2015 Practice FLASH

 MiPCT Logo Final

December 14, 2015

REMINDER: MiPCT Care Manager Summit 2015 Pre-Work Recorded CE Webinars Close 12/31/15

For those of you who have not already taken advantage of the opportunity to earn up to 6 nursing contact hours, the MiPCT Care Manager Summit 2015 Pre-Work recorded webinars will remain available until December 31, 2015. Each of the four webinars is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

Please view the 4 recorded webinars prior to December 31, 2015. The links to the webinars will no longer be available after that date. The recorded webinars are posted on the www.mipct.org website on the 2015 Summit Prework Webinars page located under the 2015 MiPCT Annual Summits tab.

Questions: micmrc-requests@med.umich.edu

2015 Practice Learning Activity Approval

As you may recall, practices can receive learning credit for both MiPCT-led and PO-led learning activities. All PO-led practice learning activities must be pre-approved by MiPCT before practices can receive credit. Please submit your practice learning activity application for approval to mipctdemo@michigan.gov as soon as possible for activities occurring before the end of 2015.

You will find the MiPCT Learning Activity Approval Form HERE. Practice learning activities will be reported in January on the Q4 MiPCT Supplemental Narrative Report and your approved learning activities will be pre-populated in this template.

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:

  • 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:

  • January 4-7, 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 December 21, 2015, 4p.m.
  • 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.

Register for upcoming MiCMRC/MiPCT CCM course dates HERE:

Please submit questions regarding the MiCMRC/MiPCT CCM course HERE:

Coming Soon! Two Updated Graphs on the MiPCT Dashboard

MDC is continually looking for ways to improve how we display data on the Dashboard to make it easier to understand and use. To that end, we are updating the following graphs:

  • Quality Page: Quality Graph
  • Trends Page: Standard Cost PMPM by Risk Group Trends – By Risk Group Category

Be on the lookout for these two updates. We will send out an email announcement when they are posted to the Dashboard.

If you have any questions, or if you would like to provide feedback or suggestions, please contact MDC HERE.

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 were the award rankings established for the MiPCT Regional Annual Summit meetings in September and October?

A: The top five practices in each category were honored at the Summit meetings and shared their stories about how they have achieved success. Practices were recognized in the following categories:

  • Best Overall – Adult and Family
  • Most Improved – Adult and Family
  • Best Overall – Diabetes Management
  • Most Improved – Diabetes Management
  • Best Overall – Pediatrics
  • Most Improved – Pediatrics

The rankings were based on the MiPCT data available in the MDC Dashboard and database. The Pediatric, Adult and Family, and Diabetes Overall awards had their component measures risk-adjusted prior to final rankings. The risk adjustment methodology was developed and implemented by MPHI.

The Most Improved awards were not risk-adjusted, but represented overall increase in rank (based on the same composite score) between the baseline measurement period (2011) and the most recent Dashboard data. For example, a practice that increased from rank 200 to 100 is considered more “improved” than one increasing from rank 50 to rank 1. The Most Improved – Diabetes Management award represented the largest percent difference between the overall Diabetes score from baseline to present.

If you have any questions, or if you would like to provide feedback or suggestions, please contact MDC.

Michigan Care 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” here.  

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 here.

MiPCT Care Manager Webinars

2015 MiPCT Care Manager Educational Webinars:

  • Date: December 18, 10-11 AM **PEDS**
  • Title: Mandated Reporting
  • Presenter: Chris Blood, LLMSW, Children’s Protectice Services Supervisor, Ingham County Department of Health and Human Services

Please click here for upcoming MiPCT Care Manager Webinars.

Stories of Your Team Based Success

Alcona Health Centers Reduces Ambulatory Care Sensitive Hospitalizations

Our goal was to reduce ambulatory care sensitive hospitalizations. To address this problem, a team was created made up of a PCP, MiPCT CM, Office Support Staff, CEO, COO, Medical Operations Manager, Physician Champion, and Care Coordinator. As a federally qualified health center (FQHC), Alcona Health Centers (AHC) is not affiliated with any hospital. Alpena Regional Medical Center (ARMC) is the acute care facility for the majority of our patients. From our participation in a Medicare ACO, we discovered our patients had unusually high in-patient costs, in large part due to recycling from ARMC to home or skilled nursing facilities (primarily Tendercare-Alpena), and back to ARMC. In a typical scenario, a patient was back in the acute care setting before ever being seen by their primary care provider (PCP).

Our providers didn’t know in real time when their patients were admitted or discharged. For example, at discharge, patients would be told to “call your doctor for an appointment,” but then didn’t follow through. Or, patients were given an appointment too far out (e.g. 6 weeks instead of the 3-5 days requested by the hospital attending) due to lack of available appointments on providers’ schedules.

On the hospital side, discharge planners didn’t know who the patient’s PCP was, or even at which site the patient was seen; discharge planners didn’t have a designated AHC contact person to call.

Changes Made to Address the Challenge We identified an AHC contact person (Discharge Liaison) that discharge planners can call directly. The Discharge Liaison identifies the patient’s PCP and site and schedules a hospital follow-up appointment. A reserved hospital follow-up appointment slot was established on every provider’s schedule, starting with one per week and increased as needed.

The Discharge Liaison was given access to ARMC’s electronic medical record, to obtain discharge summaries, lab and radiology reports, consult reports, and medication lists prior to the follow-up appointment. This information is reviewed by the Care Manager, and medication reconciliation preformed, prior to the patient seeing their PCP.

Barriers Addressed  We saw the lack of timely follow-up after an acute care admission contributing directly to hospital readmission. Barriers included:

  • Failure of patients to set up their own hospital follow-up appointments.
  • Lack of sufficient hospital follow-up appointment slots reserved on provider schedules.
  • Lack of communication between ARMC discharge planners and PCP office staff.

Improvements  A number of improvements have been initiated and sustained:

  • Real time notification of admissions, discharges and transfers to SNF’s or tertiary hospitals
  • Timely hospital follow-up with PCP (3-5 days in most cases)
  • Care Manager contact with the patient prior to PCP appointment
  • Timely medication reconciliation after acute-care stay
  • Use of a Discharge Log to identify patients with repeated admissions – those that are ambulatory care sensitive, but also those that suggest the need for end-of-life planning, or improvement in post-acute care
  • AHC representation at hospital discharge planning meetings, and input to reduce readmissions

Metrics  A discharge log tool has been developed and was used in the collection of metrics. Use of this tool for tracking hospital admissions of MiPCT patients demonstrated that admissions decreased from 60-70 patients per month, down to 40-50 per month, during the timeframe of January through October, 2015. This decrease was despite having a new hospitalist group at Alpena Regional Medical Center. Another indication of success as a result of this team-based process is that communication has improved between the hospital and the ambulatory practice.

MiPCT 2016 At-a-Glance: Important Dates for POs

Attached to this issue of the FLASH, you’ll find a schedule of MiPCT 2016 At A Glance Important Dates for POs. Please note, these dates may change throughout the year.

G/CPT Billing Update

Blue Cross Blue of Michigan Commercial, has made a change to the G9007 code criteria titled Coordinated Care, Scheduled Team Conference. For BCBSM Commercial, the new change to the G9007 code is the ability for physicians to bill the G9007 for phone or video conferencing.

Also, Priority Health Medicare Advantage covers: Face-to-face or telephonic counseling and discussion regarding Advance Directives or End-of-Life care planning and decisions for S 0257.

The updated MiPCT Multi-Payor documentation summary tool is located on the billing page on the MiPCT Demo site.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: January 11, 2016
  • Next MiPCT Practice FLASH Issue: January 25, 2016

 

November 11, 2015 CORRECTION TO THE 11/9/2015 PRACTICE FLASH:

CORRECTION to Henry Ford Medical Group Ambulatory Medical Needs Fund Team Based Success Story: Please note that these funds are not used for copays. We apologize for the error.

November 9, 2015

REMINDER: MiPCT Care Manager Summit 2015 Pre-Work Recorded CE Webinars Close 12/31/15

For those of you who have not already taken advantage of the opportunity to earn up to 6 nursing contact hours, the MiPCT Care Manager Summit 2015 Pre-Work recorded webinars will remain available until December 31, 2015. Each of the four webinars is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

Please view the 4 recorded webinars prior to December 31, 2015. The links to the webinars will no longer be available after that date. The recorded webinars are posted on the www.mipct.org website on the 2015 Summit Prework Webinars page located under the 2015 MiPCT Annual Summits tab.

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

An Evening of Learning:  Advance Care Planning,  Improving Quality of Life

The Washtenaw Health Initiative will be showing a free screening of Consider the Conversation 2: Stories about Cure, Relief and Comfort. The film highlights the importance of advance care planning and the ability to improve a patient’s quality of life. In addition, a panel of providers and patient advocates, who have engaged in advance care planning (ACP) will be available for discussion at the conclusion of the film.

Moderator: Oliver Kim, former deputy staff director, Senate Aging Committee

Panelists:

  • Ryan Fox, transition manager, Evangelical Homes of Michigan
  • Sally Jaworowski, community member and ACP advocate
  • Adam Marks, medical director, Arbor Palliative Care and assistant professor, Department of Internal Medicine, University of Michigan
  • Phil Rodgers, associate professor, Departments of Family Medicine and Internal Medicine, University of Michigan
  • Julie Seitz, ACP leader, St. Joseph Mercy Health System

Attendees will learn about:

  • The current state of ACP in Washtenaw County.
  • Common barriers to ACP and how key ACP participants—providers, patients and loved ones—can improve and increase ACP.
  • Available ACP resources and how to begin ACP conversations with loved ones.

Place: Michigan Theatre,     603 E. Liberty St., Ann Arbor, MI
Date: November 17th
Time: 6:00p to 8:00p
To register for this event: http://washtenawhealthinitiative.org/consider-the-conversation-2/

Helping Family and Caregivers Manage Stress

Right at Home in home care services will be sponsoring an informational webinar entitled: Caregiver Wellness: Power of U. This presentation will help family and professional caregivers manage stress associated with caring for a patient or loved one. It will examine the role of stress and distress and how they impact care giver’s decision making abilities.

Participants in this webinar will be able to:

  • Describe the role that stress and distress play in the decision-making process and how they impact caregiver well-being;
  • Identify practical caregiver solutions to improve holistic caregiver wellness;
  • Understand the difference between the care methodologies of “helping” versus “rescuing” and,
  • Describe the “Caregiver Wellness: U Model” to develop overall wellness, empowerment, and resilience

The webinar presenter will be Dr. Eboni Green, who is the co-founder of Caregiver Support Services. The webinar will offer complimentary CEUs.

Date:                 November 12, 2015
Time:                 3:00-4:00 PM ET
Registration:     http://members.asaging.org/members_online/registration/register.asp?mt=W1112S&af=ASA

MiCMRC/MiPCT Complex Care Management Course

The 2015 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:

  • December 7-10, 2015. Introductory Webinar December 7, 2015.  Total six hour self-study modules and post-tests, December 7-8, 2015.  In-person training December 9-10, 2015.  NOTE: Registration for this course will close as of December 3, 2015, 4p.m.
  • January 4-7, 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 December 31, 2015, 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.

Michigan Care 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

MiPCT Care Manager Webinars

New 2015 MiPCT Care Manager Educational Webinars:

Date:    November 11, 2-3pm
Title:    Utilizing Strength-Based Communication Strategies with Older Adults
Presenter:    Linda Keilman, DNP, GNP- C

Date:    November 20, 10-11am **PEDS**
Title:    Integrating Behavioral Health Into Your Pediatric Practice
Presenter:    Laurisa Cummings, LMSW

Date:    December 9, 2-3PM
Title:    “Normal” Communication in Lives That Are Anything But…
Presenter:    Renee L. McCune, PhD RN, Associate Dean, McAuley School of Nursing, University of Detroit Mercy

Date:    December 18, 10-11 AM **PEDS**
Title:    Mandated Reporting
Presenter:    Chris Blood, LLMSW, Children’s Protectice Services Supervisor, Ingham County Department of Health and Human Services

Please see link below for upcoming MiPCT Care Manager Webinars:
https://mipct.org/care-manager-webinar-conference-call-calendar/

Stories of Your Team  Based Success, featuring Henry Ford Medical Group: Ambulatory Medical Needs Fund

Problem Addressed by Team:  Henry Ford Medical Group wanted to ensure that low-income patients identified at HFHS ambulatory sites receive medically necessary services they otherwise would be unable to afford, so they can effectively address the urgent issues that harm their health. They sought a way to help the clinical team close gaps in care and assist patients in need on their path to wellness.

Funds:  Funds are collected via our Henry Ford Community Giving Campaign. These are direct payroll deductions from Employees pay based on their donation for the fund of their choice.

Changes Made:  Patients were identified that may be eligible for assistance. An additional resource was found via a community giving fund intended for ambulatory use only. They were able to utilize this funding source for ambulatory patients that are underinsured or have suffered an unexpected life event. In the past, funding for these patients was utilized strictly for in-patient clients only.

Barriers: A written process was needed to be put into place. Cost Center exchange so that no monies changed hands. At this point we can only contract with HF Pharmacies and HF Hart Medical Supply. We are having difficulties creating a payment with outside vendors, such as a transportation company.

Improvements: MiPCT patients as well as any ambulatory patient within the Henry Ford Health System may be eligible and meet the criteria for these services. For example, DME is one of the largest requests, especially items such as scales, blood pressure cuffs, crutches, glucose monitors, and wound care supplies. This fund may also be used for some medication and copays.

Impact:  These changes have had the most impact on patient and provider satisfaction, as well as helping patients close the gap in meeting their optimal level of health.

Referral Process:

  1. Member of ambulatory care team refers case to lead Case Manager (CM) via EPIC (route note to in-basket) at their facility
  2. If applicable, lead CM assigns case to other CMs for their facility (the local facility can determine the order in which this is done)
  3. CM reviews patient’s medical record to verify eligibility and understand the patient’s history
  4. CM reaches out to patient on the same date, explains next steps, and plan for follow-up
  5. CM explores alternative options to medical needs funds
    1. If CM is able to secure alternative options, they document outcome in database base and select funds no longer needed in approval/denial drop down list- proceed to step 8
    2. If CM is unable to secure alternative options- proceed to step 6
  6. CM submits request in Ambulatory Patient Medical Needs Fund (APMNF) database
    1. If amount is less than $100, CM enters in patient detail, referral reason, amount, note section, and selects approved in approval/denial drop down list
    2. If amount is greater than $100, CM completes Medical Needs Fund (MNF) request information and selects send to committee in approval/denial drop down list
  7. Committee members vote to approve or deny request within 24 hours via email
    1. Once the CM sees that at least three committee members have voted to APPROVE request, they process the payments to secure resources (see connecting patients to resources for more information)
    2. Once CM sees that at least three committee members have voted to DENY request, CM reengages patient for an update
  8. CM routes EPIC notes to original referrer and the patient’s Primary Care Physician (PCP) throughout case evaluation to keep them informed and explain next steps
  9. CM engages patient to discuss next steps and reiterates that fund is a short term solution.

Connecting Patients to Resources:

  1. Current resources patients may be able to access with medical needs funds (this is not an exhaustive list of resources to assist patients and other opportunities may be uncovered through further CM exploration):
    1. Henry Ford Pharmacies
    2. Henry Ford Health Products
  2. CM explores external resources before utilizing ambulatory medical needs fund including (see patient resource guide for more details):
    1. Discounts
    2. Coupons
    3. Alternative less expensive medications with same efficacy
    4. Payment plan through Henry Ford Pharmacy Advantage program
    5. Pharmaceutical company patient assistance programs
  3. Processing payments with Henry Ford pharmacies and Henry Ford Health Products
    1. CM receives physician referral
    2. CM investigates to uncover patient’s coverage gaps (Copay, deductible, insurance type)
    3. CM researches to see if patient can access the least expensive product and has a conversation with the primary care physician as necessary
      1. If so, CM will ask patient if they can afford the less expensive option
        1. Health products examples: Used equipment (World Medical Relief), Hart Medical, and ACS
        2. Pharmacy examples- Pulmicort is cheaper than Advair
      2. Payment plan options:
        1. Health products- plans can be set up by calling 800-859-2962
        2. Pharmacy Advantage- plans can be set up by calling 800 456 2112 option 4 Or, plans can be set up by opening an “account receivable” (AR) as an alternate payment plan option at any HFHS ambulatory pharmacy. Plan facilitated by CM and Pharmacist.
    4. If none of the payment options work, CM can discuss potential medical needs fund support with local staff member
    5. CMs can provide prescriptions electronically or in person
    6. When prescription is presented to provide medical needs fund cost center (billing account setup for cost center numbers) write in note “Please don’t fill. Only run for cost analysis using the A-PMNF fund”
    7. Keep patient and PCP updated throughout the process

referral process chart

Legal Considerations for Insurance Types:

  • Patients with commercial insurance:
    • No restrictions on cost sharing or transportation
  • Patients with government sponsored insurance (Medicare, Medicaid, Medicare Advantage, Managed Medicaid, Veterans Affairs, Tri Care):
    • Cannot pay for any cost sharing
    • CAN pay for entire cost of medication using fund pricing
    • Cannot pay for transportation at this time

Database in progress for metric report

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue:  December 14, 2015
  • Next MiPCT Practice FLASH Issue:   December 14, 2015

October 26, 2015

Have You Completed the 2015 Practice Learning Credit Requirement?

Each year, eight Practice Learning Credits are required of participating MiPCT practices. Unless otherwise specified, participants in activities should include one or more Physicians from the Practice, the Care Manager PLUS one or more other Practice Care Team members.

Some activities are centrally administered by the MiPCT and require no preapproval. At this point in the year, the following are still viable options for receiving credit:

  • Annual MiPCT Summit Participation (4 hours) (To receive credit the Practice Team as defined above, including the Physician must attend.) — the Ann Arbor summit is still an opportunity if you wish to attend.
  • 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 – there have been details in the FLASH re: the submission process and the number of credits, etc.

Activities that are not centrally administered do require pre-approval. A PO and/or practice may elect to submit approval requests for programs that are consistent with MiPCT goals.

The process for submitting an activity for preapproval using the form available on the http://www.mipct.org website:

https://mipctdemo.wordpress.com/resources/mipct-documents-and-presentations/mipctlearning-activity-approval-form

and was published in the March 23, 2015 PO and Practice FLASHes. Submit completed form at least four weeks prior to the event to: MiPCTDemo@michigan.gov.

An Evening of Learning: Advance Care Planning, Improving Quality of Life

The Washtenaw Health Initiative will be showing a free screening of Consider the Conversation 2: Stories about Cure, Relief and Comfort. The film highlights the importance of advance care planning and the ability to improve a patient’s quality of life. In addition, a panel of providers and patient advocates, who have engaged in advance care planning (ACP) will be available for discussion at the conclusion of the film.

Moderator: Oliver Kim, former deputy staff director, Senate Aging Committee

Panelists:

  • Ryan Fox, transition manager, Evangelical Homes of Michigan
  • Sally Jaworowski, community member and ACP advocate
  • Adam Marks, medical director, Arbor Palliative Care and assistant professor, Department of Internal Medicine, University of Michigan
  • Phil Rodgers, associate professor, Departments of Family Medicine and Internal Medicine, University of Michigan
  • Julie Seitz, ACP leader, St. Joseph Mercy Health System

Attendees will learn about:

  • The current state of ACP in Washtenaw County.
  • Common barriers to ACP and how key ACP participants—providers, patients and loved ones—can improve and increase ACP.
  • Available ACP resources and how to begin ACP conversations with loved ones

Place: Michigan Theatre – 603 E. Liberty St., Ann Arbor, MI

Date: November 17th

Time: 6:00p to 8:00p

To register for this event: http://washtenawhealthinitiative.org/consider-the-conversation-2/

MiPCT Complex Care Management Course

The 2015 MiPCT Complex Care Management (CCM) course is provided in a blended learning activity format. The MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

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

  • DAY 1: Live webinar: Introduction of the 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

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

Upcoming MiPCT CCM Course Dates & Registration Close Dates:

  • November 9-12, 2015 MiPCT CCM Introductory Webinar, November 9, 2015. In-person training November 10-11, 2015. (Registration for this course will close as of November 3, 2015, 4PM).
  • December 7-10, 2015 MiPCT CCM Introductory Webinar December 7, 2015. In-person training December 9-10, 2015. (Registration for this course will close as of December 3, 2015, 4PM).

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

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

Michigan Care 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

From the MI Department of Health and Human Services – Your Public Health Partner – Adverse Childhood Experiences (ACEs) Are Making Your Patients Sick

Would you be surprised to find out that two-thirds of your patients have been physically, emotionally or sexually abused or had other traumatic experiences as children? What if you learned that those experiences are making your patients sick, driving up their health care utilization, and cutting their life expectancy- sometimes dramatically? A growing body of literature regarding Adverse Childhood Experiences (ACEs) and their connection to illness and disease is gaining greater attention among medical and public health professionals, many of whom believe addressing ACEs will be necessary for moving the needle on some of society’s most intractable health challenges.

A landmark study, conducted in the 1990s by Kaiser Permanente Health System, showed that ACEs (defined as 10 forms of abuse, neglect and family dysfunction) were more common than previously believed. Among the approximately 17,000 mostly white, well-educated, middle class adults who responded to the study’s survey, about two-thirds had experienced one adverse childhood event; of those that named one, 87% named an additional ACE. The prevalence of ACEs in the original sample was as follows:

  • 28% Physical abuse; 21% Sexual abuse; 11% Emotional abuse
  • 27% Household substance abuse
  • 23% Parental separation or divorce
  • 19% Household mental illness
  • 15% Emotional neglect; 10% Physical neglect
  • 13% Mother treated violently
  • 5% Incarcerated household member

ACEs have been strongly associated with health risk behaviors like smoking, alcohol and drug abuse, disordered eating, and sexual promiscuity. Since the survey was first administered, over 50 research papers have documented associations between ACEs and a host of negative health outcomes (e.g. COPD/lung disease, heart disease, autoimmune disease, migraine/headache, obesity, poor health status, and premature death).

Ask, listen, accept. In an independent analysis of the utilization of 125,000 Kaiser Permanente patients who answered ACE questions as part of their routine patient intake, researchers unaffiliated with the original study showed a 35% decrease in doctor’s visits and 11% decrease in emergency department visits in the year after responding to ACE questions. Those decreases manifested without the provision of therapeutic intervention. One of the original study authors explained that remarkable finding: “Slowly we came to see that asking, and listening…and accepting was a very powerful tool,” adding, “the implications of this, economically…are enormous and have yet to be exploited.”

MDHHS has added information and resources about ACEs to its primary care information website: http://Michigan.gov/primarycare. Please visit the site and consider what you can do to make your practice more responsive to the needs of patients affected by ACEs. View a compelling video on the connections between abuse/trauma and health at:

http://acestoohigh.com/2013/01/07/video-end-it-now-understanding-and-preventing-child-abuse/

MiPCT Care Manager Webinars: NEW 2015 MiPCT Care Manager Educational Webinars

Date: November 11th 2-3 pm

Title: Utilizing Strength-Based Communication Strategies with Older Adults

Presenter: Linda Keilman DNP, GNP-BC

Date: November 20th 10-11am **PEDS**

Title: Integrating Behavioral Health Into Your Pediatric Practice

Presenter: Laurisa Cummings, LMSW

Date: December 9th 2-3pm

Title: “Normal” Communication in Lives that are Anything But…

Presenter: Renée L. McCune, PhD, RN Associate Dean McAuley School of Nursing University of Detroit Mercy

Date: December 18th 10-11am **PEDS**

Title: Mandated Reporting

Presenter: Chris Blood, LLMSW Children’s Protective Services Supervisor Ingham County Department of Health and Human Services

Please see link below for upcoming MiPCT Care Manager Webinars!

https://mipct.org/care-manager-webinar-conference-call-calendar/

Stories of Your Team Based Success – Marquette Internal Medicine and Pediatrics – Submitted by: Della Slavsky RN, BSN, Clinical Lead and Kerrie Smith RN, BSN, CCM

The staff at Marquette Internal Medicine and Pediatrics assessed the Transition of Care process to find ways to improve the coordination and continuity of care for patients as they transitioned between health care locations.

The Challenge: The office was provided an ADT report from the local hospital, but it was not always sent daily. There was no internal process in place for distribution of the list for follow up resulting in missed opportunities for patient contacts after discharge.

Team-Based Workgroup: In an effort to improve the TOC process we met as a group to identify barriers and potential solutions. A Fishbone diagram was created to identify and categorize barriers and opportunities for improvement. We placed barriers into categories including: Provider Organization, Provider Office, Facility, Patient, and Information Systems. We then looked at the barriers that we could address and developed interventions to overcome those barriers.

Barriers identified:

  • Emergency Department list was not provided to office
  • Inpatient list was not provided to office on a consistent and timely basis
  • No formal process for follow up with ED and IP stays
  • No access to Facility’s Information Systems

Opportunities for Improvement:

  • Obtain timely and consistent ED notification to practice
  • Obtain timely and consistent IP notifications to practice
  • Improve internal process for follow-up of ED and IP stays

Interventions:

  • Contacted facility ED Manager
  • Contacted facility Information Systems Manager
  • Met with facility Hospitalists
  • Practice office contracted with Facility to gain read only access to information systems for IP ADT lists
  • Staff workgroup developed formal TOC process for office
  • Transition of Care template developed to standardize follow-up phone calls and documentation

Tools Developed:

  • Template for Transition of Care follow up calls in EHR
  • Formal written process developed and distributed

Lessons Learned:

  • Change is not as difficult as one might think and when all staff members work together as a team.
  • Getting input from the staff that do the work is critical for implementation of process changes
  • Working with a formalized process and documentation template helps with consistency.
  • Patient satisfaction, while not formally measured, has been positive as noted during interactions

Template for first follow up call 24-48 hours after discharge:

TOC (Transition of care) note:

Admit date: DC date:

Admit reason: DC diagnosis:

DC’d to:

Patient Status/Story:

New Medications or Medication changes:

Patient concerns:

Does the patient have Home Health?

If yes, what agency:

Does the patient have other help at home (family, friends, paid help)?

Follow Up appointments:

Patient advised to bring all medications to follow up appointment and any discharge paperwork they received from the discharge facility.

Patient encouraged to call this office with any questions/concerns related to medical condition or if develops signs or symptoms of illness so patient can be seen at this office when appropriate.

TOC Process:

Marquette Internal Medicine MiPCT CM

Transitions of Care Process –

Purpose: To foster structured and coordinated care between health care settings to ensure coordination and continuity of care for patients as they transition from one health care setting to another.

Process:

Case Manager (CM) or designee, reviews admission and discharge notification ADT list.

  • Check to see if the patient is on the MiPCT list – If yes then
  • Call patient within 24-48 hours, as feasible
  • Review discharge summary forms
  • Contact patient per phone 24-48 hours after discharge
  • Assess how patient is doing that day
  • Review reason for phone call
  • Medication reconciliation (first phone call and prn)
  • Ensure follow up visits/tests are scheduled; if not, assist member as needed
  • Coordinate needed ancillary services (home health, DME, transportation assist, pharmacy needs) or contact existing services in place as appropriate to provide timely, complete and accurate information between entities
  • Provide education to patient related to s/sx to report to PCP office
  • Weekly phone calls x 4 to assess ongoing CM needs, patient condition, self management goals (if made)
  • Provide follow up to assess if follow up visits and/or tests are completed
  • Meet with patient at follow up visit, as feasible
  • Document call in EHR using the TOC template

No, patient is not on the MiPCT list

  • CM sends note in office EHR to appropriate staff nurse
  • Staff nurse contacts member as described above and documents in EHR TOC template note.

End process.

Please see the attached Fishbone Analysis Document

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 should I use the High Risk Flag on the All Payer Patient List (APPL)?

A: A High Risk Flag of ‘1’ indicates members who are likely to need care management. For your convenience, they are listed at the top of the list for each payer.

The High Risk Flag column is located on the far right of the APPL. This field contains a ‘1’ under either of the following conditions:

  • The member’s Risk Group is ‘Very High’
  • The member’s Medicare/Medicaid Dual Eligibility Flag=’1’.

Otherwise, the member’s High Risk Flag will be ‘0’

The rows of the All Payer Patient List are sorted in the following order:

  • By Payer, in alphabetical order
  • By High Risk Flag, sorted high to low (so that ‘1’ sorts to the top)
  • By Prospective Risk Score, sorted high to low

New Field Sneak Preview!!

MDC is adding a new field to the All Payer Patient List! Beginning with the November lists, a “Healthy Michigan Flag” will identify members who have coverage under the Medicaid Healthy Michigan Plan.

If you have any questions, or if you would like to provide feedback or suggestions, please contact MDC at MichiganDataCollaborative@med.umich.edu

NEXT ISSUE DATES:

  • Next MiPCT PO FLASH Issue: November 9, 2015
  • Next MiPCT Practice FLASH Issue: November 9, 2015

SEPTEMBER 29, 2015 CORRECTION TO THE 9/28/2015 PRACTICE FLASH:

Stakeholders, please be advised of an error in the Practice FLASH, published Monday, September 28, 2015:

In the “Important Dates” sidebar on the front page, we printed the Quarterly Report Due Date as 9/30/2015.  This was an error.  The correct due date is 10/31/2015.

We are sorry for any inconvenience this may have posed to you.

September 28, 2015

IMG_5406

Congratulations to the Best Practice Award Winners!

On September 16 at the MiPCT Regional Annual Summit in Grand Rapids, the Best Practice Award winners were announced.Thirty physician practices across Michigan received recognition for their achievements in patient care in six award categories.   These practices were selected from over 350 primary care practices statewide.

The six categories are:

  1. Most Improved-Adult and Family Medicine,
  2. Most Improved-Pediatrics,
  3. Most Improved-Diabetes Performance,
  4. Best Overall-Adult and Family Medicine,
  5. Best Overall-Diabetes Performance and
  6. Best Overall-Pediatrics.

Award categories assessed whether patients received appropriate screenings and whether unnecessary emergency department visits and hospital admissions were avoided.

Congratulations to the winning practices, listed below:

Adult & Family Best Overall

  • Marquette Internal Medicine Pediatric Associates
  • Fenton Medical Center, P.C.
  • Jane Castillo, MD
  • Dhiraj Bedi, DO
  • Lifetime Family Care, PLLC /A Division of Michigan Healthcare Professionals PC

Pediatrics Best  Overall

  • Pediatric Specialists of Bloomfield Hills PC
  • Pediatric Consultants of Troy PC
  • Joseph B. Luna, M.D., P.C.
  • Cereal City Pediatrics PC
  • Moazami Pediatrics

Diabetes Best Overall

  • Family Tree Medical Associates
  • St. Johns Professional Associates
  • SMG DeWitt
  • Grand Blanc Family Medicine
  • Jane Castillo, MD

Adult & Family Most Improved

  • E. Ann Arbor Med-Peds
  • Rivertown Internal Medicine and Pediatrics
  • Campustowne Family Medicine
  • Grand Rapids Internal Medicine and Pediatrics
  • Alpine Internal Medicine and Pediatrics

Pediatrics Most Improved

  • Pediatric Consultants of Troy PC
  • CHC Fort Gratiot
  • Forest Hills Pediatric Associates PC
  • Briarwood Center For Women Children & Young Adults
  • Pediatric Care of Lansing

Diabetes Performance Most Improved

  • Cherry Street Health Center
  • SMG Holt
  • St. Johns Professional Associates
  • Premier Family Physicians
  • New Day Family Medicine

Ann Arbor Summit Care Management Afternoon Session FULL

The Ann Arbor Summit Care Management afternoon session for October 29, 2015 is now full.

MiPCT Care Managers who have not registered for the Ann Arbor Summit Care Management afternoon session and wish to attend may sign up on a wait list via the Summit Registration web page https://mipct.org/resources/2015-mipct-annual-summits/. You will be contacted by October 23, 2015 if we are able to accommodate your request to attend.

Don’t Forget to Register: MiPCT Regional Annual Summits

The Topic for the 2015 in-person Summit CM education session is: “Brief Action Planning (BAP), Patient Engagement and Agenda-Setting.”  The Summit afternoon CM Session focuses on practical self-management support skills: BAP, patient engagement and agenda-setting. Build your self-management skills and learn new techniques for patient engagement that you can apply in your daily practice!

Learning Objectives include:

  • Discuss the BAP and its evidence base
  • Demonstrate early proficiency in skills of BAP
  • Explain the benefits of agenda setting
  • Demonstrate early proficiency in skills of agenda-setting
  • Demonstrate Ask-Tell-Ask
  • Learn how to effectively engage patients in their care

“MiPCT Summit 2015 Care Manager 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.

The 2015 Summit afternoon session Expert Presenters are from The Centre for Collaboration, Motivation and Innovation:

As previously announced, the dates and venues for the 2015 MiPCT Regional Annual Summits are:

  • Summit North – Thompsonville, MI
    Tuesday, October 20, 2015
    Crystal Mountain Resort & Conference Center
    Noon Project Leadership Briefing,
    followed by afternoon care management training
    REGISTRATION CLOSES 10/13/2015*
  • Summit Southeast – Ann Arbor, MI
    Thursday, October 29, 2015
    University of Michigan NCRC
    8:30 AM to Noon General Session open to all;
    Noon to 4PM care management training
    REGISTRATION CLOSES 10/22/2015*

* Registration may close earlier if capacity limits are reached.  Early registration STRONGLY encouraged.

Summit Care Manager Educational Activities Consist of NEW Prework Component, along with In-Person Session

Summit 2015 Care Manager (CM) session consists of two parts, both of which offer nursing contact hours: Completion of Prework consists of viewing 4 recorded webinars, with  an opportunity to earn up to 6.0 Nursing Contact Hours www.mipct.org/2015-summit-prework-webinars/

  1. The in-person Summit afternoon care manager education session, with an opportunity to earn 3.0 Nursing Contact Hours. www.mipct.org/resources/2015-mipct-annual-summits/

Summit Care Manager Session Prework:  

  • This year, we have partnered with the Centre for Collaboration, Motivation and Innovation (CCMI) to design a series of four prework webinars to enrich your learning experience at the in-person Summit afternoon CM education session.
  • The Summit prework consists of foundational content, offered in four, 1.5 hour pre-recorded webinars, available online, and eligible for earning nursing contact hours.
  • Our presenter is Connie Davis, RN, MN, GMP, co-director of the CCMI.  Connie Davis is an internationally known trainer, educator, speaker and consultant on health care design and health behavior change.

Please view the 4 recorded webinars prior to the live Summit event.  The links to the webinars will be available until December 31, 2015. The recorded webinars will be posted on the http://www.mipct.org website on the 2015 Summit Prework Webinars page located under the MiPCT Annual Summits tab: https://mipct.org/2015-summit-prework-webinars/

The webinars are available now. Please access the pre-recorded webinars at your convenience.

Topics for the 4 CM Session Prework webinars:
Please note the webinars are best if viewed sequentially. Viewing the webinars prior to the live Summit CM afternoon session is highly recommended.

Webinar 1: 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.

Webinar 2: 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.

Webinar 3: 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.

Webinar 4: 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.

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

  1. View the online recorded webinar
  2. Complete the webinar web-based evaluation and within the evaluation, include your email address.
  3. Upon completion and submission of the evaluation tool, your CE certificate will be sent to your email
    address
  4. Links to the prework webinars and instructions for completion are located on: https://mipct.org/care-manager-webinar-conference-call-calendar.

NOTE: We recommend that you view the webinars sequentially prior to the Summit in-person event. If you find you are unable to view them prior to the Summit, the webinars will be available online through December 31, 2015. Each of the 4 webinars and the Summit afternoon care manager in-person session are standalone, in terms of earning contact hours.

Access to a Medical Home for All

The National Center for Medical Home Implementation (National Center) is focused on ensuring all children and youth—particularly those with special health care needs—have access to a medical home.

The National Center achieves this goal through the following:

  • Developing and distributing tools and resources for medical home implementation
  • Providing technical assistance and support to practices, clinicians, families, communities, and states
  • Conducting pilot projects focused on the core components of the medical home.
  • Collaborating with local, state, and national partners to facilitate partnership and medical home system change

The National Center for Medical Home Implementation identifies state by state programs and initiatives; Michigan has been recognized for the Michigan Primary Care Transformation demonstration project. Please visit their website at:
http://www.medicalhomeinfo.aap.org or visit the Michigan State Profile at https://medicalhomeinfo.aap.org/national-state-initiatives/State-Profiles/Pages/Michigan-State-Profile.aspx

MiPCT Complex Care Management Course

The 2015 MiPCT Complex Care Management (CCM) course is provided in a blended learning activity format. The  MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

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

  • DAY 1:  Live webinar: Introduction of the 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

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

Upcoming MiPCT CCM Course Dates & Registration Close Dates:

  • October 5-8, 2015 MiPCT CCM Introductory Webinar, October 5, 2015. In-person training October 6-7, 2015. (Registration for this course will close as of October 1, 2015, 4PM).
  • November 9-12, 2015 MiPCT CCM Introductory Webinar, November 9, 2015. In-person training November 10-11, 2015. (Registration for this course will close as of November 3, 2015, 4PM).
  • December 7-10, 2015 MiPCT CCM Introductory Webinar December 7, 2015. In-person training December 9-10, 2015.  (Registration for this course will close as of December 3, 2015, 4PM).Register for all MiPCT CCM Courses Here: https://mipct.org/care-management-resource-center/ccm-online-registration-page/

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

Michigan Care 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

Stories of Your Team-Based Success: Mercy Physician Community PHO LLC

Mercy Physician Community PHO LLC has taken a step forward in not only recognizing diabetic gaps in care for their patient population, but identifying unique patient barriers contributing to these gaps.  Mercy Physician Community was then able to create a workflow for their team, closing gaps and improving patient care.

Mercy Physician Community is located in a rural area, over thirty miles from the nearest Endocrinologist office or Diabetic Educational Center. This rural location contributed to patient non-adherence to treatment plans, often due to transportation difficulties or life schedules not conducive to multiple face to face visits. A unique workflow was created.

Uncontrolled diabetic patients were identified and referred to Care Management services by the PCP for a 4-12 week program to improve blood sugars and A1C levels. Patients were advised up front by office staff that frequent visits or phone calls would be short term to jump start diabetic control. Visits were then set up on a weekly or bi-weekly basis dependent on the patients’ circumstances; telephonic visits were made in between the face to face visits that were scheduled further apart. The team felt that this schedule increased patient compliance and attendance to visits.

The Care Team then assessed and identified the patients’ barriers to blood glucose control and their current methods of self-management. Beginning needs were addressed to ensure that the patients had the right tools to manage their condition. This included a working glucometer, testing supplies, and a log book. Depending on patient needs coordination of a new testing kit and/or supplies through either mail-order their local pharmacy was completed.  Also evaluated, was the patients knowledge of their condition, including how often and best times of day to check blood sugar, target ranges and action plans.

An individualized care plan was created for each patient to include SMART goals, follow up time frames and method of future visits. Follow up visits included reviewing blood sugar logs, food logs, use of medication/insulin, any patterns in blood sugar levels, and all pertinent changes since last visit. The care team, including the patients’ PCP and office staff, met to determine any needed changes. New medications or changes in medication was completed by the PCP. The office staff scanned any logs into EMR as well as making any needed changes to the patients’ medical record.

During the program, the care team and PCP continuously explained any changes to the patients’ plan of care, along with continued brief education in areas that were contributing to their blood sugar patterns. Education included stress management activities, exercise, changes in medications, illness, and diet. SMART goals and the plan of care were updated at each patient visit as well as each team meeting.

Throughout the program, patients started to feel better and see improvement in their blood sugar. They became more open to additional care of their diabetes that had been challenging to address in the past. The practice as a whole saw increased patient compliance, routine follow up visits, and eventual openness to attending a Diabetic education program in the future. Gaps in measures such as eye exams, A1C testing, podiatry visits, even wearing diabetic shoes were readdressed and referrals were completed successfully. Patients became increasingly compliant with their medications/insulin and were less likely to let them run out. As the patients’ confidence grew with managing their diabetes, they became more comfortable with keeping regular PCP visits due to the pride in their achievements. The benefit of patients with diabetes having regularly scheduled visits with their PCP includes proactively addressing risk factors.  This has the potential to improve patients’ overall health status.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue:  Oct.12, 2015
  • Next MiPCT Practice FLASH Issue:   Oct. 26, 2015

August 31, 2015

Announcing the MiPCT/PatientPing Partnership for MiPCT Admission, Discharge, Transfer (ADT) Notifications: An Opportunity for PO Participation

We wanted to share with our practice partners that the MiPCT has transitioned from Crimson to PatientPing as a vendor partner for MiPCT patient ADT notifications to our primary care practices. PatientPing offers several advantages, including notifications on admissions and discharges at hospitals as well as post-acute care facilities across Michigan. PatientPing also allows POs to craft guidelines that are “pushed” by PatientPing to the admitting facilities so the facilities know who to contact about a MiPCT patient who has experienced a transition.

Additionally, PatientPing is working on integrating notifications directly into EHRs, as well as transmitting medication reconciliation information. Please keep in mind that this service is available for MiPCT patients at project cost to the PO or practice, to the extent that project funding allows. POs who participated in our collaboration with Crimson will be transitioned and onboarded to PatientPing first in “Wave One”. To the extent that project funding allows, we will also provide an opportunity for additional POs to participate so that their practices may also receive MiPCT patient ADT notifications as “Wave Two” participants.

If you have participated in the ADT partnership in the past, your PO ADT lead received a meeting invitation to the “Wave One” webinar. For the remaining POs, there will also be a webinar on September 25 from 1:30-2:30 PM about the opportunity to be a part of “Wave Two.” In the interim, attached is brief overview of the structure of the MiPCT PatientPing partnership.

Don’t Forget to Register: MiPCT Regional Annual Summits

The Topic for the 2015 in-person Summit CM education session is: “Brief Action Planning (BAP), Patient Engagement and Agenda-Setting.” The Summit afternoon CM Session focuses on practical self-management support skills: BAP, patient engagement and agenda-setting. Build your self-management skills and learn new techniques for patient engagement that you can apply in your daily practice!

Learning Objectives include:

  • Discuss the BAP and its evidence base
  • Demonstrate early proficiency in skills of BAP
  • Explain the benefits of agenda setting
  • Demonstrate early proficiency in skills of agenda=setting
  • Demonstrate Ask-Tell-Ask
  • Learn how to effectively engage patients in their care

“MiPCT Summit 2015 Care Manager 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.

The 2015 Summit afternoon session Expert Presenters are from The Centre for Collaboration, Motivation and Innovation: As previously announced, the dates and venues for the 2015 MiPCT Regional Annual Summits are:

  • Summit West – Grand Rapids, MI
  • Wednesday, September 16, 2015
  • Frederik Meijer Gardens and Sculpture Park
  • 8AM to Noon General Session open to all; afternoon care management training
  • REGISTRATION CLOSES 9/9/2015*
  • Summit North – Thompsonville, MI
  • Tuesday, October 20, 2015
  • Crystal Mountain Resort & Conference Center
  • Noon Project Leadership Briefing,followed by afternoon care management training
  • REGISTRATION CLOSES 10/13/2015*
  • Summit Southeast – Ann Arbor, MI
  • Thursday, October 29, 2015
  • University of Michigan NCRC
  • 8AM to Noon General Session open to all; afternoon care management training
  • REGISTRATION CLOSES 10/22/2015*

* Registration may close earlier if capacity limits are reached. Early registration STRONGLY encouraged.
Summit Care Manager Educational Activities Consist of NEW Prework Component, Along With In-Person Session

Summit 2015 Care Manager (CM) session consists of two parts, both of which offer nursing contact hours:

  1. Completion of Prework consists of viewing 4 recorded webinars, with an opportunity to earn up to 6.0 Nursing Contact Hours www.mipct.org/2015-summit-prework-webinars/
  2. The in-person Summit afternoon care manager education session, with an opportunity to earn 3.0 Nursing Contact Hours. www.mipct.org/resources/2015-mipct-annual-summits/

Summit Care Manager Session Prework:

  • This year, we have partnered with the Centre for Collaboration, Motivation and Innovation (CCMI) to design a series of four prework webinars to enrich your learning experience at the in-person Summit afternoon CM education session.
  • The Summit prework consists of foundational content, offered in four, 1.5 hour pre-recorded
    webinars, available online, and eligible for earning nursing contact hours.
  • Our presenter is Connie Davis, RN, MN, GMP, co-director of the CCMI. Connie Davis is an internationally known trainer, educator, speaker and consultant on health care design and health behavior change.

Please view the 4 recorded webinars prior to the live Summit event. The links to the webinars will be available until December 31, 2015. The recorded webinars will be posted on the http://www.mipct.org website on the 2015 Summit Prework Webinars page located under the MiPCT Annual Summits tab: https://mipct.org/2015-summit-prework-webinars/ Please access the pre-recorded webinars at your convenience.

Topics for the 4 CM Session Prework webinars:
Please note the webinars are best if viewed sequentially. Viewing the webinars prior to the live Summit CM afternoon session is highly recommended.

Webinar 1: 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.

Webinar 2: 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.

Webinar 3: 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.

Webinar 4: 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.

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

  1. View the online recorded webinar
  2. Complete the webinar web-based evaluation and within the evaluation, include your email address.
  3. Upon completion and submission of the evaluation tool, your CE certificate will be sent to your email
    address
  4. Links to the prework webinars and instructions for completion are located on: https://mipct.org/care-manager-webinar-conference-call-calendar.

NOTE: We recommend that you view the webinars sequentially prior to the Summit in-person event. If you find you are unable to view them prior to the Summit, the webinars will be available online through December 31, 2015. Each of the 4 webinars and the Summit afternoon care manager in-person session are standalone, in terms of earning contact hours.

MiPCT Pediatric Care Manager Summit Fall 2015 – Don’t Forget to Register!

  • Date: Tuesday, September 22, 2015
  • Location: U of M NCRC Bldg. 18, Ann Arbor
  • Time: 9am – 4pm

The MiPCT Pediatric Care Manager Conference will address the clinical focus areas of:

  1. Social determinants of health,
  2. Integration of behavioral health in primary care, and
  3. Palliative care

We will have 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 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.

REGISTER HERE: https://mipct.org/2015-mipct-pediatric-conference/

**Please note registration will close 9.15.15. MiPCT Pediatric Care Managers will also find that the CM Summit 2015 pre-work of 4 recorded webinars will align with the MiPCT Pediatric CM 2015 Summit, and is highly recommended. Please see 2015 MiPCT Annual Summit page: https://mipct.org/2015-summit-prework-webinars/

New! LIVE Webinar with CME Opportunity

September 17th, 2015 9am -10am
Alzheimer’s Disease and Advanced Directives: A Primer for Primary Care Physicians: 1 hour live webinar presented by Wayne Shelton, PhD, MSW. Professor of Medicine and Bioethics, Alden March Bioethics Institute, Albany Medical College and Kevin Costello, MD. Assistant Professor of Medicine and Attending, Department of Medicine, Albany Medical College

Webinar topics include:

  1. Raising awareness among healthcare providers, especially primary care physicians (PCPs), about the looming crisis of increasing Alzheimer’s disease in this country.
  2. Providing critical information and tools to prepare these healthcare providers to have constructive conversations with patients that have remaining capacity about their  preferences for medical care in the advance stage of disease
  3. Giving participants a working knowledge of the ethical basis for advance directives,  including the professional obligation to fully disclose the diagnosis of dementia and to have a meaningful conversation with each patient and his or her caregiver about advance directives.
  4. Providing tools to help physicians have meaningful conversations about advance directives with patients and their caregivers.
  5. Reminding participants of the increasing number of new Alzheimer’s patients they are likely to have under their care, and also help them capitalize on the window of opportunity for effective conversations about advance directives.

Register Here!: http://www.albany.edu/sph/cphce/phl_0915.shtml

MiPCT Regional Annual Summit Flyer Attached for your Distribution

Attached to this issue of the FLASH, please find the 2015 MiPCT Regional Annual Summit flyer. Please distribute and post to get the word out!

MiPCT Complex Care Management Course

The 2015 MiPCT Complex Care Management (CCM) course is provided in a blended learning activity format. The MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

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

  • DAY 1: Live webinar: Introduction of the 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 posttests is six hours)
  • DAYS 3 & 4: In-person training

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

Upcoming MiPCT CCM Course Dates & Registration Close Dates:

  • *September 8-10, 2015 MiPCT CCM Introductory Webinar, September 8, 2015. In-person training September 9-10, 2015. Note: Registration for this course will close as of September 1, 2015.
    *NOTE: Due to the 9/7 HOLIDAY , this course will begin on Tuesday 9/8/15 with the LIVE webinar at 9am.
  • October 5-8 2015 MiPCT CCM Introductory Webinar, October 5, 2015. In-person training October 6-7, 2015. (Registration for this course will close as of October 1, 2015).
  • November 9-12 2015 MiPCT CCM Introductory Webinar, November 9, 2015. In-person training November 10-11, 2015. (Registration for this course will close as of November 3, 2015).

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

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

Care Manager Monthly Update for August 2015

Please see the Care Manager Monthly Update, attached to this issue of the Practice FLASH for August 2015.

Michigan Care 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

Stories of Your PO Success: Sparrow Medical Group Implements Team-Based Diabetic Registry

Sparrow Medical Group (SMG) – North sought to improve the following parameters for their patients with a diagnosis of diabetes: A1C values below 8.0, and to decrease gaps in care for foot and eye exams. At SMG North, disease registries are run every other month starting in April 2014, to find gaps in care or opportunities for improvement to meet MQIC guidelines. This is in alignment with the 2015 MiPCT Clinical Area of Focus of optimizing team-based registry use for population health management. The entire office team including MiPCT RN, Physician, Medical Assistants, Office Manager and all office staff are actively involved in providing optimal care and meeting the MQIC disease specific guidelines. The MiPCT RN is well integrated into the office and works as part of the team. Outlined below is how this process is addressed by specific team members and at different points in time.

Registries
Each Medical Assistant (MA) in the SMG North office is assigned a disease registry that they are in charge of running every other month. The current disease specific registries are: diabetes, hypertension, asthma, CHF, CAD, and COPD. That same MA then “works this registry” over the next month. The MA identifies patients that need updated medical information in their record. The patient may be overdue for a scheduled office visit, have overdue or pending labwork that needs to be completed, or have an identified procedure that is specific to the disease process that needs to be reconciled. The MA sends out reminder letters to patients via the bulk communication portion of the registry (letter/mysparrow message) regarding these specific pieces of missing health data. The communication method is previously determined by the patient’s choice at registration. A diabetic registry is used to identify patients with elevated A1C’s and with gaps in care that may include: missing lab work, no office visit in past year, or no foot or eye exam in past year. As well as sending out letters to patients requesting their participation in updating their diabetic information or having the exam completed, the MA also gives a list to each doctor and RN Care Facilitator of those patients with A1C’s of 8.0 or greater. The office manager has been instrumental in building these registries and in working with staff to be knowledgeable about how to effectively work them.

Appointment Notes in EMR
The MA makes notations in “Appointment Notes” in the EMR daily schedule to prompt the front clerical staff that the patient has gaps in care. This notation is then used as a patient reminder when the front staff or MA makes their clinic reminder calls. Appointment reminder calls are made 2 days in advance of an appointment and would include the need for lab work or overdue ordered procedure if indicated. This reminder in the appointment note indicates gaps in care and is used by the MA that rooms the patient. It will remind the MA if a foot exam is needed or any other health maintenance exams are due, this will be reviewed with the physician before they go into the exam room to see the patient.

Office Visit

  1. At the time of a patient’s office visit, the front desk staff person is the initial point of contact with the patient. This staff person sets the tone of the office visit for the patient. They are very welcoming as they check-in the patient using the EMR, encouraging the
    patient to sign up for mysparrow account (patient portal) if they do not have one. They then have the patient complete a review of systems (done yearly), and medication update. Front desk staff members also use web DENIS to check for PDCM insurance benefits. If the patient is MiPCT eligible, the front staff person gives the patient a flyer describing the
    office’s MiPCT RN care manager services that are available to them.
  2. MA’s are paired with physicians, they do not typically rotate. The MA rooms the patient and sets up the DM note for the physician. The reminder in the appointment desk note of a gap in care is used by the MA that rooms the patient to make sure the missing care is addressed, such as the need for a foot exam or a urine specimen at the visit.
  3. The physician knows which patients are MiPCT eligible from an FYI flag in the header area of the patient’s record. Additionally, the daily schedule is alerted to MiPCT patients with a notation added by a front staff person the previous day. After seeing a patient and identifying a need such as an elevated A1C, the physician will “huddle” briefly with the RN
    Care Facilitator (CF) to review the patient, discuss changes in treatment, and coordinate goals the patient is working on before the RN goes in to meet with the patient.
  4. After the visit, at check out, the clerical staff will schedule the next appointment by reviewing the doctor’s instructions on the “After Visit Summary”. The appointment may be made with the RNCF, or physician or both. The staff person checking out will also review with the patient any referrals made during that visit or follow-up information.
  5. In the past year, the RNCF has provided monthly PCMH in-services on diabetes and community resources available to our patients for the staff. Additionally, the RNCF sets up group visit opportunities for patients with elevated A1C’s that the physicians, medical assistants, and CF identify.

Tools
By starting this new team based diabetic registry, many new tools have been developed including:

  • Building of the disease specific registries by the Office Manager
  • Education for the identified MA staff that will be running Disease Specific Registries
  • MiPCT Care Facilitator patient education and teaching record/documentation
  • Flyer for exam room and office areas explaining how the MiPCT Care Facilitator can help the patient

Data Elements Collected
Meaningful use scores are reviewed monthly by physicians and office manager.

Barriers
As the team started working through this process many barriers were presented including:

  • How to “work” the registry once it is run
  • Bulk communication with EMR and the need for appropriate “letters” built into EPIC
  • Identifying which patients are eligible for MiPCT or PDCM services
  • Communicating with patients that they are eligible for MiPCT services
  • Reminding physicians and medical assistants which patients are eligible for MiPCT

Lessons Learned
Everyone in the office works as a team to improve care. All Caregivers in the practice take great pride in their work when they know they are a link in the process.
NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: September 14, 2015
  • Next MiPCT Practice FLASH Issue: September 28, 2015

July 27, 2015

Summit Care Manager Educational Activities Consist of NEW Prework Component, along with In-Person Session

Summit 2015 Care Manager (CM) session consists of two parts, both of which offer nursing contact hours:

  1. Completion of Prework consists of viewing 4 recorded webinars, with  an opportunity to earn up to 6.0 Nursing Contact Hours
  2. The in-person Summit afternoon care manager education session, with an opportunity to earn 3.0 Nursing Contact Hours, (see “Expert Presenters Announced for Your Summit Afternoon CM Education Session“ following this article for more information.)

Summit Care Manager Session Prework:

  • This year, we have partnered with the Centre for Collaboration, Motivation and Innovation (CCMI) to design a series of four prework webinars to enrich your learning experience at the in-person Summit afternoon CM education session.
  • The Summit prework consists of foundational content, offered in four, 1.5 hour pre-recorded webinars, available online, and eligible for earning nursing contact hours.
  • Our presenter is Connie Davis, RN, MN, GMP, co-director of the CCMI.  Connie Davis is an internationally known trainer, educator, speaker and consultant on health care design and health behavior change.

Please view the 4 recorded webinars prior to the live Summit event.  The links to the webinars will be available August 1, 2015 to December 31, 2015. The recorded webinars will be posted on the www.mipct.org website on the CM Webinar Conference Call Calendar tab: https://mipct.org/care-manager-webinar-conference-call-calendar/. Starting August 1, 2015, please access the pre-recorded webinars at your convenience.

Topics for the 4 CM Session Prework webinars:

Please note the webinars are best if viewed sequentially. Viewing the webinars prior to the live Summit CM afternoon session is highly recommended.

  • Webinar 1: 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.
  • Webinar 2: 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.
  • Webinar 3: 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.
  • Webinar 4: 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.

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

  1. View the online recorded webinar
  2. Complete the webinar web-based evaluation and within the evaluation, include your email address.
  3. Upon completion and submission of the evaluation tool, your CE certificate will be sent to your email address
  4. Links to the prework webinars and instructions for completion are located on:  https://mipct.org/care-manager-webinar-conference-call-calendar.

NOTE: We recommend that you view the webinars sequentially prior to the Summit in-person event. If you find you are unable to view them prior to the Summit, the webinars will be available online through December 31, 2015. Each of the 4 webinars and the Summit afternoon care manager in-person session are standalone, in terms of earning contact hours.

Physicians’ Corner: Facilitating Patient Self-Management Success with BAP
by Kevin Taylor MD

  • Joe was just discharged from the hospital because of heart failure.  He had severely elevated blood pressure and was having a hard time being compliant with his medications.
  • Will and his wife are worried about his elevated liver function tests.  He admitted to drinking alcohol excessively.
  • Mary struggled with weight loss and wanted a “pill” to help her lose weight.
  • Marsha continued to have elevated blood sugars on oral agents.  She was very reluctant to start insulin injections.

These are normal profiles of who we care for in our primary care settings on a daily basis. Historically, providers have tried to influence chronic illness self-management by advising behavior change (eg., smoking cessation, exercise) or telling patients to take medications; yet clinicians often become frustrated when patients do not “adhere” to their professional advice.1,2   Many times, patients want to make changes that will improve their health but need support—commonly known as self-management support—to be successful. Patients who are supported to actively self-manage their own chronic illnesses have fewer symptoms, improved quality of life, and lower use of health care resources.3  Involving patients in decision-making, emphasizing problem-solving, setting goals, creating action plans (i.e., when, where and how to enact a goal-directed behavior), and following up on goals are key features of successful self-management support methods.4

Multiple approaches from the behavioral change literature, such as the 5 A’s (Assess, Advise, Agree, Assist, Arrange),5  Motivational Interviewing (MI), and chronic disease self-management programs6 have been used to provide more effective guidance for patients and their caregivers. However, the practicalities of these approaches in clinical settings have been questioned. The 5A’s, a counseling framework that is used to guide providers in health behavior change counseling, can feel overwhelming because it encompasses several different aspects of counseling.7 Likewise, MI and adaptations of MI, which have been shown to outperform traditional “advice giving” in treatment of a broad range of behaviors and chronic conditions,8 have been critiqued since fidelity to this approach often involves multiple sessions of training, practice, and feedback to achieve proficiency.9 Finally, while chronic disease self-management programs have been shown to be effective when used by peers in the community,10 similar results in primary care are not well established.

Brief Action Planning (BAP) is an evidence-informed, efficient self-management support technique.11 BAP is a highly structured, stepped-care, self-management support technique composed of a series of 3 questions and 5 skills. BAP can be used to facilitate goal-setting and action-planning to build self-efficacy in chronic illness management and disease prevention.12 BAP addresses many of the barriers providers have cited to providing self-management support, as it can be used routinely by both individual providers and health care teams to facilitate patient-centered goal-setting and action-planning.

The overall goal of BAP is to assist an individual to create an action plan for a self-management behavior that they feel confident that they can achieve. BAP is currently being used in diverse care settings including primary care, home health care, rehabilitation, mental health and public health to assist and empower patients to self-manage chronic illnesses and disabilities including diabetes, depression, spinal cord injury, arthritis, and hypertension.13

Attached is a Brief Action Planning Flow Chart that is a helpful tool and quick reference to use in your clinical settings.

Over the past several months I have found BAP can be useful in my busy clinical settings to support patient self-management through patient-centered goal setting. I believe providers and health care teams can learn BAP and integrate it into clinical delivery systems to support self-management for PCMH transformation.14

_______________

  1. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA
    2002;288:2469–75.
  2. Miller W, Benefield R, Tonigan J. Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. J Consul Clin Psychol 1993;61:455–461.
  3. De Silva D. Evidence: helping people help themselves. London: The Health Foundation Inspiring Improvement; 2011.
  4. Lorig K, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med 2003; 26:1–7.
  5. Schlair S, Moore S, Mcmacken M, Jay M. How to deliver high-quality obesity counseling in primary care using the 5As framework. J Clin Outcomes Manag 2012;19:221–9.
  6. Lorig KR, Ritter P, Stewart a L, et al. Chronic disease selfmanagement program: 2-year health status and health care utilization outcomes. Med Care 2001;39:1217–23.
  7. Goldstein MG, Whitlock EP, DePue J. Multiple behavioral risk factor interventions in primary care. Summary of research evidence. Am J Prev Med 2004;27:61–79.
  8. Lundahl B, Moleni T, Burke BL, et al. Motivational interviewing in medical care settings: a systematic review and metaanalysis of randomized controlled trials. Patient Educ Couns 2013;93:157–68.
  9. Dunn C, Deroo L, Rivara F. The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. Addiction 2001;96:1725–42.
  10. Lorig KR, Ritter P, Stewart a L, et al. Chronic disease self management program: 2-year health status and health care utilization outcomes. Med Care 2001;39:1217–23.
  11. Reims K, Gutnick D, Davis C, Cole S. Brief action planning white paper. 2012. Available at http://www.centrecmi.ca.
  12. Cole S, Cole M, Gutnick D, Davis C. Function three: collaborate for management. In: Cole S, Bird J, editors. The medical interview: the three function approach. 3rd ed. Philadelphia: Saunders; 2014.
  13. Brief Action Planning to Facilitate Behavior Change and Support Patient Self-Management. Damara Gutnick, MD, Kathy Reims, MD, Connie Davis, MN, ARNP, Heather Gainforth, PhD, Melanie Jay, MD, MS, and Steven Cole, MD. JCOM Vol. 21, No. 1 January 2014
  14. IBID

Expert Presenters Announced for Your Summit Afternoon Care Manager Education Session

The Topic for the 2015 in-person Summit CM education session is: “Brief Action Planning (BAP), Patient Engagement and Agenda-Setting.”  The Summit afternoon CM Session focuses on practical self-management support skills: BAP, patient engagement and agenda-setting. Build your self-management skills and learn new techniques for patient engagement that you can apply in your daily practice!

Learning Objectives include:

  • Discuss the BAP and its evidence base
  • Demonstrate early proficiency in skills of BAP
  • Explain the benefits of agenda setting
  • Demonstrate early proficiency in skills of agenda-setting
  • Demonstrate Ask-Tell-Ask
  • Learn how to effectively engage patients in their care

“MiPCT Summit 2015 Care Manager 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.

The 2015 Summit afternoon session Expert Presenters are from The Centre for Collaboration, Motivation and Innovation:

September 16th Grand Rapids Presenters:

  • Mike Hindmarsh, MA, Healthcare improvement consultant and faculty with the Centre for Collaboration, Motivation and Innovation.
  • Cory Sevin, RN, MSN, NP; Director with the Institute for Healthcare Improvement and faculty with the Centre for Collaboration, Motivation and Innovation,
  • Kriss Haren MA, MS, supervising clinical counselor and faculty with the Centre for Collaboration, Innovation and Motivation.

October 20th Thompsonville Presenter:

  • Kathy Reims MD, Assistant Clinical Professor Department of Family Medicine, School of Medicine, University of Colorado Health Sciences Center, co-directs the Centre for Collaboration, Motivation and Innovation (CCMI).

October 29th Ann Arbor Presenters:

  • Kathy Reims
  • Cory Sevin, and
  • Kriss Haren

REGISTRATION OPEN! MiPCT Regional Annual Summits

As previously announced, the dates and venues for the 2015 MiPCT Regional Annual Summits are:

  • Summit West – Grand Rapids, MI
    Wednesday, September 16, 2015
    Frederik Meijer Gardens and Sculpture Park
    8AM to Noon General Session open to all;
    afternoon care management training
    REGISTRATION CLOSES 9/9/2015*
  • Summit North – Thompsonville, MI
    Tuesday, October 20, 2015
    Crystal Mountain Resort & Conference Center
    Noon Project Leadership Briefing,
    followed by afternoon care management training
    REGISTRATION CLOSES 10/13/2015*
  • Summit Southeast – Ann Arbor, MI
    Thursday, October 29, 2015
    University of Michigan NCRC
    8AM to Noon General Session open to all;
    afternoon care management training
    REGISTRATION CLOSES 10/22/2015*

* Registration may close earlier if capacity limits are reached. Early registration STRONGLY encouraged.

MiPCT Regional Annual Summit Flyer Attached for your Distribution

Attached to this issue of the FLASH, please find the 2015 MiPCT Regional Annual Summit flyer.  Please distribute and post to get the word out!

MiPCT Pediatric Care Manager Conference Fall 2015 – Registration is Open

Registration for the MiPCT Pediatric Care Manager Conference 9/22/15 is now open.

Please register by clicking HERE:

  • Tuesday, September 22, 2015
  • University of Michigan NCRC Dining Hall, Ann Arbor
  • Full Day Event 9am – 4pm

The MiPCT Pediatric Care Manager Conference will address the clinical focus areas of 1) social determinants of health, 2) integration of behavioral health in primary care and 3) palliative care. 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.

Please note that registration will close 9.15.15. Please submit questions to micmrc-requests@med.umich.edu.

Medical Terminology Made Easier for Patients Thanks to a Web-Based Tool

A patient’s misunderstanding of health information is often a result of the patient having low health literacy skills. Many times as health professionals we find ourselves using technical terms which are familiar to us, without recognizing these technical terms are confusing and unfamiliar for patients. The University of Michigan, along with the University of Illinois at Chicago created a Plain Language Medical Dictionary Google application utilizing a grant from the National Library of Medicine. The web-based tool was built using the Center for Disease Control’s Plain Language Thesaurus for Health Communications. Users are able to browse through a list of high-level medical terms and find the plain language equivalent terms. The web-based tool can be found at the following link: http://www.lib.umich.edu/plain-language-dictionary

MiPCT Complex Care Management Course

The 2015 MiPCT Complex Care Management (CCM) course is provided in a blended learning activity format. The  MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

CCM course registration is a two-step process:

  • STEP 1:  MiPCT CCM Course Registration
  • STEP 2:  MiPCT CCM Course Day 1 Live Webinar Registration

To register for MiPCT CCM Course, please click: HERE

MiPCT CCM Course Upcoming Dates:

  • August 17-20, 2015 MiPCT CCM Training Course-Lansing (Registration for this course will close as of August 11, 2015).
  • *September 8, 9 and 10, 2015 MiPCT CCM Training Course–Lansing (Registration for this course will close as of September 1, 2015).

*NOTE:  Due to the 9/7 HOLIDAY, this course will begin on Tuesday  9/8/15 with the LIVE webinar at 9am.

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

Care Manager Monthly Update for July 2015

Please see the Care Manager Monthly Update, attached to this issue of the Practice FLASH for July 2015.

Michigan Care 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

G and CPT Billing and Coding Resource Update

As a result of our work together on the 2015 Billing and Coding Collaborative, to support  your success in servicing commercial members who would benefit from Care Management with G and CPT care management codes, the following resources have been posted on the www.mipct.org website under the “Billing Resources Tab”.

  • A “master” process map of the key steps in G- and CPT-code billing with notation of practices’ self-identified strengths
  • A contact sheet to facilitate sharing of best practices
  • Remember to check the mipct.org  website dropdown “Billing Resources Tab” on a regular basis.

Stories of Your Care Management Success, featuring Carrie Jacobson, RN, HCM: OPNS – Waterford Family Physicians

“James” is a patient with a history of chronic obstructive pulmonary disease, congestive heart failure, and diabetes. James had numerous hospitalizations and emergency room visits for exacerbations of his uncontrolled chronic conditions.  In 2013 James was one of the top three Medicare utilizers at the practice, with 9 inpatient hospitalizations and frequent ED visits. James was referred to the care management team by Dr. Woelke for assistance with addressing his chronic conditions and reducing unnecessary hospitalizations and ED visits.

After reviewing James’ chart as well as hospitalization records, the care manager found that James had a history of drug and alcohol abuse, was overweight, non-compliant with taking his medications, and was not monitoring his diet or weight.  James was enrolled in care management services in  March, 2013.

The initial care management assessment presented a look into James’ difficulties and thought process surrounding his health. James felt that going to the hospital was cheaper and easier for him because he did not have a co-pay, and was able to be taken care of quickly. James was not taking his medications as prescribed. Upon assessment of his readiness, he was not inclined to address these issues.  The initial visit with James was spent addressing major stressors in his life and how to monitor for CHF exacerbations.

James’ longterm goal was to stay out of the hospital for 2 months. Throughout James’ visits, education was provided about congestive heart failure. Initially goals were designed for James to monitor daily weights by keeping a log. Although James was not ready to change eating habits or medication adherence, a small goal was set to start watching his sodium intake.

Over the first year, many resources were used with the assistance of a home health agency.  The in-home services provided to James included additional teaching and monitoring by registered nurses, home visits by a dietitian, as well as a social worker to help with James’ financial difficulties, including appropriate housing as he was also going through a divorce.

James was not receptive to a complete lifestyle change; however, working with the care manager as well as the home health care staff assisted James in improving his understanding about congestive heart failure. One year after starting care management services, James became increasingly receptive to changing some of his habits.  In June 2014, the patient agreed to weekly phone calls to check status of weight, blood pressure and blood sugar to monitor for fluctuations more closely and catch exacerbations early.

Since June of 2014, James has not had any hospital admissions or emergency room visits. His weight is well maintained and he quickly contacts his care manager with any changes in his weight or breathing. During this time his care manager helped make adjustments in collaboration with his PCP. James is very pleased and excited about the fact that he has been out of the hospital for this length of time, never thinking this would have been possible. As a result of care management services, James’ overall health has improved.

http://micmrc.org/webinar-information

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: August 17, 2015
  • Next MiPCT Practice FLASH Issue: August 31, 2015

June 22, 2015

Physician Billing Webinar July 22 and Repeated July 28

We are excited to announce an upcoming Physician Billing & Coding webinar for physicians, offered on two different dates and times in late July.

As you know, billing and coding are very important, and we hope that physicians in your organization will be able to participate. The webinar, “MiPCT Billing Collaborative Physician Webinar: “Good for Patients – Good for Providers: Creating Sustainability for Care Management,” will be an interactive conversation covering the challenges and successes in partnering for care management, and will be led by Dr. Mary Ellen Benzik.

While all MiPCT physicians are welcome and encouraged to attend, the webinar will satisfy the required component for physicians to earn practice learning credits for the Billing & Coding Learning Collaborative series.

As a reminder, the following requirements were presented at the All-Payer MiPCT Billing Collaborative on May 12, 2015:
Four Practice Learning Credits are available to practices who participate in the Billing & Coding Collaborative Group work, including:

  • Participating in the in-person May 12 session and submitting evaluations
  • Having a physician from the practice participate in the Physician Billing & Coding Webinar
  • Participating in the continuing virtual group work that results from the May 12th discussion.

The webinars each require advance registration (the link appears highlighted below for each of the two dates offered). The password for the event is “mipct01”. This password will be emailed with webinar confirmation once the participant registers. Save the email that is sent to you. You will need it to logon to the webinar. We are looking forward to your physicians’ participation in this webinar!

Webinar Registration Information:

All individuals must register for participation in the webinar:

  • Once you have registered, a confirmation email with instructions for joining the meeting will be sent to you by messenger@webex.com.
  • Please be sure to save the confirmation email to access the webinar.

  • The subject line of the email will state: “Registration Approved for Web seminar: Good for Patients – Good for Providers: Creating Sustainability for Care Management.”

To attend, register for one of the following:

  1. Go to Link for JULY 22, 2015 NOON Webinar: HERE
  2. Register for the meeting.
  3. Event Password is “mipct01”

OR

  1. Go to Link for JULY 28, 2015 5:30 PM Webinar: HERE
  2. Register for the meeting.
  3. Event Password is “mipct01”

If you have any questions, please contact Jody Fisher fishjody@med.umich.edu.

Diabetes Self–Management Education and Support in Type 2 Diabetes – A Joint Statement Announcement
by American Diabetes Association, The American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics

An important announcement regarding type 2 diabetes education was released on June 5, 2015. A joint statement by the American Diabetes Association (ADA), American Association of Diabetes Educators (AADE), and the Academy of Nutrition and Dietetics (AND) was published that provides health care providers guidance on when and why to refer patients with type 2 diabetes to diabetes self-management education and support (DSME). In fact, the authors drew attention to four critical times people with diagnosis of type 2 diabetes should receive DSME. An algorithm was developed for provider guidance and the provision of a set of guiding principles.

A June 5, 2015 press release from the ADA stated DSME has been shown to improve outcomes including reduced A1C levels and complications, improving lifestyle behaviors and decreasing diabetes-related distress and depression. Additionally, studies have demonstrated DSME to reduce hospital admissions and readmissions, thus being cost-effective. However, a referral to DSME by one’s provider is crucial. Patients are more likely to participate (up to an 83% participation rate) if their physician makes the referral, per Linda Siminerio, RN, PHD, CDE, Professor of Medicine at University of Pittsburgh School of Medicine.

To read the entire statement and access the algorithm:
http://www.diabetesincontrol.com/images/issues/2015/06/dsme_joint_position_statement_2015.pdf

Physicians’ Corner: Improving Patient Outcomes by “Closing the Loop”
by Kevin Taylor MD

“George” has had diabetes for 12 years. Recently he came in for his 6 month planned chronic care visit. He has been retired now for the past 2 years and is finding his lifestyle has become more sedentary (especially in our Michigan winters). In our rooming process my medical assistant noted that he was no longer taking his cholesterol medication. During the visit we discussed why he was no longer taking his medication and then reviewed the trend lines for his various labs, weight and blood pressure. We also reviewed his own blood pressures and blood sugars levels. We agreed to make 3 medication changes including starting a new cholesterol medication, outline a program for increasing his activity level and made a referral to a specialist for his declining renal function and sleep apnea evaluation. We also clarified OTC medications he should avoid and encouraged him to get a shingles vaccine and a PCV 13 vaccine.

At the end of the visit I asked George to repeat back to me what he remembers from our discussion, stating “I want to make sure I do a good job of clarifying your plan for you. Can you tell me in your own words what are the plans for your health that we discussed today?”

Stephen Beeson states “What we do in the last few minutes forms a final impression that patients remember most. This closing discussion is not only important to connecting with the patients, but is also essential to conveying information and return precautions.”¹

According to the Office of the Inspector General, noncompliance with medications results in 125,000 deaths each year from cardiovascular disease alone.²  In studies of patient behavior, only about half of patients who leave a physician’s office with a prescription take the drug as directed.³  Unfortunately, it also is known that patients remember less than half of what physicians tell them just after a visit. Minority patients receive even less information about tests, treatments, procedures and prognosis than white patients. 5 According to one study, in 12 percent of discussions of new information (a lifestyle change recommendation or new medication), did the physician ask the patients to restate the physician’s instructions to know that they understood what the physician said.6

Sharing medical data with patients7, discussion of treatment effects8, increased time on health education9, and summarization of findings¹0 have all correlated with improved patient outcomes.

This technique of assessing George’s understanding is called “closing the loop.” In one study, when patients were asked to restate information given, they responded incorrectly 47% of the time. In the study, patients given the opportunity to close the loop had average hemoglobin A1 C levels lower than patients who were not.

Consistent with the literature, George was able to recall about 50% of all that we had discussed. I took the time to re-iterate the plan until he was able to recall everything we discussed. This was also summarized in his patient care plan that he received from my clerical team at check out.

Closing the loop, a simple technique of assessing patients understanding, has the potential to improve their compliance, satisfaction with the visit and clinical outcomes.

_______________

1 Beeson, S.C., Practicing Excellence. A physician’s manual to Exceptional Health Care. 2006 Studer Group LLC.
2 N, Fanale JE, Kronholm P, April 1990. “The role of medication non-compliance and adverse drug reactions in hospitalizations of the elderly.” Archives of Internal Medicine 150 (4):841-845
3 Merck Mannual of Diagnosis and Therapy, Section 22. Clinical Pharmacology. Chapter 301. Factors Affecting Drug Response.
4 Stewart JE, Martin JL. Summer 1979. “Correlates of patients’ perceived and real knowledge of prescription directions.” Contemporaray Pharmacy Practice 2(3); 144-8.
5 Stewart, A.L. et all. 1999. “Interpersonal process of care in diverse populations.” Milbank Quarterly 77 (3): 305-39, 274
6 Bodenheimer, T, et al, Helping patients manage their chronic conditions. The California Healthcare Foundation. June 2005.
7 Mazzuca SA, Weinberger M, Kurpius DJ, Froehle TC, Heister M. 1983. “Clinician Communication Associated with Diabetic Patients Comprehension of their Therapuetic Regimen.” Diabetes Care 6:347-350
8 Robbins JA, Bertakis KD, Helms LJ, Azari R, Callahan EJ, Creten DA. 1993. “The influence of physician practice behaviors on patient satisfaction.’ Family Medicine 25.
9  Keers, JC, Groen, H. Sluiter WH, Bouma J, Links TP. June 2005. “cost and benefits of a multidisciplinary intensive diabetes education programme.” Journal of Evaluation in clinical practice 11(3): 293-303
10 Comstock LM, Hooper EM, Goodwin JM, Goodwin JS. 1982. “Physician Behaviors that Correlate with Patient Satisfaction” Journal of Medical Education 57:105-112

Care Manager Monthly – Update for June 2015

Please see the Care Manager Monthly Update, attached to this issue of the Practice FLASH for June 2015.

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 older people or those 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 and 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 meet three times per week and include strengthening, cardiovascular activity 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, reaching upper cabinets, carrying groceries and so on. Participants in Enhance®Fitness are given a fitness assessment when they begin the program, again 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 www.mihealthyprograms.org

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

From the MI Department of Health and Human Services – Your Public Health Partner: Self-Management Support for Older Adults – Options Increasing in Michigan

Over the last few years, state and local agencies in Michigan have offered more and varied options to help adults manage chronic conditions, improve their health and maintain their independence. Within the Michigan Department of Health and Human Services, the Division of Chronic Disease and Injury Control, and the Aging and Adult Services Agency (formerly the Office of Services to the Aging), have led the way by funding, supporting and promoting a number of evidence-based programs that can assist older adults in proactively managing chronic conditions like arthritis, diabetes, and hypertension. Recent efforts have been coordinated in an attempt to scale these programs up across the state and establish an infrastructure that can sustain them over the long-term.

On June 10th a MiPCT care manager webinar highlighted self-management education options in Michigan, as well as an initiative that will increase the availability of these classes across the state. Practices can help to make potential participants aware of these programs and provide referrals that are often the key to getting folks connected with helpful community resources. Here is a brief recap of the programs featured in the webinar:

  • Personal Action Toward Health (PATH) and Diabetes PATH (also known as the Stanford Chronic Disease and Diabetes Self-Management Programs) are six-week workshops available free or at low cost across Michigan. Participants learn practical tools for the day-to-day management of their conditions from trained lay leaders. More information and local workshops can be found at www.mihealthyprograms.org
  • Diabetes Self-Management Education (DSME), offered through one of Michigan’s 92 certified hospital-based programs, is an additional resource for patients with diabetes. DSME provides patients with an individual plan and is for people at risk of developing diabetes, who have been diagnosed already, or who have had a change in treatment. DSME and Diabetes PATH complement each other and patients can benefit by attending both if they choose. Programs can be found at
    http://www.michigan.gov/mdch/0,1607,7-132-2940_2955_2980-13791–,00.html
  • A Matter of Balance is a falls prevention program that not only provides specific tools for decreasing the risk of falls and injuries that can result, but also the fear of falling. Contact your local Area Agency on Aging (http://www.mi-seniors.net/regionmap/) for information about local class offerings.
  • The Area Agencies on Aging Association of Michigan recently received funding from the Michigan Health Endowment Fund to expand both Diabetes PATH and A Matter of Balance across the communities served by the state’s 16 Area Agencies on Aging. They hope to serve 8,000 MI residents who are 60 years of age and older with these programs over the next year and a half. More information can be found at http://www.GreatAtAnyAgeMI.com
  • A joint statement recently released by the American Diabetes Association, American Association of Diabetes Educators and the Academy of Nutrition and Dietetics underscored the importance of provider referrals to diabetes self-management education and support and outlined 4 critical points in the lives of people with diabetes when education and support can help patients cope with their illness and make well-informed treatment and lifestyle choices. Find out more about the joint statement at:
    www.diabetes.org/newsroom/press-releases/2015/joint-statement-outlines-guidance-on-diabetes-self-management-education-support.html

Tackling the Social Determinants of Health

With the extension of MiPCT for 2 years, the leadership, with physician organization direction, has identified clinical focus areas for the balance of the project. One of these is identifying and addressing the social determinants of health.

In the RWJF/ U of Wisconsin annual community rankings, clinical care delivery impacts only 20% of health care outcomes. (www.countyhealthrankings.org) The greatest impact are those behavioral and psychosocial factors that are most effectively impacted through collaboration with our medical neighborhood.

As defined in Healthy People 2020, (www.cdc.gov›NCHS Home) the social determinants of health reflect the social factors and physical conditions of the environment in which people are born, live, learn, play, work, and age. Also known as social and physical determinants of health, they impact a wide range of health, functioning, and quality-of-life outcomes.

Examples of social determinants include:

  • Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods
  • Social norms and attitudes, such as discrimination
  • Exposure to crime, violence, and social disorder, such as the presence of trash
  • Social support and social interactions
  • Exposure to mass media and emerging technologies, such as the Internet or cell phones
  • Socioeconomic conditions, such as concentrated poverty
  • Quality schools
  • Transportation options
  • Public safety
  • Residential segregation

Examples of physical determinants include:

  • Natural environment, such as plants, weather, or climate change
  • Built environment, such as buildings or transportation
  • Worksites, schools, and recreational settings
  • Housing, homes, and neighborhoods
  • Exposure to toxic substances and other physical hazards
  • Physical barriers, especially for people with disabilities
  • Aesthetic elements, such as good lighting, trees, or benches

Poor health outcomes are often made worse by the interaction between individuals and their social and physical environment.

So what can you do?

REGISTRATION OPEN! MiPCT Regional Annual Summits

As previously announced, the dates and venues for the 2015 MiPCT Regional Annual Summits are:

  • Summit West – Grand Rapids, MI
    Wednesday, September 16, 2015
    Frederik Meijer Gardens and Sculpture Park
    8AM to Noon General Session open to all;
    afternoon care management training
    REGISTRATION CLOSES 9/9/2015*
  • Summit North – Thompsonville, MI
    Tuesday, October 20, 2015
    Crystal Mountain Resort & Conference Center
    Noon Project Leadership Briefing,
    followed by afternoon care management training
    REGISTRATION CLOSES 10/13/2015*
  • Summit Southeast – Ann Arbor, MI
    Thursday, October 29, 2015
    University of Michigan NCRC
    8AM to Noon General Session open to all;
    afternoon care management training
    REGISTRATION CLOSES 10/22/2015*

* Registration may close earlier if capacity limits are reached. Early registration STRONGLY encouraged.

MiPCT Pediatric Care Manager Conference Fall 2015 – Registration is Open

Registration for the MiPCT Pediatric Care Manager Conference 9/22/15 is now open.

Please register by clicking HERE:

  • Tuesday, September 22, 2015
  • University of Michigan NCRC Dining Hall, Ann Arbor
  • Full Day Event 9am – 4pm

The MiPCT Pediatric Care Manager Conference will address the clinical focus areas of 1) social determinants of health, 2) integration of behavioral health in primary care and 3) palliative care. 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.

Please note that registration will close 9.15.15. Please submit questions to micmrc-requests@med.umich.edu.

Michigan Care 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

MiPCT Complex  Care Management Course

The 2015 MiPCT Complex Care Management (CCM) course is provided in a blended learning activity format. The MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

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

  • Day 1 – Live Webinar – MiPCT CCM course introduction (1 hour)
  • Day 2 – Self-study modules and post-tests to be completed prior to Days 3 and 4 in-person training (total expected time to complete the self-study and post-tests is six hours)
  • Day 3 and Day 4 – In-person training days. (Full day sessions)

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

Upcoming 2015 MiPCT CCM course dates:

  • July 6-9, 2015. Introductory Webinar July 6, 2015. Total six hour self-study modules and post-tests, July 6-7, 2015. In-person training July 8-9, 2015. Registration for this course will close as of June 25, 2015, 4p.m.
  • August 17-20, 2015. Introductory Webinar August 17, 2015. Total six hour self-study modules and post-tests, August 17-18, 2015. In-person training August 19-20, 2015. Registration for this course will close as of August 11, 2015.

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

Stories of Your PO Success: UMHS Family Medicine Gaps in Care Workflow

University of Michigan Family Medicine Centers have developed a workflow to identify patients who have gaps in their care for diabetes, asthma, mammograms, cancer screening and immunizations. The Gap Reports were generated within the EMR to alert primary care providers to unmet quality indicators for their own patients. A Gap Report can be pulled for most of the major chronic disease or preventive health metrics that are being actively managed by the health system. Below is a description of key stakeholders in addressing the Gap Reports.

Panel Manager – The Panel Manager is responsible for managing the administrative work required for population management. The Panel Manager has dedicated time to pull Gap Reports, and address each gap individually. The reports can be updated as frequently as every two hours. There is a section in the medical record called Best Practice Advisory (BPAs) which references the gaps. If a gap is noted, the Panel Manager will check the patient’s record to see if the gap had been addressed, but not on the BPA List. Once the gap is closed, it will no longer generate BPAs on the list. The Panel Manager will contact the patient and schedule an appointment, if appropriate. The Panel Manager will pend orders for the provider to sign if necessary; for example, mammogram, or referral for diabetic eye exam. He or she may work directly with the provider to modify the Health Maintenance plan if appropriate for that particular patient. Often the Gap Reports are 20-30 pages long, and it may take a panel manager up to one month to address the gaps for a particular condition. The Gaps Reports are ongoing.

Physician/Primary Care Provider- The PCP may review their gap report and address gaps, in care directly if the report also allows them to monitor their own progress in quality measures.

Care Navigator- The Care Navigator may be notified for any additional follow-up if the patient is listed as a Complex Care patient. The Care Navigator also facilitates other follow-up or referrals to PharmD, Dietician or SW.

Huddle Board – Information regarding the progress on the Gaps Report can be displayed on the Huddle Board in a non-patient hallway. The clinic team meets every morning for 10-15 minutes to review the most recent results. This board provides a visual reminder of how the team is doing in one or more metrics identified as priority measures. The data trends are available for review daily. This visual reminder is very motivating to institute process improvements across the clinic team when needed.

The Gap Reports have been a useful tool for our quality improvement efforts. The reports allow us to identify specific patients who have specific needs. By focusing on standardized processes and utilizing a team approach to these gaps in care, we have been able to measurably improve the health of our populations.

To learn more please view MiPCT Educational Care Manager slides and recorded webinar:

  • April 22, 2015 “UMHS Gaps In Care, Process Management in the Primary Care Setting”
  • Presenter: Jan Pund RN-BC, UMHS Educational Nurse Coordinator, Complex Care Navigator, Ypsilanti Health Center
  • http://micmrc.org/webinar-information

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: July 13, 2015
  • Next MiPCT Practice FLASH Issue: July 27, 2015

May 11, 2015

2015 Incentive Metrics Approved

The 2015 Incentive Metrics were approved by the Steering Committee and are attached for your reference. A technical manual is being developed to accompany the incentive metric set, and will be distributed as soon as it is available. The 2015 Incentive Metrics are similar to 2014 Incentive Metrics, with a few changes:

  • PCS ED visit rate to be replaced with risk-adjusted Overall ED Visit Rate per 1000 attributed patients (due to move to ICD-10)
  • Childhood Immunization/Combo 3 added
  • Three process metrics deleted
  • Points shifted slightly

Please contact the MiPCT mailbox at mipctdemo@michigan.gov if you have any questions.

MiPCT Physician Leadership Training Program Survey:

Responses Due by May 22!

Each of our practices and physician organizations have been actively engaged in transformation over the past several years. These sweeping changes require sustained engagement from our staff and physician leaders. Physician leaders are successful when we are embedded into our practice teams and work as facilitators in the transformation process. This requires ongoing professional development for us to be successful.

MiPCT is committing to assist our physician leaders in developing the knowledge, skills and attitudes to be effective transformative leaders in their organizations.

We are in the early stages of program development and would like to get your input on what would be most helpful for you at this time. We are asking physician leaders both formal (have an FTE and job description as physician leader) and informal (no FTE but actively involved at office practice level or within the physician organization to implement change/transformation) to complete this survey. We appreciate your time, input and advice.

Please Take the Survey Here:

https://umichumhs.qualtrics.com/SE/?SID=SV_0oErYcEgpTdNC8B

Physicians’ Corner: Managing Change

by Kevin Taylor MD

We are in the process of implementing home visits for our complex patients. In this process a social worker and advanced practice nurse will meet with patients and care givers in their home for an assessment and develop a treatment plan that they will communicate to the primary care provider and care manager through our EMR system. We understand that this model of care delivery can be very impactful for many of our complex patients. However, it is a change for our practice team and our providers. For most providers they welcome the additional resources to assist in caring for these challenging patients. For a few providers the change is too much to accept and they resist. I compiled this summary of change management to assist our leadership in managing change with their providers.

“The number one obstacle to success for major change projects is resistance and the ineffective management of the people side of change”1 Ronald Heifetz states “The most common cause of failure to make progress is treating an adaptive problem with a technical fix.”2 Adaptive change involves complex challenges which can be addressed only through changes in people’s priorities, beliefs, habits and loyalties.3 “Solutions are achieved when ‘the people with the problem’ go through a process together to become ‘the people with the solution.’ The issues have to be internalized, owned, and ultimately resolved by the relevant parties to achieve enduring progress.”4

Engagement is essential when change is adaptive. There are many models to promote physician engagement (Silversin,5 Baker,6 O’Neill,7 Crabtree8). I would like to review a model that I believe is practical for IHA at this time. This is from Howard Beckman who is the Medical Director of the Rochester Independent Practice Association in Rochester New York. Dr. Beckman has published work on successfully engaging physicians in a PFP program that reduces overuse, underuse and misuse of services.

Beckman Outlines 10 Essential Steps to Effectively Engaging Physicians9

  1. Set a tone of collaboration – Make the time convenient for the practitioner, go to his/her practice/ bring food, know something that the physician excels at or is proud of. Open the conversation with, “I appreciate your visiting with us today. I’ve heard you trained at Michigan, did you know Dr. XXX?” Or “I see you have original photographs in your office. They are great. Who is the photographer?”
  2. Explain the purpose of the project. “We have decided to focus some attention on the variation we see in patient’s use of emergency department services. It’s important because it has a big impact on patient’s care but also because it is an important contributor to our financial performance. My visit here today is part of that effort.”
  3. Be non-judgmental, allowing the practitioner to become part of the solution. “As we have explored how patients use ED services, we noted that patients of some physicians seem to use the ED more than others. We are very interested in understanding why that happens. I’m hoping you can contribute to that understanding.”
  4. Present ONLY enough data to inform the discussion and explain why you are talking to him or her. “I’d like to show you this chart. It shows the variation we see in the frequency with which patients of different doctors use ED services. You are this point on the chart. Can you tell me a bit about how your practice uses the ED?” “Why do you think the rate is different from others in your community?”
  5. Listen carefully to his or her responses. Demonstrate you want to understand without judging. “So, it sounds like from your point of view opening the practice at night has safety issues? Can you tell me more about what has happened?” or “I can understand how difficult recruiting physicians can be and opening at night is not what young physicians are interested in. What do you think others have done?”
  6. Engage other staff that might be present. “What do you folks hear from patients as you work with them?”
  7. Offer praise whenever possible. “It seems like you are really trying to get folks in whenever possible. That’s great because our patient feedback says they would rather come to the office than have to travel to the ED.”
  8. Encourage staff to consider solutions to problems identified so the physician won’t have to be the solution to each problem. “Can you folks think of ways to respond to patient’s needs before the doctor is involved? Have you talked to staff in other practices?”
  9. Conclude by asking if the provider rep that has joined you can follow up on any questions emerging from the visit or provide additional information.
  10. Send a follow up thank you note summarizing the results of the meeting and reemphasizing that IHA is really interested in reducing the frequency of ED visits, especially for symptoms that can be managed in the office.

As you visit with targeted physicians, it is helpful to begin tracking the outcomes and follow-up items from your meetings in an effort to shape behavior and continuously improve subsequent meetings with targeted physicians. The following questions may be helpful for your team to answer after your first visit.

  • Using the table metaphor, were we on the same side at the end of the meeting?
  • What feedback does the observer have about making the visit more successful?
    • What specific things worked well?
    • What did not work and why?
  • Who will write the letter thanking the practitioner for his/her time for the visit? Tip: hopefully the outreach person who can mention the follow-up items they will be working on.
  • Did the physician(s) visited understand the data presented?
  • Was there a successful hand-off to the physician outreach staff?
  • What was the physician’s response to the data?
    • Denial – The data is wrong, my practice is different
    • Anger – I don’t have time for these games! You come back and review my records and then I’ll talk to you!
    • Bargaining – What do others do when confronted with these results? How can I do a better job?
  • What additional data was requested for the next meeting?
    • How long will it take (estimate) to put it together?
    • Who will be responsible for getting the data together?
  • What else is needed to help the practice/practitioner understand the need to improve performance and reduce his/her variation from others?
  • When is the next follow-up scheduled?
    • Does the meeting have to be face to face or can there be parts of the follow up plan that can be done electronically or telephonically?
    • What are the goals for the next visit? Is there additional comparative data to share, interventions to offer, literature to provide, staff to meet with?

To summarize, one way to bring all of these concepts together is to think about approaching the provider in the same way as approaching a patient with lots of self-management tasks to complete:10

  1. Engage by inquiring about their agenda
  2. Help set a practice change goal and action of their making (SMART goal)
  3. Checking confidence
  4. Ensuring follow up.

If learning more about change management is something that interests you please complete the MiPCT Physician Leadership Survey.

https://umichumhs.qualtrics.com/SE/?SID=SV_0oErYcEgpTdNC8B

_______________

1Prosci Best Practice: Practices in Business Process Reengineering Benchmark Study.

2Jack Siversin. Tactics to Strengthen Physician Engagement. April 2013.

3 Heifetz et al. The Practice of Adaptive Leadership 2009

4 Heifetz, R and Linsky, M. Leadership on the Line. Harvard Business School Press, 2002

5Kornacki, M.J. and Silversin, J. Leading Physicians through Change: How to Achieve and Sustain Results, 2nd edition American College of Physician Executives, 2012

6Neil J. Baker, M.D. Adaptive change challenges and the hemodynamics of change. IHI workshop April 2013

7O’Neill, Mary Beth Executive coaching with backbone and heart.

8Crabtree et al, Summary of the National Demonstration Project and Recommendations for Patient-Centered Medical Home.Ann Fam Med 2010: 8 (Suppl 1) S80 – S90

9Beckman H, Fisher T. Change Package. California Quality Collaborative. 2008

   10Personal Communication. Michael Hindmarsh. President, Hindsight Healthcare Strategies

MSMS Session on Opioids

MSMS is hosting some interesting training on safe opioid use for extended release and long acting varieties. As it is relevant to several Clinical Focus Areas, including our palliative care initiatives, we wanted to share the following information and details:

  • Title: ER/LA Opioid REMS: Achieving Safe Use While Improving Care
  • Dates and Locations:
    • May 14, 2015 – 9 am-12:15 pm: The Henry – Dearborn
    • June 10, 2015 – 9 am-12 pm: Crowne Plaza – Novi

All sessions are free but advance registration is required. Register at: http://www.msms.org/Education/CourseListings/Courses/ERALAOpioidREMSAchievingSafeUseWhileImprovingPatientCare.aspx

SAVE THE DATES! MiPCT Regional Annual Summits

As previously announced, the dates and venues for the 2015 MiPCT Regional Annual Summits are:

  • Summit West – Grand Rapids, MI
  • Wednesday, September 16, 2015
  • Frederik Meijer Gardens and Sculpture Park
  • 8AM to Noon General Session open to all; afternoon care management training
  • Summit North – Thompsonville, MI
  • Tuesday, October 20, 2015
  • Crystal Mountain Resort & Conference Center
  • 11 AM to Noon Project Leadership Briefing, followed by afternoon care management training
  • Summit Southeast – Ann Arbor, MI
  • Thursday, October 29, 2015
  • University of Michigan NCRC
  • 8AM to Noon General Session open to all; afternoon care management training

SAVE THE DATE! MiPCT Pediatric Conference

  • Tuesday, September 22, 2015
  • University of Michigan NCRC Dining Hall, Ann Arbor
  • Full Day Event
  • More Details to come!

Michigan Care 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

MiPCT Complex Care Management Course

The 2015 MiPCT Complex Care Management (CCM) course is provided in a blended learning activity format. The MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

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

  • Day 1 – Live Webinar – MiPCT CCM course introduction (1 hour)
  • Day 2 – Self-study modules and post-tests to be completed prior to Days 3 and 4 in-person training (total expected time to complete the self-study and post-tests is six hours)
  • Day 3 and Day 4 – In-person training days. (Full day sessions)

Register for the June 8-11 2015, MiPCT CM course at the following site:

https://mipct.org/care-management-resource-center/ccm-online-registration-page/

Upcoming 2015 MiPCT CCM course dates:

  • June 8-11 2015. Introductory Webinar June 8, 2015. Total six hour self-study modules and post-tests, June 8-9, 2015. In-person training June 10-11, 2015.
  • July 6-9, 2015. Introductory Webinar July 6, 2015. Total six hour self-study modules and post-tests, July 6-7, 2015. In-person training July 8-9, 2015.

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

A PO Story of Success

PO: Spectrum Health Medical Group

Submitter: Robin Schreur, RN BS Clinical Lead

SPECTRUM HEALTH MEDICAL GROUP IMPLEMENTS STANDARD CASE CLOSURE PROCESS: Case Study

Spectrum Health Medical Group wanted a standard process for the case closure case management process. Specifically they sought to create standard work for the care management team which would be used as a platform for analysis in the future.

Timeline

The team started putting together standard work for case closure shortly after the care management program was established in 2014.

Key Stakeholders

  • Medical Group leadership
  • IT program developers
  • SHMG CM Director
  • MiPCT Clinical leads who are RN’s
  • PCP Physician Quality leadership
  • CM team

How Team Contributed to Success

With the financial support of leadership, the Epic IT department and the SHMG Operations team via funding for a full-time project manager were allocated to this work. The project manager and the clinical leads mapped out the case closure decision tree process and placed this into standard work formatting. The IT team in partnership with the Clinical leads, utilizing the newly developed standard work, customized the electronic medical record (EMR) to capture the case closure process and reasons within the care management assessment.

The case closure status and reasons are visible to the care team, to ensure continuity and transparency of the patient status with care management.

The clinical team knows which patients are receiving care management (CM) services and when appropriate or need identified, reasons the patient is no longer receiving CM services. This ensures clear communication across the team.

Tools Developed

  • Decision tree and standard work for case closure
  • Case closure reasons and protocol for the EMR

Data Elements Collected

The team has not established metrics for the case closure process. This is in the development phase.

Barriers Addressed

  • Financial requirements via FTE allocation and commitment to CM department
  • Need for standard work to ensure continuity
  • Training and evaluation of case closure reasons

Lessons Learned

  • All care managers work from the standard work protocol.
  • Defined processes alleviated anxiety and insecurity of the care managers which was related to the lack of protocols.
  • Communications are improved by having the transparency and status readily available to the care team.

Note: The Case Closure Guide and supplemental materials are posted at: micmrc.org/webinar-information

Thank You!

MiPCT Leadership extends a special thank you to Spectrum Health Medical Group for being the first to share their PO Level Success Story. We appreciate Spectrum Health Medical Group Leaders for their support of statewide learning.

Resource Tab on the MiPCTdemo.org Website: New and Improved!

To make material easier to find, the “Resources” tab on the MiPCT website has been reorganized. Presentations have been combined with Documents and all material is now organized by topic.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: June 8, 2015
  • Next MiPCT Practice FLASH Issue: June 22 2015

April 29, 2015 CORRRECTION TO THE 4/27/2015 PRACTICE FLASH:

Stakeholders, please be advised of an error in the Practice FLASH, published Monday, April 27, 2015:

Correct title “From the MI Department of Health & Human Services* – Your Public Health Partner” (The title was incorrect.)

We are sorry for any inconvenience this may have posed to you.

April 27, 2015

MiPCT Physician Leadership Training Program Survey

Each of our practices and physician organizations have been actively engaged in transformation over the past several years. These sweeping changes require sustained engagement from our staff and physician leaders. Physician leaders are successful when we are embedded into our practice teams and work as facilitators in the transformation process. This requires ongoing professional development for us to be successful.

MiPCT is committing to assist our physician leaders in developing the knowledge, skills and attitudes to be effective transformative leaders in their organizations.

We are in the early stages of program development and would like to get your input on what would be most helpful for you at this time. We are asking physician leaders both formal (have an FTE and job description as physician leader) and informal (no FTE but actively involved at office practice level or within the physician organization to implement change/transformation) to complete this survey. We appreciate your time, input and advice.

Please Take the Survey HERE!:

PHYSICIANS’ CORNER: The Four Habits Model

by Kevin Taylor, MD

With so many new care options available—retail clinics, virtual visits, and new physician practices— patient loyalty isn’t a guarantee or even the norm any longer. So how can PCPs attract and keep patients in an era of consumer choice?

The Advisory Board Company recently published a research briefing on, “What drives consumer loyalty to primary care physician”1. They surveyed 1843 patients who had a primary care physician visit in the last 12 months. I would like to focus on one of the insights from this survey today.

A little trust, patience, and respect go a long way. Out of the 27 factors evaluated, four correlate with a patient’s self-professed likelihood to stay with, follow to a new location, and recommend their PCP.

  1. Trust PCP to make right diagnosis and recommend appropriate treatment.
  2. The PCP respects me.
  3. The PCP explains possible causes of illness and helps me stay healthy in the future.
  4. The staff are patient and helpful.

These factors are all related to interpersonal interactions between the patient and the physician or staff.

How can we promote this trust, patience and respect in our interactions with our patients?

In 1990, Terry Stein2, an Internal Medicine physician at Kaiser Permanente in Northern California, led the effort to create a workshop that offered physicians training and tools to specifically deal with patients who were angry or wanted tests or treatments the physician felt were not in their patient’s best interest. It struck a chord. Over the next few years Stein and her colleagues crafted a practical approach to help physicians use the skills they were learning consistently. That resulted in the Four Habits Model3.

The Four Habits Model is based on a high-quality conversation and a collaborative partnership. “Just one simple lesson of the model,” Stein says, “is reminding clinicians of the importance to talk to patients in their own terms, not in our medical jargon.

“The result,” Stein says, “is the quality of diagnosis goes up, which impacts first-time right treatment, which impacts health outcomes, and also helps to deepen the trust between patient and physician.” Another result is patients feel seen and heard.

The Four Habits Model

4 Habits Chart

4 Habits Chart

Much like this Kaiser program, MiPCT is planning to provide training and skill development initiatives for our physician leaders. Our goal is to empower our physician leaders to transform their practices into robust primary care medical homes. To assist in this planning process we have distributed a survey to all PO and practice leaders to complete (SEE ARTICLE ON PAGE 1 OF THIS PUBLICATION). We hope to provide programs like the Four Habits Model that will help to create loyal patients to our practices.

_______________

1The Advisory Board Company. Marketing and Planning Leadership Council. What Drives Consumer Loyalty to a Primary Care Physician? 12 Insights from the Primary Care Physician Consumer Loyalty Survey.

2http://www.huffingtonpost.com/riva-greenberg/4-habits-that-revolutioni_b_742104.html

3Getting the Most out of the Clinical Encounter:The Four Habits Model. Richard M. Frankel, PhD, Terry Stein, MD©1996, 1999, 2003 The Permanente Medical Group, Inc. Physician Education & Development Revised April 2003 in partnership with the Kaiser Permanente Institute for Culturally Competent Care

May 12 In-Person Half-Day Billing & Coding Session: Registration is Open

A half-day intensive MiPCT Billing and Coding Collaborative will be held in Ann Arbor on May 12 from 8:00 AM-noon in the Dining Hall of the North Campus Research Center (NCRC), Building 18, at 2800 Plymouth Road. (This is the same location as last year’s MiPCT Ann Arbor Summit). Parking is available onsite at the NCRC structure for a fee of $5 cash.

The session is open to both current billing and coding collaborative participants and those who have not yet participated in the collaborative but are interested. Billers, coders, Care Managers, practice managers and PO representatives are encouraged to attend. The session will focus on solution-finding, process mapping and review of some new billing and coding resources. We are pleased to say that representatives from all participating MiPCT commercial payers (BCBSM, BCN and Priority Health) have graciously agreed to attend as well.

Following the session, slides and material will be posted on the website (under the resource tab), but because of the interactive nature remote dial in will not be available. Attendance requires registration before the deadline of May 1, 2015 at:

https://jodyooo.wufoo.com/forms/may-12th-mipct-allpayer-inperson-billing-lc/

MSMS Session on Opioids

MSMS is hosting some interesting training on safe opioid use for extended release and long acting varieties. As it is relevant to several Clinical Focus Areas, including our palliative care initiatives, we wanted to share the following information and details:

  • Title: ER/LA Opioid REMS: Achieving Safe Use While Improving Care
  • Dates and Locations:
    • May 2, 2015 – 4-6 pm: Amway Grand Plaza – Grand Rapids
    • May 14, 2015 – 9 am-12:15 pm: The Henry – Dearborn
    • June 10, 2015 – 9 am-12 pm: Crowne Plaza – Novi

All sessions are free but advance registration is required. Register HERE:

Tiger Teams Update: Introductory Webinar Wednesday April 29!

The MiPCT Clinical Subcommittee is forming “Tiger Teams” to identify ways MiPCT can support PO leaders in top clinical focus areas during 2015 and 2016.

The focus areas are:

  1. Addressing social determinants of health
  2. Using registries and data to support population health
  3. Integrating behavioral health
  4. Integrating palliative care and end of life care, and 5. Appropriateness of Care.

Please send your suggestions for ways MiPCT might support your PO in these areas to Dana Watt wattd@michigan.gov.

There will be an introductory webinar for Tiger Team volunteers on Wednesday, April 29, 2015 at 2:00 p.m. Registration can be completed HERE:

Nominations Now Being Accepted for Additional MiPCT Practices

PO leaders are invited to submit nominations for ten (10) MiPCT practice openings. Nominations will be accepted until May 6, 2015, and may be submitted HERE:

In order to be considered, the following requirements must be met by the nominated practice:

  • Affiliated with an existing MiPCT PO
  • Acceptable PCMH designation
  • Available care management staffing (NOTE: The practice must have care management services available to patients, and the practice’s PO must meet a minimum 80% of a 2-care manager per 5000 MiPCT member ratio).
  • Demonstration of compliance on key PCMH capabilities, including:
    • Registry use
    • Access to 24-hour clinical decision maker
    • After-hours access for patients
    • 30% open-access/same-day scheduling

The practice replacement policy was published in the January 26, 2015 edition of the FLASH, and can be found HERE! Only complete nominations submitted by May 6, 2015 will be considered.

From the MI Department of Community Health & Human Services* – Your Public Health Partner

Colorectal Cancer Screening News – Free Continuing Education Courses & the 80% by 2018 Campaign

Did you know that colorectal cancer is the second leading cause of cancer death in the US? Yet it is one of the most preventable of cancers. What tools do you have at your disposal to make sure patients are screened and know their risk?

Continuing Education The CDC’s Division of Cancer Prevention and Control recently announced two new CDC-sponsored continuing education (CE) courses for health care providers. Screening for Colorectal Cancer (CRC): Optimizing Quality is offered in two separate versions. One is intended for primary care providers and the other for clinicians who perform colonoscopies. CE credits are available for physicians, nurses, and other health professionals without charge.

These courses provide guidance and tools for clinicians on optimal ways to implement screening to help ensure that patients receive maximum benefit. The courses were developed by nationally recognized experts in CRC screening, including primary care clinicians, gastroenterologists, and leaders in public health programs and research. The courses can be accessed HERE

The 80% by 2018 Campaign “80% by 2018” is a National Colorectal Cancer Roundtable initiative in which more than 250 local and national organizations have committed to eliminating colorectal cancer as a major public health problem and are working toward the shared goal of 80% of adults aged 50 and older being regularly screened for colorectal cancer by 2018.

The National Colorectal Cancer Roundtable, an organization co-founded by the American Cancer Society and the Centers for Disease Control and Prevention, is rallying organizations to embrace this shared goal. Has your organization taken the “80% by 2018” pledge?

For tools and resources related to the 80 by 2018 campaign, including an informative guide for primary care providers, visit the Colorectal Cancer Roundtable campaign HERE!

There is also a video for the campaign, featuring television personality Katie Couric, in which she lends her support to the 80% by 2018 campaign and notes the success and momentum of this national initiative. In the three-minute video, Couric issues a call-to-action to providers and public health professionals to ensure that all eligible adults have access to affordable CRC screening options, and urges them to address health equity issues so that all people benefit from this important cancer screening. Take a moment to view this important video at your next provider or all-practice meeting.

It is available on YouTube :

*Effective April 10, 2015, the state departments of Community Health and Human Services merged to form the Michigan Department of Health and Human Services. More information about the merger is available HERE!

From the MI Department of Community Health & Human Services* – Your Public Health Partner

Diabetes Self-Management Education Programs and Patient Centered Medical Home (PCMH)

Did you know there is a way to assist patients in your practice with their diabetes self-management and enhance your practice’s Patient Centered Medical Home (PCMH) capabilities? Diabetes self-management education (DSME) is a critical element of care for all people with diabetes (PWD) and those at risk for developing the disease. Referring patients to structured health education programs such as group classes, and maintaining a current resource list of community service areas that are of importance to the patient population (including services offered outside the practice) is referenced in Standard 4, Care Management and Support, of the 2014 NCQA-PCMH-Standards

Referring patients to one of the approximately 90 MDHHS-certified DSME programs in Michigan can be a part of the integrated plan of care that providers and care managers coordinate for patients with diabetes within your PCMH practice. The 2014-2015 BCBSM Physician Group Incentive Program Patient-Centered Medical Home-Neighbor Domains of Function Interpretive Guidelines state:

“Referrals to hospital-based diabetes educators that take place in the context of an overall coordinated, integrated care plan and include bilateral communication between the diabetes educator care management team, with individualized feedback provided to the care team following the diabetes education sessions. Diabetes educator and care team collaborate to ensure that referred patients receive needed services, and that patients understand that they should follow-up with PCMH practice regarding questions and concerns, contribute to meeting the requirements for capability 4.2.”

Standard 10.2 mentions the need for the PCMH practice to include self-management training programs that are available in the community as part of their community resource database. To assist you with that database and your patients with their self-management education and support, a list of MDCH certified DSME programs can be found HERE

*Effective April 10, 2015, the state departments of Community Health and Human Services merged to form the Michigan Department of Health and Human Services. More information about the merger is available HERE

30-Month Incentive Update

The 30-Month Incentive scores will be posted to the MDC dashboard this week. POs will receive an email from the MiPCT Demo mailbox alerting them to the score availability and will have one week to review the scores and report any concerns. This was a competitive incentive period, with many POs improving on one of more of the utilization metrics. Please note that for the registry metrics (worth 15 out of 100 points), a data submission threshold of 50% applies to each metric. This means that POs must submit registry/EHR numerator data for 50% or more of the metric’s eligible population in order to receive points for that metric. Only three POs met the 50% threshold for all seven registry metrics, so we encourage POs to work with their practices to improve registry use. If you have any concerns about your PO’s scores, please submit them to the mipctdemo@michigan.gov mailbox by the deadline.

SAVE THE DATES! MiPCT Regional Annual Summits

As previously announced, the dates and venues for the 2015 MiPCT Regional Annual Summits are:

  • Summit West – Grand Rapids, MI
    • Wednesday, September 16, 2015
    • Frederik Meijer Gardens and Sculpture Park
    • 8AM to Noon General Session open to all; followed by afternoon care management training
  • Summit North – Thompsonville, MI
    • Tuesday, October 20, 2015
    • Crystal Mountain Resort & Conference Center
    • 11 AM to Noon Project Leadership Briefing, followed by afternoon care management training
  • Summit Southeast – Ann Arbor, MI
    • Thursday, October 29, 2015
    • University of Michigan NCRC
    • 8AM to Noon General Session open to all; followed by afternoon care management training

Michigan Care 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” HERE

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

MiPCT Complex Care Management Course

The 2015 MiPCT Complex Care Management (CCM) course is provided in a blended learning activity format. The MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

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

  • Day 1 – Live Webinar – MiPCT CCM course introduction (1 hour)
  • Day 2 – Self-study modules and post-tests to be completed prior to Days 3 and 4 in-person training (total expected time to complete the self-study and post-tests is six hours)
  • Day 3 and Day 4 – In-person training days. (Full day sessions)

Register for the May 4-7, 2015, MiPCT CM course HERE:

Upcoming 2015 MiPCT CCM course dates:

  • May 4-7, 2015. Introductory Webinar May 4, 2015. Total six hour self-study modules and post-tests, May 4-5, 2015. In-person training May 6-7, 2015.
  • June 8-11 2015. Introductory Webinar June 8, 2015. Total six hour self-study modules and post-tests, June 8-9, 2015. In-person training June 10-11, 2015.
  • July 6-9, 2015. Introductory Webinar July 6, 2015. Total six hour self-study modules and post-tests, July 6-7, 2015. In-person training July 8-9, 2015.

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

Care Manager Monthly – Update for April 2015

Please see the Care Manager Monthly Update, attached to this issue of the Practice FLASH for April, 2015.

Stories of Your Care Management Success, Featuring Monica Brunetti, RN, QMHP, CCM, CCP, Hybrid Care Manager, Holt Family Practice, McLaren PHO

“Laura”, a 61 year old female with BCN insurance, was referred to care management services in person by Dr. Lessard following her office visit. The rationale for referral was poorly controlled diabetes, obesity, hypertension, hyperlipidemia, and depression. On the date of Monica’s initial visit with Laura, the patient’s A1C was 8.7, which was a noted elevation from her previous office visit and her weight was now 260 pounds, and her triglycerides were 197.

Laura had established her own self-management goals with her provider at the time of her office visit. Her self-management goal was to lose weight; one-two pounds a week over the next three months. Her plan included making changes in her diet to include portion control, lowering her carbohydrate intake, and getting routine exercise by walking daily. Her long term self-management goal was to lower her A1C to 7.0 or below over the next four to six months.

In support of this patient meeting her self-management goals, Monica conducted monthly follow-up calls to reassess her engagement in making changes that were supportive of meeting her goals, and if not, to re-evaluate the barriers she was facing in following her own action plan. Over the course of several months, there were times that Laura acknowledged that she “often made these commitments at her office visits but would stop trying over time”. She then stated, “Knowing that you are going to call has really kept me on track and motivates me to keep working on my goals”.

At a follow-up visit, Laura had lost twelve pounds and lowered her A1C to 8.0. At her most recent office visit, her weight was 240 pounds with a total weight loss of 20 pounds since engaging in care management services. She lowered her A1C to 7.1, and her triglycerides were down to 150. At this appointment, Laura stated, “I can’t believe how much this all has helped my mood. I feel great. I feel young and full of energy again”. All of this was obtained through dietary changes and maintaining a regular schedule of exercise.

Laura has established new goals for herself and is eager to demonstrate her commitment to her own wellness at her next follow up appointment.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: May 11, 2015
  • Next MiPCT Practice FLASH Issue: May 11, 2015

March 23, 2015

Your Help Needed: Please Complete Your MAPCP Surveys! Deadline: April 6, 2015

CMS’ MAPCP National Evaluation Team has distributed two online surveys to practices, and is hoping to achieve an 80% response rate by April 6, 2015. Thus, far, the MiPCT response rate is 49% for practice managers and 32% for providers – both are less than CMS’ target response rates. The MAPCP Demonstration in Michigan is the largest medical home pilot of its kind, and they are interested in learning as much as possible about the impact our MiPCT practices and providers have made over the course of the demonstration thus far. The two surveys are:

  • A 6-minute survey for practice managers that asks about basic practice characteristics (e.g., medical specialty, number of staff).
  • A 12-minute survey for health care providers which asks about medical home activities that should be completed by all physicians, nurse practitioners and physician assistants in all practices in the MiPCT.

Responses to these surveys will be analyzed by an independent research team (from RTI International, the Urban Institute, and the National Academy for State Health Policy) to produce de-identified, aggregated results. Individual responses to survey questions will neither be shared with CMS, your agency, private insurance companies, nor any other parties.

Practices have been emailed customized hyperlinks for each of these surveys. Please take a moment to complete them. If you would like them to be resent, please contact mapcp@rti.org. Any other questions about the surveys can be directed to Stephen Zukerman, PhD at 202 261-5679, or Rachel Burton, M.P.P. at 202 261-5825, or rburton@urban.org. Many thanks for your very important feedback!

Physician Leadership in the MiPCT

Physician leaders are key to successful population health in MiPCT practices. The 2015 MDCH contracts required that each PO designate a PO Physician Champion who will “communicate with all Physicians in the PO and all Participating Practices, encouraging team care and attention to other aspects of the MiPCT model.”

An attachment is included in this edition: MiPCT Physician Organization Physician Champion for Population Management that describes the role. A webinar will be held for PO Leaders on April 8, 2015 from Noon to 1:00 PM to review the expectations of the PO Physician Leader and to discuss PO observations and input.

Also included in the 2015 MDCH agreement was a new Practice Learning Credit option on Physician Leadership training. Dr. Kevin Taylor will lead the MiPCT-led training modules, and a description of the approach is also included as an attachment: 2015 Option for Practice Learning Credit: MiPCT Physician Champion Leadership Training, which will also be reviewed at the April 8th webinar.

Physicians’ Corner: Quadrant II Work: Be Brain Positive by Kevin Taylor MD

A respected practice manager noted that coaching and mentoring are the favorite parts of her job. However, she struggles to find the time for this important work. She spends a substantial part of her day “putting out fires” and “getting the daily work done”.

How do your teams manage the demands and unpredictable challenges of daily work? Do you wonder if what you have accomplished is really the most important work? We work in a time-pressured environment where it is common to have multiple overlapping commitments that all require immediate attention now. As Stephen Covey states in his 7 habits of highly effective people, “Urgency is no longer reserved for special occasions, they are everyday occurrences”1.

The Covey time management grid is an effective method of organizing your priorities. As you can see from the grid below, there are 4 quadrants organized by urgency and importance.

 Microsoft Word - Kevin's Table.docx

The bottom line is “Do important things first!” Here are some ideas to help build our own and our team members’ effectiveness by focusing on Quadrant II work!

Create a “Brain Positive” environment. The Brain in a positive state works 30 to 50% better then when the brain is in a negative state. Ways to create a “brain positive” state includes:

  • Eight minutes of meditation a day
  • Journaling for two minutes about a positive experience (it backfires if you write about negative ones!)
  • Writing a two-minute long positive email to a friend once a day

All these strategies have been found in research over the past decade to significantly increase happiness, whatever your current life circumstances. Training your brain for gratitude is one of the most powerful ways to accomplish this. Gratitude is the recognition that the present can make you happy instead of waiting for a future event. Thus, if you think of three things you are grateful for over the course of 21 days, your level of optimism in life significantly rises.

________________

1 Source: Stephen Covey, 7 Habits of Highly Effective People

2 Adapted from original article by Dave Ulacia at age http://getorganized.fcorp.com/content/are-you-working-wrong-things

3 Shawn Achor, The Happiness Advantage: The Seven Principles of Positive Psychology That Fuel Success and Performance at Work

2015 MiPCT Clinical and Operational Focus Areas

The 2015 Clinical and Operational Focus Areas have been approved by the MiPCT Steering Committee as follows:

2015 Clinical Focus Areas

  • Addressing social determinants of health and overcoming barriers
  • Patient registry and data support for population health
  • Integrating behavioral health
  • Integrating palliative and end-of-life care
  • Addressing appropriateness of care (e.g., Choosing Wisely program, etc.)

Several of these areas allow for continuity and leveraging of work begun in 2014. In addition, to allow flexibility while maintaining a focus on the areas of greatest opportunity to provide a return on project objectives. POs will be provided an opportunity to select three of the five Clinical Focus Areas most applicable and useful to their practices.

In addition to the 2015 Clinical Focus Areas, the Steering Committee also approved the following 2015 Operational Focus Areas:

2015 Operational Focus Areas 

  • Expanding the number of participating payers for greater panel MiPCT eligibility
  • Increasing G- and CPT-code billing volumes
  • Increasing patient engagement and self-management support

“Tiger Teams” will be convened for each of the Clinical Focus Areas to develop each area and drive improvement. PO and practice representatives with expertise and interest in serving on one of these teams are invited to apply for the team of their choice at: https://jodyooo.wufoo.com/forms/signup-2015-focus-area-tiger-team-membership/.

From the MI Department of Community Health – Your Public Health Partner: Two Resources to Improve Communication with Your Patients!

1) 80% by 2018 Communications Guidebook: Effective Messaging to Reach the Unscreened

The National Colorectal Cancer Roundtable has released 80% by 2018 Communications Guidebook: Effective messaging to reach the unscreened. The Guidebook, based on new market research, is designed to help educate, empower and mobilize three key audiences who are not getting screened for colorectal cancer:

  • The newly insured
  • The insured, procrastinator/rationalizer
  • The financially challenged

The guidebook, available at: http://nccrt.org/tools/80-percent-by-2018/80-by-2018-communications-guidebook/, provides infographics, banner ads, social media messages and other tools to address increasing screening rates. Specific steps that providers, including primary care doctors, can take to advance 80% by 2018 are also included.

2) MIYO – Make It Your Own

MIYO is a simple and free way to create evidence-based small media that you can use in your practice to promote healthy behaviors and mobilize your patient populations. Postcard reminders, posters and other small media are easily created on MIYO’s website. As an example, MIYO has been useful with increasing colorectal cancer screening rates. With MIYO, you can:

  • Choose from evidence-based interventions
  • Easily customize with targeted images, messages, and designs
  • Use what you’ve created with your target audience

Check out MIYO at: http://www.miyoworks.org/home. It is easy to sign-up and begin creating proven health communication pieces to better reach the audience/patients you have in mind.

For more public health information and resources for primary care, please visit our website at www.michigan.gov/primarycare.

From the MI Department of Community Health – Your Public Health Partner: Are e-Cigarettes Safe for Smokers Who Wish to Quit?

Electronic cigarettes, e-hookah, vape pens… no matter what you or your patients call them, their popularity seems to grow each day. National studies indicate that e-cigarettes are not only popular among adults, but are increasingly popular with young people. Indeed, a University of Michigan study released in December 2014 indicated that for the first time, e-cigarettes are more popular than conventional cigarettes among middle and high school students. In Michigan, the growth in e-cigarettes’ popularity has been accompanied by rising concerns among parents, educators, health professionals and legislators.

Chief among the many questions people have – are e-cigarettes safe? Poison control center reports across the nation highlight the need to treat e-cigarettes and their refills (mostly nicotine) as you would any other potentially hazardous household product. In December 2014, a toddler in New York died from ingesting the contents of an e-cigarette cartridge. Among medical providers, there may be confusion about whether to recommend use of e-cigarettes as a way to quit using traditional cigarettes or other tobacco products.

As a health professional, you may have patients who ask about e-cigarettes. If adult patients express an interest in using e-cigarettes either to replace cigarettes in settings where they are not allowed or as a tool to quit smoking, the most important thing to remember is that e-cigarettes are neither regulated nor approved by the FDA (neither the device itself nor its contents and refills). While some adults are using e-cigarettes as a means to quit tobacco use, they are not a scientifically proven method for quitting tobacco. Claims by manufacturers about their safety should be viewed with caution since no claims have been proven in peer-reviewed, scientific research. Simply put, patients who wish to quit using tobacco are best advised to use FDA-approved nicotine replacement therapy and other supports in their efforts to quit.

For more information on e-cigarettes, please visit: http://www.michigan.gov/mdch/0,4612,7-132-2940_2955_2973-340369–,00.html,

You can find a fact sheet about e-cigarettes at: http://www.michigan.gov/documents/mdch/E_Cigarette_Facts_465520_7.pdf[/

An infographic from MDCH Office of Recovery Oriented Systems of Care, may be used in exam or waiting rooms:

http://www.michigan.gov/documents/mdch/E-Cigs_Infographics_with_MDCH_Logo_RS_and_NL_479790_7.pdf

For more information about electronic cigarettes or safe and effective methods for quitting tobacco, please contact the Michigan Department of Community Health Tobacco Program at 517-335-8376. For other public health resources for primary care please visit www.michigan.gov/primarycare.

SAVE THE DATES! MiPCT Regional Annual Summits

As previously announced, the dates and venues for the 2015 MiPCT Regional Annual Summits are:

  • Summit West – Grand Rapids, MI
    • Wednesday, September 16, 2015
    • Frederik Meijer Gardens and Sculpture Park
    • 8AM to Noon General Session open to all;
    • afternoon care management training
  • Summit North – Thompsonville, MI
    • Tuesday, October 20, 2015
    • Crystal Mountain Resort & Conference Center
    • 11 AM to Noon Project Leadership Briefing,
    • followed by afternoon care management training
  • Summit Southeast – Ann Arbor, MI
    • Thursday, October 29, 2015
    • University of Michigan NCRC
    • 8AM to Noon General Session open to all;
    • afternoon care management training

New Registration Process: MiPCT Complex Care Manager Course

The 2015 MiPCT Complex Care Management (CCM) course is provided in a blended learning activity format. The MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

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

  • Day 1 – Live Webinar – MiPCT CCM course introduction (1 hour)
  • Day 2 – Self-study modules and post-tests to be completed prior to Days 3 and 4 in-person training (total expected time to complete the self-study and post-tests is six hours)
  • Day 3 and Day 4 – In-person training days. (Full day sessions)

The MiPCT CCM Course registration is now a two-step process. The two steps include the CCM course registration and the CCM Course Day 1 LIVE Webinar. Please follow these instructions when registering for the MIPCT CCM Course:

Step 1 CCM Course Registration:

  • Go to www.mipct.org, click on the “CARE MANAGEMENT RESOURCE TAB“, on the top of the page.
  • Then click on the “MiPCT CCM Course“, there will be two links for completing the registration on this page.
  • The first step of registration on the MiPCT CCM Course page is under the heading, “MiPCT CCM Course Registration
  • Click on the CCM course dates you would like to attend and complete the registration.
  • Once the registration is completed and submitted an email confirmation is sent to you indicating the successful registration.*
  • This email contains the details about the MiPCT CCM course:
    • Training schedule, day 3 and 4 in person training location address and parking information.
    • How to register for the MiPCT CCM Course Day 1 webinar.

Step 2 CCM Course Day 1 LIVE Webinar:

  • The second step of registration on this page is under the heading, “MIPCT CCM Course Day 1 LIVE Webinar Registration.” Click on the Day 1 MiPCT CCM course date you would like to attend. (Eg.Register for the April 6-9, 2015 course dates, and register for the April 6, 2015 Day 1 CCM course Webinar)
    • Once the webinar registration is completed and submitted, a confirmation email will be sent to you. This email contains the instructions and web link to join the CCM Course Day 1 Webinar.
    • Reminder: The MIPCT CCM Course Day 1 Webinar confirmation email has the link to log onto the webinar on the first day of training.

Tips for successful MIPCT CCM Course Registration

  • *Use an active, valid email address for registration. The e-mail address you provide in the registration is used to send a confirmation e-mail reply to you.
  • Please retain the emails that are sent to you following registration for the MiPCT CCM course and registration for MiPCT Day 1 CCM course. You will need to refer back to these e-mails.
  • Include your telephone number in the registration. This will only be used if a Care Management Resource Center team member needs an alternative means to reach you.
  • The MiPCT CCM course registration will be closed each month 2 business days prior to the start date of the CCM course.

Upcoming 2015 MiPCT CCM course dates:

April 6-9, 2015 – Introductory Webinar April 6

  • April 6-7, 2015 – Total six hours of self-study modules and post-tests
  • April 8-9, 2015 – In-person training

May 4-7, 2015 – Introductory Webinar Feb. 9

  • May 4-5 2015 – Total six hours of self-study modules and post-tests
  • May 6-7, 2015 – In-person training

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

Care Manager Monthly – Update for February/March 2015

Please see the Care Manager Monthly Update, attached to this issue of the Practice FLASH for February/March, 2015.

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

MiPCT Moderate, Complex and Hybrid Care Managers are required to complete a MiCMRC-approved self-management course.

For additional detail 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/ .

Stories of Your Care Management Success, Featuring Terry Norman, RN, BSN, CCM Hybrid Care Manager, Henry Ford Family Practice, Troy, HFMG, BCBSM

Terry Norman is a Hybrid Care Manager at Henry Ford Family Practice Troy within Henry Ford Health System. Terry was working with a BCBSM patient, ‘Bob’ who was a 75 year old male with past medical history with very complex issues including non ST segment elevation myocardial infarction (NSTEMI), coronary artery bypass graft (CABG), abdominal aortic aneurysm (AAA), stenting, hypertension, diabetes, hyperlipidemia and heart failure. Terry identified ‘Bob’ as a potential candidate for care management services from the daily MiPCT discharge list. ‘Bob’ had been hospitalized with unstable angina as a result of missed doses of his current medication regime due to financial issues.

Terry had worked with many of the local pharmacies in the past and was aware of several discount programs. She felt she could assist by helping ‘Bob’ find ways to decrease the cost of his medications, which would foster adherence and reduce the risk of future hospitalizations.

‘Bob’ was grateful to hear there were options available to decrease the cost of his medications. He was also willing to go to multiple pharmacies if needed to get his medication as a reduced cost. Bob shared a list of his mail order pharmacy and associated co-pays with his care manager. Terry discussed Bob’s case with an office clinical pharmacist, and the Primary Care Physician (PCP), Dr. Marla Rowe Gorosh, to explore the possibility of changing the medications regimen to achieve cost savings for the patient.

Terry determined one of the pharmacies had carried one of his medications at no cost to the patient. Other cost savings were identified by using another pharmacy which carried 6 of his other prescribed medication at a reduced cost. By using three different pharmacies Bob was able to bring the cost down to a manageable level and was able to afford his medications. He stated, “She [Terry] has been very helpful and caring and really made a difference.” In addition to cost and adherence to medication, there was an opportunity to educate Bob on the importance of each medication.

Dr. Marla Rowe Gorosh stated, “Terry was a huge asset in assisting Bob to decrease the costs of his medications during a very challenging time in his life.”

NEW: MiPCT Physician Organization and Practice Level Success Story Program – Opportunity to Earn YOUR 2015 Practice Learning Activity Credits

As the Michigan Primary Care Transformation Project (MiPCT) continues, so too does the MiPCT team’s commitment to share best practice throughout the state. Currently, many physician organizations (PO) and practices are sharing Care Management success stories with others by completing the “Share your Care Manager Success” template. Feedback regarding the MiPCT Care Manager Success stories from MiPCT payers, providers, and care managers has been very positive. We would like to build on these success stories by highlighting Physician Organization and practice level success stories implemented by the MiPCT POs and or practice site.

Beginning March 23 2015, we welcome the MiPCT practice teams to share and submit practice team based care success stories through www.mipct.org. This is an opportunity for MiPCT teams to earn their 2015 Practice Learning Activity credits.

We encourage MiPCT practice team members (ex. MiPCT CM, PCP, RN, MA, office support staff), practice leaders, and Physician Organization leaders to share your successes and lessons learned.

Elements of the MiPCT Practice Success story include:

  • Identify the practice staff involved in the team based practice success
  • What problem is the team trying to address?
  • What changes were made to address the challenge or problem?
  • What barriers did your team recognize and address during this practice change?
  • What improvements have been recognized as a result of the team-based change?

Elements of the MiPCT Physician Organization Success story include:

  • What are you trying to accomplish?
  • Why are you doing this project?
  • Key leadership involved
  • Describe the metrics collected
  • What changes have you made that resulted in the improvement?
  • How did you know your change was an improvement? (Please submit data)

Examples of MiPCT PO / practice successes may include but are not limited to the following:

  • Addressing social determinants of health and overcoming barriers.
  • Patient registry and data support for population health.
  • Integrating behavioral health.
  • Integrating palliative and end-of–life care
  • Addressing appropriateness of care (e.g., Choosing Wisely program, etc.)

How to Submit a MiPCT practice and/or PO transformation success story:

• Go to: Share your MiPCT success stories in the “Featured Links” section, www.mipct.org

Key points:

  • The PO and/or Practice may choose to request review of the PO Level or Practice Level success story for MiPCT Practice Learning activity credits. This may be indicated on the web based success story submission form.

For additional details please review 2015 MiPCT Learning Activities document which is located on the www.mipct.org, under Resources, then Documents.

An example of a practice team success is provided below.

  • Identify the practice staff involved in the team based practice success The team members involved in the practice success includes the Primary Care Provider (PCP), Care Manager (CM), office manager and Medical Assistant (MA).
  • What problem is the practice trying to address? The team had noticed there were many diabetics that had A1C>7.0 which were not noticed until they returned to their appointments with the PCP. It was also noted that many of those with elevated A1Cs were not being evaluated according to the guidelines in the registry.
  • What changes were made to address the challenge or problem? Through the use of our registry we are identifying diabetic patients with A1C>7.0. On the first of the month the office manager (who inputs information into the registry) produces a report with those patients who have A1C>7.0, if the patient does not have a return appointment within 3 months; the medical assistant reaches out to the patient to schedule the appointment. Once there is an appointment scheduled the list of patients with “out of range” A1C is shared with the PCPs and care manager. The CM and PCP both meet with the patient to during the office visit to determine the barriers to improvement in their self-management. The PCP, CM and patient then discuss the care plan and goals. The patient receives a copy of the care plan and the patient’s care plan is scanned into the EMR.
  • What barriers did your practice recognize and address during this practice change? Identifying the roles and responsible personnel for the steps in the process was a challenge. Previously the office did not have a standard process to address and follow up with patients on the diabetic gap reports.
  • What improvements have been recognized as a result of this practice success? During the 9 months since we initiated this process we have engaged 23 patients in care management and all patients have improved their A1Cs.

The MiPCT practice and PO level transformation stories will be an addition to the MiPCT care manager success stories which are currently published in the FLASH. The practice and/or PO level transformation success stories will be published every two months in the Practice FLASH.

Please submit your questions regarding MiPCT Physician Organization and Practice level success stories to: www.micmrc-requests.com.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: April 13, 2015
  • Next MiPCT Practice FLASH Issue: April 27, 2015

February 23, 2015

Practice Surveys to be Fielded as Part of Federal Evaluation of MiPCT

On Monday, February 23rd, all practices participating in the Michigan Primary Care Transformation (MiPCT) Project will

receive an email asking them to complete two short online surveys as part of a federal evaluation of the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration.

  • Practice Manager Survey: Your practice’s office manager will be asked to complete a 6-minute survey asking about basic practice characteristics (e.g., number of staff, how long you’ve had an EHR).
  • Provider Survey: All of the providers in your practice will be asked to complete a separate 12-minute survey, which asks about the degree to which they engage in activities associated with the patient-centered medical home model of care.

Practice staff who are willing to participate in this study are asked to complete these surveys by April 6, 2015.

Responses will be analyzed by an independent research team (from RTI International, the Urban Institute, and the National Academy for State Health Policy) to produce de-identified, aggregated results for the U.S. Centers for Medicare & Medicaid Services (CMS). Individual responses to survey questions will not be shared with CMS, your state’s Medicaid agency, private insurance companies, nor any other parties.

If you have any questions, please feel free to contact Steve Zuckerman (szuckerman@urban.org) and Rachel Burton (rburton@urban.org) at the Urban Institute.

Self-Assessment Data (SAD) Cadence Change Impact on Extended Access MiPCT Requirement

As you may be aware, MiPCT monitors compliance with the extended access requirements via the BCBSM PGIP SAD. MiPCT has learned that the BCBSM PGIP SAD reporting cadence has changed slightly and we will now be receiving the SAD results twice a year instead of quarterly. In the MiPCT contract, it states that practices that are out of compliance with the extended access requirements for two quarters will be subject to a revenue withhold or termination of the practice from MiPCT as determined by MDCH. Now that SAD reporting results will be available semiannually (and not quarterly), practices identified as out of compliance will be contacted and will have two months to prove compliance before penalties will be considered. If you have any questions, please contact us at mipctdemo@michigan.gov.

Physicians’ Corner: Promoting Engagement and Showing Value to Your Team

by Kevin Taylor MD

Recently, I had the opportunity to speak with a practice manager who had just assumed her new position in a busy primary care practice. I asked her how the team was doing. She noted that it was very difficult to get the staff engaged in new programs and innovations because they were so worried about making a mistake. She said generally, the physicians work well with the staff, however there were a few times when the staff felt they were treated disrespectfully by the providers. One staff person, who prided herself on her work, noted that the only time she received feedback was when she made a mistake.

A study1 recently noted that feeling valued by one’s supervisor has a more significant impact on people’s sense of trust and safety than any other behavior by a leader. Employees who say they have more supportive supervisors are 1.3 times as likely to stay with the organization, and are 67 percent more engaged.

Simon Sinek, a recognized speaker on business leadership states, “We are drawn to leaders and organizations that are good at communicating what they believe. Their ability to make us feel like we belong, to make us feel special, safe and not alone is part of what gives them the ability to inspire us”.

According to a Gallup poll conducted in 2013 called “State of the American Workplace,” when our bosses completely ignore us, 40 percent of us actively disengage from our work. If our bosses criticize us on a regular basis, 22 percent of us actively disengage. Meaning, even if we’re getting criticized, we are actually more engaged simply because we feel that at least someone is acknowledging that we exist! And if our bosses recognize just one of our strengths and reward us for doing what we’re good at, only 1 percent of us actively disengage from the work we’re expected to do.”2

How does your practice show value to your team and promote engagement? I would like to share a few ideas to consider.

Say hello to your team with a smile!

Sally Jewell, the former president and CEO of Recreational Equipment Inc. (REI), which has made the list of 100 Best Companies to Work For each year since its inception, takes seriously her personal responsibility as a role model and coach for new leaders. She has a list of non-negotiable practices she’s developed that guide her expectations of leaders at REI . Jewells wants every leader to be able to greet others authentically when they walk the halls. This involves greeting everyone by name and with a smile on your face.

This simple action by office members creates openness and connection that translates into improved quality of care for our patients.

Listen to each other.

One of the key distinctions between The Team Model of care delivery and the Traditional Model is the leadership role of the physicians. In the Traditional Model the physician takes an authoritative role with staff. Providers speak to their staff when they have something to say; with a goal to be understood. In the Team Model, physicians take a facilitative role: They take time regularly to meet with their staff and listen; seeking first to understand, then to be understood.

Sinek states, “This is what happens when the leaders of an organization listen to the people who work there. Without coersion, pressure or force, the people naturally work together to help each other and advance the company. Working with a sense of obligation is replaced by working with a sense of pride. And coming to work for the company is replaced by coming to work for each other. Work is no longer a place to dread. It is a place to feel valued.”

G.K. Chesterton says, “One sees great things from the valley; only small things from the peak.” Listening to our team allows us to “see” from their perspective. It conveys to our team their input is important and can be a powerful tool to engage our team in ongoing transformation.

________________

1Why I hate to work. Tony Schwartz and Christine Porath, The New York Times. Sunday Review. May 20th 2014.

2Simon Sinek, Leaders Eat Last: Why Some Teams Pull Together and Others Don’t

2014 1st Quarter Set of RTI Practice Reports Posted

MDC posted the 2014 1st Quarter set of RTI Practice Feedback Reports on February 9, 2015. The results contained in the reports are based on Medicare Fee-for-Service beneficiaries assigned to each practice from April 1, 2013 through March 31, 2014. To access the reports, log on to the MiPCT Dashboard, navigate to PO Reports > Download PO Reports, and then scroll down to the Medicare Practice Feedback Report section. There is one .zip file for each PO in the following format: <POname>_Medicare_Practice_Feedback_Reports_YYYY_MM.zip. Each file contains reports in PDF format for each Practice, and a Summary Report in Excel that lists the results for all non-pediatric Practices in the PO. You can use the Summary Report to compare Practice rates or to conduct additional analyses.

NOTE: MDC did not receive all the reports from RTI that we were expecting. We posted the reports that we did receive and are following-up on the missing reports. Please contact MDC if your Practice report is missing.

Support Documentation

The RTI support documentation can be found on the MDC Website’s Support page. Click the New Dashboard Reference Materials link and scroll down to the Reports Section. If you have any questions that are not answered in the support documentation, please contact us at MichiganDataCollaborative@umich.edu.

CMS Releases Updated FAQ for Code 99490

CMS recently released a new FAQ (attached) for the new Chronic Care Management Code 99490. In the latest version of the FAQ, the way in which the new CCM code affects the MiPCT patient attribution process has been updated. Previously, CMS had stated that priority in attribution would be given to the practice billing a CCM code for the patient in the most recent quarter. This has changed slightly, so that now CMS will give priority to the practice billing the latest CCM code in the look-back period (2 years) only as long as this is the latest claim billed for the patient. As soon as another non-CCM claim is billed for the patient, the attribution will be based once again on the practice with the most visits in the look-back period (which is two years for MiPCT).

MiPCT Complex Care Management Course

The 2015 MIPCT Complex Care Management (CCM) Course is provided in a blended learning activity format. The MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

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

  • Day 1Live webinar – Introduction of MiPCT CCM course
  • Day 2Self-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 4In-person training days

Register for the March 9-12, 2015, MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/march-912-2015-mipct-ccm-training/

Upcoming 2015 MiPCT CCM course dates:

March 9-12, 2015 – Introductory Webinar March 9

• March 9-10, 2015 – Total six hours of self-study modules and post-tests

• March 11-12, 2015 – In-person training

April 6-9, 2015 – Introductory Webinar April 6

• April 6-7, 2015 – Total six hours of self-study modules and post-tests

• April 8-9, 2015 – In-person training

May 4-7, 2015 – Introductory Webinar Feb. 9

• May 4-5 2015 – Total six hours of self-study modules and post-tests

• May 6-7, 2015 – In-person training

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

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

Attached to this issue of the PO FLASH is a table summarizing the Michigan Care Management Resource Center (MiCMRC)-approved self-management support training programs. MiPCT Moderate, Complex and Hybrid Care Managers are required to complete a MiCMRC-approved self-management course.

For the 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/.

Care Manager Monthly – Update for February 2015

Attached to today’s issue of the MiPCT Practice FLASH, please find the Care Manager Monthly Update for February 2015.

MiPCT 2/25/15 Care Manager Webinar: Guest Presenter Peg Nelson RN-BC, MSN, NP, ACHPN, Director Palliative Care and Pain Services, St. Joseph Mercy Oakland

In support of MiPCT’s 2015 Care Manager Education, you are invited to attend an upcoming webinar in February, 2015.

February 25, 2015 2pm-3pm; The Use of Multimodal Therapies for the Management of Pain; presented by Peg Nelson, RN-BC, MSN, NP, ACHPN, Director Palliative Care and Pain Services, St. Joseph Mercy Oakland.

“The Use of Multimodal Therapies in the Management of Pain” is approved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.”

To receive a Nursing Continuing Education contact hour for the The Use of Multimodal Therapies for the Management of Pain webinar each attendee must:

  • Register for the Webinar. To join the live webinar, login individually via your computer*.
  • Attend the entire Webinar presentation.
  • Complete and submit the evaluation form which is auto-generated at the end of the live webinar. The evaluation is only available electronically to attendees who join the live webinar via computer.

*NOTE: MiPCT is not able to issue Nursing contact hour(s) for multiple attendees viewing the webinar on one computer. MiPCT is only able to issue Nursing contact hour(s) for participants who attend and login individually to the live Webinar (i.e. viewing the recorded Webinar will not provide Nursing contact hours).

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

Stories of Your Care Management Success, Featuring Lisa Foley, MSN, MHA, RN, Internal Medicine Columbus Center, Henry Ford Health System

The patient, “Sarah,” was identified by the daily MiPCT appointment list. She was a 43 year school teacher with the diagnosis of diabetes, hypertension, and obesity. Upon review of her medical record it was noted that her last primary care appointment was 2 years ago, her last appointment with endocrinology was 3 years prior to her PCP visit, and her last appointment with gynecology was 5 years prior to this PCP appointment. At her PCP appointment 2 years ago, her A1C result was 13.5. At the appointment, Sarah stated she was not taking her medications as prescribed, nor was she checking her blood sugars. In addition, she admitted that she did not eat healthy or exercise.

The care manager discussed the case with the PCP, who agreed that care management may benefit the patient, but thought the patient may not be receptive to care management since the patient was in denial about her disease process. The care manager did meet with the patient, and during the meeting the care manager identified some of the patient’s barriers. The greatest barrier was the patient’s bad experience and fear of reoccurrence of Hodgkin’s lymphoma which she had as a teenager. Other barriers included lack of time and energy.

The patient was a busy school teacher and took everyone else’s needs first before her own. She had a sick, elderly mother. The patient had no idea what her blood sugar levels were since she had not been testing her blood sugar.

After meeting with the patient, the care manager offered to assist Sarah in learning how to self-manage her condition. The patient agreed to care management and established goals to be healthier, make time for herself, check her blood sugars daily, and take her medications as prescribed. In addition, the patient agreed to an appointment with the Diabetes Care Center and endocrinologist.

The labs drawn at the visit with the PCP showed a HgA1C of 11.5 and Hgb of 7.5. Sarah was referred to the Emergency Department for a blood transfusion for the low hemoglobin. Sarah was reluctant to go for the transfusion and ultimately refused to have the transfusion.

A work-up was planned to determine the source of the low hemoglobin. There were referrals to hematology, gastroenterology and gynecology. Hematology placed her on an iron supplement and found no cause for the low hemoglobin. The gynecologist could not find a cause for the low hemoglobin either. The gastroenterologist did find a cancerous polyp and after two surgeries, the patient was cleared of cancer.

Over the course of seven months, the care manager had several face-to-face and telephone encounters with Sarah. The outreach consisted of motivational interviewing, empathic listening, support and education on self-management of her diabetes and hypertension. Sarah did require encouragement to keep her appointments and continue with the plan of care.

Seven months after Sarah became engaged with care management, Sarah met her goals. She is checking her blood sugars daily, taking her medications as ordered, eating healthier and attending the Diabetes Care Center for further understanding of her diabetes. In addition, she was cancer free. Her lab values at the seven month interval were HgA1C of 7.5 and Hgb of 12.0.

Through care management the patient was encouraged to follow through on the work-up for her low hemoglobin which uncovered a potentially life-threatening new diagnosis. In addition, the care management assisted the patient with taking control of her diabetes.

The PCP, commented, “Care management was able to get this patient to do things that I have been not been able to do in years. The patient had a long standing history of diabetes and was in denial of her disease for years. It was very difficult for this patient to follow-up and see the specialist. Through care management we were able to uncover a potentially life-threatening new diagnosis, and the patient is managing her diabetes for the first time in years. I would recommend care management to all my patients.”

The patient stated, “Lisa was able to explain things to me in a way that I could understand, and she allowed me to do things at my own pace.”

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: March 9, 2015
  • Next MiPCT Practice FLASH Issue: March 23, 2015

January 27, 2015 Correction to Practice FLASH:
Physicians’ Corner Achieving Team-Based Care by Kevin Taylor MD

We regret that we omitted the footnotes to this article.  The footnotes appear below:

  1. California HealthCare Foundation Building Teams in Primary Care: Lessons Learned
  2. Ibid
  3. http://www.improvingprimarycare.org/
  4. http://www.improvingprimarycare.org/assessment/full

January 26, 2015

Practice Surveys To Be Fielded As Part of Federal Evaluation of MiPCT

In mid-February, all practices participating in the Michigan Primary Care Transformation (MiPCT) Project will receive an email inviting various staff to complete a short online survey, as part of a federal evaluation of the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration.

  • Your practice’s office manager will be asked to complete a 6-minute survey asking about basic practice characteristics (e.g., number of staff, how long you’ve had an EHR).
  • In addition, all of the providers in your practice will be asked to complete a separate 12-minute survey, which will ask about the degree to which they engage in activities associated with the patient-centered medical home model of care.

Practices will have 6 weeks to complete these surveys. Responses will be analyzed by an independent research team (from RTI International, the Urban Institute, and the National Academy for State Health Policy) to produce de-identified, aggregated results for the U.S. Centers for Medicare & Medicaid Services (CMS). Individual responses to survey questions will not be shared with CMS, your state’s Medicaid agency, private insurance companies, nor any other parties.

If you have any questions, please feel free to contact Steve Zuckerman (szuckerman@urban.org) and Rachel Burton (rburton@urban.org) at the Urban Institute.

Patient Experience Survey Update: Surveys have been Sent to MiPCT & Non-MiPCT Patients

The MiPCT patient experience survey was mailed out on January 16th to nearly 28,000 patients from MiPCT and non-MiPCT comparison practices. POs should inform their non-MiPCT practices that some of their patients may receive a survey. The purpose of the survey is to determine whether patients of MiPCT practices report more favorable experiences in comparison to other practices. The adult and child versions of CAHPS PCMH survey tool will be used to assess access, communication, coordination, comprehensiveness, self-management support, and care manager experience. Morpace, an NCQA-certified HEDIS CAHPS vendor has been selected to administer the survey. To encourage participation, reminder cards and phone follow-up will be conducted with non-responders. If you have any questions about the patient survey, please contact Jason Forney (jforney@mphi.org).

MiPCT Practice Replacement Process – 2015

For 2015, the limit on the number of MiPCT practices remains at 355. In early December 2014, POs with practices out of compliance on select key capabilities (e.g., sufficient CM staffing; 30% open access; after hours access; 24 access to a clinical decision maker; etc.) were notified that unless practices were compliant as of 1/31/15, they would not be eligible for 2015 continuation. In addition, it is possible that some practices may elect not to continue participation.

In the event that a practice(s) is terminated/discontinues participation in MiPCT, the following practice replacement policy will be put into effect. The policy was approved by the MiPCT Steering Committee at their January 2015 meeting.

MiPCT Practice Replacement Policy

When a practice participation opportunity becomes available, the MiPCT team will notify all MiPCT participating POs with a weblink to collect PO practice nominations. POs will have 30 days from the date of notification to submit a request to add an additional practice (s). At the closure of this period, the MiPCT team will review the PO requests in the subsequent 30 days, and make a determination about the practices to be added.

In order to be considered for MiPCT participation, the following requirements must be met:

  • Affiliation with an existing MiPCT PO
  • Acceptable PCMH designation
  • Available care management staffing (Note: The practice must have care management services available to patients and the practice’s PO must meet a minimum 80% of a 2 care manager per 5000 MiPCT member ratio)
  • Demonstration of compliance on key PCMH capabilities including:
    • Registry use
    • Access to 24 hour clinical decision maker
    • After-hours access for patients
    • 30% open access/same day scheduling

If the number of practices meeting the above criteria exceeds the number of open slots, the following factors will be considered:

    • The practice’s composite of PCMH overall rankings by health plans
    • Care management processes in place at the practice
    • Percent Medicaid patients; Practice acceptance of new Medicaid patients
    • Percent pediatric patients
    • Geographic location/medically underserved status

See?

Physicians’ Corner: Achieving Team-Based Care by Kevin Taylor MD

Over the past several months we have noted an increase in demand for our services with the rise in insured members of our community and the influenza epidemic as key drivers. Our office staff have been working hard to meet all of our patients’ needs. Unfortunately, it doesn’t always work perfectly.

As a result we have gone back to the drawing board to review our Standard Operating Procedures (SOP) for scheduling patients. After a few weeks of discussion and feedback from our team we distributed the revised SOP this past week.

“A team is a group with a specific task or tasks, the accomplishment of which requires the interdependent and collaborative efforts of its members.”[1] Think about your experience of your favorite team, whether it was a sports team or perhaps a musical ensemble. What were the elements of the team that made it effective? Several of those elements are also what makes our primary care teams effective. Research on effective primary care teams has identified these 5 elements that are necessary to be an effective team: Defined Goals, Systems, Division of Labor, Training and Communication.[2]

Achieving team-based care is one essential step toward transforming primary care to meet the quadruple aim: better care experiences, better population health, lower cost, and happier staff. But not every practice is ready for this step. Key ingredients practices must have to make team-based care feasible include:[3]

  • Engaged leadership who are committed to primary care transformation and willing to commit the resources needed to support it.
  • A data-driven quality improvement process.
  • A stable electronic health record (EHR).
  • Providers who support and encourage staff involvement in patient care.

If you already understand the basics of team-based care, or if you are ready to implement focused changes:

Start by taking a brief practice assessment[4] to highlight specific areas where your practice has room to improve.

WHAT DO THESE RESULTS MEAN?

  • A score of 1 reflects absent or minimal implementation of the key changes addressed by the item.
  • A score of 2 suggests that the first stage of implementing a key change may be in place, but that important fundamental changes have yet to be made.
  • A score of 3 is typically seen when the basic elements of the key change have been implemented, although the practice has significant opportunities to make progress with regard to one or more important aspects of the key change.
  • A score of 4 is present when most of all of the critical aspect of the key change addressed by the item are well established in the practice.

Our SOPs review both the roles and responsibilities (Division of Labor) of our team members and provide an opportunity for training and communication. This creates clarity among our team on the operational processes that we are asking the staff to follow. Just yesterday one of my colleagues commented on how much she appreciated having the SOP for patient scheduling in place noting that the SOP gives her “peace of mind” that we are all working together to meet our patient’s needs.

From the MI Department of Community Health – Your Public Health Partner: A Tool for Talking to Patients About Intimate Partner Violence

Have you ever struggled to talk to patients about intimate partner violence? If so, the Michigan Department of Community Health (MDCH) has a pocket-sized resource that can help. With easy-to-use color coded sections designed for quick reference, the Nursing Resource Guide for Intimate Partner Violence covers fundamentals of intimate partner violence as well discusses how to ensure universal screening/assessment, education, and referrals. The guide also includes sections on patient safety, cultural issues, working with teens, pregnancy/reproduction/STIs/STDs and other health consequences. To request a copy, please contact Jessica Grzywacz at grzywaczj@michigan.gov.

For more public health resources for primary care, visit our website: www.michigan.gov/primarycare

MiPCT Dashboard Release 12.0 Coming This Week with New Report Writer!

MDC plans to launch Release 12.0 of the new Dashboard this week. This release includes the following:

  • The new Report Writer! This feature enables you to design your own reports based on Dashboard data.
  • Paid claims and eligibility data through September 2014
  • An updated measurement period of July 1, 2013 through June 30, 2014
  • A sixth trend period (July 1, 2013 through June 30, 2014)

When the release is ready, we will send an email to notify users and provide all release details.

If you have any questions, or if you would like to provide feedback or suggestions, please contact MDC at MichiganDataCollaborative@umich.edu.

September 2014 G-Code Reports to be Released in February with Improvements

New G-code Reports for September 2014 will be posted in February. These reports use January 2015 attribution for claims paid in September 2014. The reports include the following improvements:

  • The data for all Payers will be included in one .xls file with a separate tab for each Payer. (Previously, separate .xls files were created for each Payer.)
  • MDC has modified our process to count only the final claim and not any previous claims adjustments.

MDC will send an email to notify users when the reports are posted.

If you have any questions, or if you would like to provide feedback or suggestions, please contact MDC at MichiganDataCollaborative@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-advisorycouncil-nomination-form/

Following is a list of upcoming PAC Conference Calls:

  • March 27, 2015, 1-2 PM
  • June 26, 2015, 1-2 PM
  • September 25, 2015, 1-2 PM
  • December 18, 2015, 1-2 PM

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

Attached to this issue of the FLASH is a table summarizing the Michigan Care Management Resource Center (MiCMRC)-approved self-management support training programs. MiPCT Moderate, Complex and Hybrid Care Managers are required to complete a MiCMRC-approved self-management course. For additional detail 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/ .

MiPCT Care Manager February Webinar

MiPCT Care Managers are invited to attend an upcoming webinar on February 25, 2015 from 2pm-3pm: The Use of Multimodal Therapies for the Management of Pain; presented by Peg Nelson, RN-BC, MSN, NP, ACHPN, Director Palliative Care and Pain Services, St. Joseph Mercy Oakland.

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.

To register for this webinar please go to

https://mipct.org/care-manager-webinar-conference-call-calendar/

MiPCT Complex Care Management Course

The 2015 MiPCT Complex Care Management (CCM) Course is provided in a blended learning activity format. The MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

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

  • Day 1Live webinar – Introduction of MiPCT CCM course
  • Day 2Self-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 4In-person training days

Register for the February 9-12, 2015, MiPCT CCM course at the following site:

https://jodyooo.wufoo.com/forms/february-912-2015-mipct-ccm-training/

Upcoming 2015 MiPCT CCM course dates:

February 9-12, 2015 – Introductory Webinar Feb. 9

  • February 9-10, 2015 – Total six hours of self-study modules and post-tests
  • February 11-12, 2015 – In-person training

March 9-12, 2015 – Introductory Webinar March 9

  • March 9-10, 2015 – Total six hours of self-study modules and post-tests
  • March 11-12, 2015 – In-person training

April 6-9, 2015 – Introductory Webinar April 6

  • April 6-7, 2015 – Total six hours of self-study modules and post-tests
  • April 8-9, 2015 – In-person training

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

Stories of Your Care Management Success, Featuring Anitra Pressley, RN, BSN, Detroit Internal Medicine, K-15, Henry Ford Health System, Medicaid Success Story

“Pearl” is a 51 year old female with Medicaid insurance who was discharged from the hospital in May 2014, for acute congestive heart failure. She was identified on the daily MiPCT hospital discharge list and referred by her PCP to the MiPCT Care Manager. Her history included sleep apnea, diabetes type II, morbid obesity, chronic kidney disease and anemia. She has had multiple admissions for fluid overload. Pearl’s weight when the case was opened was 313 lbs. She had a distended abdomen and pitting edema in her lower extremities. She complained of shortness of breath during the day even during rest. Pearl voiced discontentment with her condition and lack of faith in her medical team.

Pearl appeared to looking for someone to listen to her. She was very receptive to learning how she could make changes in her lifestyle. She shared with the care manager her sister recently died from cardiomegaly and felt it was possible she could die from heart disease as well.

The MiPCT care manager collaborated with the PCP and worked very hard to develop a trusting relationship with Pearl and calm her fears. Pearl’s plan of care included a referral to the Advanced Heart Failure Clinic, telehealth electronic in-home monitoring, home care and diagnostic cardiac catheterization. Until the patient had trust in the care manager, Pearl was reluctant to allow these services. Once the trust was established she agreed to the work up.

After the initial home care and telehealth visits, Pearl saw the benefits and was pleased with the services. Even though she agreed to the cardiac catheterization, she was very nervous. The care manager, along with the cardiology nurse, worked together to describe the procedure in detail and answer any questions Pearl had regarding the procedure. Following the cardiac catheterization Pearl was so pleased the study did not reveal an aortic valve stenosis.

Since May 2014, Pearl has lost 33 lbs. and has not been seen in the Emergency Department for her congestive heart failure. She adheres to a cardiac diet with fluid restriction. At her PCP visit in July 2014 her blood pressure was 124/72 controlled on medications. It was also noted she did not have a distended abdomen or peripheral edema. Pearl stated she felt so much better with the care manager calling her to work with her on her health issues, and as a result she now communicates more effectively with her providers on any concerns. Pearl’s shared transportation had been a barrier to her maintaining appointments. However, her sister gave her a van and the transportation is no longer an issue.

Pearl’s long term self-management goals include; maintaining a healthy lifestyle, exercising 30 minutes per day, and adhering to a cardiac/fluid restriction diet. She also plans on keeping her scheduled specialty appointments and maintaining communication with providers when she has concerns. Pearl’s statement to her MiPCT care manager was, “I could not have done it without you.”

The PCP stated, “Thanks for your diligence, Anitra. This patient illustrates the invaluable role care managers play in the patient-centered team care model. Just as it takes a ‘whole village’ to raise a child, a patient’s health and overall well-being is dependent of the entire healthcare team coordinating their efforts to bring about a good outcome.”

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: February 9, 2015
  • Next MiPCT Practice FLASH Issue: February 23, 2015

Upcoming Practice FLASH Issues:

  • PLEASE SEE 2016 Practice FLASH Page