers in Providing Care. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 14. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK2665/


 

MiCMRC/MiPCT Complex Care Management Course

The MICMRC/MIPCT Complex Care Management (CCM) Course is provided in a blended learning activity format. The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period. The course consists of:

  • Live Webinar on day 1 – introduction of MiCMRC/MiPCT CCM course
  • Self-study modules and post- tests which are completed prior to the in-person training (total expected time to complete the self-study and post tests is six hours)
  • In person training days 3 and 4

Upcoming course dates and course registration close dates:

December 5-8 , 2016. Introductory Webinar December 5th , 2016. Total six hour self-study modules and post-tests December 5-6th, 2016. In-person training December 7-8th 2016. NOTE:   Registration for this course will close as of December 1st , 2016.

January 23-26, 2017. Introductory Webinar January 23rd, 2017. Total six hour self-study modules and post-tests January 23-24th, 2017. In person training January 25-25th, 2017. NOTE: Registration will be available soon. Please watch micmrc.org for registration links.

Register for all MiCMRC/MiPCT CCM Courses Here:


REMINDER: MiPCT Care Manager Summit 2016 Pre-Work Recorded CE Webinars Close 12/31/16

For those of you who have not already taken advantage of the opportunity to earn up to 7 nursing or social work CE contact hours, the MiPCT Care Manager Summit 2016 Pre-Work recorded webinars will remain available until December 31, 2016. Four of the five webinars are approved for 1.5 CE contact hours and one is approved for 1.0 CE contact hour by both the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing, and by the Michigan Social Work Continuing Education Collaborative.

Please view the five recorded webinars prior to December 31, 2016. The links to the webinars will no longer be available after that date. The recorded webinars are posted on the http://www.mipct.org website on the 2016 Summit Prework Webinars page located under the 2016 MiPCT Annual Summits tab. Questions: micmrc-requests@med.umich.edu


Management Resource Center Approved Self-Management Support Training Programs – Update

For information about MiCMRC approved self-management programs please see the document titled “Care Management Resource Center Approved Self-Management Support Training Programs” at https://mipct.org/care-management-resource-center/ 

This document includes details for each MiCMRC approved self-management program: location, objectives, modality, resources, course date/criteria to schedule, trainer qualifications, certification/CEs, and cost.

MiPCT Moderate, Complex and Hybrid Care Managers are required to complete a MiCMRC-approved self-management course. For questions please submit to: micmrc-requests@med.umich.edu


2015 Summit Best Practice Winner Success Story

CHC Fort Gratiot Wins Most Improved Pediatric Practice

According to Deepa Nandamudi, LMSW/ACSW, Complex Care Manager for CHC Fort Gratiot, there are several factors that made a difference in their practice. First, they have a dedicated process and staff focuse on closing gaps in care. The office staff diligently follows up with parents by phone and via letters. Each visit, regardless of the reason for the visit is used as an opportunity to close gaps in care.

Additionally, ED calls are made to patients who visit the ED to remind them of extended access hours and arrange a follow-up visit, if appropriate.

They also utilize data to identify opportunities for improvement. Data analysis indicated that the most frequent driver of ED visits was constipation. Discussion with parents found that they didn’t know what to do when their child was in pain, or how to prevent constipation. The practice offered a group visit that included how to prevent constipation (e.g., with a high fiber diet that is appealing to kids), and offered information on what to do if constipation reoccurs. Care managers and physicians identified patients who could benefit from this group visit. The group visit was held at a convenient time for parents (from 5:30 to 7:30) and was a hit! As a result, group visits are now conducted for asthma, nutrition, and ADHD.

Another factor is that the care managers are centrally located but huddle once a week to discuss cases. Moreover, one care manager is a social worker and has good relationships with community mental health agencies and behavioral health resources. Community resources are monitored and published on their website and in a hardcopy binder. All employees are trained on community resources and there are good relationships with local agencies. The practice helps the agencies by documenting activity for funders, so that they can provide it to their funders as evidence of use.

There are a few hints that they would like to pass on to other practices. The whole team must know they play important roles and that others depend on them.

  • Connect your offices with community resources.
  • Define and document processes.
  • Create standard work and expectations.
  • Use your data to find out what your issues are.
  • Add a midlevel or increase your after-hours schedule if needed.

CHC Fort Gratiot hopes that the information provided here will benefit care managers, practice staff, and leadership throughout the state of Michigan as they work to provide quality care management for their patients.


Behind the Data      

By Michigan Data Collaborative

MDC’s Behind the Data section provides high-level information about the data for the MiPCT project in a Q & A format.

Q:  With the MiPCT project coming to a close at the end of 2016, what kind of reporting can we expect to see from MDC in 2017?

A:  MDC plans to release the following deliverables in 2017 to close out 2016 MiPCT reporting:

  • Dashboard Release 19.0, targeted for February 2017. This release will include:
  • Eligibility data through June 2016
  • Paid claims data through September 2016
  • Updated measurement period of July 1, 2015 through June 30, 2016
  • The 54 month incentives PDF files will be distributed, targeted for April/May 2017
  • Dashboard Release 20.0, targeted for July 2017. This release will include:
  • Eligibility data through December 2016
  • Paid claims data through March 2017
  • Updated measurement period of January 2016 through December 2016.
  • The 60 month incentives PDF files will be distributed, targeted for September/October 2017.

SIM PCMH/MiPCT Partnership – Clinical Data Submission Update

The plan for clinical data submission for SIM has changed since our last communication in the 10/10/16 PO FLASH. For the transition, SIM POs and Practices will send clinical data to MiHIN. The MiHIN/SIM team will provide direction regarding how to submit the clinical data in the near future.

If you have any questions, please contact MDC at MichiganDataCollaborative@med.umich.edu


 

 The next edition of the:

  • MiPCT PO FLASH will be distributed on Monday December 11, 2016
  • MiPCT Practice FLASH will be distributed on Monday December 11, 2016

 


 October 10, 2016

2016 MiPCT Regional Annual Summits

MiPCT Thompsonville, Ann Arbor and Grand Rapids Summit Agendas Now Available

For those planning on attending the October 13 Thompsonville, October 18 Grand Rapids, or October 26 Ann Arbor MiPCT summits, the agendas are now available and posted below.

For Thompsonville

The Thompsonville Summit:  Lunch and registration begins at 11am.  The session will begin at 11:30am.

For Ann Arbor and Grand Rapids

Morning sessions: Both sessions have a continental breakfast from 8 to 8:30.   The sessions will begin promptly at 8:30.  Please plan on arriving by 8:15.  The Grand Rapids am summit will also have a WebEx link for those who are unable to attend in person.

Afternoon Care Management Sessions begin at 1pm

 Summit Agendas

Summit North – Thompsonville, MI Tuesday, October 13,

2016 Crystal Mountain Resort & Conference Center

12500 Crystal Mountain Drive Thompsonville, Michigan 49683

 *Registration CLOSED 10/03/2016*


Summit West – Grand Rapids, MI

Tuesday October 18, 2016 Frederik Meijer Gardens and Sculpture Park

1000 E Beltline Ave NE

Grand Rapids, MI 49525

 *Registration CLOSED 10/07/2016*

  • Grand Rapids Morning Summit Webinar Log-in
  • Event:  Webinar MiPCT 2016 Annual Summit AM West Session
  •  Date:    Tuesday, October 18, 2016
  • Time:   8:30 am Eastern Daylight Time
  • Duration: 3 1/2 hours
  • Event number: 666 427 732
  • Event Password:  mipct01
  •  Click link below to join: 
  • https://mphievents.webex.com/mphievents/onstage/g.php?MTID=e80918fea03eeaaea7f8324ce15f423c1
  •  To join by audio only:
  • Call-in toll number (US/Canada): 1-650-479-3207
  • Access code: 666 427 732

Summit Southeast – Ann Arbor, MI Wednesday, October 26, 2016

University of Michigan North Campus Research Center (NCRC)

2800 Plymouth Road, Building 18

Ann Arbor, MI 48105

 Register Here    

Do Not forget to register for your FREE Parking Pass. Register for your   Parking Pass Here https://www.eventbrite.com/e/free-parking-pass-2016-mipct-summit-ann-arbor-tickets-26875104160

 *Registration CLOSES 10/17/2016*

 


 

 2016 Summit Pre-Work Webinars

MiPCT 2016 Annual Summit Care Manager Afternoon Session PREWORK

Earn Nursing or Social Work Continuing Education Contact Hours for Completing Summit PREWORK Recorded Webinars:

  • We have partnered with the Centre for Collaboration, Motivation, and Innovation (CCMI) to design a series of five pre-work webinars to enrich your learning experience at the in-person Summit afternoon CM education session.
  • The presenter is Connie Davis, RN, MN, GMP, and Co-director of the CCMI. Connie is an internationally known trainer, educator, speaker and consultant on health care design and health behavior change.
  • Viewing the webinars prior to the live Summit CM afternoon session is highly recommended.
  • Each of the 5 webinars listed below and the Summit afternoon CM in-person session are standalone in terms of earning CE contact hours.
  • *Recorded webinars are available for CE credit from now until August 1, 2017*

Steps to complete the Summit CM Prework and receive nursing or social work contact hours:

  1. Access the link on the MiPCT Summit 2016 pre-work web page https://mipct.org/
  2. View the entire online recorded webinar
  3. Click the link below the webinar titled “Request CE Credit” Click Here
  4. Complete the brief form, include your e-mail address, click submit
  5. This will generate an email message to you containing a link to complete the CE request and required evaluation form
  6. Follow instructions in the e-mail: Complete the evaluation and submit. This step generates an email to you containing the CE certificate

 New For 2016:

Stepped Care for Self-Management Support

  • This Webinar addresses population segmentation, agenda setting, social determinants of health, and patient shared decision making with complex patients.
  • “Stepped Care for Self-Management Support” is approved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.
  • “Stepped Care for Self-Management support” is approved by the Michigan Social Work Education Collaborative. Course approval #: 080416-07

MiPCT care managers who did not have the opportunity to view 2015 MiPCT Summit pre-work webinars or would like a refresher, the following webinars are available.

*Please note: if you received Nursing CE credit for the 2015 Summit pre-work webinars listed below in 2015, you will not be eligible to receive credit in 2016.

 Understanding Motivational Interviewing (MI): How the elements of Motivational Interviewing provide a context for BAP

  • “Understanding Motivational Interviewing (MI): How the elements of Motivational Interviewing provide a context for Brief Action Planning (BAP)” is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.
  • This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 081116-00
  • *If you received nursing continuing education contact hours in 2015 for this educational offering, you are not eligible to receive CE credit in 2016

Effective Communication with Patients (Ask-Tell-Ask): Identify ways to provide information consistent with the Spirit of MI

  • “Effective Communication with Patients: Ask-Tell-Ask” is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.
  • This course is approved by the Michigan Social Work Continuing Education Collaboration. Course approval #: 081116-01
  • *If you received nursing continuing education contact hours in 2015 for this educational offering, you are not eligible to receive CE credit in 2016

Understanding Brief Action Planning: Describe the components of BAP

  • “Understanding Brief Action Planning” is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.
  • This course is approved by the Michigan Social Work Continuing Education Collaboration. Course #: 081116-02
  • *If you received nursing continuing education contact hours in 2015 for this educational offering, you are not eligible to receive CE credit in 2016

Applying Brief Action Planning in the Care Setting: Identify the application of BAP in work settings

  • “Applying Brief Action Planning in the Care Setting” is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.
  • This course is approved by the Michigan Social Work Continuing Education Collaboration. Course #: 081116-03
  • *If you received nursing continuing education contact hours in 2015 for this educational offering, you are not eligible to receive CE credit in 2016

 


 New 2016 Medication Reconciliation HEDIS Measure

An inconsistency on the drug list is found in two-thirds of discharge summaries1, which contributes to nearly one in five Medicare patients being readmitted to the hospital within 30 days.2 One approach to resolving this is to reconcile medication lists with the patient shortly after discharge, which is why the National Committee for Quality Assurance Healthcare Effectiveness Data and Information set includes a quality improvement measure3 aimed at ensuring that all patients receive a medication reconciliation within 30 days of any discharge. To satisfy the measure, the medication reconciliation must be recorded in the outpatient medical record.

Medication reconciliation can be defined as a comparison of a patient’s current medications against what they were taking in a previous setting of care, to identify any discrepancies or medication-related issues4. Here are tips for performing a high-quality medication reconciliation, and improving transitions of care:

  •  Ask the patient to bring discharge instructions, medication bottles and lists, including non-prescription products (over-the-counter, vitamins, supplements)
  • Review medication bottles, and match them to the discharge instructions, including any new prescriptions
  • Address all potentially clinically significant drug therapy problems, such as therapy duplication or drug interactions, with the prescriber(s)
  • After reconciling medications, create a new list of all medications the patient should be on.
  • Go through the new list with the patient, and make sure there is one copy for the patient and another copy in the patient’s medical record.
  • Talk to your patients about the importance of maintaining an accurate and up-to-date record of all active medications. Medications can often change between settings and the list of medications can be inaccurate or outdated.
  • Encourage your patients to keep a copy of the updated medication list and bring it to all appointments. A comprehensive list of medications should include all prescription medications, herbal supplements, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives and intravenous solutions.
  • Explain to your patients that this reconciliation is done to avoid medication errors as they relate to such matters as duplications, omissions, dose, timing and adverse drug interactions.
  • Establish a process asking patients to bring their medication bottles, including all over-the-counter preparations, to every health care encounter.
  • A computer order entry system should be used when possible. It reduces errors and confusion caused by illegible handwriting.
  • The updated hospital medication list and discharge instructions are printed for education and review with the patient before he or she leaves the hospital. Request the medication list to better assist in your review and update of the chart during post-discharge medication reconciliation.
  • Always include medication reconciliation in your post-discharge visit note, whether you see your patient during an outpatient visit or you review medications over the phone with your patient.

New Medicare star ratings measure: Medication reconciliation post-discharge

About the measure The measure assesses patients age 18 and older who were discharged from an acute or non-acute inpatient stay between Jan. 1 and Dec. 1 of the measurement year. It looks at patients whose medications were reconciled from the date of discharge through 30 days after discharge (31 days total).

Medical record documentation requirements Health care providers must meet certain criteria when documenting evidence of medication reconciliation in Medicare patients’ medical records for the reconciliation to count toward this measure. Documentation in the medical record must include evidence of medication reconciliation and the date it was performed. Any of the following meets documentation criteria:

  •  A note from the provider that current and discharge medications were reconciled
  • The current medication list with a notation that references the discharge medications (for example, no changes in medication since discharge, same medications at discharge, discontinue all discharge medications)
  • Current medication list with a notation that the discharge medications were reviewed
  • Documentation of a current medication list, a discharge medication list and notation that both lists were reviewed on the same date of service
  • Notation that no medications were prescribed or ordered upon discharge

Only documentation in the outpatient chart meets the intent of the measure; an outpatient visit isn’t required. Medication reconciliation can also be done by phone.


How to receive BCBSM reimbursement for medication reconciliation post-discharge

When Medicare Advantage PPO members are discharged after a hospital stay, schedule a post-discharge office visit as soon as possible and perform medication reconciliation during the visit.

  •  The outpatient medical record must state that the “current and discharge medications were reconciled.”
  • Bill $10 for *1111F with the post-discharge office visit claim within 30 days of the discharge.
  • Medication reconciliation should be performed after every inpatient discharge.
  • CPT 2 code *1111F states, “Discharge medications reconciled with the current medication list in outpatient medical record.”
  • In addition to the office visit, Blue Cross will reimburse providers an additional $10 for billing 1111F within 30 days of a patient’s discharge.
· Description · Codes
· Discharge medications reconciled with the current medication list in the outpatient medical record · *1111F
· Transitional care management services:

· Communication (direct contact, telephone or electronic) with the patient or caregiver within two business days of discharge.

· Medical decision-making of at least moderate complexity during the service period.

· Face-to-face visit within 14 calendar days of discharge.

· *99495
· Transitional care management services:

· Communication (direct contact, telephone or electronic) with the patient or caregiver within two business days of discharge.

· Medical decision-making of at least high complexity during the service period.

· Face-to-face visit within seven calendar days of discharge.

· *99496

Reimbursement for codes 99495 or 99496 include medication reconciliation and therefore 1111F should not be billed with transitional of care codes.

There is no member cost share for 1111F.

On 7/11/16 or after, if a provider has conducted medication reconciliation post-discharge within 30 days but did not bill 1111F, a claim for 1111F can be submitted (alone.) Make sure the date of service was within 30 days of the hospital discharge to home.

Providers who have billed 1111F after 7/11/16, but with a charge of $0.01 instead of $10, providers may rebill with a $10 charge.

  1.  Perren et al. Omitted and unjustified medications in the discharge summary. Qual Saf Health Care 2009;18:205-208.
  2. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418.
  3. NCQA. Measure #46 (NQF 0097): Medication Reconciliation Post-Discharge – National Quality Strategy Domain: Communication and Care Coordination. Available at: http://store.ncqa.org/index.php/performance-measurement.html#vol2. Accessed August 28, 2016.
  4. Gleason KM, Brake H, Agramonte V, Perfetti C. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. AHRQ Publication No 11(12)-0059. Rockville, MD: Agency for Healthcare Research and Quality. Revised August 2012.

MiCMRC/MiPCT Complex Care Management Course

The 2016 MICMRC/MIPCT Complex Care Management (CCM) Course is provided in a blended learning activity format. The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period. The course consists of:

  • Live Webinar on day 1 – introduction of MiCMRC/MiPCT CCM course
  • Self-study modules and post- tests which are completed prior to the in-person training (total expected time to complete the self-study and post tests is six hours)
  • In person training days 3 and 4

Upcoming course dates and course registration close dates:

November 7-10 , 2016. Introductory Webinar November 7th , 2016. Total six hour self-study modules and post-tests November 7-8th,, 2016. In-person training November 9-10 2016. NOTE:   Registration for this course will close as of November 3rd , 2016.

December 5-8 , 2016. Introductory Webinar December 5th , 2016. Total six hour self-study modules and post-tests December 5-6th, 2016. In-person training December 7-8 2016. NOTE:   Registration for this course will close as of December 1st , 2016.

 Register for all MiCMRC/MiPCT CCM Courses Here:

 http://micmrc.org/programs/micmrc-mipct-complex-care-management-course/registration

Please submit questions regarding the MiCMRC/MiPCT CCM course

to: micmrc-requests@med.umich.edu.


MiPCT 2016 Regional Summits – Afternoon Care Manager Sessions

The 2016 in-person Summit Care Manager session: “Social Determinants of Health, Agenda Setting, and Population Management when Delivering Self-Management Support” focuses on the complex and/or high risk disengaged patient.

Learn “how to” identify the right patients for care management. Build upon your population management skills and learn new techniques for working with complex and/or high risk disengaged patients that you can apply in your daily practice!

The Summit 2016 MiPCT Care Management session consists of two parts:

  • Completion of Pre-work: Viewing recorded Webinar(s) highly recommended prior to in-person session, however may be completed at your convenience. Access at https://mipct.org/
  • Attend a Summit Afternoon in-person session.

Learning Objectives: Summit Care Management afternoon session (in person)

  •  Describe the impact of health disparities in patient care
  • Describe the critical Social Determinants of Health when supporting patients
  • Describe techniques for agenda setting with the complex/high-risk disengaged patient
  • Describe tools to facilitate shared decision making and patient empowerment
  • Discuss the importance of population segmentation for delivering self-management support
  • Learn how to apply population segmentation to a care manager’s caseload

Expert Presenters from The Centre for Collaboration, Motivation and Innovation: Kathy Reims, MD; Cory Sevin, RN, MSN, NP; Connie Davis, RN, MN, GNP; and Kelly Reilly, RN, MS, CDE

For additional Care Management Summit in person session details please see the 2016 MiPCT Summit Flyer below.

Registration: Register for the MiPCT Summit at https://mipct.org/ (Note Registration is open for Ann Arbor only until 10/17. Grand Rapids and Thompsonville registration is closed).

Continuing Education – In Person MiPCT Care Manager Session

“MiPCT Summit 2016 Care Management Session” is approved for 3.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 081116-06

*Summit Pre-work recorded webinars designed for MiPCT Care Mangers are available. Nursing and Social work continuing education contact hours are available for the Summit Pre-work webinars until August 1, 2017. Access at https://mipct.org/


Behind the Data                                                                                    

By Michigan Data Collaborative

MDC’s Behind the Data section provides high-level information about the data for the MiPCT project in a Q & A format.

  1. What can I do to help maximize my PO’s incentive scores?
  2. Missing or inaccurate data can cause lower incentive scores. One way to help improve data quality and completeness is to use the Edit Check report developed by MDC. This data validation report is run each time MDC receives clinical data from a PO, and it’s purpose is to help correct any issues and ensure MDC is receiving the most accurate clinical data from POs to incorporate into the MiPCT Dashboard.

Below is a report showing the most common issues with the clinical data for January – August 2016:

behind-the-data

The most common errors in order of prevalence are:

  • Valid Code (Valid Code is missing for Service Type Code/CPT-HCPCS/LOINC/Revenue/Diagnosis. Valid Code Must be present in at least one code field.)
  • Diastolic BP record (Service Type Code=DP with RESULT_NUM not between 40 and 200.)
  • Missing RESULT_OPERAND (If RESULT_NUM is present, RESULT_OPERAND must be equal to >, <, or =)
  • BMI records with pediatric (BMI Code BM1, BM2, BM3, BM4 where Service Date is on or after the patient’s 18th birthday.)
  • Adult BMI (Service Type Code=BM and RESULT_NUM not between 10 and 200.)
  • Systolic BP record (Service Type Code=SP with RESULT_NUM not between 60 and 300.)

Because all of these are used in incentive scoring, making data quality improvements in these areas may help increase your incentive scores!

If you have any questions or would like assistance with Edit Check Report to increase your scoring for incentive measures, please contact MDC at MichiganDataCollaborative@med.umich.edu.


SIM PCMH/MiPCT Partnership

As the MiPCT project transitions to the SIM PCMH/MiPCT Partnership, MDC is working on a plan to receive uninterrupted clinical data for the measures used for SIM. The current short-term plan is to ask for clinical data feeds for the SIM PCMH/MiPCT Partnership to be sent both to MDC and MiHIN starting in early 2017. The long term plan is for POs and Practices to send their clinical data to only MiHIN. Because this is a new process, we want to work in parallel with MiHIN until we verify that all POs and Practices can successfully send their data.

attachment-2016-mipct-regional-annual-summits-flyer-v4


 

September 12, 2016

SIM PCMH/MiPCT Partnership Initiative Application Period – Submission Deadline September 30

As the MiPCT transitions to an ongoing program in partnership with the State Innovation Model (SIM), all current MiPCT practices in good standing are eligible to apply for the SIM PCMH Initiative for Medicaid PMPM funding in 2017. The State held a webinar last Thursday (the slides are included as an attachment to this edition’s Flash as are the links to the applications and other material).

Please keep in mind that payment will flow to the submitter of the application.  Thus if a PO submits for its MiPCT practices and any PCMH practices in the five SIM regions then the PO receives the funding and is responsible for compliance and reporting.  Conversely, if a practice submits, they receive the funding , compliance, and reporting obligations.

The link for Physician Organizations applying on behalf of practices, click this link.

If you are a practice applying individually, please click this  link.


REGISTRATION OPEN!

2016 MiPCT Regional Annual Summits

Once again this year, the MiPCT Project will convene a Stakeholder Annual MiPCT Summit in three statewide regional locations.

Summit North – Thompsonville, MI

Tuesday, October 13, 2016

Crystal Mountain Resort & Conference Center

12500 Crystal Mountain Drive Thompsonville, Michigan 49683

 Register Here for Thompsonville Summit

 *Registration CLOSES 10/03/2016*


 Summit West – Grand Rapids, MI

Tuesday October 18, 2016

Frederik Meijer Gardens and Sculpture Park 1000 E Beltline Ave NE

Grand Rapids, MI 49525

Register Here for Grand Rapids Summit

*Registration CLOSES 10/07/2016*


Summit Southeast – Ann Arbor, MI

Wednesday, October 26, 2016

University of Michigan North Campus Research Center (NCRC)

2800 Plymouth Road, Building 18

Ann Arbor, MI 48105

Register Here for Ann Arbor Summit

 *Registration CLOSES 10/17/2016*


2016 Summit Pre-Work Webinars

MiPCT 2016 Annual Summit Care Manager Afternoon Session PREWORK

Earn Nursing or Social Work Contact Hours for Completing Summit PREWORK Recorded Webinars:

We have partnered with the Centre for Collaboration, Motivation and Innovation (CCMI) to design a series of five pre-work webinars to enrich your learning experience at the in-person Summit afternoon CM education session.

  • The presenter is Connie Davis, RN, MN, GMP, and Co-director of the CCMI. Connie is an internationally known trainer, educator, speaker and consultant on health care design and health behavior change.
  • Viewing the webinars prior to the live Summit CM afternoon session is highly recommended.
  • Each of the 5 webinars listed below and the Summit afternoon CM in-person session are standalone in terms of earning contact hours.
  • *Recorded webinars will be available August 29th 2016.

Steps to complete the Summit CM Prework and receive nursing or social work contact hours:

  1.  Access the link on the MiPCT Summit 2016 pre-work web page https://mipct.org/
  2. View the entire online recorded webinar
  3. Click the link below the webinar titled “Request CE Credit” Click Here
  4. Complete the brief form, include your e-mail address, click submit
  5. This will generate an email message to you containing a link to complete the CE request and required evaluation form
  6. Follow instructions in the e-mail: Complete the evaluation and submit. This step generates an email to you containing the CE certificate

New For 2016: Stepped Care for Self-Management Support

  • This Webinar addresses population segmentation, agenda setting, social determinants of health, and patient shared decision making with complex patients.
  • “Stepped Care for Self-Management Support” is approved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.
  • “Stepped Care for Self-Management support” is approved by the Michigan Social Work Education Collaborative. Course approval #: 080416-07
  • MiPCT care managers who did not have the opportunity to view 2015 MiPCT Summit pre-work webinars or would like a refresher, the following webinars are available. *Please note: if you received Nursing CE credit for the 2015 Summit pre-work webinars listed below in 2015, you will not be eligible to receive credit in 2016.

 

Understanding Motivational Interviewing (MI): How the elements of Motivational Interviewing provide a context for BAP

  • “Understanding Motivational Interviewing (MI): How the elements of Motivational Interviewing provide a context for Brief Action Planning (BAP)” is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.
  • This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 081116-00
  • *If you received nursing continuing education contact hours in 2015 for this educational offering, you are not eligible to receive CE credit in 2016

Effective Communication with Patients (Ask-Tell-Ask): Identify ways to provide information consistent with the Spirit of MI

  •  “Effective Communication with Patients: Ask-Tell-Ask” is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.
  • This course is approved by the Michigan Social Work Continuing Education Collaboration. Course approval #: 081116-01
  • *If you received nursing continuing education contact hours in 2015 for this educational offering, you are not eligible to receive CE credit in 2016

Understanding Brief Action Planning: Describe the components of BAP

  •  “Understanding Brief Action Planning” is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.
  • This course is approved by the Michigan Social Work Continuing Education Collaboration. Course #: 081116-02
  • *If you received nursing continuing education contact hours in 2015 for this educational offering, you are not eligible to receive CE credit in 2016

Applying Brief Action Planning in the Care Setting: Identify the application of BAP in work settings

  •  “Applying Brief Action Planning in the Care Setting” is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.
  • This course is approved by the Michigan Social Work Continuing Education Collaboration. Course #: 081116-03
  • *If you received nursing continuing education contact hours in 2015 for this educational offering, you are not eligible to receive CE credit in 2016

MiCMRC/MiPCT Complex Care Management Course

The 2016 MICMRC/MIPCT Complex Care Management (CCM) Course is provided in a blended learning activity format. The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period. The course consists of:

  • Live Webinar on day 1 – introduction of MiCMRC/MiPCT CCM course
  • Self-study modules and post- tests which are completed prior to the in-person training (total expected time to complete the self-study and post tests is six hours)
  • In person training days 3 and 4

Upcoming course dates and course registration close dates:

October 3-6 , 2016. Introductory Webinar October 3rd , 2016. Total six hour self-study modules and post-tests October 3-6, 2016. In-person training October 5-6 2016.

NOTE:   Registration for this course will close as of September 29th , 2016.

November 7-10 , 2016. Introductory Webinar November 7 , 2016. Total six hour self-study modules and post-tests November 7-8 2016. In-person training November 9-10 2016.

NOTE:   Registration for this course will close as of November 3 , 2016

Register for all MiCMRC/MiPCT CCM Courses Here:

http://micmrc.org/programs/micmrc-mipct-complex-care-management-course/registration

Please submit questions regarding the MiCMRC/MiPCT CCM course to: micmrc-requests@med.umich.edu


MiPCT Pediatric Summit 2016

The MiPCT Pediatric Care Manager Summit this year will address the clinical focus areas of 1) social determinants of health, specifically Adverse Childhood Experiences (ACEs) and Resiliency and 2) integration of behavioral health in primary care, including specific screening tools, as well as cultural diversity.  We will offer presentations and panel discussions about how to address these themes when working with children, youth, and families. Parents of children/youth with special health care needs will join us to help keep us family-centered in all that we do. Small group discussions will give participants the opportunity to learn from each other and to build networking relationships.

Date: September 20, 2016

Time: 8:30 am – 4 pm

Location: BCBSM Lyon Meadows Facility

53200 Grand River Avenue

New Hudson, MI 48165

 To register for the MiPCT Pediatric Summit 2016, please Click Here

 *Registration CLOSES Tuesday September 13th @ 4:30 PM*

Continuing Education:

“MiPCT Pediatric Care Management Summit” is approved for 5.5 contact hours by the Michigan Nurses Association, and approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaborative.  Course approval #: 081616-00


 

MiPCT Pediatric Summit Pre-Work

MiPCT Pediatric Care Managers will also find that the pre-summit webinar on “Specific Screening Tools for ACES and Behavioral Health” to be aligned with the summit, and is highly recommended.

The MiCMRC/MiPCT Educational Webinar: “Specific Screening Tools for ACES and Behavioral Health” will enable the learner to develop a deeper understanding of adverse childhood experiences (ACES) and behavioral health issues that are commonly treated in the pediatric primary care practice. The expert presenters are: Jane Turner, MD, Professor HP, Pediatrics and Human Development Michigan State University and Laurisa Cummings, LMSW, MiPCT Pediatric Care Manager, Care Management Supervisor, MiPCT Pediatric Clinical Lead, Children’s Medical Group of Saginaw Bay.

Nursing and Social Work continuing education contact hours for the “Specific Screening Tools for ACES and Behavioral Health” webinar may be obtained by:

– Listening to the recorded webinar which will be available by end of August.

The CE request link is posted on http://micmrc.org/webinars/continuing-ed . Click this link to initiate a request for CE Credits. This will generate an email message containing a link to complete the CE request and required evaluation form. Follow the CE instructions contained in the email. Once the required evaluation is submitted, an email will be sent containing the CE certificate.

CE credit for viewing the recorded webinar will be available until August 12, 2017. While the webinar will still be available for viewing, please note that CE credit for the viewing the recorded webinar will not be available after August 12, 2017.

Continuing Education:

 “Specific Screening Tools for Adverse Childhood Experiences (ACES) and Behavioral Health” is approved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

 This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 063016-00

For more information regarding contact hours, or for other questions, please submit to micmrc-requests@med.umich.edu


Success Story

Lindsay Schohl, RN  Hybrid Care Management and MiPCT Clinical Lead

Lakes Family Medicine Mercy Health, Muskegon

Lindsay Schohl works with the providers at Lakes Family Medicine in Muskegon, Michigan. A patient was referred to Lindsay for pain management by the primary care physician, and the patient’s spouse who is also a current patient of Lindsay’s. The patient had been struggling with pain management; she had recurrent colon cancer that she was no longer pursuing treatment for. She was told by oncology that the chemotherapy would not be curative, and her previous experience with chemotherapy did not result in good quality of life. Prior to working with the care manager she had not been receiving any follow up care by oncology and her pain was rated at 8-10/10. She was not able to sleep well, not able to drive, and not able to leave her home without excruciating pain.

The patient’s pain management skills and knowledge were lacking for multiple reasons.   She was prescribed Norco by her PCP but hadn’t been taking it. The patient was opiate naïve, and had fears of addiction that resulted from a mother who had a Norco addiction in the past.

Lindsay began communicating with the patient, providing pain management education and options for resources for pain management. The patient was adamant about declining Hospice, but she was receptive to a Palliative Care Referral for pain and symptom management. The Palliative Care Program we chose together offered a physician led approach, a one on one consult with a Palliative Care physician. Lindsay helped coordinate services for Palliative Care for this patient along with coordinating with her oncologist. Lindsay provided medication education to the patient along with addressing issues with breakthrough pain and how to handle that at home on her own with the medications Palliative Care recommended.

Through a series of nursing interventions for pain management, care coordination, and resources, the patient is doing much better. She was able to leave her home a few weekends ago to go to a comedy show with her family, she is sleeping much better. She rates her pain at a 3/10 on average, and can verbalize how to stay on top of her pain before it gets away from her and she can’t get it back under control. She continues following up with the Palliative Care physician monthly for pain and symptom management, and she continues follow up with her oncologist for support as her disease progresses. The patient reports a much better quality of life now that her pain is controlled, and thanks us for the care and support we have provided to her and her family through this difficult time.


 

Behind the Data

By Michigan Data Collaborative

MDC’s Behind the Data section provides high-level information about the data for the MiPCT project in a Q & A format.

Q: What is the incentive period used to calculate the performance incentive scores?

A: MDC published release 18 of the MiPCT Dashboard on Thursday, September 8, 2016. The data from this release will be used for the 48 month incentive measure calculations. The 48 month incentives are based on the measurement year 1/01/2015 thorough 12/31/2015, although some clinical quality metrics include an additional look-back period.

Viewing the data in release 18 will provide an early opportunity to review metrics and quantify incentive result expectations.metrics are found on both the Quality page and Utilization page of the Dashboard, and the underlying data can be viewed by clicking the See Detail link on each page. Additional information and instructions about viewing the data, see the MiPCT Dashboard User Guide (https://www.michigandatacollaborative.org/MDC/assets/MiPCT_New_Dashboard_UG.pdf). Other helpful documentation can be found on the MDC Website Support page (https://www.michigandatacollaborative.org/MDC/#/support).

New Measures Added in the 2015 MiPCT Performance Incentive  Program

  • Childhood Immunizations/Combo 3
  • Adult ED Risk Adjusted Visits (per 1000 attributed patients)
  • Pediatric ED Risk Adjusted Visits (per 1000 attributed patients)

2014 Measures Retired in 2015

  • Part I: Primary Care Sensitive ED visit rates
  • Part IV: Notification of Hospital Admissions & Discharges
  • Part IV: Follow-Up Referrals to a Community-­-Based Program or Agency
  • Part IV: Self-Management Support Offered for Chronic Condition of Focus

For more details on the incentive metrics or methodology, please refer to the MIPCT 2015 Performance Incentive documents located at https://mipct.org/resources/performance-incentives/ or contact MDC at MichiganDataCollaborative@med.umich.edu.


Attachments:

The next edition of the:

  •  MiPCT Practice FLASH will be distributed on September 26 , 2016
  • MiPCT PO FLASH will be distributed on October 10, 2016

 


 

August 15, 2016

Billing and Coding Collaborative:  The Next Steps

Thanks to those practices and POs that participated in the Billing and Coding Collaborative March webinar.   The remaining schedule for those participating in the collaborative (for four practice learning credits) is anticipated to be (dates are in process of confirmation)

  • An August 30 (11am to noon) webinar on “What claims analysis can help to tell us about follow-up PCP care after hospitalizations”
  • A September 27 (noon to 1) webinar on “Practice Level Care Management Code by Code Analysis”
  • A November 15 (noon to 1) webinar on “Care Management Billing and Coding and the 2017 SIM PCMH MiPCT Partnership”

To obtain credit, as with the other billing and coding collaborative sessions, a physician does not have to participate, however a Care Manager and at least one other practice team member (front office team member, Practice Manager, biller, coder, etc.) must participate in each session or review the taped session and keep short notes on meaningful team discussion to apply the learning to improvements for the practice.    POs may transmit the learning in a facilitated way to their practices with the same requirement for notes on meaningful discussion.  The goal of the note-taking is not for documentation only, but to facilitate actual improvements in performance and identification of areas of opportunity as well as next steps for the practice.   We will provide additional detail and notice of any prework in advance.


MiPCT in the News! 

Care Manager Success Story on WUOM!

Natalie Adewunmi, RN, an MiPCT Care Manager at IHA since May 2014 has a passion for patients.  She was featured, along with Diane Marriot, MiPCT Project Manager, in an interview with Cynthia Canty on the WUOM NPR station’s Stateside show on Thursday, August 11.  Natalie describes her work in this way:  “I believe my role as a nurse and care manager is to partner with the primary care physician to come alongside the patient and their family providing support, resources, and education. I really enjoy learning about people and hearing their stories. Living with a chronic disease or other health concern is a serious and challenging part of life. It is one of my greatest joys to see patients learn more about their chronic diseases, effectively navigate the healthcare system, and make changes that positively influence their health and wellness.”

The interview focused on the MiPCT as an example of the importance of a well-functioning primary care system in Michigan.  They noted the differences that the program has brought to patients in the state as well as to providers.  Natalie’s great example of how she partners with patients to make a difference in their lives is illustrative of the hard work done by the 345 MiPCT practices across the state.  As Natalie says, “I love being a Care Manager because I have the opportunity to use my nursing knowledge and community resources to empower patients to take steps to improve their health and wellness. I get to witness patients avoiding hospitalizations, patients making lifestyle changes that impact their future, patients taking small and big steps towards their goals, family members with improved confidence as they care for their loved ones, and patients encouraged because they know someone is there as an extra support to them. As a nurse, it doesn’t get much better than this!”

Attached is the link to listen to the complete transcript of this interview.

http://michiganradio.org/post/michigan-working-toward-next-generation-primary-care


CMS CPC+Regions Selected

More Information to Come

As you may have seen, CMS announced the selection of 14 regions and 57 payer partners for the for Comprehensive Primary Care Plus (CPC+) initiative on Monday August 1st. The announcement included Michigan as a statewide region, with Priority Health and BCBSM as the applicants/participating payers.

CPC+, and the potential Customized Patient-Centered Medical Home Model (the “Custom Option” in the State Innovation Model), are both vehicles for continuing Medicare engagement and payment in Michigan’s PCMH efforts going forward.

While more details will be developed in dialogue with the provider and payer stakeholders, it is important that Physician Organizations support their practices which are potentially eligible to participate in the CPC+ effort in formally expressing interest to CMS. Doing so is necessary to have this opportunity. Doing so does not, however, lock any practice in to specific obligations, or to ongoing participation.

More information will be circulated about this by the CPC+ payers to assure that all have the necessary information to facilitate that expression of interest in participating by practices.

The coming months will offer much opportunity for provider, payer and State government stakeholders to collaborate on aligning efforts to assure that all potential sources of funding, including CPC+ and the potential Custom Model application, advance support for PCMH-based primary care, and for optimizing the value of health care, in Michigan. We look forward to continuing our conversations soon.


From the MI Department of Health and Human Services – Your Public Health Partner

Webinar Series Regarding New CDC Guidelines for Opioid Prescribing

In April, MDHHS shared an update about a new CDC Guideline for Opioid Prescribing. The guideline targets primary care (family, general and internal medicine practices), where rates of opioid prescribing have increased at a greater rate than other specialties. The guideline provides recommendations related to three main areas of concern:

  1. Determining when to initiate or continue opioids for chronic pain;
  2. Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation; and,
  3. Assessing Risk and Addressing Harms of Opioid Use. There are four webinars scheduled, the first of which occurred on June 22nd. Slides, session transcript and audio from the first webinar are available at CDC’s Clinician Outreach and Community Activity (COCA) 2016 Webinars webpage. Free continuing education credits are available for participation. Webinars will take place on Wednesdays from 2-3 pm on the dates listed below, and cover the following topics:
  4. More recently, CDC’s National Center for Injury Prevention and Control (NCIPC), their Clinician Outreach and Communication Activity (COCA), and the University of Washington partnered to present a webinar series about the Guideline.
  • June 22nd (past) – Overview of the CDC Guideline for Prescribing Opioids for Chronic Pain
  • July 27th (past) – Non-opioid Treatments
  • August 3rd (past)– Assessing Benefits and Harms of Opioid Therapy
  • August 17th – Dosing and Titration of Opioids

The rate of death from unintentional drug poisoning in nearly quadrupled in Michigan from 1999 to 2014.1 And, the state was listed among those with the highest painkiller prescribing rates in a July 2014, CDC Vital Signs report.2 This webinar series will provide useful information and practical suggestions for managing chronic pain and using opioid painkillers, and can help providers prescribe in ways that benefit patients without exposing them to unnecessary risk. Please consider participating.

For more information and to register, visit the CDC Clinician Outreach and Community Activity (COCA) 2016 Webinars webpage.

For more public health information and resources, and other continuing education opportunities, visit the MDHHS primary care website, at: www.michigan.gov/primarycare.

[1] Michigan Prescription Drug and Opioid Abuse Task Force: Report of findings and recommendations for action, (2015). Office of the Governor, State of Michigan. http://www.michigan.gov/documents/snyder/Presciption_Drug_and_Opioid_Task_Force_Report_504140_7.pdf.

2 Centers for Disease Control and Prevention, (2014). Vital Signs Report: Opioid Painkiller Prescribing – Where You Live Makes a Difference. http://www.cdc.gov/vitalsigns/opioid-prescribing/


MiPCT Pediatric Summit 2016

The MiPCT Pediatric Care Manager Summit this year will address the clinical focus areas of 1) social determinants of health, specifically Adverse Childhood Experiences (ACEs) and Resiliency and 2) integration of behavioral health in primary care, including specific screening tools, as well as cultural diversity.  We will offer presentations and panel discussions about how to address these themes when working with children, youth, and families. Parents of children/youth with special health care needs will join us to help keep us family-centered in all that we do. Small group discussions will give participants the opportunity to learn from each other and to build networking relationships.

Date: September 20, 2016

Time: 8:30 am – 4 pm

Location: BCBSM Lyon Meadows Facility 53200 Grand River Ave,  New Hudson, MI 48165

To register for the MiPCT Pediatric Summit 2016, please Click Here

Continuing Education:

This activity has been submitted to Michigan Nurses Association for approval to award contact hours. The Michigan Nurses Association is an approver of continuing nursing education by the State of Michigan Board of Nursing.


MiPCT Pediatric Summit        

Pre-Work

MiPCT Pediatric Care Managers will also find that the pre-summit webinar on “Specific Screening Tools for ACES and Behavioral Health” to be aligned with the summit, and is highly recommended.

The MiCMRC/MiPCT Educational Webinar: “Specific Screening Tools for ACES and Behavioral Health” will enable the learner to develop a deeper understanding of adverse childhood experiences (ACES) and behavioral health issues that are commonly treated in the pediatric primary care practice. The expert presenters are: Jane Turner, MD, Professor HP, Pediatrics and Human Development Michigan State University and Laurisa Cummings, LMSW, MiPCT Pediatric Care Manager, Care Management Supervisor, MiPCT Pediatric Clinical Lead, Children’s Medical Group of Saginaw Bay.

Nursing and Social Work continuing education contact hours for the “Specific Screening Tools for ACES and Behavioral Health” webinar may be obtained by:

–  Listening to the recorded webinar which will be available by end of August.

The CE request link will be posted on http://micmrc.org/webinars/continuing-ed . Click this link to initiate a request for CE Credits. This will generate an email message containing a link to complete the CE request and required evaluation form. Follow the CE instructions contained in the email. Once the required evaluation is submitted, an email will be sent containing the CE certificate.

CE credit for viewing the recorded webinar will be available until August 12, 2017. While the webinar will still be available for viewing, please note that CE credit for the viewing the recorded webinar will not be available after August 12, 2017.

Continuing Education:

“Specific Screening Tools for Adverse Childhood Experiences (ACES) and Behavioral Health” is approved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 063016-00

For more information regarding contact hours, or for other questions, please submit to

micmrc-requests@med.umich.edu


MiCMRC/MiPCT Complex Care Management Course

The 2016 MICMRC/MIPCT Complex Care Management (CCM) Course is provided in a blended learning activity format. The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period. The course consists of:

  • Live Webinar on day 1 – introduction of MiCMRC/MiPCT CCM course
  • Self-study modules and post-tests which are completed prior to the in-person training (total expected time to complete the self-study and post tests is six hours)
  • In person training days 3 and 4

Upcoming course dates and course registration close dates:

August 22-25th, 2016. Introductory Webinar August 22nd, 2016.  Total six hour self-study modules and post-tests August 22-23, 2016.  In-person training August 24-25th  2016.  NOTE:   Registration for this course will close as of August 18th, 2016. **Saginaw Location**

September 12-15th , 2016. Introductory Webinar September 12th , 2016.  Total six hour self-study modules and post-tests September 12-13, 2016.  In-person training September 14-15 2016.  NOTE:   Registration for this course will close as of September 8th , 2016.

October 3-6 , 2016. Introductory Webinar October 3rd  , 2016.  Total six hour self-study modules and post-tests October 3-6, 2016.  In-person training October 5-6 2016.  NOTE:   Registration for this course will close as of September 29th , 2016.

Register for all MiCMRC/MiPCT CCM Courses Here:

http://micmrc.org/programs/micmrc-mipct-complex-care-management-course/registration

Please submit questions regarding the MiCMRC/MiPCT CCM course to: micmrc-requests@med.umich.edu.


From the MI Department of Health and Human Services – Your Public Health Partner

Diabetes Management and Metabolic Surgery Patients with Type 2 diabetes are often overweight. According to the American Diabetes Association more than 80% of people are obese at the time of diagnosis.1 As a provider, you may feel there is little you can do to help patients facing these health challenges, but there are options.

Consider a referral to a recognized (American Diabetes Association – ADA) or accredited (American Association of Diabetes Educators – AADE) Diabetes Self-Management Education (DSME) program. Teams of educators working within such programs can help your patients learn behavior change techniques and self-management skills that can lead to a reduction in body weight and improvement in blood glucose. The ADA, AADE and Academy of Nutrition and Dietetics have created an algorithm outlining four critical times for making a referral to DSME: 1) at diagnosis, 2) annually, 3) when new complicating factors present, and 4) when there is a transition in care.

Patients with a BMI of 35.0-39.9 kg/m²* who have participated in a DSME program and attempted to make lifestyle changes, but have not lost or kept off an adequate amount of weight or seen improvement in their blood glucose readings may benefit from more aggressive treatment. For them, metabolic surgery may be an option. Patients with a BMI ≥ 40 kg/m²* may benefit from metabolic surgery regardless of their level of blood glucose control (see table below).

The Delegates of the 2nd Diabetes Surgery Summit (DSS-II) prepared guidelines to educate providers on the benefits metabolic surgery may have as a treatment for their patients with Type 2 diabetes as evidence suggests that it can have a positive impact. 2

The guidelines are summarized in this table:

BMI Status* Blood Glucose Metabolic Surgery
BMI ≥ 40 kg/m² Adequately OR inadequately controlled Recommended in appropriate surgical candidates
BMI 35.0-39.9 kg/m² Not adequately controlled with lifestyle and optimal medication therapy
BMI 30.0-34.9 kg/m² Not adequately controlled despite optimal treatment with orals or injectable medications Considered in appropriate surgical candidates

*BMI thresholds should be reduced by 2.5 kg/m² for patients of Asian descent

Surgery should be performed in locations with multi-disciplinary teams that have experience in the management of diabetes and metabolic surgery. Providers are encouraged to follow post-operative guidelines developed by professional societies, and engage patients in ongoing and long-term management of their nutrition status following the procedure.

You can help your patients with diabetes live healthier lives by empowering them to adopt healthy habits. DSME teaches knowledge and skills that they need to make successful lifestyle changes, including reducing their weight. The Michigan Department of Health and Human Services has certified 93 DSME programs across the State so there is likely a program nearby. A list of DSME programs can be found at www.michigan.gov/diabetes. For more public health information, resources, and continuing education opportunities, visit the MDHHS primary care website, at: www.michigan.gov/primarycare.

1 Life with diabetes: A series of teaching outlines by the Michigan Diabetes Research and Training Center/Martha Funnell. – 5th Edition (2014).

2 Rubino F, Nathan DM, Eckel R, et al. Metabolic surgery in the treatment algorithm for type 2 diabetes: A joint statement by International Diabetes Organizations. Diabetes Care. 2016 June; 39(6): 861-77. http://care.diabetesjournals.org/content/39/6/861


Submitting Your MiPCT Success Story Just Got Easier

The Michigan Care Management Resource Center now features a new single web based MiPCT Success Story Template located on the micmr.org web site. The new web based template link is designed for submission of your MiPCT care managers, practice and PO success stories. This link is available on MiCMRC website www.micmrc.org

Also, The Michigan Care Management Resource Center (CMRC) is proud to announce a new Team Based Best Practice web page http://micmrc.org/best-practices

This page is dedicated to the great work that is happening across the state by MiPCT Practice Teams. The page features best practice stories that have been published in the Flash newsletters. In addition, you will able to access the tools and/or resources that have been shared by the practice.

Opportunity to Earn MiPCT Practice Learning Activity Credits: If you would like to share a Team Based Best Practice of your own; please submit your story via the new Success Story Template on www.micmrc.org


North Woodward Internal Medicine Care Manager Successfully Impacts End of Life Care

The patient and her husband, Mr. and Mrs. C, were both high utilization and on the MIPCT list. I had access to the practice EMR and could review both patient’s meds, health records etc.

Mrs. C’s diagnoses included oxygen dependent COPD, A-fib, CHF and +4 BLLE edema. At 91 years old, she was attempting to care for her 98 year old husband who had heart disease and a history of aspiration pneumonia. He also had just been discharged and was being treated for C-difficile.

The patient was not wearing 02 continuously and oxygen saturation often fell to the 80’s. She was often confused, and dyspneic. Her husband was losing weight and having difficulty with his diet, and managing ADLs.

Care management became involved and the team consisting of Karen Samosiuk , LMSW , Meg Michalek, RD, and myself, Dawn Klarich, RN, working with multiple issues of diet, safety, addressing care needs, reviewing medications, filling pill boxes, reaching consistency in the home so both could live more comfortably.

Short term included the patient to wear oxygen at all times and take all her meds as ordered. For her husband, it was helping him to understand dietary needs to avoid weight loss and understanding use of thickeners to avoid aspiration. The biggest goal was to help both address advanced directives and DPOA, along with the need for assistance in the home. We all felt they shouldn’t be living alone, but respected their wish to remain in their own home together. Our social worker worked often with them to get assistance and in home help for them. We all collaborated with home care after each hospitalization to ensure smooth transitions and that care goals were met. Their PCP was always on board with care, medication changes and was always appreciative of our involvement.

Over time, both patients became very comfortable with contacting me and the other care managers regarding questions and concerns. There were several times that ER visits were avoided with , reminders to use oxygen and take medications appropriately. Also, the addition of assistance in the home helped greatly.

As time went on, both the patient and her husband declined physically. Goals of care were discussed at each visit, and as a former hospice RN, I knew this was the best option for both patients. I still have wonderful connections within the hospice community, and knew of one RN in particular that I would trust their care to.

After several long conversations, Mrs. C agreed to hospice care only if I would be present during the admission process for support. I went to the home and sat with them to answer questions, and provided the support. This was the end of February and Mrs. C continued to decline physically. I received a call yesterday from the hospice RN that Mrs. C had fallen several times, that she was now in a hospital bed and minimally responsive. When the hospice RN arrived, she found Mr. C curled up next to her in the twin bed holding her hand. Mrs. C will probably pass within the next day or two in her own home, with her husband and family at her side. Their goal of remaining in their own home was respected and we all worked together to ensure this goal was met. Without care management, Mrs. C would probably die in the hospital connected to IV’s and ventilated.

I received a hug and a genuine thank you from the staff at North Woodward for the care that Mr. and Mrs. C were given over the last 3 years. When I began at North Woodward only 1 out of the 5 doctors would even speak to me. Now they ALL regularly refer patients on a daily basis. Any of them would tell you care management has made a huge difference in their practice.

Behind the Data

The next edition of the:

  •  MiPCT Practice FLASH will be distributed on August 29, 2016
  •  MiPCT PO FLASH will be distributed on September 12, 2016

 July 11, 2016

Billing and Coding Collaborative:  The Next Steps

Thanks to those practices and POs that participated in the Billing and Coding Collaborative March webinar.   The remaining schedule for those participating in the collaborative (for four practice learning credits) is anticipated to be (dates are in process of confirmation):

  • An August 30 (11am to noon) webinar on “What claims analysis can help to tell us about follow-up PCP care after hospitalizations”
  • A September 27 (noon to 1) webinar on “Practice Level Care Management Code by Code Analysis”
  • A November 15 (noon to 1) webinar on “Care Management Billing and Coding and the 2017 SIM PCMH MiPCT Partnership”

To obtain credit, as with the other billing and coding collaborative sessions, a physician does not have to participate, however a Care Manager and at least one other practice team member (front office team member, Practice Manager, biller, coder, etc.) must participate in each session or review the taped session and keep short notes on meaningful team discussion to apply the learning to improvements for the practice.    POs may transmit the learning in a facilitated way to their practices with the same requirement for notes on meaningful discussion.  The goal of the note-taking is not for documentation only, but to facilitate actual improvements in performance and identification of areas of opportunity as well as next steps for the practice.   We will provide additional detail and notice of any prework in advance.

SUCCESS!  100% of MiPCT Participating Practices Submitted SIM PCMH Intents to Participate!

A note of thanks to all involved in submitting Intents to Participate (ITP) for the 2017 SIM PCMH MiPCT Partnership by the June 30 deadline.  All 345 MiPCT practices (or POs on their behalf) submitted ITPs, and will be eligible to receive the application for participation when it is issued in August.   In addition, PCMH practices in the five identified SIM regions for 2017 were also eligible for ITP submission and several MiPCT POs also submitted ITPs for these as well

UPCOMING MiPCT CARE MANAGER WEBINARS

Nursing and Social Work FREE CE Opportunities

Nonpharmacological Approaches for Pain Management

Presented by Linda Keilman, DNP, GNP-BC

July 13, 2016 2:00pm – 3:00pm

“Non-Pharmacological Approaches for Effective Pain Management” is approved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 051916-00


Nonpharmacological Approaches for Behavioral and Psychological Symptoms of Dementia

Presented by Linda Keilman, DNP, GNP-BC

July 27, 2016 – 2:00pm – 3:00pm

“Non-Pharmacological Approaches for Behavioral and Psychological Symptoms” is approved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 052616-01


 Specific Screening Tools for ACES and Behavioral Health

Presented by Jane Turner, MD Professor HP, Pediatrics and Human Development and

Laurisa Cummings, LMSW, MiPCT Pediatric Clinical Lead, Children’s Medical Group of Saginaw Bay

August 12, 2016 – 10:00am – 11:00am

This activity has been submitted to Michigan Nurses Association for approval to award contact hours. The Michigan Nurses Association is an approver of continuing nursing education by the State of Michigan Board of Nursing.

 This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 063016-00


For details on opportunities for no-cost CE credit, and to register for these webinars: http://micmrc.org/continuing-edu

The Michigan Care Management Resource Center Announces a New Team Based Best Practice Web site Page

The Michigan Care Management Resource Center is proud to announce a new Team Based Best Practice web page   http://micmrc.org/best-practices

This page is dedicated to the great work that is being done across the state by Practice Teams.  The page will feature best practice stories that have been published in recent FLASH newsletters. The page will serve as an archive of stories submitted. In addition, you will able to access the tools and/or resources that have been shared by the practice.

Opportunity to Earn MiPCT Practice Learning Activity Credits:  If you would like to share a Team Based Best Practice of your own, please submit your story at www.micmrc.org by Clicking Here. There is a brief web based template to complete and subsequently a member of the CMRC team will contact you.  MiPCT Practices may earn two MiPCT Practice Learning Activity Credits for sharing a best practice document and posting the materials on the MiCMRC web site. The practice may earn two additional MiPCT Practice Learning Activity Credits if the story is published in an issue of the Flash newsletter.  If you have questions regarding the best practices you may contact the Michigan Care Management Resource Center at http://micmrc.org/contact-us.

MiPCT Care Managers – An Invitation to Earn Continuing Education Contact Hours

Educational Offering:  MiCMRC/MiPCT Pediatric Care Manager Webinar “Specific Screening Tools for Adverse Childhood Experiences (ACES) and Behavioral Health”

The MiCMRC/MiPCT Educational Webinar: “Specific Screening Tools for ACES and Behavioral Health” will enable the learner to develop a deeper understanding of adverse childhood experiences (ACES) and behavioral health issues that are commonly treated in the pediatric primary care practice. The expert presenters are: Jane Turner, MD, Professor HP, Pediatrics and Human Development Michigan State University and Laurisa Cummings, LMSW, MiPCT Pediatric Care Manager, Care Management Supervisor, MiPCT Pediatric Clinical Lead, Children’s Medical Group of Saginaw Bay.

Nursing and Social Work continuing education contact hours for the “Specific Screening Tools for ACES and Behavioral Health” webinar may be obtained by one of the following activities:

  • Attend the live webinar on August 12, 2016 from 10:00 -11:00 am -OR-
  • Listen to the recorded webinar which will be available in September.

To Register for the Live webinar:   http://micmrc.org/

Following the webinar a CE request link will be posted on http://micmrc.org/. Click this link to initiate a request for CE Credits. This will generate an email message containing a link to complete the CE request and required evaluation form. Follow the CE instructions contained in the email. Once the required evaluation is submitted, an email will be sent containing the CE certificate.

The CE request process will be the same for the recorded webinar. CE credit for viewing the recorded webinar will be available until August 12, 2017. While the webinar will still be available for viewing, please note that CE credit for the viewing the recorded webinar will not be available after August 12, 2017.

Continuing Education:

This activity has been submitted to Michigan Nurses Association for approval to award contact hours.  The Michigan Nurses Association is an approver of continuing nursing education by the State of Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 063016-00


For more information regarding contact hours, or for other questions, please submit to
micmrc-requests@med.umich.edu


MiPCT Pediatric Summit 2016

The MiPCT Pediatric Care Manager Summit this year will address the clinical focus areas of 1) social determinants of health, specifically Adverse Childhood Experiences (ACEs) and Resiliency and 2) integration of behavioral health in primary care, including specific screening tools, as well as cultural diversity.  We will offer presentations and panel discussions about how to address these themes when working with children, youth, and families. Parents of children/youth with special health care needs will join us to help keep us family-centered in all that we do. Small group discussions will give participants the opportunity to learn from each other and to build networking relationships.

Date:               September 20, 2016

Time:              8:30 am – 4 pm

Location:        BCBSM Lyon Meadows Facility, 53200 Grand River Avenue New Hudson, MI 48165

To register for the MiPCT Pediatric Summit 2016, please click here.

MiPCT Pediatric Care Managers will also find that the pre-summit webinar on “Specific Screening Tools for ACES and Behavioral Health” to be aligned with the summit, and is highly recommended. This webinar will be held on August 12, 2016 from 10 – 11 am.

To register for the pre-summit webinar on “Specific Screening Tools for ACES and Behavioral Health, please click on http://micmrc.org/webinars

For questions or further information, please submit to http://micmrc.org/contact-us


MiCMRC/MiPCT Complex Care Management Course

The 2016 MICMRC/MIPCT Complex Care Management (CCM) Course is provided in a blended learning activity format.  The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period.  The course consists of:

  • Live Webinar on day 1 – introduction of MiCMRC/MiPCT CCM course
  • Self-study modules and post- tests which are completed prior to the in-person training (total expected time to complete the self-study and posttests is six hours)
  • In person training days 3 and 4

 Register for upcoming MiCMRC/MiPCT CCM course dates at the following site

Upcoming course dates and course registration close dates:

July 18-21, 2016. Introductory Webinar July 18th, 2016.  Total six hour self-study modules and post-tests, July 18-19, 2016.  In-person training July 20-21, 2016.  NOTE:   Registration for this course will close as of July 14th, 2016.

August 1-4th, 2016. Introductory Webinar August 1st, 2016.  Total six hour self-study modules and post-tests August 1-2, 2016.  In-person training August 3-4th 2016.  NOTE:   Registration for this course will close as of July 28th, 2016.

August 22-25th, 2016. Introductory Webinar August 22nd, 2016.  Total six hour self-study modules and post-tests August 22-23, 2016.  In-person training August 24-25th  2016.  NOTE:   Registration for this course will close as of August 18th, 2016.

Register for all MiCMRC/MiPCT CCM Courses Here:

http://micmrc.org/programs/michigan-primary-care-transformation-mipct-project/registration

 Please submit questions regarding the MiCMRC/MiPCT CCM course to: micmrc-requests@med.umich.edu


Submitting Your MiPCT Care Management Success Story Just Got Easier

The Michigan Care Management Resource Center now features a new single web based MiPCT Success Story Template located on the micmr.org web site. The new web based template link is designed for submission of your MiPCT care managers, practice and PO success stories. This link is available on MiCMRC website www.micmrc.org


Care Manager Success Story

Submitted by Chelesea Deroshia – Alcona Health Center

Mrs. Jones was referred to Alcona Health Center- Cheboygan Campus care management services by her primary care physician, Dr. Donald Watson, on February 2016. Mrs. Jones suffered from type 2 diabetes, hypertension, PVD, frequent falls and chronic pain. After explaining the benefits of care management to the patient she agreed to have the services in place. During the enrollment Mrs. Jones stated that her biggest concern was her frequent falls in combination with her spinal stenosis, chronic pain and obstructive sleep apnea. At the time of enrollment Mrs. Jones weighed 252 lbs. which was having an impact on her pain and reducing her ability to take part in physical activities.

Based on her concerns, some short term goals were created to address her chronic pain and ability to sleep in her bed again. This included utilizing natural pain management strategies as well as using a wedge in bed to help her sleep more comfortably. Long term goals centered on reducing falls, and improving weight loss and A1C control. Mrs. Jones was given information on the plate method for diabetics and meal planning strategies. She was given criteria for healthy food and provided instruction on reading food labels. Mrs. Jones was also accompanied by Chelesea on an educational grocery shopping visit to assist her with healthier food choices. Furthermore Mrs. Jones was introduced to the Moving Easy Program which helped add more physical activity to her routine. To help Mrs. Jones sleep, Chelesea contacted the local DME provider and was able to negotiate a price on a wedge to help the patient sleep.

After discussing the plan of care with the PCP, the patient began to wean off her opioid medications and began utilizing the wedge while she slept, which significantly improved her comfort during the night. Since coming off the opioid medications Mrs. Jones has not had any falls. She states she feels better and more alert. In addition she has had a 20 pound weight loss since November of last year which, considering her limited mobility, is a big accomplishment. Both the patient and the PCP are happy with the progress made.


From the MI Department of Health and Human Services – Your Public Health Partner

Webinar Series Regarding New CDC Guidelines for Opioid Prescribing

In April, MDHHS shared an update about the new CDC Guideline for Opioid Prescribing. The guideline targets primary care (family, general and internal medicine practices), where rates of opioid prescribing have increased at a greater rate than other specialties. The guideline provides recommendations related to three main areas of concern:

  • Determining when to initiate or continue opioids for chronic pain;
  • Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation; and,
  • Assessing Risk and Addressing Harms of Opioid Use.

More recently, CDC’s National Center for Injury Prevention and Control (NCIPC), their Clinician Outreach and Communication Activity (COCA), and the University of Washington partnered to present a webinar series about the Guideline.

There are four webinars scheduled, the first of which occurred on June 22nd. Slides, session transcript and audio from the first webinar are available at CDC’s Clinician Outreach and Community Activity (COCA) 2016 Webinars webpage.

http://emergency.cdc.gov/coca/calls/2016/callinfo_062216.asp

Free continuing education credits are available for participation. Webinars will take place on Wednesdays from 2-3 pm on the dates listed below, and cover the following topics:

  • June 22nd (past) – Overview of the CDC Guideline for Prescribing Opioids for Chronic Pain
  • July 27th – Non-opioid Treatments
  • August 3rd – Assessing Benefits and Harms of Opioid Therapy
  • August 17th – Dosing and Titration of Opioids

The rate of death from unintentional drug poisoning in nearly quadrupled in Michigan from 1999 to 2014.1 And, the state was listed among those with the highest painkiller prescribing rates in a July 2014, CDC Vital Signs report.2 This webinar series will provide useful information and practical suggestions for managing chronic pain and using opioid painkillers, and can help providers prescribe in ways that benefit patients without exposing them to unnecessary risk. Please consider participating.

For more information and to register, visit the CDC Clinician Outreach and Community Activity (COCA) 2016 Webinars webpage.

https://emergency.cdc.gov/coca/calls/2016/callinfo_062216.asp

For more public health information and resources, and other continuing education opportunities, visit the MDHHS primary care website, at: www.michigan.gov/primarycare.

[1] Michigan Prescription Drug and Opioid Abuse Task Force: Report of findings and recommendations for action, (2015). Office of the Governor, State of Michigan. http://www.michigan.gov/documents/snyder/Presciption_Drug_and_Opioid_Task_Force_Report_504140_7.pdf.

2 Centers for Disease Control and Prevention, (2014). Vital Signs Report: Opioid Painkiller Prescribing – Where You Live Makes a Difference. http://www.cdc.gov/vitalsigns/opioid-prescribing/

Release 17.0 Measure Changes

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MiCMRC Recorded Webinar Flyer V4

MiCMRC Recorded Webinar Flyer V4

PO FLASH July 11 2016

The next edition of the Practice and PO FLASH

  • MiPCT Practice FLASH will be distributed on July 25, 2016
  • MiPCT PO FLASH will be distributed on August 1, 2016

 

June 6, 2016

PO FLASH June 2, 2016

PCMH Initiative Overview

MiPCT Payment Table June – December 2016

PDF -Information Requested of Existing MiPCT Practice

Important Announcement: June 30 Deadline for MiPCT Practices to Submit Notice of Intent to Participate in 2017 SIM MiPCT PCMH Initiative

MDHHS has released a nonbinding Notice of Intent process for practices who wish to participate in the PCMH Initiative, an MiPCT partnership with the State Innovation Model, in 2017. The process has been streamlined for current MiPCT practices and is available https://umichumhs.ut1.qualtrics.com/SE/?SID=SV_4IOAWwthVPkDDed. The deadline for returned responses is 5pm on June 30, 2016. If desired by practices, POs may respond to the Notice of Intent on their behalf. This will be followed in fall by a formal application process, with subsequent contracting.

Note that while the response to the Notice of Intent is nonbinding (i.e. a provider/practice can choose not to apply after submitting their intent), it is required to be eligible to submit an application in fall. Thus, MiPCT practices are highly encouraged to file responses to the Notice of Intent. Attached to this week’s Flash is a PPT briefing on the Notice of Intent Process as well as a document that details the information and questions included in the Notice of Intent online link.

The Notice of Intent is designed to assist in identifying the number of interested providers and to prepare resources for supporting practices in 2017, and will be included as topics in the June 7 PO Quarterly Sustainability webinar as well as in the MIPCT segment of the PGIP meeting on Friday, June 10.

PCMH Initiative Overview

PDF -Information Requested of Existing MiPCT Practice

MiPCT QUARTERLY PO SUSTAINABILITY UPDATE
Date: June 7, 2016 12:00-1:30pm
Event Password: mipct01
Join
Audio only:
Call-in toll number (US/Canada) 1-650-479-3207
Access code: 668 124 512

MiPCT Care Managers – An Invitation to Earn Continuing Education Contact Hours
Educational Offering:

Overview of Current Opioid Use in Michigan
June 7, 2016 2:30 – 3:30 pm Presented by Catherine Reid, MD

Nonpharmacologic Interventions for Depression
June 22, 2016 2:00 – 3:00 pm
Presented by Linda Keilman, DNP, GNP-BC

Nonpharmacologic Interventions for Pain Management
July 13, 2016 2:00 – 3:00 pm
Presented by Linda Keilman, DNP, GNP-BC

“Opioid Use in Michigan” will provide the participant with an increased awareness of how best to evaluate and manage patients with pain. Participants will understand the need for narcotics plus nonnarcotic and nonpharmacologic treatment modalities and monitoring of patients that are receiving narcotics.
This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 052416-01

“Nonpharmacologic Approaches for Depression” will enable the learner to define nonpharmacologic approaches/interventions, identify evidence-based approaches, and determine expected health outcomes after nonpharmacologic approaches are implemented in order to improve the care of patients with depression.
This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 041916-02

“Nonpharmacologic Approaches for Pain Management” will enable the learner to recognize pain across the life span and then offer effective, individualized, evidence-based nonpharmacologic approaches/interventions for pain management.
This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 051916-00

These activities have been submitted to Michigan Nurses Association for approval to award contact hours. The Michigan Nurses Association is an approver of continuing nursing education by the State of Michigan Board of Nursing.

New this year!

Nursing and Social Work continuing education contact hours for the educational webinars may be obtained by one of the following activities:

  • Attend the live webinar on the date listed above -OR-
  • Listen to the recorded webinar which will be available on

http://micmrc.org/webinars/continuing-ed approximately one month after the live webinar.

To Register for the Live webinar: http://micmrc.org/ Following the webinar a CE request link will be posted on http://micmrc.org/. Click this link to initiate a request for CE Credits. This will generate an email message containing a link to complete the CE request and required evaluation form. Follow the CE instructions contained in the email. Once the required evaluation is submitted, an email will be sent containing the CE certificate.

The CE request process will be the same for the recorded webinar. CE credit for viewing the recorded webinar will be available for one year following the date of the live webinar. While the webinar will still be available for viewing, please note that CE credit for the viewing the recorded webinar will not be available after that date.

For more information regarding contact hours, or for other questions, please submit to micmrc-requests@med.umich.edu

Save the Date!  Announcing MiPCT Pediatric Care Manager Summit September 20, 2016
Mark your calendars for this year’s Pediatric Summit:

  • Tuesday, September 20, 2016 
    • Blue Cross Blue Shield of Michigan Lyon Meadows Facility
    • 53200 Grand River Avenue New Hudson, MI 48165
      Full Day Event 9am – 4pm

The MiPCT Pediatric Care Manager Conference will address the clinical focus areas of social determinants of health and integration of behavioral health in primary care. The keynote topic will be Adverse Childhood Experiences (ACES) and Resiliency. We plan to have panel presentations about how to address these themes when working with children, youth and families. Parents of children/youth with special health care needs will join us to keep us family-centered in all that we do. Small group discussions will give participants the opportunity to learn from each other and to build networking relationships.

Registration information available in future FLASH Newsletters soon, or check back to https://mipct.org/

Please send questions to micmrc-requests@med.umich.edu

Announcing New MiCMRC Web Based CE Process

MiCMRC offers webinars that provide both Nursing and Social Work CE contact hours on an ongoing basis, for both live and recorded versions of the webinar. We are pleased to announce that the CE credit process has been simplified and is completely automated through the Michigan Care Management Resource Center website http://micmrc.org.
This new process will allow the individual to take control of the CE request process themselves.

This is how it works: Registration for the live webinars will take place as usual. Following the live webinar, go to the Michigan Care Management Resource Center web site http://micmrc.org/webinars. On the MiCMRC web site webinar page, locate the webinar information for the CE webinar for which you would like to request credit. Click the link titled “To Request CE Credit Click Here”. Complete the brief form, include your e-mail address, and click submit. This will generate an email message to you containing a link to complete the CE request and required evaluation form. Follow instructions in the e-mail, complete the evaluation and submit. This step generates an email to you containing the CE certificate.

The CE process for viewing the recorded webinar is also located on The CE process for viewing the recorded webinar is also located on http://micmrc.org/webinars. Locate the CE webinar you would like to view and click the “Replay Webinar” link. The webinars are listed in chronological order. After viewing the entire webinar, click the link titled “To Request CE Credit Click Here” and follow the same process as described above.

An additional new feature on the micmrc.org home page is a link to the “Continuing Education” web page. Here you will find a listing of webinars offering CE credits to care mangers, also in chronological order. Currently, there are two recorded webinars available for CE credit. They are “2015 Updated Beers Criteria” presented by Kim Moon PharmD, and “Understanding the Complexities of Cognition” presented by Linda Keilman, GNP.
To suggest webinar topics, ask any questions, or request technical assistance please e-mail: micmrc-requests@med.umich.edu

MiCMRC/MiPCT Complex Care Management Course – For MiPCT Care Managers
The 2016 MiCMRC/MiPCT Complex Care Management (CCM) Course is provided in a blended learning activity format. The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period. The course consists of:

  • DAY 1 – Live Webinar – Introduction of MiCMRC/MiPCT CCM course
  • DAY 2 – Self-study modules and post-tests which are completed prior to the in-person training (total expected time to complete the self-study and post-tests is six hours)
  • DAYS 3 and 4 – In-person training

Upcoming course dates and course registration close dates:
June 6-9, 2016, Introductory webinar June 6th, 2016. Total six hour self-study modules and post-tests, June 6-7, 2016. In-person training June 8 – 9, 2016. NOTE: Registration for this course will close June 2, 2016.

GRAND RAPIDS LOCATION! June 13-16, 2016. Introductory Webinar June 13th, 2016. Total six hour self-study modules and post-tests, June 13-14, 2016. In-person training June 15-16, 2016. NOTE: Registration for this course will close as of June 9thth, 2016.

June 16-22, 2016. Introductory Webinar June 16th, 2016. Total six hour self-study modules and post-tests, June 16-21, 2016. In-person training June 21-22, 2016. NOTE: Registration for this course will close as of June 15th , 2016.

MUSKEGON LOCATION! June 20-23, 2016. Introductory Webinar June 20th, 2016. Total six hour self-study modules and post-tests, June 20-21, 2016. In-person training June 22-23, 2016. NOTE: Registration for this course will close as of June 16th , 2016.
Register for MiCMRC/MiPCT CCM courses here.

Please submit questions regarding the MiCMRC/MiPCT CCM course to: micmrc-requests@med.umich.edu.

Remaining 2016 MiPCT Target Payment Dates by Payer The attached table contains the target payment dates for MiPCT funding to practices and POs from participating payers. These dates are projections and are subject to change. Please note that the first quarter Medicaid payments have been delayed and will be sent out by 6/9/2016. If you have any questions, please contact Amanda First at afirst@umich.edu. MiPCT Payment Table June – December 2016 (1)

Submitting Your MiPCT Care Management Success Story Just Got Easier – Coming Soon! The Michigan Care Management Resource Center will feature a new single web-based MiPCT Success Story template located on micmrc.org website. The new web-based template link is designed for submission of your MiPCT care manager, practice and PO success stories. This link will be available on MiCMRC website’s home page soon. Stay tuned to the micmrc.org website for this updated Success Story link.

Care Manager Success Story
University of Michigan Canton Health Center
Submitted by Complex Care Navigators: Debbie Schmidtke RN, BSN and Krista Yezback NP, MSN

AB is an 84 yo male with a PMH of CAD, Persistent Cardiac Valve Disease, Atrial Fibrillation, and HTN who presented to an ER and was admitted with progressively worsening dyspnea on exertion.

He reports over the past 1-2 months he had worsening dyspnea with exertion, and was only able to walk 10-15 feet before experiencing shortness of breath. SOB resolves at rest. The SOB also occurred when bending over to pick items up off the floor, and at night. He also reported every night when he goes to bed he would experience 5 minutes of difficulty breathing with wheezing which would resolve on its own and he was able to sleep with his head on 2 pillows. Patient does have venous insufficiency and has always notices a small amount lower extremity edema secondary to this.

The patient had called his PCP office and had his Lasix adjusted from 20 to 40 to 60 mg without relief of his symptoms. He generally responds well to diuretics and his weight remained stable. He was also given an albuterol inhaler to assist with the wheezing events. This treatment was not successful; patient continued to have worsening dyspnea and was advised to be evaluated in the ER.

ER admitted patient to an overnight stay in hospital. He was given IV diuretics and symptoms resolved with a 10 pound weight loss, improvement with ambulation, and able to walk to the bathroom and around the hall without difficulty.

Transition of care call was placed by the UM CHC Care Navigator’s, the morning after discharge.

Patient reports his fears of being admitted for the difficulty breathing and stated “he is not sure what happened but he never wanted it to happen again!” Reassurance was offered. We asked the patient why he thought he had been admitted. And he was not sure what had happened. He knew he had gained some fluid on his body, but he was not able to decipher how it had occurred.

We reviewed his discharge summary, medication reconciliation, and plan of care. We discussed the sensitivity of his body to volume status given his leaky heart valves as stated in his discharge summary. We scheduled a hospital follow-up visit within 10 days of discharge with his PCP. During our phone call, patient demonstrated a desire for self-management. We educated him on the role of the Care Navigator RN and how we can assist with self-management goals and increase his ability avoid future hospitalization / ER visits. Patient was agreeable.

We decided at the face to face Care Navigator Enrollment visit to discuss some basic self-monitoring goals / Self-Management Action Plan.

  • He would weigh himself daily, log the weights and call according to the clinical care guidelines
  • He would follow a 2 gram sodium restriction / day and 2 liter fluid restriction /day diet.
  • He would call the PCP clinic / Care Navigator RN if he should experience any symptoms, questions or concerns as discussed.

After the review of these goals and spending a great deal of time on the topics, we prepared some additional written resources for patient on following a low sodium diet. After taking this time, the patient reports “As silly as you might think this is, I really enjoy eating pickles and never considered the effects of the sodium from 1 pickle on my heart function.” We reviewed with the low sodium diet he should limit himself to 300 mg per serving and 1 dill pickle is greater than 800 mg.

The Care Navigator’s continued to call patient on a weekly basis for a month, and spoke to his wife as well per his request. She is his main support person. He also called in with questions as needed. We feel by following the patient closely after hospital discharge, we were able to assist with life changing self-monitoring skills, and assist patient with better quality of life, using the best practice for healthy heart management. We believe it is important to discuss with a patient why they feel they were admitted to the hospital in order to assist them with gaining insight into their health. Although this patient was aware of a low sodium diet, he was unaware of what low sodium meant, and was unaware of how this sodium affected his heart over time. This has reinforced the importance of how we listen to our patients.

At the last call to date, patient has changed his diet greatly keeping his sodium/ fluid intake within limits. He is experiencing an increase in activity tolerance, with decreased dyspnea, being able to walk 50 feet without resting. His weight remains consistent. Patient health has been stable for 3.5 months with no hospital / ER visits. He continues to be successful in his self-management goals. He continues to have close follow-up with his PCP and Specialty Physicians. The University of Michigan, Canton Health Center Care Navigator continues to follow patient today.

This is now becoming a habit. You keep me on track and it makes a difference. I can’t thank you enough.”

Publication3

May 9, 2016

Sustainability Key Messages

As a resource to MiPCT participants and stakeholders, a set of key messages regarding the transition of the MiPCT demonstration to program continuity beginning in 2017 has been developed and can be used for communication with your teams, as follows:

The Michigan Primary Care Transformation Project (MiPCT) demonstration period will end on December 31, 2016. The program will transition from a demonstration to an ongoing program in partnership with the State Innovation Model’s PCMH Initiative. The SIM PCMH Initiative is intentionally building upon and sustaining involvement of MiPCT providers and multi-payer participation, and leveraging the project’s existing infrastructure to advance the project model. Of note:

  • Discussions with participating commercial MiPCT payers is in process and looking positive for continuing participation. We are also interested in recruiting additional payers.
  • The existing 350 MiPCT practices will have the opportunity to apply for SIM PCMH Initiative participation, as will PCMH practices in the initial five SIM Community Health Innovation Regions (Muskegon County, Jackson County, Genesee County, Northern Michigan, and Washtenaw/Livingston Counties). The application process will begin in the summer of 2016 for a January 1, 2017 start date.
  • The PCMH SIM Initiative is foundational for effective Accountable Systems of Care (ASC), and all ASCs are also POs currently participating in MiPCT.
  • Continued Medicare participation and payment for the PCMH Initiative is critical, and we are exploring alternatives with CMS and CMMI, including the CPC+ program as well as a “custom” application permitted by CMS guidance.

SIM Operations Plan

The Michigan SIM Team is seeking your input on the plan for transforming Michigan’s health care system. The state will submit an operational plan for the SIM initiative to the Centers for Medicare and Medicaid Services (CMS) on May 31, 2016. The draft plan is available here for public review. They are accepting public comment through a survey of SIM initiative stakeholders. Your feedback will help guide their efforts as we move forward with implementation.

The plan outlines several areas important to MiPCT practices, including timing, attribution, and metrics.

Please follow this link to view and respond to the survey: https://www.surveymonkey.com/r/VV8BQCG Responses to the survey should be submitted by 5:00 PM on Wednesday, May 18, 2016. 

BCBSM Transition of Care Billing update

On behalf of BCBSM, the following is clarification regarding billing for the Transition of Care patient visits:

For patients not enrolled in care management (completion of a G9001 Initial Assessment), a Transition of Care patient visit can be billed as a G9002 (in person visit) or 98966, 98967, 98968 (phone codes), regardless of whether ongoing care management is anticipated.  Subsequent completion of the G9001 for patients who will be enrolled in care management is expected and considered a best practice.

Note:  Not all practices are using the Transitional Care Management (99495 and 99496) codes at this time.  For the practices who are using the TCM codes 99495 and 99496; the practice cannot bill TCM and G/CPT code (G9002 or 98966, 98967, 98968) at the same time if the work is related to “Transition of Care.”

The MiPCT Team and BCBSM presented the MiPCT Billing and Coding Webinar on March 29, 2016.  Access the slide deck and recorded webinar to learn about billing updates here:   https://mipct.org/resources/billing/

From the MI Department of Health and Human Services – Your Public Health Partner

Enhance®Fitness – An Evidence-based Physical Activity Program That’s Just Right for Older Patients

You know your older patients need physical activity to maintain their health and independence. Chances are, they know it too! In fact, the Centers for Disease Control and Prevention (CDC) recommends at least 150 minutes of aerobic activity every week for older adults, in addition to muscle strengthening activities on two or more days per week (http://www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html).

Not surprisingly, few adults meet the CDC’s recommendations for physical activity and it can be even more difficult for people who are older or who have mobility limitations. Such patients often face additional barriers to physical activity, in the form of transportation, limited finances, and uncertainty about whether traditional gyms or fitness classes are safe or accessible. If an older patient asked you for suggestions about getting active, would you know where to refer them? One option is Enhance®Fitness.

Enhance®Fitness is an evidence-based group physical activity program for older adults, proven to lower blood pressure, help prevent falls, and boost mood and activity levels, among other benefits. One hour classes are held three times per week and include strengthening, cardio and flexibility components. Exercises are specially designed to help participants engage in activities of daily living like getting in and out of the car or bathtub, reach upper cabinets, carry groceries and so on. Participants in Enhance®Fitness are given a fitness assessment when they begin the program, at 4 months and regularly thereafter to track their progress.

Enhance®Fitness is appropriate for adults at any level of fitness, as well as for people with disabilities. Certified instructors are trained to help participants adapt the exercises to challenge fit adults, and to safely accommodate those who are frail, including those who must remain seated. Classes are ongoing, and offered throughout the state. To learn more, or to find an Enhance®Fitness class near you, go to http://www.mihealthyprograms.org.

For more information and public health resources for managing chronic disease and increasing patient wellness, please visit www.michigan.gov/primarycare.

MiPCT CARE MANAGER WEBINARS

NEW 2016 MiPCT CARE MANAGER EDUCATIONAL WEBINARS

May 11, 2016 – 2:00pm

Transitions of Care – Clinical Lead Best Practice

Presented by: Della Slavsky RN, BSN, BA MiPCT Clinical Lead Upper Peninsula Health Plan

Janet Pund, BSN, RN-BC MiPCT Clinical Lead University of Michigan Health System

May 25, 2016 – 2:00pm

Summary of the 2016 CDC Guidelines for Prescribing Opioids for Chronic Pain

Presented by: Catherine Reid, MD Consulting Physician for the Office of Medical Affairs, MDHHS

June 7, 2016 – 2:30pm

Overview of Current Opioid Use in Michigan

Presented by: Catherine Reid, MD Consulting Physician for the Office of Medical Affairs, MDHHS

To register for these webinars: http://micmrc.org/webinars

MiPCT Care Managers – MPRO’s 2016 Care Coordination Summit | A Focused Approach: Hypertension & Diabetes

Join MPRO for their fifth annual Care Coordination Summit on Thursday, June 2, 2016. The summit brings together providers and stakeholders from across Michigan building a bridge for cross continuum education, sharing and networking. This year’s summit will add a focus on hypertension and diabetes and will explore how to improve care coordination related to these chronic conditions. This full-day event is being held at no cost to you. View the full agenda and register at http://summit.mpro.org.

MiPCT Care Managers – An Invitation to Earn Continuing Education Contact Hours

Educational Offering:  MiCMRC/MiPCT Care Manager Webinar “Nonpharmacologic Approaches for Depression”

The MiCMRC/MiPCT Educational Webinar: “Nonpharmacologic Approaches for Depression” will enable the learner to define nonpharmacologic approaches/interventions, identify evidence-based approaches, and determine expected health outcomes after nonpharmacologic approaches are implemented in order to improve the care of patients with depression. The expert presenter is: Linda J. Keilman, DNP, GNP-BC, Assistant Professor, Michigan State University.

New this year!  Nursing and Social Work continuing education contact hours for the “Nonpharmacologic Approaches for Depression” webinar may be obtained by one of the following activities:

Attend the live webinar on June 22, 2016 from 2:00 – 3:00 pm -OR-

–  Listen to the recorded webinar which will be available in July.

To Register for the Live webinar:   http://micmrc.org/

Following the webinar a CE request link will be posted on http://micmrc.org/webinars. Click this link to initiate a request for CE Credits. This will generate an email message containing a link to complete the CE request and required evaluation form. Follow the CE instructions contained in the email. Once the required evaluation is submitted, an email will be sent containing the CE certificate.

The CE request process will be the same for the recorded webinar. CE credit for viewing the recorded webinar will be available until June 22, 2017. While the webinar will still be available for viewing, please note that CE credit for viewing the recorded webinar will not be available after June 22, 2017.

An additional new feature on the micmrc.org home page is a link to the Continuing Education Page. Here you will find a listing of webinars offering CE credits to care mangers, in chronological order. Currently, there are two recorded webinars available for CE credit. They are “2015 Updated Beers Criteria” presented by Kim Moon, PharmD, and “Understanding the Complexities of Cognition” presented by Linda Keilman, GNP.

Continuing Education:

This activity has been submitted to Michigan Nurses Association for approval to award contact hours. The Michigan Nurses Association is an approver of continuing nursing education by the State of Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 041916-02

To suggest webinar topics, ask any questions, or request technical assistance please e-mail:  micmrc-requests@med.umich.edu

Registration is Now Open!  Michigan CB 2016 Spring Conference:  “Change Makers – Being the Difference in an Evolving World of Diabetes Management”

Saturday, May 21, 2016

Holiday Inn

17123 Laurel Park Dr., North

Livonia, MI  48152

Program Description: Attendees will learn about DSME as an evidenced-based intervention and be provided with professional resources and information about growth opportunities within the diabetes education field.

Target Audience: Health care professionals including nurses, dietitians, pharmacists, care managers, and social workers who interact professionally with diabetes patients to provide essential knowledge and skills needed for self-management.

Register online to save time. Register early to save money:

Early registration (up through May 5): $45

Late registration (May 6 – May 20): $55

Onsite registration (May 21): $65

For questions about the conference please contact one of the event committee members:

  • Ginger Ramsay, MSN, RN, CDE at ginger.ramsay@stjoeshealth.org
  • Kene Monplaisir, RPh at kstar8859@gmail.com
  • Frances Pachota, BSN, RN, CDE, CHWC at Frances.Pachota.rn@gmail.com

For questions about the registration process only, please contact Michele de la Iglesia at michele.delaiglesia@gmail.com.

Announcing New MiCMRC Web Based CE Process

MiCMRC offers webinars that provide both Nursing and Social Work CE contact hours on an ongoing basis, for both live and recorded versions of the webinar. We are pleased to announce that the CE credit process has been simplified and is completely automated through the Michigan Care Management Resource Center website http://micmrc.org.

This new process will allow the individual to take control of the CE request process themselves.

This is how it works: Registration for the live webinars will take place as usual. Following the live webinar, go to the Michigan Care Management Resource Center web site http://micmrc.org/webinars. On the MiCMRC web site webinar page, locate the webinar information for the CE webinar for which you would like to request credit. Click the link titled “To Request CE Credit Click Here”.  Complete the brief form, include your e-mail address, and click submit. This will generate an email message to you containing a link to complete the CE request and required evaluation form. Follow instructions in the e-mail, complete the evaluation and submit. This step generates an email to you containing the CE certificate.

The CE process for viewing the recorded webinar is also located on http://micmrc.org/webinars. Locate the CE webinar you would like to view and click the “Replay Webinar” link. The webinars are listed in chronological order. After viewing the entire webinar, click the link titled “To Request CE Credit Click Here” and follow the same process as described above.

An additional new feature on the micmrc.org home page is a link to the “Continuing Education” web page. Here you will find a listing of webinars offering CE credits to care mangers, also in chronological order. Currently, there are two recorded webinars available for CE credit. They are “2015 Updated Beers Criteria” presented by Kim Moon PharmD, and “Understanding the Complexities of Cognition” presented by Linda Keilman, GNP.

To suggest webinar topics, ask any questions, or request technical assistance please e-mail:  micmrc-requests@med.umich.edu

MiCMRC/MiPCT Complex Care Management Course – For MiPCT Care Managers

The 2016 MiCMRC/MiPCT Complex Care Management (CCM) Course is provided in a blended learning activity format.  The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period. The course consists of:

  • DAY 1 – Live Webinar – Introduction of MiCMRC/MiPCT CCM course
  • DAY 2 – Self-study modules and post-tests which are completed prior to the in-person training (total expected time to complete the self-study and post-tests is six hours)
  • DAYS 3 and 4 – In-person training

Upcoming course dates and course registration close dates:

May 23-26, 2016. Introductory webinar May 23, 2016. Total six hour self-study modules and post-tests, May 23

– 24, 2016.   In-person training May 25-26, 2016.   NOTE:

Registration for this course will close May 19th, 2016.

June 6-9, 2016. Introductory webinar June 6th, 2016.  Total six hour self-study modules and post-tests, June 6-7, 2016. In-person training June 8-9th, 2016.  NOTE:   Registration for this course will close June 2, 2016.

Register for MiCMRC/MiPCT CCM courses here.

Please submit questions regarding the MiCMRC/MiPCT CCM course to: micmrc-requests@med.umich.edu.

Introducing the New MDC Logo!

The Michigan Data Collaborative (MDC) is excited to announce the launch of our new logo, shown below. We believe this updated branding better represents MDC in our efforts to support existing and new healthcare data initiatives throughout the state of Michigan.

Watch for this new branding in all of our future communications, including a new and improved MDC website, email announcements, documentation, and our “Behind the Data” articles in the PO FLASH.

As the scope of our work expands, our primary focus is—and always will be—to deliver the quality, usable data you’ve come to expect.

If you have any feedback, questions, or concerns, please contact us at MichiganDataCollaborative@med.umich.edu.

MDC-logo_horizantal_1-line_light

 

Submitting Your MiPCT Care Management Success Story Just Got Easier – Coming Soon!

The Michigan Care Management Resource Center will feature a new single web-based MiPCT Success Story template located on micmrc.org website.  The new web-based template link is designed for submission of your MiPCT care manager, practice and PO success stories. This link will be available on MiCMRC website’s home page soon.  Stay tuned to the micmrc.org website for this updated Success Story link.

Care Manager Success Story

Northern Physicians Organization’s West Front Primary Care Utilizes Motivational Interviewing to Assist Patient with Weight Management

Mrs. X, a 58 year old female saw her Primary Care Provider (PCP) at West Front Primary Care in Traverse City, Michigan, where she expressed interest in meeting with a nutritionist regarding weight management. The PCP discussed the patient’s motivations and concerns for wanting to see a nutritionist and together they decided to first try working with the practice’s embedded care managers. A referral was made to Lauren Fine, RN, CCM, who has been with the practice for one year as a MiPCT Care Manager. Outreach was made to the patient and a care management initial evaluation appointment was set.

Prior to the initial evaluation appointment, Lauren met with the PCP and reviewed the patient’s past medical history, medications and known history with weight loss efforts which included bariatric surgery. Her previous bariatric surgery experience initially resulted in weight loss, however she believed that the program did not teach her skills to maintain the weight and as a result her old habits came back, causing her to regain the lost weight.

During the initial evaluation the patient talked about her current physical limitations which have limited her ability to exercise. She also discussed how she has historically used her current health issues as an excuse to not move forward in healthier lifestyle choices. Those health issues included joint disease, fatigue related to Lyme’s disease, fibromyalgia and sciatic nerve pain in her feet. In addition to these issues Mrs. X has controlled asthma and depression which is managed by her PCP.

During the evaluation, the patient identified portion control, stress eating (over eating and unhealthy food choices) and cravings for sweets as barriers to losing weight. In further analyzing the patient’s nutritional intake, Lauren and Mrs. X noted that there was a deficit in whole food intake of fruits and vegetables. Mrs. X self-identified the long term goals of losing 80lbs over the course of 2 years or 3lb/month. Working with the care manager the patient’s short term goals were identified as:

  1. Do stretches every day for at least 5 minutes for one week. (Establishing habits)
  2. Review mindful eating (patient education handout) and utilize this theory at least daily, especially with snacking
  3. Eat at least 2 whole fruits a day for one week

Five months into their work, Mrs. X continues to establish very reasonable goals and is able to accurately identify her barriers and plans to overcome them. She not only understands, but also values, that weight loss is related to lifestyle change. Mrs. X admits to feeling safe in sharing personal health information which has been key to the success of her efforts. The ability to be honest about her struggles and status without fear of judgment is unique and critical to her ability to continue for the long term.

She still has occasions when her fatigue or chronic pain prohibits her from staying on track yet she finds a way to actively engage in her goals. For example, if Mrs. X is not able to use her recumbent bicycle, she finds another activity like “Workout to Go” which focuses on gentler stretches, flexibility and strengthening exercises. If she has a busy schedule that week, she uses cut-up vegetables and other healthy grab and go foods to help stay on track. Additionally, she has begun preplanning events and times when she must eat out, so that her efforts are not sabotaged. During those times when life takes over and she cannot be as controlled in her planning, she has gained the ability to look at the long term and self-evaluate rather than criticize herself. In the past, this negative self-thinking may have led to even greater relapses. One of the mottos that Lauren believes in and uses with patients is that “actions take us either towards our goals or away from our goals”. She believes that, far too often, patients and caregivers phrase outcomes as either good or bad. Lauren states “When we take the time to reframe our thoughts in terms of goals, our motivation to change behavior is remarkably different”.

Lauren advised that she was in contact with Mrs. X every week for the first few months, alternating between face to face and telephone outreach. This has tapered off to where they now meet once per month face to face, with a telephone call in between. In reflecting on her work with Mrs. X, Lauren felt that the most important tool she had was the Motivational Interviewing skills that are the basis for developing patient centric treatment plans. The frequency of touch points with the patient and the ability to listen to the patient’s perspective helped her to assist the patient to reframe barriers into solutions.

Mrs. X notes that in addition to the obvious successes of having lost 29.6 pounds to date, she is able to use less pain medication to treat her physical symptoms, has more energy, and fewer symptom flare-ups than before she started with care management. When she does have occasional symptom flare-ups, she seems to recover quicker and the symptoms are not as severe. Lauren also noted that because of the frequency of contact with the patient there have been at least two specific situations where other clinical problems (chest pain and urinary tract infection symptoms) were detected and managed more effectively, thereby avoiding potential Emergency Department visits.

Mrs. X now looks forward to the future and is committed to “enjoying the journey” as well as the results. She has found care management services very supportive and expresses much gratitude. “I am eating and shopping thoughtfully and this is now becoming a habit. You keep me on track and it makes a difference. I can’t thank you enough.”

Behind the Data by MDC

MDC’s Behind the Data section provides high-level information about the data for the MiPCT project in a Q & A format.

Q:  How can the graphs on the MiPCT Dashboard help me to quickly see how our PO is doing?

A:  With the latest MiPCT Dashboard release (Release 16.0 on April 25, 2016), we have implemented the following graph updates to help you more easily assess how your PO is doing:

  1. The Quality and Utilization graphs were updated to make it easier to see how your PO is doing compared to the MiPCT benchmarks. Instead of two separate bars (one bar represented your PO’s rate and the other bar represented the benchmark), the graphs now include a bar for your PO’s rate and a green diamond indicating the benchmark. You can hover your mouse over the bar or the diamond to view the actual rates. Following is an example of the Quality graph: Quality Graph 1
  2. On the Trends page, the two Standard Cost PMPM graphs were consolidated into one graph and the two Diabetes Quality Measure trends graphs were consolidated into one graph, and the layout for both was redesigned. You can click on any point in the graph to see the data for each trend. Following is an example of the Diabetes Quality Measure Trends Graph:
  3. Quality Graph 2

We are excited to provide these updates to help you better visualize your rates versus benchmarks and how the rates have changed over time. If you have any questions or have any suggestions, please contact MDC at MichiganDataCollaborative@med.umich.edu.

April 4, 2016

MiPCT PO FLASH April_04_2016

MiPCT Sustainability and Continuity Update:  Great News!

We are delighted to announce that MiPCT will partner with the State Innovation Model (SIM) to support the SIM PCMH pillar.  This will be effective January 1, 2017, and will mean that the 350 existing MiPCT practices will be eligible for continuation in 2017, and that we will be expanding the MiPCT family with new PCMH practices in the five Community Health Innovation Regions (Jackson County; Muskegon County; Genesee County; Northern Region; and the Washtenaw and Livingston counties area).

Those who joined the March 12 PO Quarterly Sustainability webinar  heard from our State SIM partners about the PCMH pillar design to date.  The State will distribute material for public comment over the summer.   The slides are available on the mipctdemo.org website (under the Resources tab in the “Sustainability” dropdown), and will be updated over time.

There is much that Michigan can be proud of that has been accomplished with the hard work of all stakeholders.   The opportunity to continue this work in a way that strengthens the foundation of primary care in Michigan is very exciting.

Discussions are underway with Medicare (CMMI) and our commercial payers regarding ongoing MiPCT participation and we look forward to continuing to work together to support the success of all and to improve population health in our state.

From the MI Department of Health and Human Services – Your Public Health Partner

New CDC Guidelines for Opioid Prescribing for Chronic Pain – The Latest in Primary Care Prescribing

Most health care providers are likely aware that the United States is in the midst of a drug overdose epidemic. In the past decade, while death rates for leading causes such as heart disease and cancer have decreased substantially, the death rate associated with opioid pain medication has increased markedly.1

In Michigan, the rate of death from unintentional drug poisoning nearly quadrupled from 1999 to 2014, driven by increases in overdoses involving prescription drugs.2 In July 2014, a CDC Vital Signs report included Michigan among states in the highest category for painkiller prescription rates nationwide, with a rate of 107 painkiller prescriptions written per 100 state residents.3

Many providers experience stress in treating patients with chronic pain and are uncertain of the most recent best practices. It may be tempting, as a provider, to simply refuse to write prescriptions for opioid medications. But, chronic pain affects millions of Americans and there are legitimate uses for strong pain medications in some cases, even for non-terminal pain. It is imperative that prescribers use caution without risking undertreating pain, particularly among those at risk for inadequate pain treatment, including racial/ethnic minorities, women, and people with cognitive impairment.

With these considerations in mind, the CDC recently issued the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. The guideline targets primary care (family, general and internal medicine practices), where rates of opioid prescribing have increased at a greater pace than other specialties. The guideline provides recommendations related to three main areas of concern: 1) Determining when to initiate or continue opioids for chronic pain; 2) Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation; and, 3) Assessing Risk and Addressing Harms of Opioid Use. The table below lists strategies in each category (abbreviated).

Several entities have issued similar guidelines in the past few years, but among them there is variability in specific recommendations, intended audience and use of evidence. Moreover, many do not incorporate the “most recent scientific evidence about risks related to opioid dosage.” Increases in overdose deaths and the documented risk of opioid abusers “graduating” to heroin use, the subject of significant recent media coverage, should make this guideline a welcome resource, offering the very latest information regarding opioid prescription for primary care providers.

Initiating/Continuing Opioid Use ·Non-pharmacologic/non-opioid therapies are preferred for chronic pain

·Discuss treatment goals, including realistic goals for pain and function

·Discuss known risks/benefits, patient and provider responsibilities

Selection, Dosage, Duration, Follow-up, and Discontinuation ·Start by prescribing immediate-release opioids before  extended-release/long-acting (ER/LA) opioids

·Start with the lowest effective dosage

·Prescribe lowest effective dose of immediate-release opioids, and no greater quantity than needed for the expected duration of severe pain (3-7 days)

·Evaluate benefits / harms within 1 to 4 weeks of starting opioid therapy; Evaluate benefits/harms of continued therapy every 3 months or more frequently

Assessing Risk and Addressing Harms ·Evaluate risk factors (e.g. history of substance use disorder or overdose, concurrent benzodiazepine use) for opioid-related harms before starting/during continuation of opioid therapy

·Review patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) to determine if patient is receiving opioid dosages/dangerous combinations that increase risk for overdose

·Use urine drug testing before starting opioid therapy, and at least annually thereafter.

·Avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.

 

Full text of the MMWR Guideline can be found at: http://dx.doi.org/10.15585/mmwr.rr6501e1, and is available on the MDHHS Primary Care website (http://Michigan.gov/primarycare).

Quick reference resources for offices/exam rooms:

Other quick reference resources released in conjunction with the CDC’s Guideline for Opioid Prescribing for Chronic Pain can be found at http://www.cdc.gov/drugoverdose/prescribing/resources.html Please also visit the MDHHS primary care website (http://Michigan.gov/primarycare) for more useful information about public health approaches to chronic disease and injury prevention and treatment.

Citations

[1]Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016; 65:1–49. http://dx.doi.org/10.15585/mmwr.rr6501e1

2Michigan Prescription Drug and Opioid Abuse Task Force: Report of findings and recommendations for action, (2015). Office of the Governor, State of Michigan.  http://www.michigan.gov/documents/snyder/Presciption_Drug_and_Opioid_Task_Force_Report_504140_7.pdf.

3Centers for Disease Control and Prevention, (2014). Vital Signs Report: Opioid Painkiller Prescribing – Where You Live Makes a Difference. http://www.cdc.gov/vitalsigns/opioid-prescribing/

 

Addressing Social Determinants of Health (SDOH) and Behavioral Health Integration (BHI) – the Role of the Practice Team

  • 80% of health care outcomes depend on factors outside of clinical care delivery. (ROBERT WOOD JOHNSON COMMUNITY HEALTH RANKINGS)
  • Mental health high-cost patients were younger, lived in poorer neighborhoods, and had different health care utilization patterns, compared to other high-cost patients, i.e., those with complex chronic disease or cancer. (HEALTH AFFAIRS, JAN 2016)
  • The simple question, “Do you (ever) have difficulty making ends meet at the end of the month?” has a sensitivity of 98% and specificity of 60% in predicting poverty. (AAFP)

As the advanced medical home begins to address these complex situations it requires:

  • Practice teams which utilize registries which capture and address these at a population level
  • Partnerships with our medical neighborhoods
  • Processes within our practices to optimize treatment protocols and community linkages

MiPCT has created a toolkit to support POs and practices to be successful in addressing SDOH and BHI.

The link is here. Or head to:

  • https://mipct.org/
  • Go to the Resources tab and click “Social determinants of health and behavioral health – A Practical Guide”

A practice-focused webinar will be held on “Toolkit for Integrating Social Determinants of Health and Behavioral Health”: Wednesday, April 13, 2016 from 1:30pm – 2:30pm. Click here to join.

Upcoming MI CB of AADE Spring Conference, “Change Makers – Being the Difference in an Evolving World of Diabetes Management”

Submitted by Frances Pachota, BSN, RN, CDE, CHWC

Looking to expand your knowledge of diabetes education? Wondering how you can collaborate with Diabetes Self- Management Education (DSME) program educators to best support your patients with their diabetes self-management? Then the Michigan Coordinating Body (MI CB) of the American Association of Diabetes Educators (AADE) Spring Conference might be just what you have been looking for.

The MI CB of AADE Spring Conference, “Change Makers – Being the Difference in an Evolving World of Diabetes Management” is being held on Saturday, May 21, 2016 at the Holiday Inn in Livonia. Attendees will learn about DSME as an evidenced based intervention and be provided with professional resources and information about growth opportunities within the diabetes education field.

Education sessions will be provided by Certified Diabetes Educators (CDE’s) on topics such as the pathophysiology of diabetes, oral and injectable diabetes medications, diabetes nutrition, tips for teaching patients, and what DSME programs can do to help add to your patients care team and assist you with providing diabetes self- management education and support for your patients living with diabetes.

This activity has been submitted for approval to award continuing education contact hours for nurses, dieticians, and pharmacists. Registration for the conference will be open in April at the cost of $45 early registration, $55 late registration. For more information about the conference and how to register in April, contact Frances Pachota, BSN, RN, CDE, CHWC at Frances.Pachota.rn@gmail.com, or Ginger Ramsay, MSN, RN, CDE at ginger.ramsay@stjoeshealth.org.

MiPCT Care Manager Webinars

NEW 2016 MiPCT CARE MANAGER EDUCATIONAL WEBINARS

Date: April 15th 10-11 am

Title: Autism Screening, Formal Testing, and Treatment: Determining the Next Steps in the Plan

Presenter: Laurisa Cummings, LMSW Children’s Medical Group of Saginaw Bay

 

Date: April 27th 2-3pm

Title: Understanding the Complexities of Cognition

Presenter: Linda J. Keilman, DNP, GNP-BC

Assistant Professor, Gerontological Nurse Practitioner

Michigan State University, College of Nursing

To register for these webinars: http://micmrc.org/webinars

MiPCT Care Managers – An Invitation to Earn Social Work and Nursing Continuing Education Contact Hours

Educational Offering:  MiCMRC/MiPCT Care Manager Webinar:  “Understanding the Complexities of Cognition”

The MiCMRC/MiPCT Educational Webinar: “Understanding the Complexities of Cognition” webinar focuses on the use of evidence-based tools for improved assessment and management of patients with potential cognitive impairment.  The purpose of this activity is to enable the learner to define basic cognitive functions, describe the components of a brief mental status examination, and identify evidence based tools to use for assessing cognition, thus improving the care of patients with potential cognitive impairment. The expert presenter is Linda J. Keilman, DNP, GNP-BC, Michigan State University College of Nursing, Assistant Professor, Health Programs.

New this year!  Social Work and Nursing continuing education contact hours for the “Understanding the Complexities of Cognition” webinar may be obtained by one of the following activities:

Attend the LIVE webinar on April 27, 2016 from 2:00 – 3:00pm OR

-Listen to the recorded webinar which will be available late May 2016.

Details about the steps and requirements for completion will be coming soon via the upcoming FLASH Newsletter and http://www.micmrc.org

To register for the live webinar:   http://micmrc.org/

Continuing Education:

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 022316-07

“Understanding the Complexities of Cognition” is approved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

For more information regarding contact hours, or for other questions, please submit to
micmrc-requests@med.umich.edu

MiCMRC/MiPCT Complex Care Management Course – For MiPCT Care Managers

The 2016 MiCMRC/MiPCT Complex Care Management (CCM) Course is provided in a blended learning activity format.  The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period. The course consists of:

  • DAY 1 – Live Webinar – Introduction of MiCMRC/MiPCT CCM course
  • DAY 2 – Self-study modules and post-tests which are completed prior to the in-person training (total expected time to complete the self-study and post-tests is six hours)
  • DAYS 3 and 4 – In-person training

Upcoming course dates and course registration close dates:

May 23-26, 2016. Introductory webinar May 23, 2016. Total six hour self-study modules and post-tests, May 23- 24, 2016.   In-person training May 25-26, 2016.   NOTE: Registration for this course will close May 19th, 2016.

June 6-9, 2016. Introductory webinar June 6th, 2016.  Total six hour self-study modules and post-tests, June 6-7, 2016. In-person training June 8-9th, 2016.  NOTE:   Registration for this course will close June 2, 2016.

Register for MiCMRC/MiPCT CCM courses herePlease submit questions regarding the MiCMRC/MiPCT CCM course to: micmrc-requests@med.umich.edu.

Submitting Your MiPCT Care Management Success Story Just Got Easier – Coming Soon!

The MiCMRC will feature a new single web-based MiPCT Success Story template located on micmrc.org website.  The new web-based template is designed for submission of your MiPCT care manger, practice and PO success stories. This link will be available on MiCMRC website’s home page soon.  Stay tuned to the micmrc.org website for this updated Success Story link.

Care Manager Success Story

Submitted by Jane Ruhl, RN, BSN, CCM, Complex Care Manager from Oaklawn Medical Group – Marshall Internal Family Medicine

In September of 2015 Ms. S was referred per the request of the hospital case manager for care management services due to multiple ED visits. The patient was identified as being at-risk secondary to high ED utilization. The care manager met with Ms. S to conduct an initial assessment which revealed numerous psychosocial needs, educational needs and a need for self-management support.

Ms. S had multiple ambulatory care sensitive ED visits in 2015, primarily related to abdominal pain. Ms. S had multiple needs for community referrals as well as referrals to specialists, something the ED was not providing effectively. It was clear that Ms. S would benefit from care management services to assist with community referrals, care coordination as well as education and support. Current active diagnoses include: Crohn’s disease, peptic ulcer, bipolar disorder and chronic back pain. The patient had recently moved to the area and had a limited support system. Her current support is her husband who works part-time, and she has been receiving SSI assistance. They have a transportation barrier secondary to having no vehicle. In addition, Ms. S struggles with bipolar disorder and when initially assessed was dealing with severe depression. The patient sees a psychiatrist every three months; however, due to the current transportation issue she is not seeing a therapist and has difficulty accessing behavioral health resources.

The overall goal was to reduce ED utilization and provide appropriate access to care in the primary care setting. Ms. S, the care manager and the physician developed an action plan by which the patient would call the care manager if she had concerns, the care manager would then assess the situation and provide education/support or if needed coordinate a same day appointment with the provider for further evaluation. If the physician was not available the care manager would see the patient that day. This plan was also discussed with the patient’s gastroenterologist and health plan case manager.

Referrals were made to behavioral health and community service agencies regarding transportation assistance. With the ability to now access behavioral health services, Ms. S is seeing a therapist every two weeks. There has been great improvement in her depressive symptoms and she has set a goal to do one household chore daily which she is now able to take part in. In addition she is planning to volunteer at the local animal shelter which has been made possible by the transportation services.

Since the introduction of care management Ms. S’s ED use has decreased 50%. In addition, the ability to access behavioral health and community services has positively impacted her depressive symptoms and her ability to self-manage. Ms. S states she is very proud of the progress she has made and feels good about her ability to volunteer in the community. She states “she has finally found her way.” Furthermore her primary care physician, health plan case manager and gastroenterologist have stated that they are pleased with her progress.

Behind the Data

MDC’s Behind the Data section provides high-level information about the data for the MiPCT project in a Q & A format.

Q: Why is PO engagement with the data on the MiPCT Dashboard so important?

A: MDC’s MiPCT Dashboard provides information to participating POs to support the achievement of MiPCT project goals. The core areas of the Dashboard are: membership/populations, quality of care, and utilization.

Through the Dashboard, MDC can help POs to improve population health, enhance patient care delivery and patient experience, and collaborate to reduce utilization in the following ways:

·         Presenting a full picture of care – regardless of payer

·         Measuring population-wide quality and outcomes

·         Identifying high risk populations with chronic and co-morbid conditions

POs can use the data on the Dashboard pages and reports to not only view their own PO results, but also to compare their own PO’s performance against the MiPCT benchmarks and the performance of other participating POs.

The Report Writer also provides additional options for filtering and customizing data results to display or download for quick and easy analysis. For example, the 42 month incentives will be calculated from the data in Release 16.0 of the Dashboard (available mid-April). POs can use the Report Writer to build a customized report to compare incentive metric rates by practice or by provider and identify areas of improvement before the incentive reports are released.

NEXT ISSUE DATES:

Next MiPCT P.O. FLASH Issue: May 9, 2016

Next MiPCT Practice FLASH Issue: April 18, 2016

March 7, 2016

Web-based Quarterly Report Updates https://mipct.mihealth.org/

Effective with the 2016 Q1 report, MiPCT will no longer require completion of the Care Coordination Expenses section of the web-based quarterly report. Care manager compensation and benefits should still be reported in the Care Manager Detail section. The Care Coordination Expenses section will remain visible as read-only. These changes will be made to the website before the end of March. Please wait until the end of March to create your report for quarter one.

The following categories are no longer required:

  • Training
  • Education
  • Certification
  • Travel
  • Care Management Tracking Software
  • Other

Sign Up Now! Registration Opens for the 2016 MiPCT-Led Billing and Coding Collaborative (4 Practice Learning Credits)

Again this year, the MiPCT will centrally host a Multipayer Billing and Coding Learning Collaborative (4 practice learning credits for successful completion) to continue our efforts to assist and support POs and practices in robust structures that support G- and CPT-code billing for embedded care management services.

Expectations for 2016 practice team participants include:

  • Front office staff, Care Manager and other interested PO or non-physician practice team members would need to participate in three to four MiPCT-led team webinars (with pre and post work). The timing of webinars would be spread throughout the year (e.g., March, May, July, December). (Note: Physicians are not required to participate in the team webinars.) Practice teams will be need to participate in the majority of the hosted webinars (e.g., in the instance of scheduling conflicts, up to one webinar can be reviewed retrospectively from the posted online material.)
  • Physician participation in one Physician-focused webinar.
  • Depending upon the preferences of the collaborative participants, an in person half day session may also be included.

Expectations for 2016 PO representatives who wish to participate in the collaborative on behalf of their practices include:

  • Participation as outlined above
  • Demonstration (via submitted minutes or other documentation) evidence that the collaborative material was conveyed in a meaningful way to practices and is incorporated in workflow/practice
  • Submission of the names and addresses of practices involved

Please register by March 21 if your practices (or your PO on behalf of practices) intend to participate in the 2016 Billing and Coding Collaborative.

  • Link for Practices HERE
  • Link for PO on Behalf of Practices HERE

Good News! MiPCT May Help You Meet the Specialized Registry Requirement in the Public Health Reporting Measure of Meaningful Use in 2016

If your practices are sending EHR data from a certified EHR Technology (CEHRT) to MDC to meet MiPCT requirements, you may have the option to name MDC as a specialized registry for the purposes of fulfilling the Meaningful Use EHR Incentive Program’s Public Health specialized registry reporting (Measure 3: The EP is in active engagement to submit data to a specialized registry). More information is found in CMS FAQ 13653.

The following requirements constitute a specialized registry in the Meaningful Use Requirements, and describe the exploration that MDC has done (see Chart at bottom of page).

Please speak with your meaningful use coordinator to see if this option is one you would like to pursue. Your monthly All Payer Patient List will have the list of your MiPCT participating practices. Check with your IT professionals to see which practices are sending data from your CEHRT to MDC.

Practice PAC Recruitment Flier Attached

Attached is a flier that Care Managers or Physicians in MiPCT practices can give to MiPCT members or caregivers who would be good candidates for Patient Advisory Council participation. To make things even easier, at your request, we will send you a set of hardcopy fliers ready for you to hand out. If you want a set mailed to you, please let Jody Fisher (fishjody@umich.edu) know.

If you have any questions about the Patient Advisory Council, please contact Diane Marriott (dbechel@umich.edu) or 734 998 0390.

SAVE THE DATES! MiPCT Regional Annual Summits

The dates and venues for the 2016 MiPCT Regional Annual Summits are:

Summit West – Grand Rapids, MI

  • Tuesday, October 18, 2016 – confirmed
  • Frederik Meijer Gardens and Sculpture Park
  • 8AM to Noon General Session open to all;
  • afternoon care management training

Summit Southeast – Ann Arbor, MI

  • Wednesday, October 26, 2016 – confirmed
  • University of Michigan NCRC
  • 8am to Noon General Session open to all;
  • afternoon care management training

Summit North – Thompsonville, MI

  • Thursday, October 13, 2016 – tentative
  • Crystal Mountain Resort & Conference Center
  • 11 AM to Noon Project Leadership Briefing,
  • followed by afternoon care management training

CE Opportunity and Educational Offering: MiCMRC/MiPCT Care Manager Webinar: “Understanding the Complexities of Cognition”

The MiCMRC/MiPCT Educational Webinar: “Understanding the Complexities of Cognition” webinar focuses on the use of evidence-based tools for improved assessment and management of patients with potential cognitive impairment. The purpose of this activity is to enable the learner to define basic cognitive functions, describe the components of a brief mental status examination, and identify evidence based tools to use for assessing cognition, thus improving the care of patients with potential cognitive impairment. The expert presenter is Linda J. Keilman, DNP, GNP-BC, Michigan State University College of Nursing, Assistant Professor, Health Programs.

New this year! Social Work continuing education contact hours for the “Understanding the Complexities of Cognition” webinar may be obtained by one of the following activities:

  • Attend the LIVE webinar on April 27, 2016 from 2:00 – 3:00 pm -OR-
  • Listen to the recorded webinar which will be available late May, 2016. For details “coming soon” check www.micmrc.org

 

Details about the steps and requirements for completion will be coming soon – via upcoming FLASH Newsletter and www.micmrc.org .

To Register for the Live webinar HERE:

Continuing Education:

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 022316-07

This activity has been submitted to Michigan Nurses Association for approval to award contact hours. The Michigan Nurses Association is an approver of continuing nursing education by the State of Michigan Board of Nursing.

For more information regarding contact hours, or for other questions, please submit HERE

MiPCT and Non-MiPCT Care Managers – An Invitation to Earn Social Work Continuing Education Contact Hours for the MiCMRC/MiPCT Complex Care Management Training Course

New This Year! Social Work continuing education contact hours are available for completing the “MiCMRC/MiPCT Complex Care Management Training Course”

The previous form of Nursing relicensure rules still apply for this course. (See below)

To Register for the course HERE

CONTINUING EDUCATION

Social Work:

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 021816-01

Number of Social Work CE Contact Hours approved: 16

Nursing:

The activity listed above applies to the following Michigan Board of Nursing (MBON) Rules for Relicensure:

Nursing Workshop dealing with patient care issues (no formal contact hours or CEs).

MBON Rule 2(1). A maximum of 10 continuing education hours may be earned for participation in a workshop dealing with patient care issues offered by a health care organization or professional organization that falls outside the already accepted methods of approval that have already been adopted by the Board.

For more information regarding contact hours, or for other questions, please submit HERE

Statewide MiPCT Patient Advisory Council Member Nominations

The statewide MiPCT Patient Advisory Council (PAC) is an advising resource to the Steering Committee, subcommittees and other MiPCT groups (PO Advisory Council, etc.). Our goal is to ensure that the patient voice is incorporated in MiPCT implementation and operations. We are recruiting additional nominations for this state-wide advisory group, which meets quarterly via conference call. Members should be:

  1. MiPCT patients (especially patients who have experience with care managers)
  2. Able to use their own experience constructively
  3. Able to see beyond their own experience
  4. Able to listen to and hear differing opinions

Member nominations are now being accepted HERE

Following is a list of upcoming PAC Conference Calls:

  • March 18, 2016, 1-2 PM
  • June 17, 2016, 1-2 PM
  • September 16, 2016, 1-2 PM
  • December 16, 2016, 1-2 PM

MiCMRC/MiPCT Complex Care Management Course for MiPCT Care Managers

The 2016 MiCMRC/MiPCT Complex Care Management (CCM) Course is provided in a blended learning activity format.The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period.The course consists of:

  • Day 1 – Live Webinar Introduction of MiCMRC/MiPCT CCM course
  • Day 2 – Self-study modules and post-tests which are completed prior to the in-person training (total expected time to complete the self-study and post tests is six hours)
  • Days 3 – 4 – In person training

Upcoming course dates and course registration close dates:

  • March 28-31, 2016. Introductory Webinar March 28th, 2016.Total six hour self-study modules and post-tests, March 28-29, 2016.In-person training March 30-31,2016.NOTE: Registration for this course will close as of March 24th, 2016.
  • April 4-7, 2016. Introductory Webinar April 4th, 2016.Total six hour self-study modules and post-tests, April 4-5th, 2016.In-person training April 6-7th, 2016. NOTE: Registration for this course will close as of March 31st, 2016.

Register for all MiCMRC/MiPCT CCM Courses HERE

Please submit questions regarding the MiCMRC/MiPCT CCM course HERE

New 2016 MiPCT Care Manager Educational Webinars

March 9th Webinar 2-3pm

  • Title: Depression in the Older Adult
  • Presenter: Linda J. Keilman, DNP, GNP-BC Assistant Professor, Gerontological Nurse Practitioner, Michigan State University, College of Nursing

March 18th Pediatric Webinar 10-11am

  • Title: Children and Youth with Epilepsy
  • Presenter: Cynthia L. Leino-Handford, RN, Education & Advocacy Specialist, Epilepsy Foundation of Michigan

March 23rd Webinar 2-3pm

  • Title: Effective Communication with Physicians
  • Presenter: Maureen Murphy RN, BSN, FNP-BC

April 15th Pediatric Webinar 10-11am

  • Title: Autism Screening, Formal Testing, and Treatment: Determining the Next Steps in The Plan
  • Presenter: Laurisa Cummings, LMSW, Children’s Medical Group of Saginaw Bay

To register for these webinars: http://micmrc.org/webinars

Stories of Your Care Management Success, featuring Jane Deremiah, Care Manager, Spectrum Health Medical Group-Gaslight Family Practice

On October 12, 2014, Ms. Johnson was referred to Jane Deremiah, Care Manager at the Gaslight Family Practice office for care management by her PCP. The PCP was concerned for the patient’s safety, need for continued mental health treatment and care coordination. After a review of the EMR, Jane conferenced with the PCP and interim care manager who had briefly worked with the patient in the COMPASS program (Care of Mental, Physical and Substance Use Syndromes). It was determined that Ms. Johnson would benefit from care management services.

During the first meeting with Ms. Johnson, Jane assessed what was of most concern to her as well as assessing for risk and safety. Ms. Johnson was having difficulty managing severe, weeping, itchy dermatitis affecting her trunk, back, legs and arms. She had bilateral pitting edema. Ms. Johnson was not taking many of her medications including the important topical agents ordered for her.

A huge concern for Ms. Johnson was the continued profound grief at witnessing the shooting and death of her son. She exhibited symptoms of depression in her isolation and inactivity. Her PHQ9 score was 23 and she expressed that she wished she were dead. Upon further discussion she revealed that she had no plan to kill herself but could not understand why her son was dead and she lived on. While the daughter in law also witnessed the shooting, she was becoming frustrated as the care giver feeling Ms. Johnson was “stuck in her grief”.

Additional challenges and barriers were identified. Neuropsych testing had revealed possible vascular dementia. Ms. Johnson continued to have unprocessed grief but was unable to continue to attend grief counseling because of lack of transportation. The depression was affecting adequate nutrition and restorative sleep. There were limited family caregivers.

Based on this assessment, Jane and Ms. Johnson began to formulate the plan of care including long and short term goals. In the short term, they would focus on getting her dermatitis under better control, work on becoming physically stronger, find the best way to take medications and address grief. In the long term, the Ms. Johnson’s goals included identifying the safest permanent living environment of her choice, improved nutrition, significant improvement in the depression (measured by PHQ9 score) and ability to process her grief in a healthy way.

Interventions included a dermatology referral, an extensive home health regimen which included topical therapy, soaks dressing changes and oral Prednisone. Home PT, OT and home health aide assisted with enabling Ms. Johnson to do her ADLs. Ms. Johnson resumed enrollment in the in the COMPASS program. Jane updated the COMPASS team on recent developments resulting in their recommendation to start an anti-depression medication as well as trial of medication for sleep. The daughter-in-law agreed to assist Ms. Johnson with weekly medication box setup as well as bring her needed groceries. Meals on Wheels were also implemented.

With home health services in place, much needed time was now available for Ms. Johnson and her family to make a decision regarding a permanent safe living situation. In addition, Ms. Johnson responded favorably to the added attention and contact. Her skin conditioned dramatically improved. Jane’s regular, consistent contacts enabled Ms. Johnson to express her grief and frustrations. Her passivity gradually improved. Unfortunately, there was a setback when Ms. Johnson had a respiratory crisis resulting in a multi-day hospitalization. She was discharged to a skilled nursing facility due to weakness and shortness of breath. Jane maintained communication with the facility social worker regarding Ms. Johnson’s wishes for living options after discharge.

In the end, Ms. Johnson was able to return home through successful coordination with Jane and the Primary care team. Her medication regime was simplified. A neighbor was hired to provide morning and evening ADL care. Her skin condition and edema were well managed. Home physical therapy continued to work with Ms. Johnson to reinforce home safety and gradually help her gain back strength and endurance. The daughter-in-law continued to help manage her medications. Ms. Johnson is tasking her medications accurately and eating well. Her depression is improving with a PHQ9 score of 9 though she still faces some challenges with sleep and sadness surrounding her son’s death.

Ms. Johnson plans to stay in her home for as long as possible and her goal is to see her granddaughter graduate from high school. Her daughter-in-law’s stress level is also reduced due to the extra supports built into Ms. Johnson’s plan of care.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: April 6, 2016
  • Next MiPCT Practice FLASH Issue: March 21, 2016

 

February 8, 2016

Billing Medicare the Chronic Care Management Code for Non-MiPCT Patients

CMS has asked us to remind practices and POs that the 99490 Chronic Care Management code is billable on a monthly basis for non-face-to-face care coordination services furnished to non-MiPCT Medicare beneficiaries with multiple chronic conditions. The code cannot be billed for Medicare MiPCT patients who appear on monthly member lists, as Medicare already pays a PMPM for these patients. If the code is billed and paid for a MiPCT patient, the payment will be retracted after a CMS reconciliation. For additional information on the code, please see page 5 of the Multipayer MiPCT Billing and Coding grid on the “Billing, Coding, and Payment” dropdown tab of the www.mipct.org website under “Resources.”

NOTE: Enrollment is now CLOSED for this event: MiPCT Practices: Earn Eight (8) Practice Learning Credits! MiPEC Improvement Summit 3/23/2016

In addition to the Practice Learning Credit options outlined in the 2016 agreement, an additional option has been approved. Practices may earn eight (8) MiPCT Practice Learning Credits by attending the Michigan Patient Experience of Care (MiPEC) Improvement Summit on March 23, 2016 from 8:00 AM to 4:00 PM. The summit will be held on the Lansing Community College-West campus at 5708 Cornerstone Drive, Lansing, MI.

As with the other practice learning activity options, to receive credit, a primary care provider, care manager and one other member of the office team must attend. The MiPEC Improvement Summit flier is attached to today’s version of the FLASH for further information about the Summit.

This option may hold special appeal for MiPCT Practices that also participate in the MiPEC, although POs and primary care practices not currently participating in MiPEC are also welcome to attend if they are interested in learning more.Practices interested in attending should contact Lisa Mason at lmason@gdahc.org at the Greater Detroit Area Health Council (GDAHC) and include the following information:

  • Practice name
  • PO or other organization
  • Email address
  • Phone number, and
  • Whether they are a MiPCT practice

If you have additional questions, please send a message to mipctdemo@michigan.gov mailbox with “MiPEC Improvement Summit Practice Learning Credits” in the subject line or contact Lisa Mason at 313-596-0811.

New Toolkit & Framework to Better Understand and Address Social Determinants of Health and Behavioral Health

America leads the world in medical research and medical care, and for all we spend on health care, we should be the healthiest people on Earth. Yet on some of the most important indicators, like how long we live, we’re not even in the top 25, behind countries like Bosnia and Jordan. It’s time for America to lead again on health, and that means taking three steps. The first is to ensure that everyone can afford to see a doctor when they’re sick. The second is to build preventive care like screening for cancer and heart disease into every health care plan and make it available to people who otherwise won’t or can’t go in for it, in malls and other public places, where it’s easy to stop for a test. The third is to stop thinking of health as something we get at the doctor’s office but instead as something that starts in our families, in our schools and workplaces, in our playgrounds and parks, and in the air we breathe and the water we drink. The more you see the problem of health this way, the more opportunities you have to improve it. Scientists have found that the conditions in which we live and work have an enormous impact on our health, long before we ever see a doctor. It’s time we expand the way we think about health to include how to keep it, not just how to get it back.

(RWJF ” A New Way to Talk About Social Determinants” 2015)

The MiPCT Clinical Subcommittee – with PO leadership, front line providers and local experts, have created a framework and toolkit to allow caregivers in the state of Michigan a way to better understand and address the social determinants of health and behavioral health.

There is a growing body of research demonstrating the relationships between the conditions in which people grow, learn, and work as well as their health outcomes. Determinants of health include social & economic factors, health behaviors, environmental factors, genetic makeup and healthcare services. Although the importance given to each of these factors varies considerably by population and the analytic methodology used, social/economic factors are estimated to account for 30-40% of health outcomes and behavioral factors for an additional 30-40% of health outcomes.

The opportunity for primary care to impact behavioral health – including mental health and substance abuse, is significant:

  • Fifty percent of all behavioral health disorders are treated in primary care. (Kessler et al., NEJM.)
  • Up to 40% of patients in primary care have a behavioral health need. (Martin et al., Lancet. 2007)
  • In addition, almost 50% of psychotropic medication appointments occur in non-psychiatric primary care providers (Pincus et al., JAMA. 1998).

We will demonstrate the toolkit and associated resources in a 1-hour webinar for POs presented three times the week of February 15th, with a practice-focused webinar on February 25th.

PO-Focused Webinars (Same webinar, presented on 3 different dates):

  • Tuesday, February 16, 5:30 PM
    • Webinar: Toolkit for Integrating Social Determinants of Health and Behavioral Health (Note: You must pre-register in order to attend this webinar) Register Here
  • Wednesday, February 17, Noon
    • Webinar: Toolkit for Integrating Social Determinants of Health and Behavioral Health (Note: You must pre-register in order to attend this webinar) Register Here
  • Thursday, February 18, 8AM
    • Webinar: Toolkit for Integrating Social Determinants of Health and Behavioral Health (Note: You must pre-register in order to attend this webinar) Register Here

Practice-Focused Webinar:

  • Thursday, February 25, 8AM
    • Webinar: Toolkit for Integrating Social Determinants of Health and Behavioral Health (Note: No pre-registration required for this webinar) Click Here to Join Webinar

Announcing The Michigan Care Management Resource Center Enhanced Website

New for January 2016, The Michigan Care Management Resource Center (MiCMRC) unveils the updated and enhanced website http://www.micmrc.org

The new site features:

  • Clinical programs (MiPCT and more)
  • MiCMRC/MiPCT Complex Care Management course registration
  • Upcoming MiCMRC/MiPCTCare Management Webinar announcement and registration
  • Care Management 101- A suggested roadmap of staged content for the new care manager to guide developmental activities over the first year
  • New Topics page with organized resources and tools: Advance Care Planning, Palliative Care, Pediatrics, Medication Management, Transition of Care, PCMH and Team Based Care, Chronic Conditions, Quality and Population Health Management, Elderly Population and Behavioral Health
  • Features a searchable library of recorded MiCMRC/MiPCTCare Management webinars and associated materials

Note: The website redesign entailed transitioning to an open non password protected micmrc.org web site. Please take a few minutes to visit www.micmrc.org

MiPCT participants are encouraged to contribute tools and best practices to assist with enhancing delivery of care management statewide. To submit best practice/tools/resources, please contact: micmrc-requests@med.umich.edu

Your feedback and suggestions for enhancements are welcome.Please provide feedback via micmrc-requests@med.umich.edu

MiPCT Care Managers: An Invitation to Earn Nursing and Social Work Continuing Education Contact Hours

Educational Offering: MiCMRC/MiPCT Care Manager Webinar: “High Risk Medications in Older Adults – Beers Update 2015”

The MiCMRC/MiPCT Educational Webinar: “High Risk Medications in Older Adults – Beers Update 2015” webinar focuses on the recently updated Beers guidelines. The American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults is an explicit list of PIMs best avoided in older adults in general and in those with certain diseases or syndromes, prescribed at reduced dosage or with caution or carefully monitored. The updated Beers criteria were announced October, 2015. The expert presenter is Kimberly Moon, PharmD, Manager, Clinical Pharmacy Stars BCBSM.

New this year! Nursing and Social Work continuing education contact hours for the “High Risk Medications in Older Adults – Beers Update 2015” webinar may be obtained by the following activities:

  • Attend the LIVE webinar on February 10, 2016 from 2:00 – 3:00 pm -OR-
  • Listen to the recorded webinar which will be available March, 2016. For details “coming soon,” check http://www.micmrc.org

To Register for the Live webinar: http://micmrc.org/

Continuing Education:

High Risk Medication in Older Adults – Beers’ Update 2015” is approved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 100816-05

For more information regarding contact hours, or for other questions, please submit to:

micmrc-requests@med.umich.edu

New 2016 MiPCT Care Manager Educational Webinars

February 10th 2-3pm

  • Title: 2015 Updated Beers 2015 Criteria
  • Presenter: Kim Moon, PharmD, Manager, Clinical Pharmacy Stars Team BCBSM

February 24th 2-3pm

  • Title: 2015 Summit Best Practice Award Presentations
  • Presenters:
    • Dr. Gerald Lee, Alpine Internal Medicine and Pediatrics, Spectrum Health Medical Group;
    • Dee Dailey, Integrated Health Partners PO Leader Representing Cereal City Pediatrics and Moazami Pediatrics;
    • Chelsea Hauschild, New Day Family Medicine;
    • Deepa Nandamudi, LMSW/ACSW, Complex Care Manager, CHC Fort Gratiot, Physician Healthcare Network, PC

March 9th 2-3pm

  • Title: Depression in the Older Adult
  • Presenter: Linda J. Keilman, DNP, GNP-BC Assistant Professor, Gerontological Nurse Practitioner, Michigan State University, College of Nursing

March 18th Pediatric Webinar 10-11am

  • Title: Children and Youth with Epilepsy
  • Presenter: Cynthia L. Leino-Handford, RN, Education & Advocacy Specialist, Epilepsy Foundation of Michigan

March 23rd 2-3pm

  • Title: Effective Communication with Physicians
  • Presenter: Maureen Murphy RN, BSN, FNP-BC

To register for these webinars: http://micmrc.org/webinars

Practice PAC Recruitment Flyer Attached

Attached is a flier that Care Managers or Physicians in MiPCT practices can give to MiPCT members or caregivers who would be good candidates for Patient Advisory Council participation. To make things even easier, at your request, we will send you a set of hardcopy fliers ready for you to hand out. If you want a set mailed to you, please let Jody Fisher (fishjody@umich.edu) know.

If you have any questions about the Patient Advisory Council, please contact Diane Marriott (dbechel@umich.edu) or 734 998 0390.

MiCMRC/MiPCT Complex Care Management Course Registration – 2016 Updates

New in 2016, the MiCMRC/MiPCT Complex Care Management (CCM) course is open to Care Managers who are interested in learning about complex care management and not employed as a Care Manager in a MiPCT practice.The MiCMRC/MiPCT CCM course is designed to prepare the health care professional for the role of Complex Care Manager. In an effort to meet the learners’ needs, MiCMRC has posted a 2016 course schedule exclusively for Non-MiPCT Care Managers.The 2016 CCM course schedule for Non-MiPCT Care Managers is available: http://micmrc.org/programs/pdcm-phase-iii/registration

Course Fee for Non-MiPCT Care Managers: The MiCMRC/MiPCT CCM $250.00 course fee for Non-MiPCT Care Managers includes the standardized evidence-based course and access to MiCMRC live and recorded webinars.Opportunities to earn Nursing and Social Work Contact Hours via future webinars will be provided periodically.Please see the attached MiCMRC/MiPCT CCM course flyer for details.

Registration:

To register Non-MiPCT Care Managers for the MiCMRC/MiPCT CCM course please access: http://micmrc.org/programs/pdcm-phase-iii/registration

NOTES: If you have 15 or more Non-MiPCT Care Managers in your area and would like the MiCMRC team to provide a regional training at your location please submit your request to: micmrc-requests@med.umich.edu

For PO Leaders who support both MiPCT and Non-MiPCT practices, the registration for MiPCT Care Managers has not changed.To register MiPCT Care Managers please access: http://micmrc.org/programs/michigan-primary-care-transformation-mipct-project/registration

Processing CCM course fee for the Non-MiPCT CMs: The MiCMRC will use an invoice process to receive the course fee. The individual who registers for the course will need to identify the person responsible for the course fee. The invoice will be sent to the person identified at time of registration as follows:< Name, e mail, Address, City, State, Postal Code, and Country.

Reconciliation Steps: BCBSM PDCM Phase III value-based reimbursement CCM training requirement for the Non-MiPCT Care Managers will be confirmed with BCBSM. (MiCMRC/MiPCT CCM course completion date, Care Manager name, BCBSM Practice Unit ID). Following completion of the course each month your PO will receive a table with the name of Non-MiPCT CM who completed the course. We will request your assistance with providing the BCBSM Practice unit ID for each Non-MiPCT CM.

For questions please contact micmrc-requests@med.umich.edu

MiCMRC/MiPCT Complex Care Management Course for MiPCT Care Managers

The 2016 MiCMRC/MiPCT Complex Care Management (CCM) Course is provided in a blended learning activity format.The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

Completion of the MiCMRC/MiPCT CCM Course occurs over a 4-day period. The course consists of:

  • Day 1 – Live Webinar Introduction of MiCMRC/MiPCT CCM course
  • Day 2 – Self-study modules and post-tests which are completed prior to the in-person training (total expected time to complete the self-study and post tests is six hours)
  • Days 3-4 In person training

Upcoming course dates and course registration close dates:

  • March 28-31, 2016. Introductory Webinar March 28th, 2016.Total six hour self-study modules and post-tests, March 28-29, 2016.In-person training March 30-31,2016.NOTE: Registration for this course will close as of March 24th, 2016.
  • April 4-7, 2016. Introductory Webinar April 4th, 2016.Total six hour self-study modules and post-tests, April 4-5th, 2016.In-person training April 6-7th, 2016. NOTE: Registration for this course will close as of March 31st, 2016.

Register for all MiCMRC/MiPCT CCM Courses Here: https://mipct.org/care-management-resource-center/ccm-online-registration-page/

Please submit questions regarding the MiCMRC/MiPCT CCM course to: micmrc-requests@med.umich.edu.

Statewide MiPCT Patient Advisory Council Member Nominations

The statewide MiPCT Patient Advisory Council (PAC) is an advising resource to the Steering Committee, subcommittees and other MiPCT groups (PO Advisory Council, etc.). Our goal is to ensure that the patient voice is incorporated in MiPCT implementation and operations. We are recruiting additional nominations for this state-wide advisory group, which meets quarterly via conference call. Members should be:

  1. MiPCT patients (especially patients who have experience with care managers)
  2. Able to use their own experience constructively
  3. Able to see beyond their own experience
  4. Able to listen to and hear differing opinions

Member nominations are now being accepted at: https://jodyooo.wufoo.com/forms/patient-advisory-council-nomination-form/

Following is a list of upcoming PAC Conference Calls:

  • March 18, 2016, 1-2 PM
  • June 17, 2016, 1-2 PM
  • September 16, 2016, 1-2 PM
  • December 16, 2016, 1-2 PM

Seeking MiPCT Care Manager Success Stories

As we reflect on the MiPCT accomplishments, we would like to thank all of the MiPCT Care Managers who submitted their MiPCT Care Manager Success stories! The feedback we receive about the FLASH newsletter ” MiPCT Care Manager Success stories” is very positive.

As we begin 2016, we are seeking stories of MiPCT Care Manager success. We know they are out there! You may be wondering why take time to submit a MiPCT Care Manager Success story? Not only do you receive the recognition that you deserve, but you also help out colleagues who may be facing a similar situation. Please submit your Care Manager Success stories via www.micmrc.org. 

Please submit your Care Manager Success stories to: www.mipctdemo@michigan.gov

Please submit questions to: micmrc-requests@med.umich.edu

Earn 2016 Practice Learning Requirements by Submitting a Best Practice Success Story!

The benefits of submitting a Practice Team Based success story include sharing of best practices and providing helpful information to colleagues that may be in a similar situation, in addition to receiving well deserved recognition.

Another important reason to submit your practice’s success story is that it may be used toward Practice Learning Requirements. Section 1.i. states “Submission of formal best practice consisting of documentation that includes the underlying policy, process, workflow, data illustrating the implementation and improvement resulted from results, standardized tool, protocol, and a contact person willing to take questions from other POs and Practices (2 points for submission).

For information on 2016 MiPCT Practice Learning Activities, please visit:

https://mipct.org/resources/practice-learning-activities/

With all of these good reasons, we look forward to many more submissions.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: March 7, 2016
  • Next MiPCT Practice FLASH Issue: February 22, 2016

 

January 11, 2016

Good News from BCBSM!

Effective January 1, 2016, members whose groups are participating in our Provider Delivered Care Management (PDCM) program and participate in a High Deductible Health Plan with a Health Savings Account (HDHP w/HSA) are no longer required to pay cost-share if the deductible requirement is not satisfied.

PDCM services will be reimbursed at 100 percent with no cost share (deductible, co-pay or coinsurance). Our systems have been updated with this change. If you have questions, you may contact Lori Boctor at (313) 448-3341 or at lboctor@bcbsm.com

Announcing The Michigan Care Management Resource Center Enhanced Website

New for January 2016, The Michigan Care Management Resource Center (MiCMRC) unveils the updated and enhanced website www.micmrc.org

The MiCMRC website features:

  • Clinical programs (MiPCT and more)
  • MiCMRC/MiPCT Complex Care Management course registration
  • Upcoming MiCMRC/MiPCT Care Management webinar announcement and registration
  • Care Management 101: A suggested roadmap of staged content for the new care manager to guide developmental activities over the first year
  • New Topics page with organized resources and tools: Advance Care Planning, Palliative Care, Pediatrics, Medication Management, Transition of Care, PCMH and Team-Based Care, Chronic Conditions, Quality and Population Health Management, Elderly Population and Behavioral Health
  • Features a searchable library of recorded MiCMRC/MiPCT Care Management webinars and associated materials

Note: The website redesign entailed transitioning to an open, non-password protected www.micmrc.org website. Please take a few minutes to visit www.micmrc.org.

MiPCT participants are encouraged to contribute tools and best practices to assist with enhancing delivery of care management statewide. To submit best practice/tools/resources, please contact: micmrc-requests@med.umich.edu. Your feedback and suggestions for enhancements are welcome. Please provide feedback via micmrc-requests@med.umich.edu.

MiPCT Care Managers: An Invitation to Earn Nursing and Social Work Continuing Education Contact Hours

Educational Offering: MiCMRC/MiPCT Care Manager Webinar: “High Risk Medications in Older Adults – Beers Update 2015”

The MiCMRC/MiPCT Educational Webinar, “High Risk Medications in Older Adults – Beers Update 2015” focuses on the recently updated Beers guidelines. The American Geriatrics Society’s (AGS) Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults is an explicit list of PIMs. PIMs are best avoided in older adults in general; but especially in those with certain diseases or syndromes, and are prescribed at reduced dosage, or carefully monitored.

The updated Beers criteria were announced October, 2015. The expert presenter is Kimberly Moon, PharmD, Manager, Clinical Pharmacy Stars BCBSM.

New this year! Nursing and Social Work continuing education contact hours for the “High Risk Medications in Older Adults – Beers Update 2015” webinar may be obtained by the following activities: 

  • Attend the LIVE webinar on February 10, 2016 from 2:00 – 3:00 pm -OR-
  • Listen to the recorded webinar which will be available late February, 2016.

Details about the steps and requirements for completion will be coming soon – via upcoming FLASH Newsletter and www.micmrc.org.

To Register for the Live webinar: www.micmrc.org

Continuing Education:

“High Risk Medication in Older Adults – Beers’ Update 2015” is approved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 100816-05

For more information regarding contact hours, or for other questions, please submit to:

micmrc-requests@med.umich.edu

MiPCT Care Manager Webinars

NEW 2016 MiPCT Care Manager Educational Webinars:

  • Date: Monday, January 25, 2-3PM
  • Title: Get Connected. Get Answers. 211
  • Presenter: Sarah Kile, BS, Executive Director, 211
  • Date: February 10, 2-3PM
  • Title: 2015 Updated BEERS Criteria
  • Presenter: Kris Moon, PharmD, Manager, Clinical Pharmacy Stars Team, BCBSM
  • Date: March 23, 2-3PM
  • Title: Effective Communication with Physicians
  • Presenter: Maureen Murphy, RN, BS, FNP-BC

To register for these webinars: http://micmrc.org/webinars

Practice PAC Recruitment Flyer Attached

Attached is a flier that Care Managers or Physicians in MiPCT practices can give to MiPCT members or caregivers who would be good candidates for Patient Advisory Council participation. To make things even easier, at your request, we will send you a set of hardcopy fliers ready for you to hand out. If you want a set mailed to you, please let Jody Fisher (fishjody@umich.edu know.

If you have any questions about the Patient Advisory Council, please contact Diane Marriott (dbechel@umich.edu) or 734 998 0390.

Statewide MiPCT Patient Advisory Council Member Nominations

The statewide MiPCT Patient Advisory Council (PAC) is an advising resource to the Steering Committee, subcommittees and other MiPCT groups (PO Advisory Council, etc.). Our goal is to ensure that the patient voice is incorporated in MiPCT implementation and operations. We are recruiting additional nominations for this state-wide advisory group, which meets quarterly via conference call. Members should be:

  1. MiPCT patients (especially patients who have experience with care managers)
  2. Able to use their own experience constructively
  3. Able to see beyond their own experience
  4. Able to listen to and hear differing opinions

Member nominations are now being accepted at: https://jodyooo.wufoo.com/forms/patient-advisory-council-nomination-form/

Following is a list of upcoming PAC Conference Calls:

  • March 18, 2016, 1-2 PM
  • June 17, 2016, 1-2 PM
  • September 16, 2016, 1-2 PM
  • December 16, 2016, 1-2 PM

 

MiCMRC/MiPCT Complex Care Management Course Registration 2016 Updates

New in 2016, the MiCMRC/MiPCT Complex Care Management (CCM) course is open to Care Managers who are interested in learning about complex care management and not employed as a Care Manager in a MiPCT practice. The MiCMRC/MiPCT CCM course is designed to prepare the health care professional for the role of Complex Care Manager. In an effort to meet the learners’ needs, MiCMRC has posted a 2016 course schedule exclusively for non MiPCT Care Managers. The 2016 CCM course schedule for Non MiPCT Care Managers is available: http://micmrc.org/programs/pdcm-phase-iii/registration

Course Fee for Non-MiPCT Care Managers: The MiCMRC/MiPCT CCM $250.00 course fee for Non MiPCT Care Manager includes the standardized evidence-based course and access to MiCMRC live and recorded webinars. Opportunities to earn Nursing and Social Work Contact Hours via future webinars will be provided periodically. Please see the attached MiCMRC/MiPCT CCM course flyer for details.

Registration: To register non MiPCT Care Managers for the MiCMRC/MiPCT CCM course please access: http://micmrc.org/programs/pdcm-phase-iii/registration

NOTES:

Processing CCM course fee for the Non-MiPCT Care Managers: The MiCMRC will use an invoice process to receive the course fee. The individual who registers for the course will need to identify the person responsible for the course fee. The invoice will be sent to the person identified at time of registration as follows: < Name, e mail, Address, City, State, Postal Code, and Country.

Reconciliation Steps: BCBSM PDCM Phase III value-based reimbursement CCM training requirement for the Non MiPCT Care Managers will be confirmed with BCBSM. (MiCMRC/MiPCT CCM course completion date, Care Manager name, BCBSM Practice Unit ID) . Following completion of the course each month your PO will receive a table with the name of non MiPCT CM who completed the course. We will request your assistance with providing the BCBSM Practice unit ID for each non MiPCT CM. For questions please contact micmrc-requests@med.umich.edu.

MiCMRC/MiPCT Complex Care Management Course

The 2016 MICMRC/MiPCT Complex Care Management (CCM) Course is provided in a blended learning activity format. The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period. The course consists of:

  • DAY 1 Live Webinar – Introduction of MiCMRC/MiPCT CCM course
  • DAY 2 Self-Study Modules and Post-Tests which are completed prior to the in-person training (total expected time to complete the self-study and post-tests is six hours)
  • DAYS 3 & 4 In-Person Training Days

Upcoming Course Dates and Course Registration Close Dates:

  • February 1-4, 2016. Introductory Webinar January 4, 2016. Total six hour self-study modules and post-tests, January 4-5, 2016. In-person training January 6-7, 2016. NOTE: Registration for this course will close as of January 25, 2016 4p.m.
  • March 28-31, 2016. Introductory Webinar March 28, 2016. Total six hour self-study modules and post-tests, March 29-30, 2016. In-person training March 31, 2016. NOTE: Registration for this course will close as of March 24, 2016, 4p.m.

Register for upcoming MiCMRC/MiPCT CCM course dates at the following site: https://mipct.org/care-management-resource-center/ccm-online-registration-page/

Please submit questions regarding the MiCMRC/MiPCT CCM course to: micmrc-requests@med.umich.edu.

Behind the Data by MDC

MDC’s Behind the Data section provides high-level information about the data for the MiPCT project in a Q&A format.

Q:

How can I help our Care Managers work with the Healthy Michigan portion of their Medicaid population?

A:

Because the Healthy Michigan population is quite different than the traditional Medicaid population, the ability to differentiate between them is helpful. Starting in November 2015, MDC added a Healthy MI Flag field to the All Payer Patient Lists (APPLs). This field identifies members who have coverage under the Medicaid Healthy Michigan Plan. A “1” in this field indicates that a member has this coverage; a “0” or no entry indicates that they do not.

After you open the APPL file in Excel, you can filter the contents to view only the Healthy Michigan population and then view additional information about each patient, including:

• Utilization for the last 6 months (Inpatient and ED Visits as well as Readmissions)

• Chronic conditions (number of conditions, whether or not they have Diabetes, Asthma, CHF, COPD, Hypertension, Obesity, ADHD, CAD or CKD)

• Number of Maintenance Drugs for the most recent 6 months of data

The Healthy MI Flag field provides additional information to help your Care Managers make better informed decisions about support options to offer this population.

Note: The APPLs are initially pre-sorted by PO and Practice Unit. Each Practice’s patients are then sorted by Payer. For each Payer, the patients are sorted by High Risk Flag and Prospective Risk Score. This ensures that patients with the highest risk are at the top of each Payer’s grouping.

For additional information about the All Payer Patient Lists, see the All Payer Patient List Information document on the MDC Website Support page.

https://www.michigandatacollaborative.org/MDC/assets/All_Payer_Patient_List_Info_Updated_doc.pdf

Stories of Your Care Management Success Michele Myles – Complex Care Coordinator, Partners in Care

I received a referral from a PCP for Mr. Murphy in March of 2015 who had a diagnosis of diabetes and had an A1c of 9.6% His PCP informed me that the patient had “literacy issues” which may be contributing to Mr. Murphy’s lack of adherence to his instructions.

In addition, I reviewed Mr. Murphy’s medical record. He was 54 years old with additional diagnoses of asthma, back pain, polymyalgia rheumatic, and obesity. Other health information revealed: weight of 300lbs, BMI of 42.43, Total Cholesterol 240, LDL 157, HDL 56, Triglycerides 133, and a BP of 134/90. Furthermore there was no record of any recent eye exam and he did not have current urine for micro albumin.

I met with Mr. Murphy in the physician’s office to conduct his assessment. Mr. Murphy shared his life story, including his inability to read or write. He could recognize individual numbers but was unable to comprehend numbers that were greater than two digits. He was able to drive as long as he stayed in his community and was able to recognize street signs by their shape. His sister-in-law assisted him paying his bills, however was reluctant to ask for help when he went to the doctor due to the fact that he was embarrassed and wanted to keep his health issues private. When asked when his last eye appointment was he replied “I had one at the DMV”. Up until this time Mr. Murphy had never received an eye exam from a physician. He was unable to identify his meds by name. When asked how he kept his medications straight and he stated he identified them by color, “I take a yellow one in the morning, and I take 6 reds on Sunday”. He agreed to meet again and bring his medications.

When he brought his meds to the office I asked him to explain when he took them. One of his medication bottles was empty. He was recently started on a new medication and did not have a pill bottle for this med even though he was given a starter sample and also a prescription was sent to his pharmacy. Mr. Murphy admitted he may have mixed up two of his medications, stating “I took 6 of something Sunday”.

With Mr. Murphy’s permission I contacted the pharmacy and talked at length to the pharmacist with Mr. Murphy listening regarding his literacy issues. The pharmacist flagged his record and we formulated a plan for the pharmacist to go over all of Mr. Murphy’s meds prior to him leaving the pharmacy. In addition Mr. Murphy would take a picture of his meds with his cell phone and set a timer to remind him. Furthermore Mr. Murphy, because of the plan with the pharmacy would only use the current pharmacy. He is now using a pill box which he brings to his appointments and is able to verbalize the correct schedule. He has been able to keep track of his medications and is able to plan for refills.

Our next priority was to get him scheduled for his routine screening tests. I located an ophthalmologist near his home and together scheduled an eye appointment. The receptionist was informed that he would need assistance with his forms. Due to his literacy concerns I drew a map for Mr. Murphy using Google Earth as he is unable to read names of streets; however is able to identify shapes of signs. He proudly reported two weeks later that he was able to get to his appointment, was assisted with his forms and passed his eye test. Moving forward he now understands the importance of having an eye exam every year. He also had his urine tested for micro albumin and was within normal limits.

In addition to the need for an eye exam his next priority was to reduce his weight. He set a personal goal to lose 50 pounds. He started working out at a local gym every other day and began receiving educational material on nutrition. I consulted our program’s dietitian and she provided me with a meal plan using pictures. He is able to follow it but is also using other strategies to help keep him focused on his weight loss. He is shopping the periphery of the store and avoiding processed foods. I have made calls to Mr. Murphy every 2 to 3 weeks to help keep him on track and address any difficulties he was having following his plan.

He had a routine appointment with his PCP in October 2015. His weight was down to 265 pounds. He mentioned to his PCP he was getting positive comments about his weight, in that everyone has noticed a difference in his appearance. His A1c at this appointment was 5.8%. His PCP discontinued one of his medications, and has set another goal to lose an additional 50 pounds.

Currently Mr. Murphy is working on improving his skills at self-advocacy. Recently I assisted him with forms he needed for his wellness visit. Even though he denied depression during the assessment, he admitted to feeling down and thought he has been depressed for the last 10 years. He denied these feelings with his PCP as he “didn’t want anyone looking down on me”. I educated him on depression including benefits of treatment, medication and talk therapy.

As part of his education on improving self-advocacy, we talked about developing an agenda when he sees the PCP. The agenda would include the following:

  1. Bring all pill bottles including supplements for medication reconciliation.
  2. Bring his foot cream so the doctor could reorder.
  3. Discuss Mr. Murphy’s feelings of depression.

To assist him in remembering the items on his list I drew a pill bottle, a foot and a sad face on his paperwork. After his appointment I checked the EMR and smiled when I saw all 3 agenda topics were addressed at his appointment. In light of Mr. Murphy’s depression his PCP decided to try a trial of an antidepressant. Two weeks later I followed up with Mr. Murphy who was already feeling better claiming, “I’m on top of the world,” and, “I don’t know what I was afraid of.”

We have discussed the eventual closure of his case. He told me recently that he is interested is trying to learn how to read again. I am currently checking on local resources to help him.

Anything is possible.

Seeking MiPCT Care Manager Success Stories

As we reflect on the MiPCT accomplishments, we would like to thank all of the MiPCT Care Managers who submitted their MiPCT Care Manager Success stories! The feedback we receive about the FLASH newsletter ” MiPCT Care Manager Success stories” is very positive.

As we begin 2016, we are seeking stories of MiPCT Care Manager success. We know they are out there! You may be wondering, “Why take time to submit a MiPCT Care Manager Success Story?” Not only do you receive the recognition that you deserve, but you also help out colleagues who may be facing a similar situation.

Microsoft Word - Seeking Care Manager Success Stories v1.docx

Please submit your Care Manager Success stories to: www.mipctdemo@michigan.gov.

Please submit questions to: micmrc-requests@med.umich.edu

NEXT ISSUE DATES: 

  • Next MiPCT P.O. FLASH Issue: February 8, 2016
  • Next MiPCT Practice FLASH Issue: January 25, 2016

Flash Publication Schedule:

  • Volume 5, Issue 4, (April 4, 2016)
  • Volume 5, Issue 5, (May 9, 2016)
  • Volume 5, Issue 6, (June 6, 2016)
  • Volume 5, Issue 7, (July 11, 2016)
  • Volume 5, Issue 8, (August 1, 2016)
  • Volume 5, Issue 9, (September 12, 2016)
  • Volume 5, Issue 10, (October 10, 2016)
  • Volume 5, Issuse 11, (November 14, 2016)
  • Volume 5, Issue 12, (December 12, 2016)