2015 PO FLASH

MiPCT Logo Final

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

December 14, 2015

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.

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 here. Please note, these dates may change throughout the year.

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:

a. MiPCT patients (especially patients who have experience with care managers)

b. Able to use their own experience constructively

c. Able to see beyond their own experience

d. Able to listen to and hear differing opinions

Member nominations are now being accepted here.

Following is a list of upcoming PAC Conference Calls:

• March 18, 2016, 1-2 PM

• June 17, 2016, 1-2 PM

• September 16, 2016, 1-2 PM

• December 16, 2016, 1-2 PM

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 Protective Services Supervisor, Ingham County Department of Health and Human Services

Please see this link  for upcoming MiPCT Care Manager Webinars.

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

MiCMRC/MiPCT Complex Care Management Course Registration – 2016 Updates

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

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

Registration: Register for the non-MiPCT Care Managers for the MiCMRC/MiPCT CCM course here.

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

For PO Leaders who support both MiPCT and non-MiPCT practices, the registration for MiPCT Care Managers has not changed. To register MiPCT Care Managers please access: http://micmrc.org/course-registration-mipct.

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

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

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.

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.

Stories of Your Care Management Success, Featuring Marty Smoker, Borgess Internal Medicine at Woodbridge Hills

Mr. Carroll was referred through the ADT system for care management services for a post hospital follow up. The patient was discharged with a diagnosis of subdural bleed subsequent to a fall. The purpose of the call would be to complete a post-discharge safety/risk assessment. During the assessment routine medication reconciliation was completed and a review of the post discharge instructions was completed. It was noted that the patient was to hold his Aspirin (ASA) for 10 days post discharge, however because of the overwhelming hospitalization Mr. Carroll did not make note of the instruction in detail at the time of discharge. The patient’s spouse had not received the discharge instructions and at the time of the care manager’s call could not locate them. The care manager and patient discussed the medications he was taking since arriving home from the hospital. Per this conversation the care manager discovered that Mr. Carroll was taking his ASA and did not recall receiving instructions at the time of discharge to discontinue the ASA for ten days.

The care manager reviewed the discharge instructions in detail including holding the ASA for 10 days. Short-term goals were addressed to include reviewing the discharge instruction error with the provider, having the patient come in for a follow up appointment. In addition, the care manager instructed Mr. Carroll on the signs and symptoms of a bleed and to report any changes to the provider immediately. Self-management goals included the patient being able to describe the purpose of each medication and to take the medications as prescribed. The timely follow up call by the care manager including review of the discharge instructions and thorough medication reconciliation, contributed to the avoidance of a possible rehospitalization with repeat bleed leading to more serious complications. The care manager was able to identify and quickly rectify the medication instructions and coordinate a follow up office visit with Mr. Carroll’s PCP. The patient’s wife was appreciative of the care manager’s diligence as well as the provider who appreciated the “good catch” actions of the care manager.

NEXT ISSUE DATES:

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

 

November 9, 2015

Tune in at Noon on November 17 for the Quarterly PO Webinar!

Our next quarterly PO webinar will take place on November 17 at noon and will feature updates on the following:

  • MDC Enhancements and Data Improvements
  • 2016 Practice/PO/MDHHS Contract Update
  • Review of CMS 2016 Fee Schedule Changes and Opportunities for 2016

Webinar Login Info:

Webinar Login Link:
https://mphievents.webex.com/mphievents/onstage/g.php?MTID=ee6efba325b655a9d53a85177f434920f
Event number:  663 081 251
Event password: mipct01

If joining by audio only: Call-in toll number (US/Canada) 1-650-479-3207

Access code: 663 081 251

Statewide MiPCT Patient Advisory Council Member Nominations

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

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

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

Following is a list of upcoming PAC Conference Calls:

  • December 18, 2015, 1-2 PM
  • March 18, 2016, 1-2 PM
  • June 17, 2016, 1-2 PM
  • September 16, 2016, 1-2 PM
  • December 16, 2016, 1-2 PM

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/

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 DaysUpcoming 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

MDC Deliverables Update!

Over the past few months, MDC has been busy making improvements to existing products and working on future improvements that we will launch soon. These improvements and updates include:

  • Additions to the All Payer Patient Lists
    • High Risk flag (Released April 2015)
    • Healthy Michigan Plan flag for Medicaid beneficiaries (Coming Soon) – This flag identifies members who are covered through the Medicaid Expansion
  • Updates to the Report Writer – New Totals and Overall Measures (Released August 2015)
  • Improvements to standard cost in MiPCT Dashboard Enhancement 14.01 (Coming in November 2015)
    • Assigned standard cost for claims that were previously blank
    • High and Very High Risk groups show the largest increases
    • Medicare populations contain the greatest number of Very High and High risk patients
  • MDC Website updates (Coming soon)

We will provide additional details during the upcoming Quarterly PO Webinar on 11/17 and when each update/improvement is launched. We will provide information via email and on the MDC Website.

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

Behind the Data by MDC

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

Q:     How 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

Stories of Your Care Management Success, Featuring Gail Pickett, RN, ProMED – Borgess Internal Medicine

“Ruth”, a 57 year old female, had diabetes for several years.  Her treatment plan included  the approach of diet, exercise and oral medications.  After a follow up A1C check of 11.2 the physician and the patient together, determined that this approach was no longer effective and they both agreed on the need to advance to insulin for management. The physician advised the patient of Care Management services and the patient agreed to meet with Gail the Care Manager.

Gail and “Ruth” reviewed the purpose of Care Management, established a care plan and began establishing an implementation plan. The patient was receptive to the Care Management Services and was open and motivated to make changes.

Together they created a care plan that started with small and realistic goals. The Care Manger noted that the patient was not eating breakfast, so they started with dietary changes to include adding a regular breakfast to her morning regimen. They also focused on increasing physical activity, by adding exercise of walking 10-15 minutes per day.  Education including injection instructions and medication management was initiated with the new insulin order, and a long term goal of an A1C below 7 within 6 months was set.

The Care Manager along with the physician and patient collaborated to improve the patients evidence based outcomes. Improvements concluded with a decrease in the patients A1C within a four month period. Also, that patient participates in increased physician activity to include daily exercise, as well as attending annual visits for diabetes. Gail worked with “Ruth” to close preventative gaps in care not previously completed, including colonoscopy, diabetic eye exam, and foot exam.  Additionally, the Care Manager assisted the patient in obtaining discount vouchers for her insulin.

“Ruth” now maintains regular blood tests for her diabetes and is currently adhering to dietary and exercise routines. The patient A1C is 6.4 and she is very pleased with the outcomes and progress made. The patient states that she appreciates the assistance of someone who educated her and supported her efforts and actions. She often responds to calls with, “Thank you for calling and checking on me.”

NEXT ISSUE DATES:

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

October 12, 2015

The Care Management Afternoon Session at the 10/29/15 Ann Arbor Summit is FULL

The Summit Ann Arbor Care Management afternoon session 10/29/15 is now full. However, MiPCT Care Managers who have not registered for the Summit Ann Arbor Care Management afternoon session and wish to attend may sign up on a wait list via the MiPCT Summit Ann Arbor registration web page:  https://mipct.org/resources/2015-mipct-annual-summits/

You will be contacted by 10/23/15 if we are able to accommodate your request to attend.

There IS still space available for anyone wishing to attend the morning portion of the MiPCT Summit, which includes a presentation by Elizabeth Hertel from the Michigan Department of Health and Human Services, Best Practice Awards, and an Evaluation Update.

Summit North (Thompsonville) Registration Closes Tomorrow!

Please be advised that registration for the MiPCT Regional Annual Summit – North in Thompsonville to be held on October 20th, will close tomorrow, October 13, 2015.

Many thanks to those who have already registered.

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 at Crystal Mountain Resort
    Noon Project Leadership Briefing,
    followed by afternoon care management training
    REGISTRATION CLOSES 10/13/2015*
  • Summit Southeast – Ann Arbor, MI – Thursday, October 29, 2015 at 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.

Statewide MiPCT Patient Advisory Council Member Nominations

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

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

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

Following is a list of upcoming PAC Conference Calls:
•        December 18, 2015, 1-2 PM
•        March 18, 2016, 1-2 PM
•        June 17, 2016, 1-2 PM
•        September 16, 2016, 1-2 PM
•        December 16, 2016, 1-2 PM

MiCMRC/MiPCT Complex Care Management Course

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:

  • November 9-12, 2015. Introductory Webinar November 9, 2015.  Total six hour self-study modules and post-tests, November 9-10, 2015.  In-person training November 11-12, 2015.  NOTE: Registration for this course will close as of November 3, 2015, 4p.m.
  • 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.

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.

NEW 2015 MICMRC/MiPCT Care Manager Educational Webinars

The MICMRC/MiPCT Care Manager educational webinar for this month will be held on October 23, 2015 – 2-3PM.   The webinar,  “Improving Medication Adherence,” will be presented by Kimberly Moon, PharmD, Manager, Clinical Pharmacy Stars Team BCBSM.

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

MiPCT Dashboard Release 14.0 Posted on 9/23

MDC posted MiPCT Dashboard Release 14.0 on September 23, 2015. Please log in to the Dashboard to review your data and reports, which contain the following updates:

  • Paid claims data through March 2015
  • Eligibility data through December 2014
  • Patients from the December 2014 attribution lists
  • An updated measurement period of January 1, 2014 through December 31, 2014
  • Seventh trend point on the Trends pages (January 1, 2014 through December 31, 2014)

NOTE: Release 14.0 data is utilized in the 36 month incentive measure calculations. You can use the Dashboard to review your results and compare your PO’s rates to the rates of other participating POs and to the overall MiPCT benchmark rates.

Updated documentation, including the Release Notes and User Guide, can be found on the MDC Support website
https://www.michigandatacollaborative.org/MDC/support.jsp.
If you have any questions, or if you would like to provide feedback or suggestions, please contact MDC at
MichiganDataCollaborative@med.umich.edu.

Stories of Your Care Management Success, Featuring Mary Kramer-Rabine, Marquette Family Medicine, UP Health System, PO UPHP

This was a direct referral to care management by the PCP.  The patient presented to the clinic after moving to the area to establish care.  The Care Manager (CM) met with the patient and the PCP at the initial office visit.  The patient was unemployed, homeless, wheelchair dependent, had very little support, and had multiple chronic health conditions.

The patient had been discharged from a nursing home and was living in a local shelter.  The patient had no income, no transportation, and was using a second hand wheel chair and cushion.  Needed services included chronic pain management, wound care management and care coordination as there were multiple providers and specialties involved in providing care.

The CM and patient met to prioritize health care goals and create a plan of care.   Short term and long term goals were developed in conjunction with the patient and the PCP.

The PCP ordered Home Health for wound care and in home physical therapy at the shelter.  The CM helped arrange transportation to get to medical appointments.

The CM assisted with the application process for housing for the disabled and now the patient has moved out of the shelter and lives independently with community support.

The CM assisted in the process of getting a new custom fit power driven wheel chair.  Since the chair has been obtained there has not been any further skin break down on the patient’s hands from pushing the wheels of the borrowed wheelchair and the patient also has a proper cushion for the seat resulting in less skin break down and less back pain.

The CM ensured communication occurred between all the specialties involved allowing for each specialty to be aware of treatment plans, medications ordered, changes in treatment plan and patient adherence to the recommended plan of care. Initially not all progress notes were being shared between each discipline and the CM worked to facilitate coordination.  The CM requested the patient  medical records many times to get this process initiated.

During the course of the 2 year period in which the patient was in enrolled in care management,   planned hospital admissions for wound debridement occurred.  There was only one unplanned inpatient admission.  This admission happened during a time when previous social issues recurred.  Due to stressors the patient was experiencing,  medical appointments were missed and also gaps in following recommended care instructions or prescribed medication regimen.  After a time the social situation changed and the patient started going to appointments and following the recommended plan of care.

The patient is determined to walk again and is working with PT to gain strength and endurance and is now in the initial stages of accomplishing this goal.

The patient has had many social and medical hurdles and concerns to manage over the past two years.  It has been a rocky road with managing pain medications and social issues.  A new goal is to go back to work and the patient has completed an application at Michigan Rehabilitation.

The patient has been motivated to make changes overcoming many emotional, social and medical situations. It took time to find the “right” fit for a provider in our clinic.  It has been very rewarding working with this patient and has taught me to not give up, to trust your gut feelings, to continue support and to be open and honest and even assertive when it is appropriate.

The Care Manager discharged this patient from Care Management services and the patient continues to receive care in the general population of the clinic.   Care Management services will be available if needed in the future.

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:     What is the difference between concurrent and prospective risk?
A:     MDC uses the following definitions for current and prospective risk in the MiPCT Dashboard and reports:

Concurrent risk scores use information about health spending indicators during the current risk year timeframe (typically the current measurement year) to identify the risk of a patient or group of patients. The concurrent year timeframe is indicated on the home page of the MiPCT Dashboard and in the header of each dashboard section that contains risk scores.

Prospective risk scores use information about health spending indicators from a previous 12-month period to identify the risk of a patient or group of patients in a future year. Some health status indicators, such as the diagnosis of a chronic condition, are accurate predictors of health spending not only in the current year, but also in future years. For example, acute conditions carry more weight concurrently; chronic conditions affect both concurrent and future scores.

On the MiCPT Dashboard’s Population page, the “Risk Scores by Payer” section displays the average concurrent and prospective risk scores by Payer for the current timeframe. You can view the data in a graph or bar chart format. The bar graph provides a visual view of risk scores by Payer. The table provides the actual risk score data by Payer.

To assign risk, Truven Health provides MDC with MiPCT project risk scores using the DxCG Risk Smart™ software licensed from Verisk Analytics, Inc. to assign a set of Diagnostic Cost Group (DCG) scores to each person for whom eligibility data is received. To apply a consistent methodology across all Payers, claims and eligibility data for all members are run through a single Dx CG Risk Smart commercial model typically from a 12-month period. This Dx CG Risk Smart commercial risk score model helps to identify high-cost cases for care- and disease-management intervention,  assessment, and disease burden to improve healthcare cost and quality.

For additional information about how Truven assigns risk scores, see the following Truven documentation:

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

Risk_Scores_by_Payer

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: November 9, 2015
  • Next MiPCT Practice FLASH Issue: October 26, 2015

September 14, 2015

  • No Issue Published This Month

August 17, 2015

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

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 for the 9/22/15 MiPCT Pediatric Care Manager Summit!

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

REGISTER HERE: **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.

**NEW** Pre-Conference Webinar hosted by Dr. Jane Turner!

Join Dr. Turner in: “Preparation for MiPCT Pediatric Summit”
Date:     Friday, August 21, 2015
Time:     10:00am, Eastern Standard Time
Duration:     1 hour

REGISTER HERE!

Please also view attached palliative care articles for discussion:

Submit questions to MiCMRC at: http://micmrc.org/contact-us

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

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, PpatientPing 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 leads will receive a meeting invitation to the “Wave One” webinar.   For the remaining POs, there will also be a webinar on September 23 from 9-10am 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.
 
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 until December 31, 2015. The recorded webinars will be posted on the www.mipct.org website on the 2015 Summit Prework Webinars page located under the 2015 MiPCT Annual Summits tab: .

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.

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!

Statewide MiPCT Patient Advisory Council Member Nominations

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

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

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

Following is a list of upcoming PAC Conference Calls:

  • September 25, 2015, 1-2 PM
  • December 18, 2015, 1-2 PM

New Enhancements Added to the MiPCT Dashboard Report Writer!

On August 6th, several updates were added to the Report Writer tool on the MiPCT Dashboard to improve functionality
and usability. They include:

  • The Report Writer sections automatically display all options (You no longer have to expand each section.)
  • Total selection boxes were added for several measure groups. These display the totals for all components in the group combined.
  • Overall rate selection boxes were added for several measure groups. These display the combined rate for all components of a measure group.

NOTE: This month’s “Behind the Data” feature in the PO FLASH references the Report Writer and how you can
use this tool to target areas for improvement.

For additional information and details, see the following documents, which are located on the Support page
of the MDC Website:

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

Behind the Data by mdc-logo-word.fw

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

Q:

On the Dashboard, the Quality Graph shows that most of my PO’s diabetes measure rates are below the MiPCT benchmarks. From the tables below the graph, I can see that the Commercial payers had the lowest rates. What other information can I access to help me target areas for improvement?

A:

From the Report Writer, you can easily run a report that lists all your Practices and their associated diabetes measure rates for only the commercial population. To do so, complete the following steps:

  1. Click the PO Reports tab, and then select Report Writer.
  2. In the Display Data for box, confirm that your PO is selected.
  3. In the Select Report Detail Level box, select Practice.
  4. In the Quality section, under the Chronic Conditions heading, select Commercial.
  5. Verify that all of the diabetes measures are selected.
  6. Select to display the report on the page or in an Excel spreadsheet.

The resulting report lists all of the Practices in your PO with their associated rates, limited to the diabetes measures and the commercial population. From here you can determine actions to help improve your diabetes metrics.

For more detailed information about the Report Writer, see the Report Writer User Guide HERE!

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

RW_Quality_for_Behind_the_Data_article_2015-08

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:

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

Register for upcoming MiPCT CCM course dates HERE!

Upcoming Course Dates and Course Registration Close Dates:
September 8-10, 2015

  • Introductory Webinar September 8, 2015.  Total six hour self-study modules and post-tests, September 8, 2015.
  • In-person Training September 9-10, 2015.

NOTE: Registration for this course will close as of September 1, 2015, 4 p.m.

October 5-8, 2015

  • Introductory Webinar  October 5, 2015.  Total six hour self-study modules and post-tests, October 5-6, 2015.
  • In-Person Training October 7-8, 2015.

NOTE:  Registration for this course will close as of October 1, 2015, 4 p.m

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

Stories of Your  Care Management Success, featuring Laurie Smith, LMSW, HCM, Everingham Clinic, Medical Network One Health Solutions, BCBSM – Medicare Advantage

While screening the BCBSM (Blue Cross Blue Shield of Michigan) gaps in care list, it was determined that “Sue” had an elevated HbA1C of 8.6, was overdue for  her annual health maintenance exam, and the last time she was seen by her  primary care provider was several months ago.  The MiPCT list was reviewed for her eligibility.

Sue was a 77 y/o at the time she was screened for care management.  Her chronic conditions included Type 2 diabetes, hyperlipidemia, hypertension and ischemic heart disease.

During the outreach call to the patient, Sue admitted to not taking her diabetes medication because it caused bloating.  Sue agreed to meet with the care manager face-to-face during the initial call.  During the first face-to-face visit Sue stated she was not testing her blood sugar because she did not have glucometer strips.  Sue agreed to enroll in care management.

Improvement of Sue’s HbA1C was established as the long term goal.  Sue and the care manager began to work on a plan to achieve this goal through Sue’s self-management of her condition.  The patient learned about her diabetes medication. This included how to take her diabetes medication with meals, which then alleviated the bloating.  During her follow-up with the primary care provider (PCP) her health maintenance exam was completed and the care manager, along with the medical assistants helped Sue obtain new prescriptions for her glucometer supplies.

The care manager met with Sue over several weeks.  Their visits focused on helping Sue gain an understanding about her diabetes medication, meal planning and her chronic conditions.   This included teaching Sue about her diabetes, hypertension, and hyperlipidemia and how lifestyle changes such as exercise and diet could positively impact her health.  Through coaching calls, Sue also revealed that she often falls asleep before taking her bedtime dose of her diabetes medication. When the PCP was consulted about lack of adherence to  her medication, the PCP changed the administration time to the morning instead of bedtime.  Additional topics of discussion were symptoms of hypoglycemia, avoiding constipation and increasing physical activity.

While engaged in care management, Sue experienced a stroke and an amputation of a toe.  During her hospitalization the care manager coordinated her care, which included scheduling appointments with specialists.  Sue reported that despite her hospitalization,  her blood sugars were the best they have ever been as evidenced by her improved HgA1C of 7.3.

Soon after the hospitalization the care manager transferred this case to a high intensity care manager (HICM) who now follows the case through in-home visits.  The goals set through HICM include increasing balance and lower limb strength through physical therapy.  The goals of improving her daily nutrition and diet were carried over to the HICM care manager.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue:  September 14, 2015
  • Next MiPCT Practice FLASH Issue:   August 31, 2015

July 13, 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:

Go to Link for JULY 22, 2015 NOON Webinar:
https://mphievents.webex.com/mphievents/onstage/g.php?MTID=e8e24ee01ceb3005d40bde145d4f63840

Register for the meeting.

Event Password is mipct01

OR

Go to Link for JULY 28, 2015 5:30 PM Webinar:
https://mphievents.webex.com/mphievents/onstage/g.php?MTID=e63817dac4a39e68562e07064005ce118

Register for the meeting.

Event Password is mipct01

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

Hypertension Control Process Improvement Guide for Practices

On June 11, 2015, CDC Division for Heart Disease and Stroke Prevention released a new quality improvement action guide to help clinicians improve hypertension control. The Hypertension Control Change Package for Clinicians provides health care practices with a comprehensive list of evidence-based process improvements, throughout the patient visit and beyond, to efficiently and effectively care for patients with hypertension. The guide also provides examples of tools that can be adopted by or adapted to individual practices or health systems.

The American Heart Association Guideline Advantage team is planning a webinar on the change package, geared toward
clinicians. This webinar will be July 28th, 2015, 2p ET. The registration link for the July 28th webinar:
https://learn.heart.org/activity/3509782/detail.aspx.

NEW FLASH Publication Schedule

As of this month, both the PO and Practice FLASH publications will be distributed once monthly. Following is the publication schedule for both newsletters through the end of this calendar year:

PO FLASH:
July 13, 2015
August 17, 2015
September 14, 2015
October 12, 2015
November 9, 2015
December 14, 2015

Practice FLASH:
July 27, 2015
August 31, 2015
September 28, 2015
October 26, 2015
November 9, 2015
December 14, 2015

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 mipct.org website under the “Billing and Coding 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 and Coding Resources” on a regular basis.

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: https://cindysoo.wufoo.com/forms/2015-pediatric-conference/

  • 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.

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.

Enhancement 13.01 for the MiPCT Dashboards and Reports Posted 7/10

  • MDC posted Enhancement 13.01 on July 10, 2015.  This enhancement includes the following updates:
    Fixes to the Breast Cancer Screening and Cervical Cancer Screening measure calculations for the supplemental data. The supplemental data rates now use time frames consistent with the HEDIS measures found in the Clinical Quality Measures table.
  • Added the following columns to the Clinical Quality Measure table drill-down lists:
    • Master Patient ID – MDC’s unique patient ID for each member that allows identification of an individual across Payers and across Dashboard releases.
    • Clinical Numerator – a “1” indicates that a clinical registry record is associated with a patient.
    • Clinical Denominator – a “1” indicates that the patient qualified for the supplemental denominator. The Clinical Numerator and Denominator fields will assist analysts in identifying the patient contribution to the supplemental data rates.
  • The current reporting period’s PO-Practice-Provider attribution has been applied to all trend points, consistent with the attribution and trending methodology in previous Dashboard releases.

Updated documentation, including the Release Notes and User Guide, can be found on the MDC Support website https://www.michigandatacollaborative.org/MDC/support.jsp.

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:

MiPCT patients (especially patients who have experience with care managers)

Able to use their own experience constructively

Able to see beyond their own experience

Able to listen to and hear differing opinions

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

Following is a list of upcoming PAC Conference Calls:

  • September 25, 2015, 1-2 PM
  • December 18, 2015, 1-2 PM
  1. MiPCT Complex Care Management Course
  2. 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 on https://mipct.org/care-management-resource-center/ccm-online-registration-page/

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, the 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.

Stories of Your Care Management Success, featuring Natalie Adewunmi, RN, HCM, IHA Family Medicine Arbor Park

Ms. Y has a history of CKD, DM, Obesity, Asthma, Depression, HTN and CVA.  Recently “Ms. Y” was enrolled in the transition of care (TOC) program during her inpatient stay.  Based on Ms. Y’s risk stratification score at the time of admission, she appeared to be a patient who may benefit from care management.  Ms. Y has BCBSM Medicare Advantage health plan.

The care manager reviewed Ms. Y’s clinical information from her hospital admission.  Additionally the care manager discussed Ms. Y’s case with her primary care physician (PCP) and provided an update regarding her recent hospitalization.  Ms. Y’s PCP agreed that Ms. Y would benefit from care management.    Ms. Y was contacted by the care manager and she agreed to participate in care management services.

During the initial conversation with the patient, the care manager assessed how the patient felt about her health, how she managed her conditions, and whether there were areas or concerns that the patient would like to understand or improve about her health.

Ms. Y was reporting hypoglycemic episodes, profound fatigue, frequent UTIs, chest pain symptoms and a general lack of caring for herself.  In addition to her self-care, Ms. Y was also caring for her granddaughter.  Ms. Y shared that it was becoming increasingly difficult for her to provide care for her granddaughter.

The patient agreed to enrollment in care management.  At the time of her enrollment the following problems were identified:

  • Challenges with self-management of her Diabetes
  • Ms. Y reported decline in her overall health and symptom complaints
  • Difficulty with maintaining regular follow up with her treatment team,  and her specialists
  • Stress related to balancing her commitments to her family and managing her own health care needs, symptoms
  • Hospitalizations and ED visits r/t failed outpatient antibiotic treatment and multiple allergies

Barriers were identified:

  • Overcoming depression
  • Pressure from family commitments
  • Lack of motivation
  • Knowledge deficits of chronic conditions
  • Anxiety related to taking medication, procedures, and specialists

Short Term goals were identified to support the following self-management skills:

  • Check and monitor her blood sugars daily
  • Attend post-acute follow-up appointments
  • Education of symptoms and how to manage the symptoms

Long Term goals were discussed and the patient shared her priorities as follows:

  • To become independent in scheduling, attending and managing multiple specialty appointments
  • To be able to return to church
  • Being able to set limits with caring for her granddaughter
  • Joining a gym, lose weight
  • Become more active physically and socially to improve her depression

In addition to the primary care physician the other providers that were on the patient’s medical team included a cardiologist, infectious disease specialist, and an endocrinologist.

Ms. Y met with the care manager and over several weeks she achieved many successful outcomes.   Ms. Y routinely completes her prescribed lab work and she is able to schedule and attend her PCP and Specialists appointments.  Her HgA1C greatly improved and her insulin dose has decreased.  She had a weight loss of 30lbs and plans to join a gym.  Ms. Y regularly attends church services.  The communication between Ms. Y and her family members has improved and she feels she has more support.   The patient verbalized she appreciates having a care manager who is able to spend more time with her to discuss her health concerns and she feels great about her progress.

  1. Behind the Data by   mdc_logo
  2. MDC’s Behind the Data section provides high-level information about the data for the MiPCT project in a Q & A format.
  3. Q:     What information can I find on the MiPCT Dashboard timeline?
  4. A:     The timeline provides an important visual of the timeframes used for the different types of data included in each Dashboard release. The timeline provides timeframes for the following:
  • Attribution – Shows the attribution month that was used for the Dashboard release. This is typically the last month of the measurement year.
  • Chronic Conditions – Obesity rates are calculated using data from the most recent measurement year. All other chronic condition rates are calculated using all available data.
  • Quality Measures – Breast cancer screening rates are calculated using data for the measurement year plus one year prior to the measurement year. Cervical cancer screening rates are calculated using data for the measurement year plus two years prior to the measurement year. All other quality measure rates are calculated using data for the measurement year.
  • Standard Cost – Displays standard cost information for patients who have claims within the measurement year. The standard cost amounts are calculated for a one-year period (typically the measurement year). MDC receives standard cost data from Truven Health Analytics. More information can be found in the Standard Cost Model document on the MDC Website.
  • Utilization Measures – The 12-month rates are calculated using the measurement year. The 6-month rates are calculated using the most recent six months of data available.
  • Risk Scores – This data comes from Truven Health Analytics, which assigns Diagnostic Cost Group (DCG) scores to eligible MiPCT patients.  The scores are assigned based on the most recent twelve months of data (typically the measurement period).
  • Trends – Shows the timeframe used for each trend period. (Each trend includes a three month run-out period for claims).

For more detailed information on time periods for the data used on these dashboards, see the MiPCT Data Timeline.

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 P.O. FLASH Issue: August 17, 2015
  • Next MiPCT Practice FLASH Issue: July 27, 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:

Go to Link for JULY 22, 2015 NOON Webinar: HERE

Register for the meeting.

Event Password is “mipct01”

OR

Go to Link for JULY 28, 2015 5:30 PM Webinar: HERE

Register for the meeting.

Event Password is “mipct01”

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

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?

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.

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.

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:

MiPCT patients (especially patients who have experience with care managers)

Able to use their own experience constructively

Able to see beyond their own experience

Able to listen to and hear differing opinions

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

Following is a list of upcoming PAC Conference Calls:

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

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

June 8, 2015

MiPCT Welcomes Ten New MiPCT Practices

The selection process has been completed for the ten practice openings. We are pleased to announce the addition of the following:

  • Harbour View Family Medicine – Affina/LHN
  • Bronson Lake View Family Care Decatur – Bronson HealthCare Group
  • Bronson Lake View Family Care Paw Paw – Bronson HealthCare Group
  • Northern Pines Health Center – Northern Physician Organization
  • SMG Ionia – Sparrow Physician Health Network
  • Baldwin Family Health Care – Wexford / Crawford
  • Baldwin-Grant Clinic – Wexford / Crawford
  • Munson Healthcare Grayling Community Health Center – Wexford / Crawford
  • Munson Healthcare Prudenville Community Health Center – Wexford / Crawford
  • White Cloud Wilcox Clinic – Wexford / Crawford

Over 70 practice nominations were submitted, spanning 17 Physician Organizations. The selection process began with the elements identified as requirements in the Practice Replacement Policy approved by the Steering Committee:

  • Affiliation with an existing MiPCT PO
  • Acceptable PCMH designation
  • Available care management staffing (i.e., 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

Given the high number of practice nominations, the additional factors outlined in the Practice Replacement Policy were also assessed, including acceptance of new Medicaid patients, the percent of the practice’s panel that represented Medicaid membership, and medically under-served status.

The new practices will begin MiPCT participation on October 1, 2015.

REGISTRATION OPEN! MiPCT Regional Annual Summits

As previously announced, the dates and venues for the 2015 MiPCT Regional Annual Summits are as follows (click the name of the Summit for which you wish to register):

• 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*

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.

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!

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:

MiPCT patients (especially patients who have experience with care managers)

Able to use their own experience constructively

Able to see beyond their own experience

Able to listen to and hear differing opinions

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

Following is a list of upcoming PAC Conference Calls:

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

MiPCT Best Practice Work Group Outcome Documents Available

In order to capture, document, and share MiPCT Care Manager best practice models and improvement processes from across the state, a MiPCT Care Management Best Practice Workgroup was formed in the summer of 2014. By evaluating and analyzing best practice work of MiPCT Care Managers, the workgroup sought to develop a guideline to assist organizations in recognizing Care Manager activities that can optimize efficiency and effectiveness. They were charged with developing a care management delivery best practice model for complex and moderate risk patients.

The workgroup developed two documents that address the MiPCT Care Management Path 5 Step Process. The document, titled “MiPCT Care Management 5-Step Process Algorithm,” is an algorithm of the 5-Step Process including Risk Stratification, Admission and Non-Admission Care Path. The document provides a high level, “at a glance” process algorithm that Care Managers may find useful. The purpose of this document is to present process steps which have been identified as key elements for the delivery of care management.

The document titled “MiPCT Care Management 5-Step Process Detailed” takes a more in-depth approach to practice integration of the 5-Step Process. This document delineates each step of the process in greater detail, along with suggested care management activities for each step.

Both documents may be accessed via the Care Management Resource Center website (listed under “Resources”)
http://micmrc.org/care-management

This work is a compilation of the contributions of the entire workgroup, which we would like to recognize here, with our sincere thanks for all your time and effort:

  • Karen Bennett – Sparrow Health Medical Group,
  • Maureen Braun – IHA,
  • Ruth Clark – Integrated Health Partners
  • Belinda Fish – UMHS
  • Peg Jacobs – UMHS
  • Lynn King – Affina/LHN, MiPCT Clinical Lead
  • Mary Kramer – UPHP
  • Anne Levandoski – UPHP
  • Victoria Lee – Advantage Health Physicians
  • Diane McLeod – Sparrow Medical Group
  • Chris Rusin – United Physicians
  • Lindsay Schohl – Affina/LHN
  • Robin Schreur – Spectrum Health Medical Group, MiPCT Clinical Lead
  • Della Slavsky – UPHP, MiPCT Clinical Lead
  • Tammy Starks – IHP
  • Heidi Steinhebel – IHA
  • Juliann Testy – Henry Ford Medical Group, MiPCT Clinical Lead
  • Susan Viviano – Advantage Health
  • Loretta Warda, MiPCT Clinical Lead

MiPCT Clinical Leadership and Team:

  • Dr. Kevin Taylor
  • Dr. Jean Malouin
  • Marie Beisel
  • Donna Mimikos
  • Sue Vos
  • Betty Rakowski

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 July 6-9 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:

  • 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.
  • August 17-29, 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.

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

Stories of Your Care Management Success featuring Marilyn Flewellen RN, MBA, BSN, Henry Ford Internal Medicine Detroit Northwest

“Charles” is a 46 y/o with history of hypertension, diabetes, and COPD. He smokes one pack of cigarettes per day. Charles was identified by the care manager as a possible candidate for care management upon review of the emergency department discharge list. The complaint listed on the discharge list was cough related to his chronic respiratory illness and chest pain due to muscle strain from the cough.

The Care Manager reviewed Charles’ medical record and found documentation stating he continued to smoke despite his chronic respiratory illnesses. It also showed that his blood pressure and diabetes were not controlled well. Charles agreed to care management during the first phone contact and agreed to be scheduled for a follow up office visit.

During the initial encounter with Charles, he disclosed that he had not been compliant with his medical plan. He stated he had been experiencing increased periods of anxiety and stress related to multiple family issues. He confided with the care manager shared he does drink alcohol. Charles expressed a desire to learn better ways to cope with his stress. He agreed to care management encounters every week for two weeks and then every two to four weeks thereafter.

Charles agreed his increased anxiety and stress levels were negatively impacting his chronic illness management. He also expressed that he wanted to learn how to avoid unnecessary emergency department visits. Following this discussion the short and long term goals were established.

Short term goals included:

Take all medication as prescribed.

Follow up with primary care provider within one week.

Charles was able to avoid an ER visit for 30 days and all other short term goals were met within one week.

Long term goals included:

Decrease stress and anxiety as evidenced by self-report of symptoms

Attend behavioral health counseling within 30 days

Attend regular Alcohol Anonymous (AA) meeting within 30 days

Improve management of chronic illness; diabetes, HTN, COPD

Smoking cessation (decrease smoking over 3 months)

Diabetic Education and diet modification (he did not attend classes but did seek out information regarding glucose management and diet)

Medication adherence (on-going)

Charles agreed to behavioral health counseling and also has been attending AA meetings. He has been regularly attending both the counseling and AA meetings. After two months he had decreased his smoking from 1 pack per day to ½ pack through the aid of pharmaceutical smoking cessation medications. He did attend diabetic education classes and has been minimizing foods high in salt, starch and fat.

Through care management, Charles also improved self-management of his chronic conditions as evidenced through medication adherence, monitoring his blood pressure weekly, and his blood sugar daily. His blood pressure improved from 140/90 to 129/85. His A1C improved also from 7.5 to 6.8.

His concerns and progress toward his goals are discussed at each of his visits with the Care Manager. Encouragement is offered for his continued self- management of his chronic conditions. The Care Manager collaboratively communicates with the behavioral health therapist and diabetic educator. Charles recently reported, “I’m very appreciative of having additional coaching support.” He stated that care management outreach helps to keep him on track.

Behind the Data by   mdc_logo

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

Q: Why are the HEDIS measures for MIPCT so different from the HEDIS measures for my plan?

A: The HEDIS measures used in the MiPCT project are calculated differently from NCQA HEDIS measures in the following ways:

The MDC anchor date is based on the last day of reporting for the MiPCT project release; the HEDIS anchor date is based on December 31st of the measurement year.

MDC uses HEDIS measure eligibility requirements, but uses additional MiPCT eligibility requirements for certain measures.

HEDIS specifies continuous enrollment with a specific payer; MDC specifies only that there is continuous enrollment in MiPCT. (There can be a change in payer as long as the new payer is also in MiPCT.)

Currently, the MDC quality measures are based on HEDIS 2012 specifications. We will be migrating to the HEDIS 2015 specifications in a future release.

For additional information, see the Chronic Conditions section of the MiPCT Dashboard User Guide, which can be found on the MDC Website’s Support page:
https://www.michigandatacollaborative.org/MDC/assets/Report_Writer_User_Guide.pdf

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

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: June 22, 2015
  • Next MiPCT Practice FLASH Issue: June 22, 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 Due May 22, 2015!

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

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!

November 2014 G-Code Reports Posted with New Detail Reports Included

New G-code Reports for November 2014 were posted this week on the Download PO Reports page of the MiPCT Dashboard. The reports use April 2015 attribution for claims paid in November 2014.

In addition to the high-level monthly and aggregated totals reports, you will find G-Code Detail reports for each Practice

include in your PO’s zip file. The G-Code Detail reports enable you to view more specific information about each G-Code and CPT code claim included in the aggregate reports.

In each Practice’s Detail Report, all Payers are include on the same tab, with the claims initially sorted alphabetically by Payer and then by Patient Last Name. Each report contains all Care Management claims received by MDC (starting from

April 2012 for BCBSM and BCN and from July 2013 for Priority Health) up to the “Claims Paid Through” date listed in the header of the report. The reports include both paid and rejected claims (but do not include details about why a claim was rejected).

Quick Reference documents for these reports are available in the New Dashboard Reference Materials section of the MDC Support Page: https://www.michigandatacollaborative.org/MDC/#/support

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:

MiPCT patients (especially patients who have experience with care managers)

Able to use their own experience constructively

Able to see beyond their own experience

Able to listen to and hear differing opinions

Member nominations are now being accepted at:

https://jodyooo.wufoo.com/forms/patient-advisory-council-nomination-form/

Following is a list of upcoming PAC Conference Calls:

  • 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

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:

https://mipct.org/care-management-resource-center/ccm-online-registration-page/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 27, 2015

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 HERE!

MiPCT Physician Leadership Training Program Survey

Each of our practices and physician organizations has 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!:

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 MiPCT Demo mailbox mipctdemo@michigan.gov by the deadline.

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.

MiPCT Dashboard Release 13.0 Coming Soon!

MDC plans to launch Release 13.0 of the MiPCT Dashboard within a week.

This release includes the following:

  • Paid claims data through December 2014
  • Eligibility data through September 2014
  • Patients from the September 2014 attribution list
  • An updated measurement period of October 1, 2013 through September 30, 2014

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

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

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:

Addressing social determinants of health

Using registries and data to support population health

Integrating behavioral health

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!

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, July6-7, 2015. In-person training July 8-9, 2015.

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

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, Bldg. 18, Dining Hall
    • 8AM to Noon General Session open to all; followed by afternoon care management training

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:

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

Member nominations are now being accepted HERE:

Following is a list of upcoming PAC Conference Calls:

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

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

April 14, 2015 CORRECTION TO THE 4/13/2015 PO FLASH:

Stakeholders, Please be advised of an error in the PO FLASH, published yesterday, April 13, 2015: 

The Accountable System of Care Capacity Assessment closes on Friday, May 1st, 2015 at 5:00pm. (The deadline was extended at the request of several organizations to allow additional time for completion.) The assessment can be completed here: https://redcap.mphi.org/surveys/?s=D3765bHC7C

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

April 13, 2015

SIM Accountable System of Care Capacity Assessment Closes Today, April 13!

An assessment was created to inform the selection of model test regions. A Word document is attached to today’s issue of the PO FLASH.

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.

2015 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 HERE!

BCBSM Billing Update: MiPCT/Provider Delivered Care Management Practice

Claims for eligible PDCM/MiPCT members that deny due to the diagnosis billed (obesity/mental health) will no longer be paid automatically from the PGIP reward pool. As indicated during our billing roadshows last year, if there is another diagnosis that can be billed in the “first/primary” diagnosis position on the claim form, please status those claims with that information and payment should be issued. However, if there is no other diagnosis that can be billed, BCBSM will need to be notified of that denied claim. You can open an issue on the Collaboration site (if you have access to it), send an email to valuepartnerships@bcbsm.com or contact Lori Boctor at lboctor@bcbsm.com or by phone at 313-448-3341.

October 2014 G-Code Reports Posted April 7, 2015

New G-code Reports for October 2014 were posted on the Download PO Reports page of the MiPCT Dashboard. The reports use March 2015 attribution for claims paid in October 2014.

There are two reports (monthly and aggregated totals). Each report’s file contains a tab for each Payer (BCBSM, BCN, and Priority Health). The files are located in the <PO name>_G-Code_Reports_MiPCT_Overall_2014_10.zip file.

A Quick Reference Guide for these reports is available in the New Dashboard Reference Materials section of the MDC Support Page.

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:

MiPCT patients (especially patients who have experience with care managers)

Able to use their own experience constructively

Able to see beyond their own experience

Able to listen to and hear differing opinions

Member nominations are now being accepted HERE!

Following is a list of upcoming PAC Conference Calls:

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

New Registration Process: 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
  • 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)

As of today, the MiPCT CCM Course registration will be 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.*
    • The following 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. ( ex. Register for the May 4-7, 2015 course dates, and register for the May 4, 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.

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

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

Upcoming 2015 MiPCT CCM course dates:

May 4-7, 2015 – Introductory Webinar May 4, 2015

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

June 8-11, 2015 – Introductory Webinar June 8, 2015

  • June 8-9, 2015 – Total six hours of self-study modules and post-tests
  • June 10-11, 2015 – In-person training

July 6-9, 2015 – Introductory Webinar July 6, 2015

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

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

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

Stories of Your Care Management Success, featuring Becca Joostens RN, Grand Rapids Family Medicine, Spectrum Health Medical Group

Situation:

A forty-nine year old male MiPCT eligible patient (Medicare) was initially identified and screened for possible care management while reviewing scheduled provider appointments. The patient was had Diabetes type II and mental developmental delay contributing to poor compliance with diabetic medication adherence as evidenced by elevated A1c for his diabetes. After the initial screening and review of the medical records, the provider agreed that this patient was appropriate for care management.

Background:

Patient history includes morbid obesity, diabetes, HTN, hyperlipidemia, MRSA, sleep apnea, hypothyroidism, neuropathy and venous insufficiency. Patient was largely independent with ADLs and transportation, however needed extra time, care and attention paid to education and instructions. Patient had some housing difficulties; moving several times during the period of time he was actively working with the care manager. During the care management episode of care, the patient was admitted to the hospital for pneumonia with sputum positive for MRSA. Oxygen therapy had to be initiated and was part of the discharge plan.

Post discharge:

CT identified lymphadenopathy and a 6 month follow up scan was recommended. Care was coordinated with the sleep clinic and pulmonologist. The patient became highly engaged with care manager after a discussion regarding his morbid obesity and other chronic illnesses effecting lung capacity and increasing his needs for oxygen therapy.

Assessment:

The initial care management assessment revealed difficulty with insulin dosing and a poor understanding of diet and exercise and the role they play in the management of diabetes. The patient’s diet consisted of daily fast food meals which he was unwilling to give up because this was his social outlet. One challenge identified was the patient’s inability to read/comprehend blood glucose readings from his glucometer. Also revealed was the patient’s confusion about taking his thyroid medication because he could not read the label on the medication container.

Recommendation and Care Management Interventions and Plan:

Referral to Core Health, a Spectrum Health Home Based program, to reach patients in their homes who have diabetes. This program utilizes an RN and community health worker.

Close collaboration with Core Health regarding patient goals which were eventually met.

Coordination with pulmonology to titrate oxygen use and educate patient on CPAP use.

Continuous education on diet: nutritious snack options and avoiding high calorie / glycemic foods.

Self-management skill development: Patient brought medication containers to every appointment with care manager as frequent as once/ week until care manager and patient was confident in patient’s ability to manage medications.

Coordination with nephrology for recommended follow-up.

Coordination with the sleep clinic for recommended follow up for untreated sleep apnea.

Collaboration with on-site pharmacy regarding patient medication regimen. Adjustment of Lipid meds medication.

Education on skin integrity and risk for skin breakdown and infection related to diabetes, venous insufficiency and edema. Patient had a flea infestation in home for several months.

Goal Setting:

Decrease amount of snack food

Identify carbohydrate information in food and decrease intake at fast food

Increase exercise and problem solving related to reasonable exercises and overcoming barriers to exercise

Outcomes:

Weight loss

  • Starting weight on 6/12/2014: 379lbs
  • Most recent weight on 3/4/2015: 325lbs

Improved Blood Pressure:

  • Starting BP: 198/84
  • Recent BP (after 7 months) 126/68

Improved A1c:

  • Starting A1c on 5/30/2014: 8.4
  • Most recent A1c on 11/17/2014: 6.4  (This improvement was with no change in medication dosing— only changes in current regimen and lifestyle changes.)

Decreased Oxygen needs

  • Post hospitalization: 3 liters continuous
  • Current oxygen use: nocturnal use only with CPAP machine. Patient able to maintain 96% saturation when walking up 28 stair steps

Improved self confidence

  • Patient expressed to care manager that the PCP and care manager had given him the “excitement and confidence to be able to change.”
  • Patient now has excitement for learning new things about his meds and how he can improve his health.

Improved medication adherence and understanding. Diet improvement:

  • Only orders and eats salads when he goes to fast food restaurants.
  • Keeps crackers, popcorn and other health snacks in the Stopped drinking regular soda. Drinks flavored water instead.

Exercise

  • Walking around trailer park. Will walk in Lowes which is nearby his home and rides his bike in the park.

NEXT ISSUE DATES:

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

2015 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/.

September 2014 G-Code Reports Posted March 19, 2015

New G-code Reports for September 2014 were posted on the Download PO Reports page of the MiPCT Dashboard. The reports use February 2015 attribution for claims paid in September 2014.

Starting this month (March 2015), the report format has been updated. There are still two reports (monthly and aggregated totals), but there is now one file for each report, and each file contains a tab for each Payer (BCBSM, BCN, and Priority Health). The files are located in the <PO name>_GCode_Reports_MiPCT_Overall_2014_09.zip file.

A Quick Reference Guide for these reports is available in the New Dashboard Reference Materials section of the MDC Support Page (https://www.michigandatacollaborative.org/MDC/#/support).

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:

MiPCT patients (especially patients who have experience with care managers)

Able to use their own experience constructively

Able to see beyond their own experience

Able to listen to and hear differing opinions

Member nominations are now being accepted at:

https://jodyooo.wufoo.com/forms/patient-advisory-council-nomination-form/

Following is a list of upcoming PAC Conference Calls:

  • April 10, 2015, 1-2 PM
  • June 26, 2015, 1-2 PM
  • September 25, 2015, 1-2 PM
  • December 18, 2015, 1-2 PM

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

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/ .

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

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 http://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 http://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

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.”

NEXT ISSUE DATES:

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

March 9, 2015

SAVE THE DATES! MiPCT Regional Annual Summits

Your Opinion Counts

In response to evaluation responses for the 2014 Northern Summit which took place in Gaylord in October, we invited participants to provide feedback on the meeting structure they would like to see for the 2015 MiPCT Regional Annual Summit-North. The responses to that survey resulted in a tie.

On December 1, we send out a second request for responses to the survey to break the tie: 59% of the respondents prefer the 2014 approach: A 1 hour webinar/call with MiPCT leadership and a full afternoon of care manager training with clearer sound and better AV support. Many thanks for your feedback. As a result, we will follow the same format as last year, and will hold the 2015 MiPCT Summit North at the Crystal Mountain Resort in Thompsonville, located on the northwest region of the state.

We are pleased to announce the dates and venues for the 2015 MiPCT Regional Annual Summits:

  • Summit West – Grand Rapids, MI

Wednesday, September 16, 2015

Frederik Meijer Gardens and Sculpture Park

  • Summit North – Thompsonville, MI

Tuesday, October 20, 2015

Crystal Mountain Resort & Conference Center

  • Summit Southeast – Ann Arbor, MI

Thursday, October 29, 2015

University of Michigan NCRC

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
  • 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)

As of today, the MiPCT CCM Course registration will be 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 http://www.mipctdemo.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. ( ex. Registered 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.

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:

MiPCT patients (especially patients who have experience with care managers)

Able to use their own experience constructively

Able to see beyond their own experience

Able to listen to and hear differing opinions

Member nominations are now being accepted at:

https://jodyooo.wufoo.com/forms/patient-advisory-council-nomination-form/

Following is a list of upcoming PAC Conference Calls:

  • April 10, 2015, 1-2 PM
  • June 26, 2015, 1-2 PM
  • September 25, 2015, 1-2 PM
  • December 18, 2015, 1-2 PM

Stories of Your Care Management Success, Featuring Nancy Mantyk, RN, BA, CCM, Henry Ford East Jefferson, Henry Ford Health System, Medicare Patient

“Ms. C” is a 67 year-old female with well-controlled diabetes mellitus, anxiety and uncontrolled essential hypertension. Ms. C recently had an allergic reaction to her blood pressure medication, which led to a medication change. Prior to this reaction, her blood pressure was controlled. At this time, Ms. C was experiencing increased stress, due to caring for her 102-year old mother. Ultimately, her mother passed away.

The case manager had worked closely with the family during Ms. C’s mother’s illness, and had already built a trusting relationship with Ms. C while working with her mother. Services were coordinated, and support and educational interventions were provided to help Ms. C and her sister understand their mother’s chronic diseases, enabling them to manage her at home and help prevent ED visits and hospital stays.

When Ms. C began having health problems herself, she contacted the case manager directly for assistance. At that time she was grieving the loss of her mother and her brother. Ms. C. shared with the case manager that her brother passed away shortly after her mother. When her brother passed away, she stated, “The only thing wrong with him was his blood pressure.” Ms. C discussed with the case manager she was having anxiety and difficulty sleeping, which prompted her to contact the case manager. She would become anxious and stressed when her blood pressure dipped below 130/80. She was afraid her blood pressure would go too low during the night and as a result, would omit her blood pressure medications. Eventually she had an ED visit for uncontrolled blood pressure of 189/97.

Dr. Dizon, her primary care physician (PCP), and the case manager worked as a team to closely monitor Ms. C’s blood pressure, make medication adjustments and provide support and education to control her blood pressure. The case manager provided education on how sodium in the diet affects the blood pressure, a low-sodium diet, label-reading and other options to season her food to avoid sodium. She was taught how to correctly take her blood pressure, including parameters for normal readings, and was provided reassurance. Education on anxiety and the effect it can have on blood pressuring was also provided. Ms. C was educated on relaxation techniques and stress relief, as well as grief and loss. She was encouraged to see the nurse practitioner in the PCP office for counseling as well. Ms. C set goals, which included blood pressure control, to begin exercise classes, and to follow a low-sodium diet.

The “teach-back” method was used when instructing Ms. C on her plan of care and medication changes. Ms. C required and received ample assurance and support. At one point, she needed intensive case management with daily contacts. These calls were primarily centered on nutritional and emotional support, including reassurance related to her blood pressure medications, and encouragement to meet her goals to manage her blood pressure. For a time, she continued to struggle with anxiety, grief and loss. Ms. C would avoid talking about her mother and try to push the thoughts out of her head. Eventually, she became receptive to a referral for counseling for grief and loss. She was referred to the nurse practitioner in Integrated Depression Care for Primary Care.

Ms. C has benefited from the support, monitoring and education that case management provided, and is now able to self-manage her conditions. She and her sister go to exercise class 3-4 times each week. Ms. C is following her low-sodium diet, and her sleep has improved. She is taking her medication for anxiety, along with her blood pressure medications and is, “feeling better.”

Ms. C’s blood pressure is now stable at 115/66, and her diabetes remains controlled. She has not returned to the ED, and continues to follow-up with her PCP. Her own goals have been met.

In addition to the case manager, the other team members who were involved in the success of Ms. C’s care included Dr. Dizon, her PCP, and Carol Newton, CNP – Integrated Depression Care.

Dr. Dizon commented, “The care coordination with the case manager was very effective in helping manage the patient’s chronic medical conditions.” Ms. C commented on her care, stating, “Excellent, perfect, you helped me so much!”

NEXT ISSUE DATES:

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

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).

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:

MiPCT patients (especially patients who have experience with care managers)

Able to use their own experience constructively

Able to see beyond their own experience

Able to listen to and hear differing opinions

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

Following is a list of upcoming PAC Conference Calls:

  • April 10, 2015, 1-2 PM
  • June 26, 2015, 1-2 PM
  • September 25, 2015, 1-2 PM
  • December 18, 2015, 1-2 PM

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/ .

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

February 9, 2015

Achieving Team-Based Care

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 1:

  • 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 assessment2 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.
  1.  http://www.improvingprimarycare.org/
  2.  http://www.improvingprimarycare.org/assessment/full

Check Out the New Report Writer Included in Release 12.0 of the MDC Dashboard!

Have you tried the new Report Writer yet? The Report Writer enables you to select individual components from each Dashboard page to view and print in one report. Please check it out and let us know what you think!

You can access the Report Writer after you log on to the Dashboard by selecting PO Reports > Report Writer.

For additional details and instructions, see the Report Writer User Guide:

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

We will include updates and new features in upcoming enhancements or releases of the MiPCT Dashboard. To provide comments or suggestions, please contact MDC at MichiganDataCollaborative@umich.edu.

Resources for Starting Successful Patient and Family Advisor Programs

First, congratulations to the MiPCT practices that are participating in the MiPCT/GDAHC Voice of the Patient initiative. These practices received in-person training from the Institute for Patient and Family Centered Care and are leading the way in incorporating the patient perspective to improve both patient experience and engagement.

In addition, the Greater Detroit Area Health Council (GDAHC) and Michigan Primary Care Transformation Project (MiPCT) are seeking individuals who are interested in becoming knowledgeable about how to establish a successful Patient/Family Advisor (PFA) program in physician practices.

The attachment labeled “PFA Resources Fact Sheet” with this FLASH contains a menu of offerings of training and resources for individuals who would in turn agree to serve as expert consultants to help other practices who may be interested in establishing a Patient/Family Advisor program in the future. Both existing participants in the GDAHC/MiPCT Voice of the Patient initiative as well as others are invited to apply.

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.

Stories of Your Care Management Success, Featuring: Cynthia Buck RN, Complex Care Manager, Grand Valley Medical Specialists, PC, POWM

Cynthia Buck, RN is a MiPCT Complex Care Manager (CCM) at Grand Valley Medical Specialists, PC; affiliated with Physicians’ Organization of Western Michigan (POWM). She provides MiPCT care management service to both moderate and complex patients. Cynthia began working with “Debbie”, a 65 year old woman, in March of 2013 after she was referred for MiPCT care management services by her primary care provider (PCP). Debbie has Medicare insurance.

Debbie presented with a history of diabetes, cardiac disease, and has been bed-bound for years. She requires frequent lab work and finds it difficult to keep medical appointments because of limited mobility. She had been seen in the emergency department (ED) in the past and treated for a urinary tract infection (UTI) and dehydration. More recently, Debbie was seen in the ED for severe pain which was diagnosed as kidney stones.

During the initial MiPCT Care Manager meeting with Cynthia, the family reported Debbie’s care was too difficult for them to manage at home. Cynthia conferenced with the PCP and shared the family’s concern, and a referral for home health care services was made to evaluate Debbie’s status in home and obtain ordered lab work. In addition to home care services Cynthia began discussing a referral to a skilled nursing facility (SNF) for rehabilitation with the goal of increasing Debbie’s mobility and independence. Both Debbie and her family were receptive to short-term SNF placement.

Cynthia assisted the family in selecting a SNF that was able to manage Debbie’s bed-bound condition. Concurrently, she provided education and support to Debbie and her family as she was experiencing difficulty adjusting to her new environment due to ongoing urological problems. Cynthia also coordinated Debbie’s care between her family, the SNF, urologist’s office, and PCP.

The PCP and care manager discussed Debbie’s history of increased anxiety with new situations and history of cardiac infarction. Together they planned to have Cynthia contact Debbie every other day initially by phone to help reduce her stress through education, support and answering questions.

Cynthia contacted the personnel at the SNF and requested that they attend a care team conference for Debbie. During the care team conference Cynthia learned the SNF team was planning to discharge Debbie the following week. Her medical status was not improving and she was not participating in physical therapy (PT).

Cynthia observed Debbie often had low blood sugars and considered the low blood sugars as contributing to the patient’s difficulty in participating in physical therapy. Debbie was upset about the planned SNF discharge because she wanted to continue to work towards her goals. Her short-term goal was to be able to transfer from bed to wheelchair independently, and her long-term goal was to walk again.

Debbie remained very motivated to work in physical therapy and knew she could improve her participation if her blood sugars were more controlled. The SNF team considered the new information Cynthia shared and agreed to hold the planned discharge and continue to work with Debbie on achieving her self-management goals.

Soon, improvement in Debbie’s mobility was noted. She was able to transfer from bed to wheel chair independently and walk 78 steps with a walker! Her husband stated, “We are finally on our way!”

By July, Debbie was able to transfer from bed to wheelchair and from wheelchair to bed independently. She could ambulate 325 feet with a walker and was ready to return home. Cynthia assisted the patient and family in planning for Debbie’s discharge. Debbie was discharged home with orders for home care skilled nursing and physical therapy.

Cynthia contacted Debbie by phone once she returned to her home. Debbie shared she continued to work with the physical therapist at home and remained motivated to maintain her mobility. She still could not believe the progress she made and was very glad to be back in her home.

NEXT ISSUE DATES:

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

January 26, 2015

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

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 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.

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 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.

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/

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

January 12, 2015

24-Month Incentive Update

We are pleased to announce that the incentive appeal process is complete and both scores and payment have been finalized. The Medicare portion of the incentive payment should be distributed by January 31st. The Medicaid incentive payment amounts will be available soon and will be incorporated into the quarterly Medicaid payment cycle, and the payment report that includes both the Medicare and Medicaid incentives will be uploaded to the MDC dashboards.

MiPCT Dashboard Release 12.0 Coming Soon!

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

  • Paid claims and eligibility data through September 2014
  • An updated measurement period of July 1, 2013 through June 30, 2014

We will send an email to notify users and provide additional details on release day.

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

MiPCT Care Manager 2015 Webinars — New Webinar Registration Process

In the spirit of continuous improvement, we have updated the MiPCT Care Manager Webinar registration process for 2015. The old MiPCT Care Manager Webinar registration steps relied on a process where tentative dates were sent out to people’s calendars. The new webinar registration steps are based on a process where each individual has the ability to choose the webinars they wish to attend.

Individuals will need to register for the 2015 MiPCT Care Manager Webinar they wish to attend. The new process will ensure you have current dates and times for each scheduled MiPCT Care Manager Webinar. The webinar events will no longer be sent to your calendars.

MiPCT Care Manager Webinar titles, dates, and times will be announced in the FLASH. You may register using the following two methods, starting with this issue of the FLASH. Please find notification of scheduled MiPCT Care Manager Webinars and links for registration below:

On the www.mipct.org web site:  https://mipct.org/care-manager-webinar-conference-call-calendar/

By e-mail notification which will contain a MiPCT Care Manager Webinar Registration link.

The MiPCT website has a calendar with the upcoming Care Manager Webinar titles, dates and times to assist you in planning for future MiPCT Care Manager webinars of interest https://mipct.org/care-manager-webinar-conference-call-calendar/.

If you have any questions, please submit to mipctdemo@michigan.gov

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 Kathy Gouvea, RN, Grand Valley Internal Medicine, Spectrum Health Medical Group

Kathy Gouvea, RN, is a Certified Diabetic Educator (CDE) and Hybrid Care Manager at Grand Valley Internal Medicine (GVIM). In her role, she provides care management services to the diabetic population of this busy internal medicine practice.

“Pat” was a direct referral from the physician subsequent to having labs completed and noted to have an elevated A1C value of 11.4. The referral was via a warm hand-off completed the same day as the primary care provider (PCP) appointment. Kathy screened Pat for appropriateness for care management after receiving the referral. She reviewed and verified Pat’s Priority Health insurance coverage for Care Management service. Kathy explained care management services to Pat who in turn agreed to participate in care management.

Initially, Pat’s knowledge of his diagnosis and readiness to participate in managing his care were assessed. Based on these findings, Kathy and Pat agreed to a plan of care centered on improving diabetic outcomes, achievable and consistent with his care goals.

The primary barrier identified was a knowledge deficit of diabetes and the inability to “fit” the condition into Pat’s everyday life. Kathy began educating Pat in conjunction with the following short term goals:

  • Understand the relationship of diet and exercise to A1C and blood sugar results
  • Use the V-Go 20 insulin device

They also identified the following long-term goal:

  • Decrease A1C by 5 points or below 6

Kathy recognized Pat’s progress as a result of care management when he demonstrated confidence in his ability to directly access the practice team when needed and identify the care manager as an extension of the physician. After four months of telephonic and face-to-face visits, Pat achieved his long-term clinical goal, an A1C below 6. While receiving care management services Kathy educated and empowered Pat in self-management focused on carb counting, insulin adjustment and improved confidence with blood sugar testing. Pat is no longer receiving care management services due to his ability to demonstrate successful self- management of his medical needs.

NEXT ISSUE DATES:

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

Upcoming PO FLASH Issues:

  • Please see 2016 PO FLASH page