2014 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 22, 2014

New MiPCT Co-Director!

One of the MiPCT’s three Co-Directors, Carol Callaghan, will be retiring at end of this month after working more than 40 years for the state in the Michigan Department of Community Health. She will be missed!

Taking over as Co-Director will be Sue Moran, Senior Deputy Director of MDCH’s Public Health Administration, formerly with the MDCH Medicaid Program. Sue can be reached via the MiPCT mailbox at MiPCTDemo@michigan.gov. Please join us in welcoming Sue to the MiPCT Leadership group!

24-Month Incentive Update

The 24 month incentive metric scores have been finalized and payment reports will be submitted to payers at the end of December for payment in late December or early January. We did find an issue with a registry vendor which resulted in six POs gaining additional registry points and a slight shift in PO rankings.

Care Manager Sufficiency Ratio for 2015

In 2014, the Care Manager sufficiency ratio was calculated without Priority members included, pending an assessment of membership distribution and care management sufficiency experience. The majority of POs at this point now meet the requirement with Priority members included. Hence, 2015 sufficiency rates will be calculated including Priority Health members.

Updated FAQ from CMS on the New Chronic Care Management (CCM) Code

Since the last FLASH, CMS has issued an update to their original FAQ regarding the use of the Chronic Care Management code for non-face-to-face care coordination (CCM) . Medicare will use CPT code 99490 to operationalize the new code. The updated FAQ provides additional detail about its interface with the MAPCP (Multipayer Advanced Primary Care Practice) program of which the MiPCT practices are a part.

The FAQ provides additional information about when practices can bill the CCM codes and when they cannot. In brief, MAPCP payment (i.e. the $9.50 PMPM equivalent for attributed Medicare members) and CPT code 99490 for Medicare are mutually exclusive for any given beneficiary for any given month.

Key themes in the updated FAQ include that:

• Practices should not assume that because they participate in MAPCP programs that they meet the requirements for billing the 99490 code.

• Practices can bill for nonattributed members. CCM payment will be recouped if billed for a patient that has been attributed (i.e. the Medicare members on the multipayer list).

• Because the new code requires demonstration of patient consent, CMS will give it priority over an MAPCP payment.

• If a practice bills a CCM code for a nonattributed member, CMS will consider this in future attribution. Thus over time, nonattributed patients for whom the new CCM code are billed will become attributed over time.

• If several practices (speciality or primary) bill the new code for the same patient in a time period, payment is issued to the practice that successfully bills first.

Care Managers Encouraged to Target ED Overuse

MiPCT Care Managers are encouraged to reach out to eligible patients that have high rates of emergency department utilization.

On the monthly patient lists, there are flags for the number of ED visits in the last 6 months, the number of ED visits in the last 12 months, and the estimated number of potentially avoidable ED visits within the previous 12 month period (as defined by an algorithm developed by New York University). Care Managers and physicians are encouraged to use these data fields to determine which patients may be using the emergency department at a high rate, to address overutilization and/or inappropriate use of emergency room services.

MiPCT Complex Care Management Course

The registration for the January 5-8, 2015 MiPCT CCM course will be closed for new registrations on December 29, 2014 at 5PM due to the holiday schedule. If you have candidates for the January CCM please register the candidates before the close of registration at 5pm on December 29, 2014.

To register please go to: https://jodyooo.wufoo.com/forms/january-58-2015-mipct-ccm-training/. Once a candidate registers, automated emails will sent to the email listed on the registration with further instructions on the course including times, location and parking.

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

 

Upcoming 2015 MiPCT CCM course dates:

January 5-8, 2015 – Introductory Webinar Jan. 5

• January 5-6, 2015 – Total six hours of self-study modules and post-tests

• January 7-8, 2015 – In-person training

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

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

Stories of Your Care Management Success, Featuring Anita Tuneff, Moderate Care Manager, IHA, IHA-Milan Family Medicine

A Medicare patient LS was originally enrolled in MiPCT Complex Care Management 4/1/13 following a hospital admission for Metabolic Encephalopathy. Although LS developed a good relationship with a Complex Care Manager she did not seem to understand the importance of better blood sugar control. Her A1c was 13.2 and she was not ready to make any life style changes.

LS was transferred from the MiPCT Complex Care Manager to Anita, a moderate care manager for Diabetes self- management. LS was always friendly, but very indifferent when discussing changes to improve her health. She was repeatedly “too busy” and was not eating meals or taking her medications regularly. The patient eventually stopped responding to Anita’s calls and the case was closed to care management on 12/12/13.

On 5/20/14 LS was re-enrolled in care management by Anita with an A1c of 16.0 after a referral from her PCP. The patient was very friendly and willing to engage with Anita, but did not seem motivated to make healthy changes. LS did not understand the implications of elevated blood sugars, and shared she was “very busy”. She expressed she did not always like to come to the PCP office, because she felt her PCP “yelled at her”, even though her PCP was always very gentle in her discussions regarding the importance of better blood sugar control.

The patient’s medical record indicated that LS should be checking her blood sugar four times a day, taking insulin with meals and additional oral diabetic medications. LS freely admitted she was not following any of her PCP’s orders.

On 5/23/14 LS was admitted to the hospital for confusion, CVA, and uncontrolled DM. This hospitalization was the turning point for the patient. She finally realized her uncontrolled blood sugars had major implications on her health.

Once LS was discharged from the hospital her family became involved in her care. With coaching from Anita the patient’s daughter began helping her with meal planning and regularly scheduled meals. Her husband began to support LS also.

The care manager continued to provide diabetic education and LS soon realized she could control her blood sugars if she followed a diabetic diet and took her medications regularly. LS followed up with her Endocrinologist and medication adjustments were made.

Anita continued to provide LS with regular visits to answer questions, help coordinate care, and continue to provide education on Diabetes and A1c results. Anita provided educational materials which included, medication information, patient resources, information about hyper and hypoglycemia, meal planning, and managing sick days. Anita provided ongoing support and congratulated her on the improvements she was making.

Today the patient’s A1C is 6.1. She is administering her insulin as ordered. Due to her controlled blood sugar LS has decreased the amount of blood sugar checks from four times a day to twice a day.

LS continues to actively manage her health as evidenced by her Ophthalmologist visit, controlled BP, and maintenance of a log where she records her blood sugars and blood pressures which she brings to every PCP appointment. Since LS has been successful in controlling her blood sugar, she now feels empowered and motivated to reach another health goal of losing five pounds in the next month.

As the patient’s health status stabilized Anita provided a contact person in the office other than herself who could answer patient questions knowing the care manager was always available as a resource if needed. Anita focused on the things LS was doing and not on the things she was not doing. The care manager’s consistent interventions and supportive relationship made LS more willing to contact the office and accept PCP and practice team care management. As a result, the patient’s overall health has improved and she is now able to manage her health.

NEXT ISSUE DATES:

• Next MiPCT P.O. FLASH Issue: January 12, 2015

• Next MiPCT Practice FLASH Issue: January 26, 2015

 

December 8, 2014

Q&A Document Issued on New Non-Face-to-Face CMS Code

CMS has issued a FAQ guidance document (attached) regarding the new Chronic Care Management non-face-to-face code and how it will work for providers in the MiPCT and the sister projects in other states in the multipayer demonstration. Many of the questions in the FAQ were covered at the demonstration extension discussion at the summits. For example, MiPCT participants cannot bill the new code for attributed Medicare patients on the member list, but can bill for nonattributed Medicare members. However, CMS further conveys in the new guidance that if a MiPCT provider bills a CCM code for a nonattributed patient, that CMS will prioritize the claim for the purpose of attribution, making it more likely that the previously unattributed patient would become an attributed member for the MiPCT practice.

MiPCT Dashboard Release 11.0 Coming Soon!

MDC expects to launch Release 11.0 of the new Dashboard this month. It includes the following:

  • A new Depression Screening Clinical Quality Measure
  • Paid claims and eligibility data through June 2014
  • An updated measurement period of May 1, 2013 through April 30, 2014

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

Important! We are providing the Depression Screening data so you can review it prior to the 30-month incentives release. Please review this data and let MDC know if anything seems out of the ordinary. It is important for MDC to

receive feedback on all incentive-related measures found in the dashboard prior to the calculation of incentives. Additional details will be included in the 11.0 release notes.

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

MichiganDataCollaborative@umich.edu.

MiPCT Patient Experience Survey: Coming January 2015

Recognizing that the demands of the holiday season may hinder participation, the launch date of the MiPCT patient experience survey has been delayed until January 2015. 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. Nearly 28,000 surveys will be mailed to patients from MiPCT and non-MiPCT comparison practices. 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 Complex Care Management Course

The 2014 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 January 5-8, 2015 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/january-58-2015-mipct-ccm-training/

Upcoming 2015 MiPCT CCM course dates:

January 5-8, 2015 – Introductory Webinar Jan. 5

• January 5-6, 2015 – Total six hours of self-study modules and post-tests

• January 7-8, 2015 – In-person training

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

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

Stories of Your Care Management Success

Featuring Novella Lanzanas, RN, BSN, Henry Ford Medical Center-Warren

“Marcie” is a patient with uncontrolled diabetes with HgA1C between 12.9 and 15.0 from February 2012 to March 2013. She does not tolerate Metformin and was only on Glyburide 10mg twice daily. She refused insulin multiple times in the past.

Marcie was identified from the MiPCT List from her elevated HgA1C. The patient’s HgA1C in March 2013 was 15.0. She once was prescribed Metformin, but had side effects so she only took Glyburide 10mg BID.

The care manager made the initial Case Manager outreach to Marcie in August 2013 at which time she introduced herself, her role and spoke with Marcie about her understanding of diabetes and its complications. Marcie shared, “Oh I know what it is. My husband died from complications of diabetes at 53.” She went on to say, “I am having lunch with my friends right now, so I have to go.” The care manager inquired if she could call Marcie another time. Marcie, stated, “You can try. I work 2 jobs and I’m very busy.” The care manager thought she could help Marcie with insulin readiness to control her diabetes by using motivational interviewing and education.

A few weeks later the care manager saw Marcie was scheduled for an office visit with her primary care physician for abdominal pain and took the opportunity to meet with her face to face. Marcie’s morning blood sugars were usually running between 300 and 400. She was only checking blood sugars once every couple of weeks and had some recent readings close to 500. Marcie works as a cashier at a gas station where candy bars are easily accessible throughout her work day. She admitted she knew she should avoid eating candy bars. When Marcie was questioned about controlling her diabetes, she voiced opposition to using insulin. The care manager continued to assess her knowledge of a diabetic diet and offered medical nutrition services. Marcie agreed to see a dietician.

Late in September 2013, Marcie met with a dietician. Afterward, she decided to make some diet changes and see how these changes impact her blood sugars. She also began monitoring her blood sugars almost every day but only when home and not traveling. Marcie typically travels 1 to 2 weeks at a time 3 to 4 times per year. During a visit with Marcie the care manager reinforced the importance of consistent blood sugar monitoring. Marcie developed a care plan goal of improving the consistency of blood sugar monitoring and maintaining a diabetic diet.

Two months passed before Marie spoke with her care manager again. The patient reported her diet consisted of more salads and fish. Her blood sugar ranges decreased from 300 and 400 to blood sugar readings between 200 and 300. Marcie understood there was still room for improvement. The Care Manager introduced the use of insulin as a treatment option again. This time Marcie replied, “I am seriously thinking about it now.”

The care manager scheduled a face to face appointment with Marcie the following week. Through motivational interviewing she learned Marcie is a widow with grown children and that her ability to continue to travel was her motivating factor. Marcie realized in order to travel more she would need to be healthier. She agreed to the use of insulin. Before she left the clinic an order for Lantus was sent to her pharmacy and Marcie participated in an insulin administration demonstration. The care manager closely monitored Marcie’s response to insulin until her blood sugars stabilized with the use of 20 units of Lantus daily. In April 2014, Marcie’s HgA1C had improved from 15.0 to 8.1. The PCP commented, “Tremendous success. I tried more than a year to get the patient started on insulin.”

The patient’s HgA1C improved through self- management of her diabetes with the use of insulin and glyburide daily, an improved diet and increased activity. Marcie stated, “I could not believe I waited this long to start insulin. I’m so happy with my success. It makes me feel good! I told my daughter, my care manager is wonderful and she helped me a lot, I could call anytime.”

Update: This patient was discharged to care management when her HgA1C was down to 8.1. The Care Manager was confident the patient would continue to pursue her health goals and continue to self-manage her diabetes. Marcie continues to follow up with PCP. Her HgA1C continued to decline; it was 7.6 in June 2014, and 6.4 in October 2014.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: December 22, 2014
  • Next MiPCT Practice FLASH Issue: December 22, 2014

 November 17, 2014

PO Visioning Meeting Recap

Over 50 PO leaders attended the in-person PO visioning meeting on November 4. To start the meeting, we discussed the PO survey results (which incorporated input from POs that could not attend the meeting). The survey results recap is attached in a PowerPoint file to this FLASH edition (PO Visioning Survey Results). Highlights included that:

  • The vast majority of POs view embedded care management as central to their long term strategy and intend to continue beyond 2016
  • Registry and data support, increasing G and CPT code volumes, and expanding the number of participating payers are the top three items recommended as 2015 priorities
  • Most practices intend to continue MiPCT participation in 2015

Additionally, a brief recap of the summary level provider survey results were also discussed, as were proposed changes to the 2015 MDCH /PO/Practice contracts. (Also recapped on the attached PowerPoint presentation).

A capture of key themes of the resulting discussion and PO leader input is also included on the attached MS Word file (PO Visioning Session – Summary of Key Themes). Our great thanks to those who attended in person and to those who provided feedback on the survey.

24-Month Incentive Update

MiPCT and the MDC are still working to address concerns raised by POs during the one-week review period. We will update POs once the final scores and payment amounts are calculated. We do not expect any significant changes in scores or rankings.

MiPCT Patient Experience Survey: Coming Soon!

As part of the evaluation of MiPCT, we will be conducting a patient experience survey from December 2014 through February 2015. 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 the 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. Over 27,000 surveys will be mailed to patients from MiPCT and non-MiPCT comparison practices. 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).

2014 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 by November 28 for activities occurring before the end of 2014.

You will find the MiPCT Learning Activity Approval Form at

https://mipct.org/resources/mipct-documents-and-presentations/mipct-learning-activity-approval-form-2-19-2013/. Practice learning activities will be reported in January on the Q4 MiPCT Supplemental Narrative Report and your approved learning activities will be pre-populated in this template.

MiPCT Complex Care Management Course

The 2014 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 December 8-11, 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/december-811-2014-mipct-ccm-training/

Upcoming 2015 MiPCT CCM course dates:

January 5-8, 2015 – Introductory Webinar Jan. 5

  • January 5-6, 2015 – Total six hours of self-study modules and post-tests
  • January 7-8, 2015 – In-person training

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

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

Stories of Your Care Management Success

  •  Becki Strawderman, RN, HCM, Otsego Memorial Group, CIPA, and
  •  Lori Lynn, RN, HCM, Cherry Street, CIPA

Becki, a MiPCT HCM, was contacted to assist in care coordination of a Medicare patient who lived in Lewiston and had been treated at Otsego Memorial Hospital (OMH) after sustaining several fractured ribs, pneumothorax, and leg injury from a fall off a ladder. The 65 y/o patient had spent 9 days in OMH when he was discharged and released to the care of his family (brother and sister-in-law) in Grand Rapids, four hours from his home in Lewiston. During his convalescense with his family in Grand Rapids, MI he developed complications, which included bilateral pulmonary embolisms, a pleural effusion, bilateral deep vein thrombus and urinary retention. After an eight day inpatient stay in a Grand Rapids hospital the patient was released again to his family living in Grand Rapids to convalesce. He suffered further complications, and again had to be readmitted for sepsis and bilateral pleural effusion. The patient had spent 29 days out of 37 days in the hospital.

It was evident that the patient’s health was too fragile for him to return to his home in Lewiston, MI. Therefore, a discharge plan inclusive of follow-up care in Grand Rapids would require additional care coordination as the patient’s primary care provider was located four hours away. The patient was discharged from the hospital and follow up care arranged at a MiPCT practice, Cherry Street, in Grand Rapids. Becki contacted Lori, the HCM at the Cherry Street practice and provided a care update to help facilitate a comprehensive post-hospital transition.

Lori and the practice team from Cherry Street collaborated with Becki from the Otsego Memorial Group while providing transition of care follow-up, and at the Cherry Street Practice in Grand Rapids, while the patient convalesced with his family.

Two months after his last discharge from the Grand Rapids hospital the patient was well enough to return to his home in Lewiston. The Cherry Street team provided the patient copies of his medical record in lieu of mailing it to his primary care physician. This was done in case the patient had to stop on his return to Lewiston for any needed care.

Becki was grateful for the coordination of care provided by the Cherry Street practice team. In turn, Lori and the practice team were proud of the patient’s favorable outcome and thankful for the patient’s uneventful trip home to Lewiston, MI.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: December 8, 2014
  • Next MiPCT Practice FLASH Issue: November 24, 2014

October 20, 2014

Reminder: 2014 MiPCT Summit Evaluations Due October 24

Many thanks for attending the 2014 MiPCT Regional Annual Summits in Gaylord, Ann Arbor and Grand Rapids this month! Please take a moment to share your thoughts on the Summit with us on the Online Evaluation form. To complete the evaluation, go tohttps://mipct.org/annual-summit-evaluation/. The password for the page is “2015andbeyond”. All lower case, with no spaces. Once on the page, you will see a page that looks like the adjacent screenshot. Just click on the link for the session you attended. If you have earned CE Nursing Credits, once you complete the Afternoon Evaluation form, your certificate will be available both on your screen as a link, as well as in your email. Please complete your evaluation by October 24.

November 4th MiPCT PO Visioning Meeting  in Lansing

On Tuesday, November 4th, an MiPCT PO Visioning Meeting will be held at MSMS (120 W Saginaw St, East Lansing) from 2:30 to 4:30 pm in the Boardroom. All PO Leaders are invited. Though in-person attendance is encouraged, a dial-in will also be available for those who cannot travel. The goal of the meeting will be to solicit PO input about 2015 MiPCT initiatives and design. Watch your email for an Outlook notice and a pre-meeting survey to collect participant ideas and suggestions. Those planning to participate will be asked to RSVP by October 31.

24 Month Incentive Update

The 24 month incentive payments are still on track to be paid out in November 2014. Scores will be released for PO review shortly. As usual, POs will have one week to review incentive scores before payments are calculated. If you have any questions, please contact Amanda First at afirst@med.umich.edu.

October 30th Deadline for Obtaining Practice Learning Credits for Summit Virtual Team Participation and Webinar Chat Q/A Follow-Up Document

Practice teams (a physician, care manager and one other team member) who used the Summit webinar viewing option (either real-time or by watching the recording), or who sent part of the team to a Summit in-person session with others participating virtually, the deadline for submitting minutes of team discussion is nearing.

To obtain the four (4) Practice Learning Credits for teams that participated (all or in part) virtually, if you have not done so yet, please submit minutes of meaningful team discussion regarding the Summit key take-away points that your practice can use by October 30, 2014 to mipctdemo@michigan.gov. The subject line should say: “Summit Practice Team Minutes” and include the practice’s name and PO affiliation. (The recorded webinar is available on the mipctdemo.org website at: https://mipct.org/resources/presentations/)

This applies to practice teams that:

  • Registered for and viewed the live webinar link, and watched the live webinar as a team; or
  • Viewed the recorded webinar as a team; or
  • Sent part of their team to an in-person Summit session, and had the others view by webinar.

On a related note, a Q/A sheet is attached for questions posed on the webinar chat questions that did not get addressed during the Summit. Please note that additional information on the resources that Elizabeth Hertel discussed is included.

October 2014 BCBSM Billing Road Show – Summary of Questions and Answers

BCBSM conducted in-person Billing Road Show meetings throughout the summer of 2014. As a result of questions raised during these sessions, BCBSM has gathered these questions along with answers and created a summary document.

Attached please find the 2014 Billing Road Show Document and the BCBSM Commercial PDCM Billing presentation. You can also access these documents via https://mipct.org/resources/mipct-documents-and-presentations/

PCPCC Learning Event: Patient-Centered Best Practices October 23, Noon – 1PM

Join the PCPCC Center for Care Delivery and Integration on Thursday, October 23rd at Noon ET to learn how two very different primary care practices approached their transformation to a patient-centered medical home and employed new strategies to improve outcomes for their patients, especially those with diabetes.

These practices are among the 52 practices in the Maryland Multi-payer PCMH Pilot (MMPP), which Discern administers for the Maryland Health Care Commission.

Register at: https://www1.gotomeeting.com/register/918495968

MDC’s October 2014 MiPCT All-Payer Patient Lists to be Posted This Week

The Michigan Data Collaborative will post the October 2014 MiPCT All-Payer Patient Lists this week. An email announcing the release will be sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports page of the MiPCT Dashboard. The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_10.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).

MiPCT Complex Care Management Course

The 2014 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 November 10-13, 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/november1013-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM course dates:

  • November 10-13, 2014 – Introductory Webinar Nov. 10
    • November 10-11, 2014 – Total six hours of self-study modules and post-tests
    • November 12-13, 2014 – In person training
  • December 8-11, 2014 – Introductory Webinar Dec. 8
    • December 8-9, 2014 – Total six hours of self-study modules and post-tests
    • December 10-11, 2014 – 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. The programs listed below include information regarding course date/criteria to schedule.

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

Stories of Your Care Management Success: Featuring Karen McWilliams, RN, HCM, Lakeshore Medical Center-Shelby, Lakeshore Health Network

Karen McWilliams, RN, is a Hybrid Care Manager at Lakeshore Medical Center-Shelby within Lakeshore Health Network. Karen was working with a patient covered by BCBSM insurance. He is a 67 year old male with Benign Prostatic Hypertrophy (BPH), Hypertension (HTN), Gout, and Hypercholesterolemia. The patient’s Prostate-Specific Antigen (PSA) was being monitored and took a sudden jump in July of 2013. He consulted with an Urologist in Muskegon and had surgery for Prostate cancer in July of 2013. Following his discharge he received a call from Karen.

He accepted care manager services the first month after his surgery. Within a couple of weeks of surgery he developed some complications. These included elevated blood pressure, anxiety, depression, development of a fistula, and urinary catheter. The fistula resulted in further surgeries including a colostomy and subsequent reverse colostomy. He continued with care management during this time. He and his wife describe care management as their “lifeline”.

Karen was able to help coordinate services with the urologist in Muskegon, Gastroenterologist in Grand Rapids, Cardiologist in Lansing, home care nurses and ostomy nurse. She coordinated lab work and preoperative procedures, performed medication reconciliation after each procedure, confirmed discharge orders after each procedure, and encouraged healthy behaviors to promote optimal healing. Karen even assisted the patient in preparing to go hunting safely with his urinary catheter and colostomy. He was able to take numerous trips to the other side of the state to his cottage because as he stated, “I have my connection with my care manager [Karen] if I need anything”.

His surgical incisions healed without complications and his chronic conditions remained stable throughout his recovery. Blood Pressure stabilization and a healthy diet promoted optimal healing. His depression and anxiety improved with treatment. Ultimately, his colostomy was reversed and is now well healed. On February 13, 2014 Karen and the patient met face to face for the first time when his PCP gave him the good news that his labs showed his PSA was <0.01.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: November 10, 2014
  • Next MiPCT Practice FLASH Issue: November 24, 2014

October 6, 2014

GREAT NEWS: The MiPCT Has Been Extended by CMS Through 2016!

The MiPCT received official notice on September 24, 2014 that CMS’ participation in the demonstration will continue through December 31, 2016. This means that:

  • The current Medicare payment structure ($9.50 PMPM) would continue as it is structured now (e.g., incentive, practice transformation and care management components)
  • POs (in cooperation with their practices) would continue to sign participation agreements with MDCH.
  • The CMS national evaluation with RTI will cover the 2012-14 period, and the MPHI state evaluation will cover the entire five year (2012-2016) period.

The annual summits this week will provide fuller detail regarding what is known to date. We are tremendously excited by the announcement and look forward to together continuing to shape the future of primary care in our state and in our nation.

The PO Visioning meeting that was discussed earlier in the year (but was postponed until a final decision was made by CMS regarding extension), is now being rescheduled.

RTI (Our Federal Evaluator) to Again Conduct Stakeholder Interviews

CMS has contracted with RTI, the Urban Institute, the National Academy for State Health Policy (NASHP), and the Henne Group to evaluate the impacts of Medicare and Medicaid’s participation in the MiPCT. Researchers from these organizations plan to visit our state November 12th-14th to interview key people involved in this initiative. The federal evaluators may have contacted you last year about participating in an interview during their last site visits in October and November 2013.

A member of the RTI evaluation team, Lexie Grove, may contact you in the coming weeks to request an interview. If you are approached about being interviewed, we hope you will make time to speak with these researchers. In an effort to minimize inconvenience to you, evaluators will schedule interviews at a place and time that is convenient for you (for
example, at your practice before it opens, after it closes, or during your lunch break).

The purpose of the interviews is to learn more about how you deliver care. For example, the researchers might ask you about your Care Manager(s), how you use health IT, or what changes you have recently made to your practice. They might also ask how you are using the Medicare payments, and about the impact you think any practice changes are
having on your patients.

Earlier in the year, you may have been contacted by the federal evaluators requesting your assistance in setting up focus groups that will be conducted with Medicare and Medicaid patients. The purpose of the focus groups is to learn more about patients’ experience with care provided as part of MiPCT. The interview request is separate from any previous requests you may have received regarding focus groups.

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

Able to listen to and hear differing opinions

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

The next PAC conference call will be held: Friday, 12/12/2014 at 1:00 PM.

BCBSM Wellness & Care Management Programs Webinar Rescheduled to October 21

The webinar about BCBSM Wellness and Care Management programs, previously scheduled for 9/18, has been rescheduled for Tuesday, October 21st, from 1 to 2 p.m. Please mark your calendars! At this webinar, BCBSM employees will discuss care management and case management resources that are available for practices to use in managing BCBSM patients who aren’t eligible for MiPCT.

To attend, simply follow these instructions at the time of the event:

To join the webinar:
1.     Go to https://bcbsm.webex.com/bcbsm/j.php?J=737844372&PW=67935ad6df5a585c0d
2.     If you are not logged in, log in to your account.
Meeting Number: 737 844 372
Meeting Password: 1234

To dial into the call:
1.     Please call: Toll-Free: 1-800-4625837
2.     Follow the instructions that you hear on the phone. Cisco Unified MeetingPlace meeting ID: 737 844 372

Recap of BCBSM PDCM Billing Road Show Webinars

Many questions were posed during the recent BSBCM PDCM Billing Road Shows held throughout the state.  In an effort to consistently communicate the same information to all MiPCT participants, there will be a webinar session on October 13, 2014.  The purpose of this webinar will be to share all the questions and corresponding answers discussed and to provide the participants with an opportunity to ask additional questions.   The login information follows:

October 13, 2014 – 9:00 – 11:00 a.m.
Meeting Number:     737 936 161
Meeting Password:     pdcm

To start this meeting

  1. Go to https://bcbsm.webex.com/bcbsm/j.php?J=737936161&PW=67935ad6df1b0e0c54
  2. If you are not logged in, log in to your account.
  3. Teleconference information
  4. Please call one of the following numbers:
    Toll-Free: 1-800-4625837
    Local: 1-313-2254000

Follow the instructions that you hear on the phone. Cisco Unified MeetingPlace meeting ID: 737 936 161

MiPCT Complex Care Management Course

The 2014 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 October 13-16, 2014 MiPCT CCM course at the following site:  https://jodyooo.wufoo.com/forms/october-1316-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM course dates:
October 13-16, 2014  – Introductory Webinar October 13
•    October 13-14, 2014 – Total six hours of self-study modules and post-tests
•    October 15-16, 2014 – In person training

November 10-13, 2014 – Introductory Webinar Nov. 10
•    November 10-11, 2014 – Total six hours of self-study modules and post-tests
•    November 12-13, 2014 – In person training

December 8-11, 2014 – Introductory Webinar Dec. 8
•    December 8-9, 2014 – Total six hours of self-study modules and post-tests
•    December 10-11, 2014 – In person training

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

MiPCT Dashboard Updates

MDC posted Enhancement 10.01 of the MiPCT Dashboard on September 30th. With this Enhancement, the Breast Cancer Screening and Cervical Cancer Screening Clinical Quality Measures (CQMs) are now supplemented with clinical data from Electronic Health Records (EHRs) submitted by the MiPCT POs. So far, 36 out of 37 POs have successfully submitted their EHR data to support the data.

Below is a summary and clarification of the two types of measures using EHR data:

On the Dashboard’s Quality Page, you’ll find Clinical Quality Measures with supplemented numerators and denominators. These measures are the claims-based measures you are familiar with, supplemented with data from each PO’s EHR. The supplemental data either increases the numerator (by finding evidence of a test that does not already have a claim in our database) or decreases the denominator (through exclusionary information such as mastectomies for the Breast Cancer Screening).  The overall effect is to increase rates by approximately two percent.

Also on the Dashboard’s Quality Page is a second table with Electronic Clinical Quality Measures (eCQMs), which are the Clinical Quality Measures that use both EHR data and claims data to create rates. These differ from the supplemented CQMs in that they have numerators that are exclusively created with clinical data from the MiPCT PO EHRs. Combining clinical and claims data is an important step to attempt to quantify the quality of care received by the MiPCT population.

Let us know how you use this data going forward by contacting MDC at MichiganDataCollaborative@med.umich.edu. We appreciate your feedback!

Stories of Your Care Management Success, Featuring Susan Carsten, LMSW, HCM, Mason Pediatrics

Susan Carsten LMSW is a Hybrid Care Manager at Mason Pediatrics in Lansing.  Dr. Resnick referred a patient to Susan with the request to help the patient “Mary” and her mother due to a concern of possible school expulsion. Mary has a diagnosis of Attention Deficit Hyperactivity Disorder and Susan agreed that Mary could benefit from MiPCT Care Management Services.

The patient and her mother were scheduled to appear before the school board for a hearing. Mary was going to be expelled from school because of threatening harm to other students who were reportedly bullying her. Mary and her family were homeless recently.  She was experiencing difficulty in dealing with her emotions and feelings.  Mary was routinely seeing a behavioral health therapist.  In addition, Mary had been referred to PAR Rehabilitation services for a complete evaluation of her needs.

Susan had determined the short term goal for Mary was to avoid from being expelled from school.  Susan attended the school board meeting where the hearing focused on whether to expel Mary from school due to a third violation of school policy for threatening to harm other students. At this meeting an agreement was reached to avoid expulsion from school.  In the agreement Mary would finish the 2013-2014 school year by submitting homework and completing arranged testing. Mary remained on non- disciplinary suspension through the end of the school year. She would have to be tested for special education services before re-entry.  Mary’s disciplinary proceedings were suspended with the agreement that she ceased the harassing/bullying behavior and continued counseling.  Her care manager, Susan would continue to advocate for Mary to ensure she receives the services needed. Mary was also expected to address her mental health needs and learn better ways of coping with her emotions.

The patient’s mother and Susan were relieved Mary was not expelled from school.  Mary’s mother was in agreement her to be tested for special education services as well.

Dr. Resnick was pleased with Susan’s patient advocacy at the school board meeting.  As a result of Susan attending the meeting additional information was obtained regarding the symptoms and behaviors Mary was experiencing. This information helped the Care Manager support Mary through her treatment plan and assisted with assessing her progress.

NEXT ISSUE DATES:

•     Next MiPCT P.O. FLASH Issue:  October 20, 2014
•     Next MiPCT Practice FLASH Issue:  October 20, 2014

September 22, 2014

Please Complete the PO Survey on Additional Payers to Add to the MiPCT in 2015: Help Us Help You!

PO leader(s) will receive a survey this week that will be distributed via the micptdemo@michigan.gov mailbox regarding the additional payers (beyond Medicaid, Medicare, BCBSM, BCN and Priority Health) that would be most helpful to recruit to the MiPCT in 2015. The requested return date is September 30, 2014. The results will be used to identify the payers most key to MiPCT practices. POs are asked to consider being a part of the outreach visits with potential additional payers.

Practice Learning Credits Available for Summit Participation!

Four (4) Practice Learning Credits are available for Summit participation for practice teams (a physician, care manager and one other team member) who complete one of the following:

  • Attend in-person (each team member must register for the Ann Arbor or Grand Rapids 8:30 to noon in-person sessions, and initial the “sign in/sign out” sheet separately).
  • Register for the October 9th, 8:30 to noon live webinar link, watch the live webinar as a team, and submit minutes of SUBSEQUENT meaningful team discussion regarding the Summit (e.g., the “take-away” key points that your practice can use) to mipctdemo@michigan.govby October 30th, 2014. The subject line should say: “Summit Practice Team Minutes” and include the practice’s name and PO affiliation.
  • View the recorded webinar (to be posted by October 15th on the mipct.com website under the “Summit” tab) as a team and submit minutes of SUBSEQUENT meaningful team discussion regarding the Summit (e.g., the “take-away” key points that your practice can use) to mipctdemo@michigan.gov by October 30th, 2014. The subject line should say: “Summit Practice Team Minutes” and include the practice’s name and PO affiliation.
  • Send part of the team to an in-person Summit session, and have the others view by webinar and submit minutes of A SUBSEQUENT meaningful team discussion regarding the Summit (e.g., the “take-away” key points that your practice can use) to mipctdemo@michigan.gov by October 30th, 2014. The subject line should say: “Summit Practice Team Minutes” and include the practice’s name and PO affiliation.

Registration is Open for the 2014 MiPCT Regional Annual Summits

We are excited to announce that registration is now open for the 2014 MiPCT Annual Summits. Please register for the Summit session of your choice using one of the registration links listed at the end of the article.

Morning Session – Open to All

The morning session is an all-stakeholder meeting that is open to all! This year, the theme for the morning is: “The Future of Primary Care: MiPCT in 2015 and Beyond” and will feature:

  • An update on MiPCT evaluation results to date, 2015 funding details, and continuity/sustainability
  • Celebrating MiPCT stakeholder partner achievements!
  • Best practice sharing
  • A segment on positioning your PO and Practice for MiPCT 2015 and beyond
  • A great chance to network and take the work even farther together

For details on how to earn Practice Learning Credits, see article on Page 1, entitled: “Practice Learning Credits Available for Summit Participation!”

Afternoon Session – Care Manager Education

The Summit afternoon sessions are designed for MiPCT Care Managers. MiPCT stakeholders (physicians, POs, health plans, practice managers, multidisciplinary MiPCT practice teams, care managers, purchasers, members, etc.) are welcome to attend also.

Summit 2014 afternoon session topics include Palliative Care and MiPCT Care Management Best Practice Work Group Update. The session will provide opportunities for MiPCT Care Managers to enhance their Palliative Care skills and knowledge of effective communication regarding the seriously ill.

Palliative Care RN Expert Presenters:

  • Ann Arbor and Grand Rapids Summits – Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN, Palliative Care Service Nurse Practitioner at North Shore Medical Center, Salem, MA.
  • Gaylord Summit – Moni Franks BSN, CHPCA, CCM; Program Coordinator – Pain & Palliative Care, Mercy Health Saint Mary’s Hospital.

MiPCT Best Practice Work Group Update Presenters:

  • All 3 Summits – MiPCT Central Coordinator, Master Trainers and Clinical Leads

This continuing nursing education activity was approved by the Michigan Nurses Association, an approver, by the State of Michigan Board of Nursing. MIPCT 2014 Summit Care Management afternoon session attendees will receive 3.0 nursing continuing education credits.

Dates and Locations:

Morning Summit sessions – There are two in-person locations (one will have a webinar link allowing remote attendance as well):

  • Ann Arbor – University of Michigan North Campus Research Center (NCRC), October 7, 2014 – 8:00 AM to Noon
  • Grand Rapids – Frederik Meijer Gardens, October 9, 2014 – 8:00 AM to Noon (this location will also have a live webinar link allowing those who cannot travel to participate).

NOTE: After consultation with our northern participants, it was decided that the Gaylord in-person morning Summit session will not be held this year. Northern participants are invited to either attend the Ann Arbor or Grand Rapids in-person sessions, participate via webinar link from their location on October 9th, or listen to the recorded webinar of the October 9th session, which will be available on the mipct.org site by October 15, 2014.)

Afternoon Summit sessions – Care Manager Education:

  • Gaylord – Ostego Conference Center October 1, 2014 – 11:30am – 4:30 pm
  • Ann Arbor – University of Michigan North Campus Research Center (NCRC), October 7, 2014 – 1:00 pm — 4:30pm
  • Grand Rapids – Frederik Meijer Gardens, October 9, 2014 – 12:45 pm — 4:30pm

NOTE: The Gaylord afternoon Summit will begin at 11:30am with a special hour-long live briefing session with MiPCT Leadership on 2015 to present. An update on MiPCT evaluation to date and sustainability/continuity will also be provided.

Register at:

The attached flier contains additional details, and can be distributed to practices, etc.

All-Payer MiPCT Care Management Billing Collaborative: Your Opportunity to Sign Up Now!

To assist and support POs and practices in robust structures that support G- and CPT-code billing for embedded care management services across payers, an All-Payer MiPCT billing collaborative will begin in early fall and continue through early 2015. The collaborative will work in concert with our BCBSM and Priority Health Plan partners. The structure includes one half-day, in-person session (on the morning of October 30) that is supplemented with monthly webinars.

The approach supports a “train-the-trainer” spread of learning to other practices in the PO. Each interested PO is invited to select one or two practices (additional practices would be accommodated to the extent possible) to participate in the collaborative along with a PO representative. The charter for the collaborative is included as an attachment for your reference.

A team would generally consist of:

  • PO leaders (executives/those responsible for financial planning)
  • Practice Manager
  • Billers and Coders
  • Care Managers

A physician from each practice team would participate in one webinar focusing on the physician’s role in coding and billing. The focus is on a multipayer perspective, and experts from each participating commercial plan have generously agreed to be involved. Some prework is required of all participating teams. Visit (HERE) for the prework survey.

Three (3) Practice Learning Credits are available for teams that complete the September through December portion of the work. A webinar is available on the mipctdemo.org website (HERE) that describes the all-payer collaborative for sharing with your interested partners. This webinar link is also available on the All Payer Billing Collaborative page (HERE). The charter for the collaborative is included as an attachment.

To sign up to participate in the All-Payer Billing Collaborative, please send an email to mipctdemo@michigan.gov by September 29th with the subject line: All-Payer Billing Collaborative. Please indicate the contact person within your PO, the PO name, and the practices you wish to involve.

Please visit the MiPCT All Payer Billing Collaborative Page to view the All Payer Billing Collaborative page, where you will find a copy of the charter, a link to the prework, an informative “All Payer Billing Collaborative” webinar link, and other important information!

Statewide MiPCT Patient Advisory Council Member Nominations

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

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

Member nominations are now being accepted at:

https://jodyooo.wufoo.com/forms/patient-advisorycouncil-nomination-form/. The next PAC conference call will be held: Friday, 12/12/2014 at 1:00 PM.

MiPCT Pediatric Conference Follow-Up

During the MiPCT Pediatric Conference held on September 17, 2014 many pediatric resources were shared throughout the day long conference. While there are numerous Pediatric resources available in our State, a request to develop a list of the top Pediatric resources was requested and agreed upon as a need by those in attendance. In keeping with this request a Pediatric Resource list has been developed and reviewed by various providers of pediatric services including but not limited to; Dr. Jane Tuner, pediatrician, Children Special Health Care Services, The Family Center and Parent to Parent. The list of Pediatric resources, the services they provide and contact information can be found in the attachment titled, Top Pediatric Provider Resources.

BCBSM Wellness & Care Management Programs Webinar Rescheduled to October 21

The webinar about BCBSM Wellness and Care Management programs, previously scheduled for 9/18, has been rescheduled for Tuesday, October 21st, from 1 to 2 p.m. Please mark your calendars! At this webinar, BCBSM employees will discuss care management and case management resources that are available for practices to use in managing BCBSM patients who aren’t eligible for MiPCT.

To attend, simply follow these instructions at the time of the event:

To join the webinar:

1. Go to https://bcbsm.webex.com/bcbsm/j.php?J=737844372&PW=67935ad6df5a585c0d

2. If you are not logged in, log in to your account.

Meeting Number: 737 844 372

Meeting Password: 1234

To dial into the call:

1. Please call: Toll-Free: 1-800-4625837

2. Follow the instructions that you hear on the phone.Cisco Unified MeetingPlace meeting ID: 737 844 372

MDC’s September 2014 MiPCT All-Payer Patient Lists to be Posted this Week

The Michigan Data Collaborative will post the September 2014 MiPCT All-Payer Patient Lists this week. An email announcing the posting will be sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports page of the new MDC MiPCT Dashboard. The patient list .zip file includes a list of all MiPCT patients for the

PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_09.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).

Updates to BCBSM Medicare Advantage PDCM Billing Guidelines

This is an overview of the billing codes which have been updated for BCBSM Medicare Advantage PDCM Billing as of August 2014. The updated guidelines are available at https://mipctdemo.files.wordpress.com/2012/04/medicare_advantage_pdcm_billing_guidelines-final_august_2014.pdf. Please note the following changes:

1. Added procedure code 98968 to first page:

As of Jan.1, 2014, added code S0257*.

These billing guidelines and payment policy are in regard to HCPCS codes G9001*, G9002*, G9007*, G9008*, and S0257* as well as CPT codes 98961*, 98962*, 98966*, 98967*, 98968*, 99487* and 99489*.

2. Under procedure code G9001, added “agree”:

Claims Reporting Requirements

  • For patients not entering into care management, the claim date of service reported should be the date of the face-to-face component.
  • For patients who are entering care management, the claim date of service reported should be the patient enrollment date. (Note: Prior to enrollment, patients must formally agree they understand and consent to the care plan and its goals, and agree to be actively engaged in the activities identified to meet goals.)

3. Expanded the nomenclature for procedure codes 98961 and 98962:

Group Education and Training

98961* Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients.

98962* Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients

4. Updated the billing chart for 99487 and 99489

All these changes align with the changes in the BCBSM Provider Delivered Care Management Commercial Payment Policy and Billing guidelines.

Recap of BCBSM PDCM Billing Road Show Webinars

Many questions were posed during the recent BSBCM PDCM Billing Road Shows held throughout the state. In an effort to consistently communicate the same information to all MiPCT participants, there will be two webinar sessions scheduled in the near future. The purpose of these webinars will be to share all the questions and corresponding answers discussed and to provide the participants with an opportunity to ask additional questions. The two sessions will be held on September 30, 2014 and October 13, 2014. Each of the respective sessions has a separate call-in number, following:

September 30, 2014 – 1:00 – 3:00 p.m.

Meeting Number: 738 662 728

Meeting Password: pdcm

To start this meeting:

1. Go to https://bcbsm.webex.com/bcbsm/j.php?J=738662728&PW=67935ad6df1b0e0c54

2. If you are not logged in, log in to your account.

Teleconference information:

1. Please call one of the following numbers:

Toll-Free: 1-800-4625837

Local: 1-313-2254000

2. Follow the instructions that you hear on the phone.

Cisco Unified MeetingPlace meeting ID: 738 662 728

October 13, 2014 – 9:00 – 11:00 a.m.

Meeting Number: 737 936 161

Meeting Password: pdcm

To start this meeting

1. Go to https://bcbsm.webex.com/bcbsm/j.php?J=737936161&PW=67935ad6df1b0e0c54

2. If you are not logged in, log in to your account.

Teleconference information

1. Please call one of the following numbers:

Toll-Free: 1-800-4625837

Local: 1-313-2254000

2. Follow the instructions that you hear on the phone. Cisco Unified MeetingPlace meeting ID: 737 936 161

MiPCT Complex Care Management Course

The 2014 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 October 13-16, 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/october-1316-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM course dates:

October 13-16, 2014 – Introductory Webinar October 13

  • October 13-14, 2014 – Total six hours of self-study modules and post-tests
  • October 15-16, 2014 – In person training

November 10-13, 2014 – Introductory Webinar Nov. 10

  • November 10-11, 2014 – Total six hours of self-study modules and post-tests
  • November 12-13, 2014 – In person training

December 8-11, 2014 – Introductory Webinar Dec. 8

  • December 8-9, 2014 – Total six hours of self-study modules and post-tests
  • December 10-11, 2014 – In person training

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

Stories of Your Care Management Success Pam Szymanski, RN, CM, Domino Farms Family Medicine, Dexter Family Medicine, UMHS

Pam Szymanski, RN is a MiPCT Complex Care Navigator at Domino Farms Family Medicine and Dexter Family Medicine within the University of Michigan Health System. Pam was working with a patient covered by Medicare insurance. Mr. L was referred to Pam by the patient’s PCP for frequent hospitalizations. His diagnosis included CHF, COPD, OSA (on BiPAP-bi-level pressure airway device), CRI Obesity, and Pulmonary HTN. Mr. L. receives specialty services from Pulmonary and the Neurology sleep clinic. In a three month period Mr. L was hospitalized three times for CHF and/or COPD exacerbations.

Mr. L was obese and not using his BiPAP at bedtime. Pam discussed with him the importance of using the BiPAP at bedtime and assessed his understanding of this intervention and any barriers that may be preventing him from complying. His complaint was that he would fall asleep with the BiPAP on, but the forced air through the BiPAP woke him up at night. He also was waiting from the Medical Supply Company to deliver the ASV (automatic Servo ventilation) attachment for the BiPAP.

Pam contacted Mr. L’s pulmonologist and neurologist (who ordered the ASV) with a patient update. Both physicians were aware that Mr. L was not using the BiPAP as he should and he really needed the ASV attachment. Mr. L insisted that the 2-4 liters of oxygen via nasal cannula at bedtime was keeping his oxygen saturations in the 90’s while he slept. To confirm the patient’s sleeping oxygen saturation level Pam requested an order for an overnight saturation study to be done. The study revealed that Mr. L’s oxygen saturations dropped in the low 80’s several times during the night.

Mr. L and Pam began discussions related to the correlation of weight loss related to less strain on his heart and improved respiratory status. He agreed with a plan to lose weight and brought his wife with him to an appointment so she could support a change in diet and physical activity.

Pam educated Mr. L regarding the importance of calling her or the office with any change in symptoms so treatment could be initiated early and hospitalization avoided. Mr. L. voiced agreement as he too wanted to avoid further hospitalizations.

Mr. L lost weight and experienced less respiratory difficulty. His blood gases improved, walking distance improved and he is able to work at his hobby of woodworking in his garage. In following up with Mr. L. she learned he had not received the ASV attachment from the Medical Supply Company. Pam contacted the company again and learned Mr. L needed further testing to get the ASV attachment approved for the BiPAP machine. A blood gas with 2 liters of oxygen was ordered and the results of this test were within the range needed for the ASV approval.

Mr. L received the ASV attachment; however, he was not using the BiPAP machine consistently as ordered. Pam continued to educate and encourage Mr. L. to use the BiPAP machine every night. She made several contacts to the pulmonologist and neurologist who both discussed the importance of using the BiPAP with Mr. L at each of his scheduled appointments. Pam arranged two mask fitting appointments with the Medical Supply Company to address any issues Mr. L experienced with mask fit to improve his use of the BiPAP machine. Mr. L shared with Pam that he was able to do more and feeling much better. He continued to question if BiPAP was necessary for him.

During a subsequent follow up appointment with his PCP, pulmonologist, and neurologist, all three physicians agreed to have the BiPAP machine removed from the home. Although it was anticipated that Mr. L would be relieved, instead he said he would like to keep the BiPAP machine and try to get used to using it every night.

Since receiving MiPCT care management services Mr. L has lost weight, become more active and he has not been hospitalized. During phone visits with Pam he shares how frequently he is using the BiPAP machine and his blood gas results have improved.

Pam continues to support Mr. L as he continues to work on his goal of losing more weight by making healthy food choices and increasing his physical activity. She provides praise and encouragement for his healthy choices.

NEXT ISSUE DATES:

• Next MiPCT P.O. FLASH Issue: October 6, 2014

• Next MiPCT Practice FLASH Issue: October 20, 2014

 September 8, 2014

Registration is Open for the 2014 MiPCT Regional Annual Summits

We are excited to announce that registration is now open for the 2014 MiPCT Annual Summits.

Morning Session – Open to All

The morning session is an all-stakeholder meeting that is open to all! This year, the theme for the morning is: “The Future of Primary Care: MiPCT in 2015 and Beyond” and will feature:

  • An update on MiPCT evaluation results to date, 2015 funding details, and continuity/sustainability
  • Celebrating MiPCT stakeholder partner achievements!
  • Best practice sharing
  • A segment on positioning your PO and Practice for MiPCT 2015 and beyond
  • A great chance to network and take the work even farther together

Afternoon Session – Care Manager Education

The Summit afternoon sessions are designed for MiPCT Care Managers. MiPCT stakeholders (physicians, POs, health plans, practice managers, multidisciplinary MiPCT practice teams, care managers, purchasers, members, etc. are welcome to attend also.

Summit 2014 afternoon session topics include Palliative Care and MiPCT Care Management Best Practice Work Group Update. The session will provide opportunities for MiPCT Care Managers to enhance their Palliative Care skills and knowledge of effective communication regarding the seriously ill.

Palliative Care RN Expert Presenters:

  • Ann Arbor and Grand Rapids Summits – Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN, Palliative Care Service Nurse Practitioner at North Shore Medical Center, Salem, MA.
  • Gaylord Summit – Moni Franks BSN, CHPCA, CCM; Program Coordinator – Pain & Palliative Care, Mercy Health Saint Mary’s Hospital.

MiPCT Best Practice Work Group Update Presenters:

  • All 3 Summits – MiPCT Central Coordinator, Master Trainers and Clinical Leads

The MiPCT 2014 Summit Care Manager Session has been submitted to the Michigan Nurses Association for approval to award contact hours. The Michigan Nurses Association is an approver of continuing nursing education is the State of Michigan Board of Nursing.

Dates and Locations:

Morning Summit sessions – There are two in-person locations (one will have a webinar link allowing remote attendance as well):

  • Ann Arbor – University of Michigan North Campus Research Center (NCRC), October 7, 2014 – 8:00 AM to Noon
  • Grand Rapids – Frederik Meijer Gardens, October 9, 2014 – 8:00 AM to Noon (this location will also have a live webinar link allowing those who cannot travel to participate).

NOTE: After consultation with our northern participants, it was decided that the morning Summit in-person Gaylord session will not be held this year. Northern participants are invited to either attend the Ann Arbor or Grand Rapids in-person sessions, participate via webinar link from their location on October 9th, or listen to the recorded webinar of the October 9th session, which will be available on the mipctdemo.org site soon afterward.)

Afternoon Summit sessions – Care Manager Education:

  • Ann Arbor – University of Michigan North Campus Research Center (NCRC), October 7, 2014 – 1:00 pm-4:30pm
  • Grand Rapids – Frederik Meijer Gardens, October 9, 2014 – 1:00 pm-4:30pm
  • Gaylord – Ostego Conference Center October 1, 2014 – 11:30am – 4:30 pm

NOTE: Gaylord morning Summit session will not take place this year. The Gaylord afternoon Summit will begin at 11:30am. The Gaylord Afternoon Summit will begin with a special hour-long Live briefing session with MiPCT Leadership on 2015 to present an update on MiPCT evaluation to date and sustainability/continuity.

Register at:

The attached flier contains additional details, and can be distributed to practices, etc.

MiPCT Pediatric Conference for Care Managers and Physicians

Date: September 17, 2014
Time: 9AM to 4PM
Location: BCBSM-Lyon Meadows Facility, 53200 Grand River Ave., New Hudson, MI (Conf. Room B)
Meals: A continental breakfast and lunch will be served.

Learning Objectives: The overall goals of the conference are to clarify the role of the care manager in pediatrics, to learn new strategies to work with systems (including the practice team and community agencies), to improve skills in partnering with families, and to improve strategies to identify high risk individuals who are likely to benefit most from care management services.

Format: We will have brief presentations from representa-tives of community agencies. Most of the day will be spent in small group discussion, facilitated by pediatric professionals and parent representatives. Principles of family-centered care coordination and partnering with families will be infused into all case discussions. Cases to be discussed include children and youth with autism spectrum disorder, the NICU grad with complex needs, asthma and depression.

In an effort to plan for small group discussion and facilitate networking, registration for conference attendance is required. Please register for the MiPCT Pediatric Conference for Physicians and Care Managers no later than Monday, September 8, 2014 by going to: https://jodyooo.wufoo.com/forms/mipct-pediatric-conference-registration/.

All-Payer MiPCT Care Management Billing Collaborative Your Opportunity to Sign Up Now!

To assist and support POs and practices in robust structures that support G- and CPT-code billing for embedded care management services across payers, an All-Payer MiPCT billing collaborative will begin in early fall and continue through early 2015. The collaborative will work in concert with our BCBSM and Priority plan partners. The structure includes one half-day, in-person session that is supplemented with monthly webinars.

The approach supports a “train-the-trainer” spread of learning to other practices in the PO. Each interested PO is invited to select one or two practices (additional practices would be accommodated to the extent possible) to participate in the collaborative along with a PO representative. The charter for the collaborative is included as an attachment for your reference. A team would generally consist of:

  • PO leaders (executives/those responsible for financial planning)
  • Practice Manager
  • Billers and Coders
  • Care Managers

A physician from each practice team would be involved in one webinar focusing on the physician’s role in coding and billing. The focus is on a multipayer perspective, and experts from each participating commercial plan have generously agreed to be involved. Some prework is required of all participating teams. Three (3) Practice Learning Credits are available for teams that complete the September through December portion of the work. A webinar is available on the mipctdemo.org website that describes the all-payer collaborative for sharing with your interested partners. The charter for the collaborative is included as an attachment.

To sign up to participate in the All-Payer Billing Collaborative, please send an email to mipctdemo@michigan.gov by September 19th with the subject line: “All-Payer Billing Collaborative.” Please indicate the contact person within your PO, the PO name, and the practices you wish to involve.

MiPCT Palliative Care Webinar September 10, 2014: Leading Goals of Care

Webinar — Palliative Care: Leading Goals of Care; September 10, 2014, 12pm–1pm; Presented by David Weissman, MD, Medical College of Wisconsin.

Objectives:

  • List a ten-step protocol for leading a family goal-setting meeting.
  • Identify three reasons for clinician-family conflict over end-of-life goals.
  • Describe two approaches to resolving conflicts over end-of-life goals.

Presenter:
DAVID E. WEISSMAN, M.D., FAAHPM is a nationally recognized palliative care expert who will present the Webinar topic: Leading Goals of Care. Dr. Weissman’s current appointments include:

  • Professor Emeritus; Medical College of Wisconsin
  • Co-Director, EPERC; Medical College of Wisconsin (www.eperc.mcw.edu)
  • Consultant; Center to Advance Palliative Care (2008-present)
  • Co-Director; Palliative Care-Outpatient Integration (IPAL-OP); CAPC, New York

CME Information:  The Practice Transformation Institute is accredited by the Michigan State Medical Society to provide Continuing Medical Education for physicians. The Practice Transformation Institute designates this live activity for a maximum of one (1) AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

MiPCT Palliative Care Webinars Qualify for MiPCT Practice Learning Activity Credits as Follows: The following scenarios each qualify for MiPCT Practice Learning Activity credits.

  • MiPCT CM and a MiPCT PCP attend a Palliative Care webinar and have a follow-up discussion. Meeting minutes are documented and include next steps/implementation plan. (2 MiPCT Practice Credits), OR
  • MiPCT PCP attends Palliative Care webinar and has a subsequent team meeting, including the CM, to discuss next steps/implementation plan. (2 MiPCT Practice Credits).

To receive Continuing Medical Education credit for this webinar you must complete the following:

  • Register for the webinar. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=662099811
  • On 9/10/14 join the live webinar, and 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 Continuing Medical Education credit for multiple attendees viewing the webinar on one computer. MiPCT is only able to issue Continuing Medical Education credit for participants who attend and login individually to the live webinar (i.e. viewing the recorded webinar will not provide Continuing Medical Education).

Attached please find a ‘SAVE the DATE Flyer” for this Webinar. Help us get the word out to the MiPCT primary care physicians and care Managers by distributing this flyer!
Please submit questions to: micmrc-requests@med.umich.edu.

“MiPCT Care Manager Palliative Care Webinar: Giving Bad News/DNR,” presented by David Weissman, MD – was held on August 27. The recording and slides from that presentation can be found athttps://mipct.org/resources/presentations/

Statewide MiPCT Patient Advisory Council Member Nominations

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

Members should be:

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

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

  • The date of the next PAC Conference Call is: Friday, December 12, 2014 at 1:00 PM

BCBSM Webinar to be Offered September 18

Webinar Title: BCBSM Blue Health Connection: Care Management Resources

Presenters: Kim Walsh and Diane Baker, BCBSM Wellness, Care Management and Health Promotion Department

Time and Date: Thursday, September 18th, 3-4 p.m.

Overview: Mark your calendars! BCBSM staff will present the programs and resources available to physician practices
and care managers who have patients in need of referral to care management or case management services. This applies to both MiPCT providers who have patients that are not eligible for the program, as well as non-MiPCT providers.

These programs are available to BCBSM members, and the presentation will include specific phone numbers that can be
used to access services.

BCBSM Offering PDCM Billing Roadshow on September 24

BCBSM is offering another PDCM Billing Roadshow on September, 24. Get all your questions answered and learn more about our PDCM program. If you have specific claim examples or questions, please bring them with you, or email them to providerpartnerships.com beforehand. We encourage all billers and any other care team members that are involved with PDCM and PDCM Oncology to attend.

Registration is required, so please email providerpartnerships@bcbsm.com to RSVP. See Billing Road Show Flyer for details.

On September 24, from 1 – 4 PM, PDCM Billing Roadshow in the Aqua Training Room at the BCBSM Lyon Meadows facility at 53200 Grand River Avenue in South Lyon.

MiPCT Complex Care Management Course

The 2014 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 October 13-16, 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/october-1316-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM course dates:

  • October 13-16, 2014 – Introductory Webinar October 13
    • October 13-14, 2014 – Total six hours of self-study modules and post-tests
    • October 15-16, 2014 – In person training
  • November 10-13, 2014 – Introductory Webinar Nov. 10
    • November 10-11, 2014 – Total six hours of self-study modules and post-tests
    • November 12-13, 2014 – In person training

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

Dashboard Release 10.0 Update

MDC plans to launch Release 10.0 of MiPCT Dashboard this week. It includes the following:

  • A fifth trend point (Jan 2013-Dec 2013)
  • Updated trend points that use a 3-month run-out and attribution from the final month of the trend period
  • Quality Measures supplemented with clinical data
  • Paid claims and eligibility data through March 2014
  • An updated measurement period through December 2013

Because of the data flow improvements, expect to see variances compared to past rates. When the release is ready, we will send an email with more detailed information.

Important: The old Dashboard will no longer be accessible when Release 10.0 is posted. If you have not already done so, MDC urges you to log on to the new Dashboard and contact us if you have any issues or concerns. After Release 10.0 is posted, your only option to access MiPCT data and reports is through the new Dashboard. Please ensure that you will be ready when the final switchover occurs.

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

New Level-2 Logon Page for the MiPCT Dashboard

Some users have had difficulty logging on to the new MiPCT Dashboard using the Internet Explorer (IE) browser. As a result, MDC has developed a new level-2 logon page to resolve this issue.

Now, after you log on using your level-1 password and click the Redesigned MiPCT Dashboards and Reports link, a new level-2 logon page displays where you type your Username and level-2 password, and then click Submit.

Important: You may need to clear your browser’s cache in order for the new logon page to display. If you have any questions, please contact MDC at MichiganDataCollaborative@med.umich.edu.

Stories of Your Care Management Success, Featuring Angela Weir RN, BSN, HCM, Marquette General Family Medicine, UPHP

Angela Weir RN, BSN, is a MiPCT hybrid care manager at Marquette General Family Medicine; an Upper Peninsula Health Plan provider. She began working with a 55 year old male, with BCBSM insurance, who had a diagnosis of DM, hyperlipidemia, HTN, and obesity. He had been struggling for over two years to get better control of his DM. When Angela first began working with him his A1C was 9.0 and his weight was 252 pounds.

During the patient’s first six months of Care Management the patient was very resistant to making lifestyle changes. Despite Angela’s efforts to engage him in the management of his chronic conditions, he gained 14 pounds and his A1C remained high at 8.8. Although Angela’s interventions did not show weight reduction, Angela remained encouraged because the patient voiced a willingness to continue to participate in care management. Soon he began to make small changes that if continued would positively impact his health. He returned to the gym and began working with his personal trainer. He began talking to his family about his desire to control his blood sugars and began making healthier food choices.

Angela provided patient education regarding diabetic group education held at the Primary Care Provider (PCP) office. The diabetic group visit is a multi-disciplinary approach to care and includes a guest speaker. Members of the multi-disciplinary team include the MiPCT Care Manager, a dietician, and a visit with the physician. At each diabetic group visit open discussion regarding the struggles people face while trying to make lifestyle changes occur and group members offer one another support through these changes. The patient agreed to attend the diabetic group and afterward expressed he found the diabetic group visit very helpful.

After one year in Care Management with Angela the patient has learned to better manage his diabetes through lifestyle changes. His A1C is now 6.7, he has lost the 14 pounds he had gained previously and now makes going to the gym part of his daily routine. He is pleased with his decision to make his health and diabetes control a priority in his life.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: September 22, 2014
  • Next MiPCT Practice FLASH Issue: September 22, 2014

August 25, 2014

MiPCT Pediatric Conference for Care Managers and Physicians

Date: September 17, 2014

Time: 9AM to 4PM

Location: BCBSM-Lyon Meadows Facility, 53200 Grand River Ave., New Hudson, MI (Conf. Room B)

Meals: A continental breakfast and lunch will be served.

Learning Objectives: The overall goals of the conference are to clarify the role of the care manager in pediatrics, to learn new strategies to work with systems (including the practice team and community agencies), to improve skills in partnering with families, and to improve strategies to identify high risk individuals who are likely to benefit most from care management services.

Format: We will have brief presentations from representa-tives of community agencies. Most of the day will be spent in small group discussion, facilitated by pediatric professionals and parent representatives. Principles of family-centered care coordination and partnering with families will be infused into all case discussions. Cases to be discussed include children and youth with autism spectrum disorder, the NICU grad with complex needs, asthma and depression.

In an effort to plan for small group discussion and facilitate networking, registration for conference attendance is required. Please register for the MiPCT Pediatric Conference for Physicians and Care Managers no later than Monday, September 8, 2014 by going to: https://jodyooo.wufoo.com/forms/mipct-pediatric-conference-registration/.

All-Payer MiPCT Care Management Billing Collaborative Your Opportunity to Sign Up Now!

To assist and support POs and practices in robust structures that support G- and CPT-code billing for embedded care management services across payers, an All-Payer MiPCT billing collaborative will begin in early fall and continue through early 2015. The collaborative will work in concert with our BCBSM and Priority plan partners. The structure includes one half-day, in-person session that is supplemented with monthly webinars.

The approach supports a “train-the-trainer” spread of learning to other practices in the PO. Each interested PO is invited to select one or two practices (additional practices would be accommodated to the extent possible) to participate in the collaborative along with a PO representative. The charter for the collaborative is included as an attachment for your reference. A team would generally consist of:

  • PO leaders (executives/those responsible for financial planning)
  • Practice Manager
  • Billers and Coders
  • Care Managers

A physician from each practice team would be involved in one webinar focusing on the physician’s role in coding and billing. The focus is on a multipayer perspective, and experts from each participating commercial plan have generously agreed to be involved. Some prework is required of all participating teams. Three (3) Practice Learning Credits are available for teams that complete the September through December portion of the work. A webinar is available on the mipctdemo.org website (https://mipct.org/resources/presentations/) that describes the all-payer collaborative for sharing with your interested partners.

To sign up to participate in the All-Payer Billing Collaborative, please send an email to mipctdemo@michigan.gov by September 8th with the subject line: “All-Payer Billing Collaborative.”

Please indicate the contact person within your PO, the PO name, and the practices you wish to involve.

MiPCT Palliative Care Webinars for Primary Care Physicians and Care Managers

MiPCT is offering two Palliative Care Webinars in August 2014, primarily designed for a physician audience. MiPCT care managers are also welcome to attend. CME is available for the live webinars; see below for details.

MiPCT Palliative Care Webinars Qualify for MiPCT Practice Learning Activity Credits as Follows:

The following scenarios each qualify for MiPCT Practice Learning Activity credits.

  • MiPCT CM and a MiPCT PCP attend a Palliative Care webinar and have a follow-up discussion. Meeting minutes are documented and include next steps/implementation plan. (2 MiPCT Practice Credits), OR
  • MiPCT PCP attends Palliative Care webinar and has a subsequent team meeting, including the CM, to discuss next steps/implementation plan. (2 MiPCT Practice Credits).

Presenter:

DAVID E. WEISSMAN, M.D., FAAHPM is a nationally recognized palliative care expert who will present the Webinar topics: Giving Bad News and DNR. Dr. Weissman’s current appointments include:

  • Professor Emeritus; Medical College of Wisconsin
  • Co-Director, EPERC; Medical College of Wisconsin (www.eperc.mcw.edu)
  • Consultant; Center to Advance Palliative Care (2008-present)
  • Co-Director; Palliative Care-Outpatient Integration (IPAL-OP); CAPC, New York

Webinar 1 — Palliative Care: Giving Bad News/DNR: August 27, 2014, 12pm–1pm; Presented by David Weissman, MD, Medical College of Wisconsin.

Objectives:

  • List a six-step approach to giving bad news.
  • Describe two methods of starting a DNR discussion.
  • Identify three common patient misconceptions of the CPR procedure.

CME Information:

The Practice Transformation Institute is accredited by the Michigan State Medical Society to provide Continuing Medical Education for physicians. The Practice Transformation Institute designates this live activity for a maximum of one (1) AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

To receive Continuing Medical Education credit for this webinar you must complete the following:

  • Register for the webinar. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=662689954
  •  On 8/27/14 join the live webinar, and 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 Continuing Medical Education credit for multiple attendees viewing the webinar on one computer. MiPCT is only able to issue Continuing Medical Education credit for participants who attend and login individually to the live webinar (i.e. viewing the recorded webinar will not provide Continuing Medical Education).

Attached please find a ‘SAVE the DATE Flyer” for this webinar. Help us get the word out to the MiPCT primary care physicians and care managers by distributing this flyer!

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

Webinar 2 — Palliative Care: Leading Goals of Care; September 10, 2014, 12pm–1pm; Presented by David Weissman, MD, Medical College of Wisconsin.

Objectives:

  • List a ten-step protocol for leading a family goal-setting meeting.
  • Identify three reasons for clinician-family conflict over end-of-life goals.
  • Describe two approaches to resolving conflicts over end-of-life goals.

CME Information:

The Practice Transformation Institute is accredited by the Michigan State Medical Society to provide Continuing Medical Education for physicians. The Practice Transformation Institute designates this live activity for a maximum of one (1) AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

To receive Continuing Medical Education credit for this webinar you must complete the following:

  • Register for the webinar. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=662099811
  • On 9/10/14 join the live webinar, and 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 Continuing Medical Education credit for multiple attendees viewing the webinar on one computer. MiPCT is only able to issue Continuing Medical Education credit for participants who attend and login individually to the live webinar (i.e. viewing the recorded webinar will not provide Continuing Medical Education).

Attached please find a ‘SAVE the DATE Flyer” for this Webinar. Help us get the word out to the MiPCT primary care physicians and care Managers by distributing this flyer!

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

Statewide MiPCT Patient Advisory Council Member Nominations

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

Members should be:

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

Member nominations are now being accepted at:

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

The dates of the 2014 PAC Conference Calls are:

  • Friday, September 5, 2014 at 1:00 PM
  • Friday, December 12, 2014 at 1:00 PM

BCBSM Offering 2 PDCM Billing Roadshows in September 2014

BCBSM is offering two PDCM Billing Roadshows in September, 2014. Get all your questions answered and learn more about our PDCM program. If you have specific claim examples or questions, please bring them with you, or email them to providerpartnerships@bcbsm.com beforehand. We encourage all billers and any other care team members that are involved with PDCM and PDCM Oncology to attend.

Registration is required, so please email providerpartnerships@bcbsm.com to RSVP. See Billing Road Show Flyer for details.

  1. On September 4, from 2-4 pm, PDCM Billing Roadshow Videoconference for Marquette
  2. On September 24, from 1 – 4 PM, PDCM Billing Roadshow in the Aqua Training Room at the BCBSM Lyon Meadows facility at 53200 Grand River Avenue in South Lyon.

MDC’s August 2014 MiPCT All-Payer Patient Lists to be Posted this Week

The Michigan Data Collaborative will post the August 2014 MiPCT All-Payer Patient Lists this week. An email announcing the release will be sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports page of the new MDC MiPCT Dashboard. The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_08.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).

Dashboard Release 10.0 Update

MDC has updated the launch date to early September for Release 10.0 of the MiPCT Dashboard. It includes the following:

  • A fifth trend point (Jan 2013-Dec 2013)
  • Updated trend points that use a 3-month run-out and attribution from the final month of the trend period
  • Quality Measures supplemented with clinical data
  • Paid claims and eligibility data through March 2014
  • An updated measurement period through Dec. 2013

Because of the data flow improvements, you can expect to see variances compared to past rates. When the release is ready, we will send an email with more detailed information on what to expect.

Important! The old dashboard will no longer be accessible when Release 10.0 is posted. If you have not already done so, MDC urges you to log on to the new Dashboard and contact us if you have any issues or concerns. After Release 10.0 is posted, your only option to access MiPCT data and reports is through the new dashboard. Please ensure that you will be ready when the final switch over occurs.

If you have any questions, or if you would like to provide feedback or suggestions, please contact MDC at MichiganDataCollaborative@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. The programs listed in the attached table include information regarding course date/criteria to schedule.

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 2014 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 September 8-11, 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/september-811-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM course dates:

September 8-11, 2014 – Introductory Webinar September 8

  • September 8-9, 2014 – Total six hours of self-study modules and post-tests
  • September 10-11, 2014 – In person training

October 13-16, 2014 – Introductory Webinar October 13

  • October 13-14, 2014 – Total six hours of self-study modules and post-tests
  • October 15-16, 2014 – In person training

November 10-13, 2014 – Introductory Webinar Nov. 10

  • November 10-11, 2014 – Total six hours of self-study modules and post-tests
  • November 12-13, 2014 – In person training

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

Stories of Your Care Management Success

Barbara Robbins, RN, BA, HCM, West Front Primary Care, NPO

Barbara Robbins, RN, BA is a MiPCT Hybrid Care Manager working with West Front Primary Care in Traverse City, Michigan. This practice is affiliated with the Northern Physician Organization. Barbara initiated MiPCT Care Management services with a Priority Health patient Mrs. B in September of 2013. She was referred to care management by her PCP for improved control of hypertension, GERD, sleep apnea symptoms and weight loss.

At Mrs. B’s initial meeting with Barbara on October 11, 2013, knowledge of her health and potential barriers were assessed. The barriers identified included knowledge deficits relating to healthy eating habits and her motivation toward physical activity. A self-management action plan was developed to reflect goals of increased activity, better eating habits, and improved knowledge of healthy behaviors.

Mrs. B began meeting with Barbara every month for face to face visits which she believed were most beneficial. She valued the care manager visits as she gained knowledge about better eating habits, healthy behaviors, and gained the support she needed to keep herself motivated. Over the course of five months, Mrs. B had six face to face encounters with Barbara during which time she began to see a decline in weight. Mrs. B’s weight decreased from 253 to 224 pounds and her blood pressure improved from 142/76 to 118/76.

As a result of MiPCT Care Management services Mrs. B has gained the confidence to manage her weight independently. She understands how to overcome the barriers that prevented weight loss in the past. Currently, Mrs. B. is working towards her goal of discontinuing her blood pressure medications. She remains committed to the positive lifestyle changes she has made. Mrs. B continues to have face to face care management meetings with Barbara every three months. She is monitoring her blood pressure at home and is hopeful that as her weight continues to decrease she may no longer need the blood pressure medication.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: September 8 2014
  • Next MiPCT Practice FLASH Issue: September 22, 2014

August 18, 2014

Care Management Billing Collaborative Rolling Out in Fall! Learn More at the August 25 Webinar!

To assist and support POs and practices in robust structures that support G- and CPT-code billing for embedded care management services, an MiPCT billing collaborative will begin in early fall and continue through early 2015. The collaborative will feature one half-day, in-person session with supplemental monthly webinars. The approach supports a “train-the-trainer” spread of learning to other practices in the PO. Each interested PO is invited to select one or two practices (additional practices would be accommodated to the extent possible) to participate in the collaborative along with a PO representative. The charter for the collaborative is included as an attachment for your reference. A team would generally consist of:

  • PO leaders (executives/those responsible for financial planning)
  • Practice Manager
  • Billers and Coders
  • Care Managers

A physician from each practice team would be involved in one webinar focusing on the physician’s role in coding and billing. The focus is on a multipayer perspective, and experts from each participating commercial plan have generously agreed to be involved. Some prework is required of all participating teams.

Three (3) Practice Learning Credits are available for teams that complete the September through December portion of the work.

Practices and POs with best practices are invited to share their success (please email dbechel@umich.edu).

To provide a preview of the collaborative opportunity and answer any questions, a webinar will be held on August 25 from 10:30 to 11:30 AM ET.

Webinar Login Information:

Event: MiPCT All-Payer Billing Collaborative Webinar

Date: Monday, August 25th, 2014

Event Number: 667 024 273

Event Password: mipct01

 

To join the online meeting

  1. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=667024273
  2. If requested, enter your name and email address.
  3. If a password is required, enter the meeting password: mipct01
  4. Click “Join”.
  5. Follow the instructions that appear on your screen.

To join the audio conference only 

Call-in Number: 1-650-479-3207

Access Code: 667 024 273

Please join us on the 25th to learn more!

MiPCT Palliative Care Webinars for Primary Care Physicians and Care Managers

MiPCT is offering two Palliative Care Webinars in August 2014, primarily designed for a Physician audience. MiPCT Care Managers are also welcome to attend. CME is available for the Live Webinars; see below for details.

Presenter: DAVID E. WEISSMAN, M.D., FAAHPM is a nationally recognized palliative care expert who will present the Webinar topics: Giving Bad News and DNR. Dr. Weissman’s current appointments include:

  • Professor Emeritus; Medical College of Wisconsin
  • Co-Director, EPERC; Medical College of Wisconsin (www.eperc.mcw.edu)
  • Consultant, Center to Advance Palliative Care (2008-present
  • Co-Director; Palliative Care-Outpatient Integration (IPAL-OP); CAPC, New York

Webinar 1 — Palliative Care: Giving Bad News/DNR:

August 27, 2014, 12pm–1pm; Presented by David Weissman, MD, Medical College of Wisconsin.

Objectives:

  • List a six-step approach to giving bad news.
  • Describe two methods of starting a DNR discussion
  • Identify three common patient misconceptions of the CPR procedure.

CME Information: The Practice Transformation Institute is accredited by the Michigan State Medical Society to provide Continuing Medical Education for physicians. The Practice Transformation Institute designates this live activity for a maximum of one (1) AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

To receive Continuing Medical Education credit for this webinar you must complete the following:

  • Register for the Webinar. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=662689954
  •  On 8/27/14 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 Continuing Medical Education credit for multiple attendees viewing the webinar on one computer. MiPCT is only able to issue Continuing Medical Education credit for participants who attend and login individually to the live Webinar (i.e. viewing the recorded Webinar will not provide Continuing Medical Education).

Attached please find a ‘SAVE the DATE Flyer” for this Webinar. Help us get the word out to the MiPCT Primary Care Physicians and Care Managers by distributing this flyer!

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

Webinar 2: Palliative Care — Leading Goals of Care:

September 10, 2014, 12pm–1pm; Presented by David Weissman, MD, Medical College of Wisconsin.

Objectives:

  • List a ten-step protocol for leading a family goal-setting meeting.
  • Identify three reasons for clinician-family conflict over end-of-life goals.
  • Describe two approaches to resolving conflicts over end-of-life goals.

CME Information: The Practice Transformation Institute is accredited by the Michigan State Medical Society to provide Continuing Medical Education for physicians. The Practice Transformation Institute designates this live activity for a maximum of one (1) AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

To receive Continuing Medical Education credit for this webinar you must complete the following:

  • Register for the Webinar. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=662099811
  • On 9/10/14 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 Continuing Medical Education credit for multiple attendees viewing the webinar on one computer. MiPCT is only able to issue Continuing Medical Education credit for participants who attend and login individually to the live Webinar (i.e. viewing the recorded Webinar will not provide Continuing Medical Education).

Attached please find a ‘SAVE the DATE Flyer” for this Webinar. Help us get the word out to the MiPCT Primary Care Physicians and Care Managers by distributing this flyer!

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

Statewide MiPCT Patient Advisory Council Member Nominations

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

Members should be:

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

Member nominations are now being accepted at:

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

The dates of the 2014 PAC Conference Calls are:

  • Friday, September 5, 2014 at 1:00 PM
  • Friday, December 12, 2014 at 1:00 PM

MiPCT Pediatric Conference for Care Managers and Physicians

 Date: September 17, 2014

Time: 9AM to 4PM

Location: BCBSM-Lyon Meadows Facility, 53200 Grand River Ave., New Hudson, MI (Conf. Room B)

Meals: A continental breakfast and lunch will be served.

Learning Objectives: The overall goals of the conference are to clarify the role of the care manager in pediatrics, to learn new strategies to work with systems (including the practice team and community agencies), to improve skills in partnering with families, and to improve strategies to identify high risk individuals who are likely to benefit most from care management services.

Format: We will have brief presentations from representa-tives of community agencies. Most of the day will be spent in small group discussion, facilitated by pediatric professionals and parent representatives. Principles of family-centered care coordination and partnering with families will be infused into all case discussions. Cases to be discussed include children and youth with autism spectrum disorder, the NICU grad with complex needs, asthma and depression.

In an effort to plan for small group discussion and facilitate networking, registration for conference attendance is required. Please register for the MiPCT Pediatric Conference for Physicians and Care Managers no later than Monday, September 8, 2014 by going to: https://jodyooo.wufoo.com/forms/mipct-pediatric-conference-registration/.

Twenty-Four Month Incentive Score Release in October

MDC is scheduled to release the 24-month incentive scores in October 2014. These scores cover the period of 7/1/2013 through 12/31/2013.

The 24-month metrics combine previous Practice Capability, Quality, and Utilization outcome metrics with 8 new electronic Clinical Quality Metrics (eCQM). The eCQM metrics award a maximum of 15 points based on the Physician Organization’s capability to submit registry/EHR data to MDC.

The 30-month metrics, covering the period of 1/1/2014 through 6/30/2014, will shift the emphasis of the eCQM metrics from infrastructure to outcomes. Points will be awarded based on a combination of the PO’s percentile ranking and rate improvement, over a baseline period calculated by averaging the score of two previous years (1/1/2012 through 1/31/2012 and 1/1/2013 through 12/31/2013).

To view additional information and details, go to mipct.org and select Documents from the Resources menu. Questions can be sent to mipctdemo@michigan.gov.

MiPCT Complex Care Management Course

The 2014 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 September 8-11, 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/september-811-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM course dates:

September 8-11, 2014 – Introductory Webinar September 8

  • September 8-9, 2014 – Total six hours of self-study modules and post-tests
  • September 10-11, 2014 – In person training

October 13-16, 2014 – Introductory Webinar October 13

  • October 13-14, 2014 – Total six hours of self-study modules and post-tests
  • October 15-16, 2014 – In person training

November 10-13, 2014 – Introductory Webinar Nov. 10

  • November 10-11, 2014 – Total six hours of self-study modules and post-tests
  • November 12-13, 2014 – In person training

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

Dashboard Release 10.0 Coming Soon!

MDC expects to launch Release 10.0 of the new Dashboard at the end of this month. It includes the following:

  • A fifth trend point (Jan 2013-Dec 2013)
  • Updated trend points that use a 3-month run-out and attribution from the final month of the trend period
  • Quality Measures supplemented with clinical data
  • Paid claims and eligibility data through March 2014
  • An updated measurement period through Dec 2013

When the release is ready, an email will be sent to notify users and provide the release details.

Important! The old Dashboard will no longer be accessible when Release 10.0 is posted. If you have not already done so, MDC urges you to log on to the new Dashboard and contact us if you have any issues or concerns. After Release 10.0 is posted, your only option to access MiPCT data and reports is through the new Dashboard. Please ensure that you will be ready when the final switchover occurs.

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

Looking for 20 Practices!

Through a partnership with the Greater Detroit Health Council (GDAHC) and the Institute for Patient & Family-Centered Care (IPFCC), the leading national organization in incorporating the patient’s perspective in care decisions, twenty MiPCT practices have a special training opportunity.

The training is for practices interested in beginning or enhancing patient advisor programs. Up to four Practice Learning Credits will be awarded for the twenty practices selected from those who apply.

The attached flier describes the opportunity in greater detail, and can be distributed to practices. For more information, please contact dbechel@umich.edu by August 21 to be included.

2014 Provider & Staff Survey: Due Monday Sept. 1

The MiPCT Core Team is asking all POs & PHOs to disseminate the 2014 Provider & Staff Survey to your practices. All practice staff members including providers, care managers, and administrative staff are encouraged to participate.

The purpose of the survey is to assess the experiences of providers, care managers, and staff in their implementation of MiPCT. Since a similar survey was completed in 2012, we also hope to examine the ways in which practices may have changed since the initiation of the project.

An email was sent out all POs/PHOs this past Monday with instructions and a survey link (https://dataentry.ibem-is.org/surveys/?s=jIIqqGWIbi), which should be forwarded to all of your practices.

If you have not received this information or have any questions, please contact Jason Forney (jforney@mphi.org). As it is very important that we hear from all MiPCT practices, we appreciate your help in distributing this survey!

Stories of Your Care Management Success: Lynn Czech, RN, BSN, Henry Ford Lakeside Pediatrics, Henry Ford Health System

Lynn Czech, RN, BSN is a MiPCT Hybrid Care Manager at Henry Ford Lakeside Pediatrics within Henry Ford Health System. Lynn provided care management for a Medicaid (Molina) patient, ‘Emily’. ‘Emily’ was delivered by emergency C-section in January 2013 at 26 +1/7 weeks gestation due to pre-eclampsia. She weighed 669 grams (1 pound 7.6 ounces), 31 cm (12.2 inches) and was small for gestational age. ‘Emily’ was treated for respiratory distress syndrome, jaundice, anemia, pneumonia and apnea at birth. She has bronchopulmonary dysplasia, retinopathy of prematurity, and delayed linear growth. She also experienced a grade 2 intra-ventricular hemorrhage that resolved prior to hospital discharge.

‘Emily’ was intubated for 11 days while in the NICU. She was discharged home after 102 NICU days on 1/16 L oxygen and she weighed 4 pounds 15.4 ounces in April, 2013. Home care visits were initiated. ‘Emily’ had one ER visit, several visits to specialists and three well-visits with primary care prior to a Primary Care Physician referral for care management interventions in August of 2013.

‘Emily’s’ parents were completely engaged in their daughter’s care, eager to learn and expressed they wanted to do the best they could because ‘Emily’ had such a “rough start in life.” Lynn explained care management to both parents at their first meeting. The parents said, they would “gladly participate in care management if it will help Emily.” These first-time parents were eager to learn about preemie care and growth and development, which were discussed at length. Importance of adequate caloric intake and supplemental vitamins to assure proper growth was stressed. Lynn reviewed ‘Emily’s’ multiple diagnoses, appropriate actions needed to take and potential outcomes based on appropriate actions.

After an ER visit in late August 2013 for cough / DIB, follow-up care management visits routinely included a review of signs and symptoms of respiratory distress and appropriate actions to take. Lynn reviewed ‘Emily’s’ medications with her parents and discussed appropriate times to use them. Despite the Primary Care Physician’s medical interventions ‘Emily’ had two additional ER visits for DIB / wheezing. She was referred to an allergist for evaluation of persistent coughing, DIB, and wheezing. Her medications were adjusted and she was placed on maintenance asthma medications, as well as PRN albuterol. An asthma action plan was provided for her parents to follow as was education and support to empower appropriate parental decisions.

After her wheezing was controlled ‘Emily’ was seen in the ER twice for viral gastrointestinal infections. Education of the parents continued regarding viral infections, appropriate symptomatic care, and when to seek medical attention.

Due to developmental deficits, ‘Emily’ was referred to PT/OT, Developmental Assessment Clinic and Early On programs to provide developmental interventions. To accommodate their transportation limitations and dad’s work schedule, care coordination was provided enabling ‘Emily’ to have several specialists’ appointments the same day, in one location.

Early on in the case, and because ‘Emily’ is a preemie, the parents were unsure of their decisions and rushed to the ER for care. ‘Emily’s’ dad works as a transporter at Henry Ford Macomb Hospital in the ER. He frequently asked advice from the ER physicians and nurses regarding her care and was advised to bring her to the ER, which they did. Since care management was implemented Dad has relied on Primary Care and care management for continuity of care.

Henry Ford Health System has an after-hours on-call RN service to provide advice for Henry Ford patients and families. The on-call nurses provide exceptional service and if presented with ‘Emily’s’ preemie history and Mom’s over-the-phone clinical description, it was believed she would be sent to the ER. Because her primary care team was aware of ‘Emily’s’ baseline retracting and respiratory effort, they felt further ER visits could be avoided if the family contacted Lynn directly. The family was provided with a work BlackBerry phone number for Lynn so they could contact her directly when they felt it was necessary.

After meeting with Lynn and talking on the phone several times they started to contact Lynn daily to discuss ‘Emily’s’ current concerns, breathing patterns, feeding challenges, parenting advice, etc. Appropriate same day appointments were scheduled, and several ER visits were avoided based on these calls. More recently, ‘Emily’s’ parents appear more confident in their parenting skills and secure in their decision-making. Now they occasionally call “to double check” and reinforce their decisions rather than just automatically seeking care at the ER.

‘Emily’ has not had an ER visit since just before Christmas 2013. Her parents continue to follow-up with the Primary Care Physician and all recommended specialties, including audiology, ophthalmology, neonatology, allergy, PT/OT, Early On and the Developmental Assessment Clinic appropriately. ‘Emily’ regularly receives her Synagis injections as recommended.

‘Emily’ is now 13 months old and weighs 16 pounds 2 ounces. She has not had any episodes of wheezing or respiratory ailments since starting maintenance medications in September 2013. She continues to strive, and is meeting many developmental milestones despite her preemie status and delayed linear growth.

‘Emily’s’ PCP stated, “The education of this family has been a big challenge and ‘Emily’s’ health has significantly improved. This family is lucky to have you [Lynn]. You’ve [Lynn] become such a part of their lives that you’ll probably be invited to her birthday parties!”

‘Emily’s’ parents stated, “I don’t know what we would’ve done without you [Lynn]. You help us in so many ways. You always answer your phone, even when you know it’s me asking another 1000 questions. You are like ‘Emily’s’ angel. We are so happy you have been there to help us get through all this.”

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: August 25, 2014
  • Next MiPCT Practice FLASH Issue: August 25, 2014

July 28, 2014

IMPORTANT: The July 29 PO 1-2pm Meeting will Now Be a Webinar

As you have seen in the FLASH, we had planned an in-person July 29th meeting in Okemos from 1-3pm to discuss PO Leader perspectives and thoughts on the MiPCT 2015 and post-demonstration model design. We have learned from CMS that the decision on demonstration extension will not be available by that date. Hence, the in-person PO visioning session will be delayed until September. A date is being identified for the September in-person session and we will send a “save the date” soon.

We would like to use the 1pm time on July 29th for a one-hour webinar for an MiPCT Update and PO Open Forum Discussion. In addition to providing an MiPCT update, it will be an opportunity to discuss your questions and comments. The login information appears below:

  • Date: Tuesday, July 29
  • Time: 1:00 – 2:00 PM
  • Event Number: 660 543 376
  • Event Password: mipct01

To join the online meeting:

  1. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=660543376
  2. If requested, enter your name and email address.
  3. If a password is required, enter the meeting password: mipct01
  4. Click “Join”.

To join the audio conference only

  • Call-in toll number (US/Canada): 1-650-479-3207
  • Access code: 660 543 376

Looking for 20 Practices!

Through a partnership with the Greater Detroit Health Council (GDAHC) and the Institute for Patient & Family-Centered Care (IPFCC), the leading national organization in incorporating the patient’s perspective in care decisions, twenty MiPCT practices have a special training opportunity.

The training is for practices interested in beginning or enhancing patient advisor programs. Up to four Practice Learning Credits will be awarded for the twenty practices selected from those who apply.

The attached flier describes the opportunity in greater detail, and can be distributed to practices. For more information, please contact dbechel@umich.edu.

MiPCT/PDCM Billing Roadshow Schedule Attached

We are excited to bring the MiPCT/PDCM Billing Roadshows back to a town near you. Please join us to learn the billing guidelines of Provider Delivered Care Management (PDCM). The Billing Roadshow Schedule Flier is attached for your convenience. Please note the Marquette Billing Road Show date is to be determined.

Statewide MiPCT Patient Advisory Council Member Nominations

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

Members should be:

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

Member nominations are now being accepted at:

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

The dates of the 2014 PAC Conference Calls are:

  • Friday, September 5, 2014 at 1:00 PM
  • Friday, December 12, 2014 at 1:00 PM

Save the Date! Pediatric Care Managers’ In-Person Meeting, September 17

An all day, in-person Pediatric Care Manager meeting is scheduled for September 17, 2014. The meeting will be held at the Blue Cross Blue Shield of Michigan Lyon Meadows Conference Center, 53200 Grand River Avenue, Wixom, MI.

We plan to offer a webinar on Friday, August 15, to prepare for the face-to-face meeting. We will have some brief presentations to the whole group on Sept 17, but most of the day will be spent in small groups for discussion, problem solving and sharing resources. An email with more detailed information will be forthcoming in August.

MDC’s July 2014 MiPCT All-Payer Patient Lists Posted 7/23

The Michigan Data Collaborative posted the July 2014 MiPCT All-Payer Patient Lists on July 23, 2014. An email announcing the release was sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports page of the new MDC MiPCT Dashboard. The patient list .zip file includes a list of MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_07.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).

MDC MiPCT Dashboard Updates

Enhancement 9.01 to be Launched this Week

MDC expects to launch Enhancement 9.01 of the new Dashboard this week. It includes the following new Electronic Clinical Quality Measures (eCQMs):

  • Adult BMI Reporting Rate
  • Adult Tobacco Use Assessment
  • Pediatric BMI Reporting Rate
  • Pediatric Tobacco Use Assessment

Note: “eCQM” as used in the MiPCT Dashboard is a generic term used to describe electronic quality measures developed by the MiPCT project. They are not the same as the eCQM definitions used by CMS.

When the enhancement is released, MDC will send an email to notify users and provide the release details.

New Dashboard Login Issues

We have been working to resolve any remaining issues that POs are having logging on to the new Dashboard. When these issues are resolved, we will disable the old Dashboard and send out a notice. If you have not done so already, MDC urges you to log on to the new Dashboard (which has the most up-to-date data) and contact us right away if you have any issues or concerns.

Practice Users Can Now Access the New Dashboard

MDC now has the ability to restrict data down to the Practice level, which means that we can allow Practice users to access the Dashboard (if their account requests are approved by the PO Authorizers). Practice-level users can request accounts using the same method as PO-level users (by accessing the MDC Website http://www.MichiganDataCollaborative.org, navigating to the Accounts page, and clicking the Request Account button.)

Please be aware that your PO Authorizers may be receiving account verification requests from MDC, so you may want to define a policy for approving Practice Dashboard users if you have not already done so.

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

Fast Facts on Palliative Care

In a previous issue of the PO FLASH (June 16, 2014), the resource “Fast Facts and Concepts in Palliative Care” was introduced. These resources provide key topics important to clinicians caring for patients facing life-limiting illness. There are over 250 Fast Facts. The link is: http://www.eperc.mcw.edu/EPERC/FastFactsandConcepts

The following palliative care topics (which were presented in MiPCT webinars in July) and the corresponding Fast Facts that can enhance the clinicians understanding of these topics, are:

• Advance Care Planning- Fast Fact #162

• Pain Assessment and Management- Fast Facts #68, #69

Download the free Palliative Care Fast Facts App from the iTunes Store! There is a mobile version of Palliative Fast Facts for iPhone and iPad. The application can be located through iTunes. There is no charge for the iOS application.

For additional Palliative care resources, visit:

MiPCT Care Manager Upcoming Webinars

In support of MiPCT’s 2014 clinical focus on Palliative Care you are invited to attend two webinars this summer:

August 27, 2014, 12-1pm; Palliative Care – Giving Bad News/Do Not Resuscitate (DNR);

  • Presenter: David Weissman, MD, Project Director, Founder, Medical College of Wisconsin
  • Target Audience: Physicians and Care Managers.

September 10, 2014, 12-1pm; *Palliative Care – Learning Goals of Care;

  • Presenter: David Weissman, MD, Project Director, Founder, Medical College of Wisconsin
  • Target Audience: Physicians and Care Managers.

Anticoagulation Toolkits available from Michigan Anticoagulation Quality Improvement Initiative

The BCBSM Hospital Collaborative Quality Initiative MAQI2 (Michigan Anticoagulation Quality Improvement Initiative) has created two very useful and comprehensive anticoagulation toolkits. One is for providers who administer anticoagulation medication, and the other is for patients who receive anticoagulation medication.

These toolkits were created by MAQI2 consortium participants who are experts in anticoagulation care. Developed from best practices identified in data collected in patient registries as a part of the Initiative – the goal was to provide practitioners and patients with up-to-date, reliable, and easy to use source information on anticoagulation.

If your practice provides any level of anticoagulation management to patients these toolkits could be very useful to you and your patients. The toolkits are free and available at www.anticoagulationtoolkit.com

MiPCT Complex Care Management Course 

The 2014 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 August 18-20, 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/august-1821-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM course dates:

August 18-21, 2014 – Introductory Webinar August 18

  • • August 18-19, 2014 – Total six hours of self-study modules and post-tests
  • • August 20-21, 2014 – In person training

September 8-11, 2014 – Introductory Webinar September 8

  • • September 8-9, 2014 – Total six hours of self-study modules and post-tests
  • • September 10-11, 2014 – In person training

October 13-16, 2014 – Introductory Webinar October 13

  • October 13-14, 2014 – Total six hours of self-study modules and post-tests
  • October 15-16, 2014 – In person training

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

MiPCT Primary Care Webinar August 2014 for Primary Care Physicians and Care Managers

 MiPCT is offering a Palliative Care Webinar August 27, 2014 primarily designed for a Physician audience. MiPCT Care Managers are also welcome to attend.

Presenter: David E. Weissman, M.D., FAAHPM is a nationally recognized palliative care expert who will present the Webinar topics: Palliative Care: Giving Bad News and DNR.

Dr. Weissman’s current appointments include:

  • Professor Emeritus; Medical College of Wisconsin
  • Co-Director, EPERC; Medical College of Wisconsin (www.eperc.mcw.edu)
  • Consultant, Center to Advance Palliative Care (2008-present)
  • Co-Director; Palliative Care-Outpatient Integration (IPAL-OP); CAPC, New York

 Webinar: August 27, 2014, 12pm–1pm; Palliative Care: Giving Bad News/DNR; presented by David Weissman, MD, Medical College of Wisconsin.

Objectives:

  • List a six step approach to giving bad news.
  • Describe two methods of starting a DNR discussion
  • Identify three common patient misconceptions of the CPR procedure.

CME Information: The Practice Transformation Institute is accredited by the Michigan State Medical Society to provide Continuing Medical Education for physicians. The Practice Transformation Institute designates this live activity for a maximum of one (1) AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

To receive Continuing Medical Education credit for this webinar you must complete the following:

  • Register for the Webinar. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=662689954
  • On 8/27 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 Continuing Medical Education credit for multiple attendees viewing the webinar on one computer. MiPCT is only able to issue Continuing Medical Education credit for participants who attend and login individually to the live Webinar (i.e. viewing the recorded Webinar will not provide Continuing Medical Education).

 Attached please find a ‘SAVE the DATE Flyer” for this Webinar. Help us get the word out to the MiPCT Primary Care Physicians and Care Managers by distributing this flyer! Please submit questions to: micmrc-requests@med.umich.edu.

MiCMRC Care Manager Monthly Update: July, 2014

Webinar resources and other important information are included in the attached “July 2014 MiCMRC CM Monthly Update” document.

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. The programs listed in the attached table include information regarding course date/criteria to schedule.

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

Stories of Your Care Management Success: Angela Weir RN, BSN, HCM, Marquette General Family Medicine, Upper Peninsula Health Plan

Angela Weir RN, BSN, is a hybrid care manager at Marquette General Family Medicine; an Upper Peninsula Health Plan provider. Angela began working with a 50 year old patient with BCBSM insurance with a history of obesity, HTN, and DM. The patient was frustrated because he had been trying to lose weight unsuccessfully. He was on medication to control his blood pressure and an oral DM medication. His A1C was 7.0 when he first started working with care manager but wanted to improve it. He was concerned if he didn’t start making changes this A1C would continue to climb. He had been trying to lower his A1C for over one year without success.

Angela spoke with the patient to identifying his goals. He wanted to stop taking some of his medication and reduce his A1C below 7 in three months. He planned to accomplish this by losing weight. Initially, he needed a lot support and Angela called him weekly to follow up on his progress and discuss his goals. Slowly he began to increase his physical activity and improve his diet.

 After three months he had lost 19 pounds and his A1C deceased to 6.3. Due to his progress Angela decreased her phone visits with the patient from weekly to monthly. During each call Angela continued to assess the patient’s ability to maintain his new lifestyle and offered support and education when needed.

Six months after the patient began receiving care management services with Angela the patient was able to discontinue his blood pressure medication and decrease the dosage of the medication to control his blood sugar in half. His A1C remained below 7.0 and he lost an additional 16 pounds for a total weight loss of 35 pounds. His BMI decreased from 38.4 to 33.59.

The patient was seen by the Primary Care Provider (PCP) in December of 2013. Since then he has maintained his weight loss, and his blood pressure and DM continue to be well controlled. As a result he is no longer actively followed by Angela.

 NEXT ISSUE DATES:

  • • Next MiPCT P.O. FLASH Issue: August 18, 2014
  • • Next MiPCT Practice FLASH Issue: August 25, 2014

 July 14, 2014

You Are Invited! MiPCT 2015 Visioning Session for PO Leaders

On July 29th, an in-person PO Leader Stakeholder MiPCT 2015 Visioning Meeting will be held in Okemos from 1-3pm. The goal is to obtain PO leader perspectives on MiPCT 2015 design and invite your ideas and priorities in building an even stronger primary care future in Michigan. A separate session will be planned for care team members including Care Managers and physicians at a later date.

As we transition to ongoing program sustainability, we highly value the opportunity to incorporate your insight and informed perspectives in this PO Leader listening and brainstorming session. The in-person meeting will be held at MPHI in the Main ILC Room, Suite 380 at 2436 Woodlake Circle in Okemos. Program material will be distributed prior the meeting date.

We hope that you will be able to join us and look forward to a wonderful discussion as we together build the future for Triple Aim sustained success.

Looking for 20 Practices!

Through a partnership with the Greater Detroit Health Council (GDAHC) and the Institute for Patient & Family-Centered Care (IPFCC), the leading national organization in incorporating the patient’s perspective in care decisions, twenty MiPCT practices have a special training opportunity.

The training is for practices interested in beginning or enhancing patient advisor programs. Up to four Practice Learning Credits will be awarded for the twenty practices selected from those who apply.

The attached flier describes the opportunity in greater detail, and can be distributed to practices. For more information, please contact dbechel@umich.edu.

Opportunity to Comment on Revised CMS Monthly Chronic Care Management Code Language

The long-awaited 2015 Physician Fee Schedule containing the revised CMS monthly Chronic Care Management code language was released the evening of July 3, 2014. A webinar with a debrief was conducted for POs and practices on July 9th (materials are attached for reference). In brief:

  • The new monthly code for Medicare FFS would go into effect on January 1, 2015 at a rate of $41.92/month.
  • The code is targeted at reimbursing for non-face-to-face care management services for Medicare patients with two or more chronic conditions that would benefit from care coordination
  • Several of the changes that Michigan suggested to CMS last year were reflected in the revised language. For example, the NP/PA requirement as well as reference to a national PCMH designation or recognition were removed.
  • The revised language specifically includes reference to potential (not yet declared) demonstration extension so that practices cannot “double dip” (receive PMPM on a population basis for all attributed Medicare members, as well as bill the new code and receive payment). However, practices could bill the new code for Medicare patients who are not attributed to the practice, even in the event of extension.

Like last year, we have an opportunity on behalf of all MiPCT stakeholders to submit comments to CMS. Comments should be sent to dbechel@umich.edu by August 2, 2014 with the subject line: “Comment on CMS Revised CCM Code Language”. Please include the following: 1) page number and section reference you are referring to; 2) a concise description of your comment and why it poses a problem; and 3) alternative language that you would suggest. We will compile comments, and obtain review of the compiled version with stakeholders and Steering Committee and submit the comments at the end of August to CMS.

MiPCT/PDCM Billing Roadshow Schedule Attached

We are excited to bring the MiPCT/PDCM Billing Roadshows back to a town near you. Please join us to learn the billing guidelines of Provider Delivered Care Management (PDCM). The Billing Roadshow Schedule flier is attached for your convenience. Please note the Marquette Billing Roadshow date is to be determined.

BCBSM PDCM G and CPT Code Billing Document

Blue Cross Blue Shield of Michigan has updated their PDCM billing documents. The revised documents including the current roadshow presentation, guidelines and FAQs are located on mipct.org website. Once on the mipct.org home page, click on the “Resources” tab, then click on the “Documents” tab. On the Documents page, resources are listed under the title, “Billing and Payment.” The link to the documents page on mipct.org is: http://https://mipct.org/resources/mipct-documents-and-presentations/.

2014 Q2 Narrative Supplement

In addition to completing the web-based report at https://mipct.mihealth.org/, PO quarterly reporting for 2014 Q2 will include completion of a supplemental narrative report using an Excel template that will be distributed via email from the demo mailbox. Both are due no later than July 31st. Please return the Excel report to mipct@michigan.gov.

Statewide MiPCT Patient Advisory Council Member Nominations

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

Members should be:

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

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

The dates of the 2014 PAC Conference Calls are:

  • Friday, September 5, 2014 at 1:00 PM
  • Friday, December 12, 2014 at 1:00 PM

MiPCT Dashboard Updates

MDC launched Release 9.0 of the new Dashboard on 7/1. For information about this release, please see the MDC Dashboard Release Notes document at https://www.michigandatacollaborative.org/MDC/assets/MDC_MiPCT_ReleaseNotes.pdf.

MDC staff have been working to resolve issues that POs are having logging on to the new Dashboard. Once the issues are resolved, the old Dashboard will be disabled, and you will be notified. Please log on to the new Dashboard (which has the most up-to-date data), and contact us if you have any issues or concerns.

Additionally, MDC now has the ability to restrict data down to the Practice level, which means that we can allow Practice users to access the Dashboard (if their account requests are approved by the PO Authorizers). Practice-level users can request accounts using the same method as PO-level users (by accessing the MDC Website at www.MichiganDataCollaborative.org, navigating to the Accounts page, and clicking the Request Account button.)

Please be aware that PO Authorizers may begin receiving account verification requests from MDC. Please consider defining a policy for approving Practice Dashboard users if you have not already done so.

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 Upcoming Webinars

In support of MiPCT’s 2014 clinical focus on Palliative Care you are invited to attend two webinars this summer.

  • August 27 , 2014, 12-1pm; Palliative Care – Giving Bad News/Do Not Resuscitate (DNR);

Presenter: David Weissman, MD, Project Director, Founder, Medical College of Wisconsin

Target Audience: Physicians and Care Managers.

  • September 10, 2014, 12-1pm; *Palliative Care – Learning Goals of Care;

Presenter: David Weissman, MD, Project Director, Founder, Medical College of Wisconsin

Target Audience: Physicians and Care Managers.

Save the Date! Pediatric Care Managers’  In-Person Meeting, September 17

An all day, in-person Pediatric Care Manager meeting is scheduled for September 17, 2014. The meeting will be held at the Blue Cross Blue Shield of Michigan Lyon Meadows Conference Center, 53200 Grand River Avenue, Wixom, MI. An email with more detailed information will be forthcoming.

MiPCT Complex Care Management Course

The 2014 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 August 18-20, 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/august-1821-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM course dates:

August 18-21, 2014 – Introductory Webinar August 18

  • August 18-19, 2014 – Total six hours of self-study modules and post-tests
  • August 20-21, 2014 – In person training

September 8-11, 2014 – Introductory Webinar September 8

  • September 8-9, 2014 – Total six hours of self-study modules and post-tests
  • September 10-11, 2014 – In person training

October 13-16, 2014 – Introductory Webinar October 13

  • October 13-14, 2014 – Total six hours of self-study modules and post-tests
  • October 15-16, 2014 – In person training

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

Stories of Your Care Management Success: Janet Pund RN-BC, Complex Care Navigator, Ypsilanti Health Center, University of Michigan Health System

Janet Pund, RN-BC is a Complex Care Navigator at Ypsilanti Health Center within the University of Michigan Health System. Jan began working with Mr. B when he was discharged from the hospital after being treated for heart failure. Mr. B’s diagnoses include Heart Failure, Atrial Fibrillation, Hypertension, CKD, Chronic Venous Insufficiency, Chronic Interstitial Lung Disease and s/p CVA in 2007. Mr. B is covered by Medicare insurance.

When Janet began working with Mr. B he was a frail 79 year old gentleman. He had been a world renowned cellist, and then a professor until his stroke in 2007 ended his stellar career. He was born in Denmark, with an Icelandic mother so claimed both countries of origin. He lived with his wife, who doesn’t drive, and his children and grandchildren all live in Denmark.

Transportation to and from visits was an issue. Mrs. B didn’t drive and Mr. B couldn’t drive anymore. Janet found resources for reasonable rides for medical appointments with the help of the office social worker (SW).

Mr. B was newly diagnosed with atrial fibrillation and put on Coumadin. Due to the constraints of being home bound Janet was able to get him a home PT/INR machine to make it easier to monitor his INR. These results were reported to and followed by the anticoagulation clinic.

Mr. B had a home care nurse along with PT/OT and a SW referral to assess continued needs. Janet kept in frequent contact with the home care nurse as his condition continued to deteriorate. He had hospitalizations in late October and November. After his third hospitalization Mr. B was sent home with oxygen. The PCP, Janet, and the visiting nurse worked together to obtain a hospital bed and bedside commode to be placed in the living room for Mr. B. Prior to this he was attempting to go up and down stairs with his wife’s help. He began to use a walker rather than his cane and spent more and more of his days in bed. A portable PO2 monitor was provided to allow the wife to report his oxygen percentages to the office and his oxygen was adjusted as needed by the PCP.

Janet and Mr. B’s wife discussed palliative care and what the service could offer her and Mr. B. She was very interested in this. Janet huddled with the PCP who was reluctant to order palliative care at that time. The PCP made home visits when it became too difficult for Mr. B to come to the office. Ultimately, the PCP did order palliative care.

Arbor Hospice, an organization that provides both Palliative Care and Hospice service, was notified and a nurse practitioner was at the home within 48 hours of the referral. The agency provided additional aide help to bathe, dress and even feed Mr. B. His wife had been his sole caretaker and she was beginning to have health issues because of the stress of this. The nurse practitioner kept in contact with Janet to update her on Mr. B’s illness and they collaborated with the PCP to obtain orders for medications and durable medical equipment as it was needed. Mr. B transitioned to Hospice care after a few weeks.

In May 2013, Mr. B was notified by the Icelandic government that he was to be the recipient of their country’s highest civilian award for his musical achievements. While he wasn’t able to travel to Iceland for the ceremony his sons did and he was able to watch via Skype that the Hospice staff was able to facilitate.

Mr. B passed away in June 2013. He never had another hospitalization after his last in November 2012. He died peacefully at home as he wished as his wife lay next to him holding him until the end. She was grateful to have been given the chance to do that with all the support from the Arbor Hospice staff, and the PCP office team to ensure that his care was managed at home and his end of life wishes were met.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: July 28, 2014
  • Next MiPCT Practice FLASH Issue: July 28, 2014

 June 30, 2014

July 9 PO Webinar

The next Quarterly PO Webinar will be held on July 9, from 12:00 – 1:30 PM.  Topics will include:

  1. An overview by the Institute of Patient & Family Centered Care (IPFCC) on patient advisors at a practice level; and
  2. An update on the monthly CMS Chronic Care code, and 2015 CMS funding.

Remaining 2014 MiPCT Target Payment Dates by Payer

The attached table contains the target payment dates for MiPCT funding to practices and POs from participating payers. Please note that these dates are projections and are subject to change. Updates to the table will be provided in upcoming editions of the FLASH as they are available.

Looking for 20 Practices!

Through a partnership with the Greater Detroit Health Council (GDAHC) and the Institute for Patient & Family-Centered Care (IPFCC), the leading national organization in incorporating the patient’s perspective in care decisions, twenty MiPCT practices have a special training opportunity.

The training is for practices interested in beginning or enhancing patient advisor programs.  Up to four Practice Learning Credits will be awarded for the twenty practices selected from those who apply.

The attached flier describes the opportunity in greater detail, and can be distributed to practices.  For more information, please contact dbechel@umich.edu.

You Are Invited! MiPCT 2015 Visioning Session for PO Leaders

On July 29th, an in-person PO Leader Stakeholder MiPCT 2015 Visioning Meeting will be held in Okemos from 1-3pm.  The goal is to obtain PO leader perspectives on MiPCT 2015 design and invite your ideas and priorities in building an even stronger primary care future in Michigan.   A separate session will be planned for care team members including Care Managers and physicians at a later date.

As we transition to ongoing program sustainability, we highly value the opportunity to incorporate your insight and informed perspectives in this PO Leader listening and brainstorming session.   The in-person meeting will be held at MPHI in the Main ILC Room, Suite 380 at 2436 Woodlake Circle in Okemos.   Program material will be distributed prior the meeting date.

We hope that you will be able to join us and look forward to a wonderful discussion as we  together build the future for Triple Aim sustained success.

Statewide MiPCT Patient Advisory Council Member Nominations

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

Members should be:

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

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

The dates of the 2014 PAC Conference Calls are as follows:

  • Friday, September 5, 2014 at 1:00 PM
  • Friday, December 12, 2014 at 1:00 PM

BCBSM Symposium “Physician and Patient Experience”

BCBSM’s  Corporate Marketing and Consumer Experience department held a “Physician and Patient Experience” themed Market Insight Symposium on Wednesday June 4, 2014 featuring  a presentation centering on physician/member/health plan interactions, and a panel discussion of PGIP PCMH  MiPCT Physicians and Care Managers.   The symposium is a quarterly meeting for BCBSM employees.

Panel topics included Care Management services and the associated positive impacts on their practices’ and patients’ experiences and outcomes.

The panel members included:

  • Kevin Taylor, MD, Integrated Health Associates, Co-Medical Director, MiPCT
  • Phil Rodgers, MD, Associate Professor, Family Medicine, University of Michigan Health System
  • Alexander Ruthven, MD, Huron Family Practice Center
  • Heidi Steinhebel, RN, BSN, CCM, CCP,  Lead Care Manager, Integrated Health Associates
  • Kelly Yero, RN, BSN, BA,  Ambulatory RN Case Manager, Henry Ford Health System, MiPCT Clinical Lead

The panelists shared their insights regarding care management delivery in their practice settings.  They highlighted stories of patient care, which included the care manager, physician and patient collaborating and developing a plan to address the patient’s health concerns.  This team approach results in improved patient outcomes and reduction of unnecessary utilization of Emergency room visits and or Hospital admissions.  The panel presenters each described how the practice team has evolved to actively include the patient as a vital member of the health care team.

Juliann Testy- Recipient of the Clara Ford Nursing Excellence Award- Quality Pillar

Juliann Testy is the 2014 Recipient of the Clara Ford Nursing Excellence Award.

Juliann  is currently the manager for the Henry Ford Health System’s Ambulatory Nurse Case Managers and has been managing the Michigan Primary Care Transformation (MIPCT) demonstration project that was implemented in January 2012.

Juli is seen by her colleagues as a role model, an inspiration, dedicated and a wonderful co-worker and leader. Excerpt from Juli’s nominations:

“Juli Testy has personally and professionally led our team of 10-22 Nurse Case Managers through the uncharted territory of the MiPCT Demonstration Project. She is an exemplary leader who has used her skills to keep our group on course to successfully effect change in the Primary Care Clinic setting. With her support, our group has successfully decreased avoidable Hospitalizations and Emergency Department visits in the System significantly. To validate the statistical content of the MiPCT program, she is instrumental in continuously developing quality data collection tools, specific billing codes and tirelessly collaborating with the HFHS IT department.

With the additional challenge of Henry Ford’s Epic EMR implementation coinciding with continuing development of the MiPCT program, she was able to successfully integrate the MiPCT coding and the case management documentation required within Epic. If there is one word that describes Juli, it would be dedication. Juli embodies the spirit of an innovator and is a true “team player”. She puts her all into everything she undertakes. Juli is always willing to assist as needed and makes herself available to her staff at all times. She consistently displays a great attitude and can find a way to infuse humor despite the stresses and challenges that being a change agent can bring.“

Excerpt from Juliann’s Nomination:

“While working as a case manager on K-15, Juliann was asked to be the clinical lead representing HFHS in the Michigan Primary Care Transformation (MiPCT) project. The project was new and Juliann jumped right into these uncharted waters. The position was quickly becoming much more of a responsibility than anyone anticipated. The title required a three-week intensive training period at Geisinger Health in Pennsylvania. Afterwards, she returned to complete the orientation of approximately 15 new case managers who were hired for the MiPCT project, while managing the handful of veteran case managers already embedded in a few outpatient internal medicine clinics. Juliann has taken all of the changes, frustrations, complaints and successes with grace and professionalism. With her guidance, the project has been a huge success. Our group was awarded Henry Ford Health System’s 2012 Focus on People Award. Congratulations Juliann!”

MiPCT would like to highlight individuals who have been recognized for professional achievements related to population health in future MiPCT FLASH Newsletters.  Please share your achievements by submitting a brief statement via mipctdemo@michigan.gov.

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

On the following page 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. The programs listed below include information regarding course date/criteria to schedule.

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/.

A Message from BCBSM to all MiPCT Participating Physician Organizations:

To support provider-delivered care management (PDCM), a 5% uplift on all E&M codes (for all BCBSM-attributed members) was implemented for MiPCT-participating practices effective July 1, 2013.

As previously communicated on July 12, 2013 in a MiPCTDEMO communication, using the uplift mechanism to support PDCM enables us to avoid using substantial PGIP incentive pool funds for make-whole MiPCT payments, which means more funds are available to support PO practice transformation and reward PO performance and improvement.

As previously mentioned, the uplifts are being deducted from the tabulated make- whole rewards. The July 2014 reward is the first we were able to deduct these uplifts. Some POs will not receive a payment this cycle, and may still have an overage (from the tabulated 5% uplifts) that will affect future make-whole payments. Please note that BCBSM will not seek reimbursement from POs but will instead reduce future make-whole payments by the overage.

MiPCT Care Manager Webinars for July

In support of MiPCT’s  2014 clinical focus for Palliative Care you are invited to attend two webinars in July 2014.

  • July 2, 2014, 2pm-3pm; Advance Care Planning; presented by Julie Seitz, MSBA, RN, St Joseph Mercy Health System, Advance Care Planning, Leader, Instructor and Facilitator.
  • July 9, 2014   2pm-3pm;   *Palliative Care –  Pain Assessment;   presented by Peg Nelson, RN-BC, MSN, NP, ACHPN, Director Palliative Care and Pain Services, St. Joseph Mercy Oakland.

*The July 9, 2014 Palliative Care Pain Assessment webinar 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 receive Nursing Continuing Education contact hour for the Palliative Care –Pain Assessment 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.

MiPCT Complex Care Management Course

The 2014 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 July 7-10, 2014 MiPCT CCM course at the following site:  https://jodyooo.wufoo.com/forms/july-710-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM course dates:

July 7-10, 2014  – Introductory Webinar July 7

  • July 7-8, 2014 – Total six hours of self-study modules and post-tests
  • July 9-10, 2014 – In person training

August 18-21, 2014 – Introductory Webinar August 18

  • August 18-19, 2014 – Total six hours of self-study modules and post-tests
  • August 20-21, 2014 – In person training

September 8-11, 2014 – Introductory Webinar September 8

  • September 8-9, 2014 – Total six hours of self-study modules and post-tests
  • September 10-11, 2014 – In person training

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

Release 9.0 of the MiPCT Dashboard to be Launched this Week

MDC expects to launch Release 9.0 of the new MiPCT Dashboard this week, which will include the following:

Electronic Clinical Quality Measures (on the Quality page), which are based on the EMR data received from each PO

  • Paid claims and eligibility data through January 2014
  • An updated measurement period through October 2013

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

Important! The old Dashboard will no longer be accessible starting with the 9.0 release. MDC encourages all of our users to log in and view the new Dashboard so that we can troubleshoot any issues you may have prior to the launch of 9.0.

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

MiPCT/PDCM Billing Roadshow Schedule Attached

We are excited to bring the MiPCT/PDCM Billing Roadshows back to a town near you.  Please join us to learn the billing guidelines of Provider Delivered Care Management (PDCM).  The Billing Roadshow Schedule Flier is attached for your convenience.

MDC’s June 2014 MiPCT All-Payer Patient Lists Posted  6/26

The Michigan Data Collaborative posted the June 2014 MiPCT All-Payer Patient Lists on June 26, 2014. An email announcing the release was sent to Dashboard users.

The MiPCT All-Payer Patient Lists are located on the Download PO Reports page of the new MDC MiPCT dashboards.  The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_06.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).

Stories of Your Care Management Success:
Lynn Czech RN, BSN, MiPCT Hybrid Care Manager, Henry Ford – Sterling Heights Pediatrics

Lynn Czech, RN, BSN is a MiPCT Hybrid Care Manager at Henry Ford Sterling Heights Pediatrics within Henry Ford Health System. “Juan”, age 12, was a Medicaid insured patient identified on the daily emergency department discharge list by Lynn as someone who might benefit from MiPCT care management services. Lynn conducted a transition of care call. During their first conversation, Juan’s mother reported that Juan was playing in his first basketball game of the season when he jumped to take a shot. As he came down he twisted and “fell into a heap” on the court. Juan was unable to sit up and was in extreme pain. He was taken to the emergency department by his mother.  X-rays confirmed bilateral fractures to the growth plates of both tibias, and Juan was transferred to Children’s Hospital of Michigan for further management.  Fortunately, he did not require surgery.  He was placed in bilateral knee braces, given crutches and discharged home with no weight bearing for 6 weeks. Juan’s mother stated to Lynn, “I can’t believe this is happening”. She seemed overwhelmed by the situation and unsure of what to do.

Arrangements were made for DME equipment including a shower chair, elevated toilet seat, wheelchair, walker, and a temporary ramp for home entry.  Juan’s mother declined additional adaptive devices, stating “this is temporary.” Juan was unable to flex his knees with the immobilizers on; making it difficult for him to get in and out of a vehicle. As a result, additional arrangements were made for in-home physical and occupational therapy, as well as temporary home-schooling.

Lynn reviewed and discussed Juan’s neurologic / vascular assessment with his mother so she would be able to identify and report any problems if they occurred.  Lynn also advised Juan’s mother on appropriate nutritional intake to promote tissue healing and prevent constipation due to Juan’s decreased mobility and use of pain medication.

Juan’s teacher visited his home two to three times a week to review course materials and provide lessons and tests so he would not fall behind in school.  However, his mother expressed that Juan was sad and feeling down because his friends would call or text occasionally, but only one or two friends visited him during his first two weeks at home.  She said he missed playing basketball and seeing his friends.  Since she did not know all his friends on the basketball team and at school, Lynn suggested she talk to his teacher.  For the remainder of his recovery at home, they arranged for his friends to visit opposite the days his teacher came (so it would not interfere with his school lessons).  Juan looked forward to these visits.  His mother reported his spirits were lifted and he completed his homework quicker and worked harder in therapy.

Juan returned to the orthopedist six weeks after his injury. His leg braces were removed at that time.  He was advised to continue with PT and OT twice a week for four to six weeks and to follow up with orthopedist in three months.  Gym restrictions are in place and Juan cannot participate in vigorous activity until cleared by PT.

Juan’s pain had been managed by a non-steroidal anti-inflammatory drug (NSAID) for the majority of his recovery, but his mother recently reported that he had some abdominal discomfort. A change to an over the counter analgesic and antipyretic was recommended, which has been successful in eliminating his abdominal pain.  Juan has returned to school without the use of assistive devices and is allowed extra time between classes due to his fatigue.  His mother expressed he continues to progress toward a full recovery and stated to Lynn, “Thank you so much for helping us during this time.  We would’ve done what we needed to do, but it was a relief knowing I had someone to call whenever we needed anything.  Having his friends schedule their visits was a great suggestion.  It was a big lift to his spirits and I believe helped him recover faster.  You are wonderful.”

MiCMRC Care Manager Monthly Update: June, 2014

Depression Management conference calls: There were four Depression Management conference calls in June.  June 4, 2014, included the Southeast region, June 11, 2014 included the North region, June 18, 2014 included the West region and June 25, 2014 included the MiPCT Social Workers.

Reference Materials:

  • ICSI Collaborative Care for Depression in the Primary Care setting
  • MQIC Depression in Primary Care Guideline
  • Veterans’ Affairs Primary care Diagnosis and Management
  • MiPCT Care Manager Conference Call Depression Part III

Pediatric conference call titled Childhood Obesity: Feeding Practices and Eating Behavior was held on June 20, 2014.

Please see the full MiCMRC Care manager Monthly Update for June 2014, attached.

Save the Date!   Pediatric Care Managers’  In-Person Meeting, September 17

An all day, in-person Pediatric Care Manager meeting is scheduled for September 17, 2014. The meeting will be held at the Lyon Meadows Conference Center for Blue Cross Blue Shield of Michigan, at 53200 Grand River Avenue, Wixom, MI. An email with more detailed information will be forthcoming.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue:     July 14, 2014
  • Next MiPCT Practice FLASH Issue:     July 28, 2014

June 16, 2014

Looking for 20 Practices!

Through a partnership with the Greater Detroit Health Council (GDAHC) and the Institute for Patient & Family-Centered Care (IPFCC), the leading national organization in incorporating the patient’s perspective in care decisions, twenty MiPCT practices have a special training opportunity.

The training is for practices interested in beginning or enhancing patient advisor programs. Up to four Practice Learning Credits will be awarded for the twenty practices selected from those who apply.

The attached flier describes the opportunity in greater detail, and can be distributed to practices. For more information, please contact dbechel@umich.edu.

July 9 PO Webinar

The next Quarterly PO Webinar will be held on July 9, from 12:00 – 1:30 PM. Topics will include:

  1. An overview by the Institute of Patient & Family Centered Care (IPFCC) on patient advisors at a practice level; and
  2. An update on the monthly CMS Chronic Care code, and 2015 CMS funding.

Statewide MiPCT Patient Advisory Council Member Nominations

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

Members should be:

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

Member nominations are now being accepted at:

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

The dates of the 2014 PAC Conference Calls are as follows:

  • Friday, September 5, 2014 at 1:00 PM
  • Friday, December 12, 2014 at 1:00 PM

MiPCT Palliative Care Curriculum 2014 

MiPCT has selected Palliative Care as one of the four clinical focuses for 2014. The other clinical focuses include, Depression Management, Diabetes Management and Identification of High-Risk Patients. To outline and plan the 2014 MiPCT Palliative Care Curriculum, MiPCT has partnered with subject matter experts. We are pleased to announce the MiPCT Palliative Care subject matter experts: Phil Rodgers MD, Associate Director, Hospice and Palliative Care, Medicine Fellowship Program, University of Michigan; and David Weissman, MD, Project Director, Founder, Medical College of Wisconsin Palliative Care Program. These two experts will enhance the understanding of the principles of Palliative Care and its importance in primary care practice. Dr. Rodgers and Dr. Weissman are leading the Palliative Care curriculum planning and development for MiPCT.

The Palliative Care curriculum is a multi-platform delivery design which includes (see link to table, below):

  • Webinar Series (Topics identified for PCPs and Care Managers)
  • Fast Facts & Concepts in Palliative Care
  • Palliative Care topic addressed at the MiPCT Annual Summit, Fall 2014
  • Regional Care Manager Conference Calls
  • Practice FLASH newsletter articles

Palliative Care TABLE 1 Graphic

Dr. Weissman has recommended the MiPCT project introduce clinicians to Fast Facts and Concepts. Fast Facts and Concepts in Palliative Care are available through EPERC (End of Life Palliative Education Resource Center). The link, http://www.eperc.mcw.edu/EPERC/FastFactsandConcepts, provides information about Fast Facts, as well as the link to Fast Facts. These resources provide key topics important to clinicians caring for patients facing life-limiting illnesses.

There will be introductions of pertinent palliative care topics, as well as links to the resources through EPERC in various issues of the FLASH. We encourage physicians, care managers and practices to read these resources as MiPCT continues to focus on Palliative Care and its applicability to seriously ill patients.

For additional Palliative Care resources, go to: http://micmrc.org/palliative-care

MDC Release 9.0 Update

Release 9.0 of the new Dashboard is expected to launch the week of June 30, 2014. It will include the following:

  • Clinical Measures (on the Quality page)
  • Paid claims and eligibility data through January 2014
  • An updated measurement period through October 2013

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

Please note that the old Dashboard will no longer be accessible starting with the 9.0 release. MDC encourages all of our users to log in and view the new Dashboard so that we can troubleshoot any issues you may have prior to the launch of 9.0.

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

MiPCT Complex Care Management Course 

The 2014 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 July 7-10, 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/july-710-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM course dates:

July 7-10, 2014 – Introductory Webinar July 7

  • July 7-8, 2014 – Total six hours of self-study modules and post-tests
  • July 9-10, 2014 – In person training

August 18-21, 2014 – Introductory Webinar August 18

  • August 18-19, 2014 – Total six hours of self-study modules and post-tests
  • August 20-21, 2014 – In person training

September 8-11, 2014 – Introductory Webinar September 8

  • September 8-9, 2014 – Total six hours of self-study modules and post-tests
  • September 10-11, 2014 – In person training

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

Stories of Your Care Management Success

Elizabeth Eaton, RN, MPH, MiPCT Clinical Lead, Sparrow Medical Group-North 

Elizabeth Eaton, RN, MPH is a care manager at Sparrow Medical Group-North, and a MiPCT Clinical Lead. She has been working with a 61 year old man with diabetes, who is covered by BCN insurance. A year ago when she began working with “Tom”, his A1C was 11.4, and he weighed 174 pounds. He was referred to care management by his primary care provider (PCP).

Elizabeth met with Tom and his wife. During the initial visit, Elizabeth assessed Tom’s eating habits and diet. He was eating a lot of quick, easy snacks, and fast food, and he was skipping meals. Tom’s wife voiced concerns about his eating, and they both agreed that he “loves food and loves to eat”. He did not participate in any exercise except what he got at work. Tom had been working for his local city Street and Sanitation department, but he was currently laid off. He developed a plan to improve his diet and increase his exercise with support and guidance from Elizabeth.

Elizabeth met with Tom and his wife a week later. He had his A1C checked and it was 11.2. Elizabeth provided teaching to Tom and his wife on how to use an insulin pen the PCP had recently prescribed for him. Insulin titration was needed, and Tom agreed to close follow up with Elizabeth while his dosages were being determined.

Elizabeth provided seven follow up telephone calls between September 21st and November 8th. During those phone calls, Elizabeth helped to adjust Tom’s insulin using an established protocol until he reached morning blood sugar levels of 110-130. They discussed what he was eating and possible tweaks to his diet that might be helpful. Tom was always asking questions about his food choices. During this time, he also started walking two times a week and eventually was walking three times a week. Tom was not employed during this time. Money was an issue. Elizabeth helped him get the best price for his test strips and coupons for his medications.

He returned to work by November 8th. Elizabeth and Tom had talked previously about what he would take with him to work in his truck to help him avoid fast food, and make sure he had consumed enough food to balance the insulin he had taken. He always knew he could call Elizabeth at the office with any questions or concerns.

During the next office visit, Tom’s PCP expressed that Tom’s diabetes was under much better control than before he began working with Elizabeth. His A1C was 7.4 at that time. A year later, Tom had an office visit, with his PCP and a follow up clinical support visit with Elizabeth. During that visit the PCP charted, “excellent control on current management. He was congratulated on his progress”. Tom’s A1C was 6.9 at that time, and his weight was 166 pounds. He reported walking 20 minutes each day, playing volleyball on Tuesday evenings, and thinking of adding a second night of volleyball to his weekly schedule.

Tom and his wife attended a group diabetic visit Elizabeth conducted a month later. Both Tom and his wife demonstrated confidence in his choices and progress. He expressed that he is doing well, and is comfortable calling Elizabeth anytime if he has questions. Tom now weighs 162 pounds, his A1C is 6.8, he is now on an oral anti-diabetic medication, and no longer needs insulin.

NEXT ISSUE DATES:

• Next MiPCT P.O. FLASH Issue: June 30, 2014

• Next MiPCT Practice FLASH Issue:June 30, 2014

 May 19, 2014

MiPCT “v.2” Sustainability Update & Care Manager Sufficiency Ratio Interim Consideration

An update on MiPCT sustainability and continuity was included in the PO webinar held on 5/14/2014. The slides are attached and are included along with the webinar link on the mipctdemo.org website under “Presentations”. The 5/14/2014 update included messaging from the discussions with each payer to date. The findings are quite constructive and it is exciting to ensure that this important work will continue. A follow-up webinar is planned with more specific details for late June when we expect to have the refined CMS wording on their proposed chronic care management code.

Though the news about 2015 continuity and sustainability is positive, in the interim (from 5/24/2014 to 6/24/2014), in the event of a Care Manager resignation that puts the PO below the 80% sufficiency requirement at a 2 Care Manager per 5000 MiPCT member ratio, the PO or practice will not be responsible for replacing the position. When additional details are available regarding the specifics of funding continuity, the requirement will resume.

Patient Advisory Council Member Nominations

The 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 the implementation and operations of the MiPCT. The council is comprised of patients serviced by the MiPCT. We are recruiting additional nominations for this state-wide PAC, which meets quarterly via conference call.

Members should be:

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

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

The dates of the 2014 PAC Conference Calls are as follows:

  • Friday, June 6, 2014 at 1:00 PM
  • Friday, September 5, 2014 at 1:00 PM
  • Friday, December 12, 2014 at 1:00 PM

Stories of Your Care Management Success: Deanna Koscielny, RN, HCM – Marquette General Family Medicine – Lakewood, UPHP

Deanna Koscielny, RN, is a hybrid care manager at Marquette General Family Medicine Lakewood; an Upper Peninsula Health Plan provider. Deanna was working with a patient covered by BCBSM insurance. “Mary” is a 52 year old female referred to care management due to newly diagnosed Type 2 Diabetes Mellitus. At her initial visit with the care manager, Mary shared that she struggles with sugar cravings and a “chocolate addiction”. She also discussed her irregular eating schedule, often not eating until suppertime.

Deanna worked with Mary on simple goal setting, which included establishing a more regular eating pattern, including more healthy foods in her diet, and weight loss. Deanna educated Mary on the long term complications of diabetes, how to take the medication to control her blood sugar, the importance of testing her blood sugar levels, and how to use her glucometer.

Deanna had regular phone contact with Mary in the first couple weeks after the initial visit. Mary went through various stages of denial and experienced medication side effects. Deanna was concerned during this period that Mary would give up and not be able to follow through with her goals. During this time Deanna provided Mary with support and encouragement. By the time she met with Mary for a two week follow up visit Mary seemed to be tolerating her medications, she was eating better, her blood sugar levels were within range, and she had begun to accept her diagnosis.

Mary recently had her three month follow visit with her Primary Care Provider (PCP) and her A1C improved and her BMI from 30 to 27. Her PCP was happy to report that she was doing so much better and has really turned her health around. This provider has seen the positive impact care management can have on patient outcomes and asks Deanna to help anytime one of her patients is struggling with diabetes management or other chronic health issues.

MDC Launching a New MiPCT Dashboard Format May 21st

The Michigan Data Collaborative (MDC) is excited to launch a new and improved Dashboard to display the MiPCT data on May 21, 2014. This new Dashboard format is based on the Tableau platform, and will provide a more intuitive and flexible environment for our users. The new Dashboard will be released as Enhancement 8.01 and will contain the same data as the old Dashboard (currently, release 8.0 data). The old Dashboard will remain available until Release 9.0 is posted (June 2014).

On May 8th MDC hosted a webinar to introduce everyone to the new Dashboard format. To listen to the webinar, or review the slide deck and Q & A document, go to the Support Page and expand the Data Reference Material section. A link to the webinar, slides, and Q and A document are provided at the top of the section.

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

February and March 2014 G-Code Reports Update

MDC is waiting for one last data file, and then we will produce and post the February and March 2014 G-Code reports. When the reports are available, MDC will send out notice via email and the What’s New page on the MDC Website.

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

MDC’s April 2014 All Payer Patient Lists Reposted

Last week, MDC recreated and reposted the April 2014 All Payer Patient Lists (APPLs) to include patients from a large Washtenaw County employer group who were inadvertently left off the original April patient list that BCN submitted. All other Payers’ patients remain unchanged. However, every PO’s patient list was impacted—some greater than others, depending on their location in Michigan.

MDC sent out notice via email and the What’s New page on the MDC Website.

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

MDC’s May 2014 MiPCT All Payer Patient Lists to be Released this Week

The Michigan Data Collaborative plans to post the May 2014 MiPCT All Payer Patient lists this week. An email announcing the release will be sent to Dashboard users. The MiPCT All-Payer Patient lists are located on the Download PO Reports tab of the MDC MiPCT dashboards. The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_05.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).

MiPCT Complex Care Management Course

The 2014 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 & 4 – In person training

Register for the June 9-12, 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/june-912-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM Course Dates:

  • June 9-12,2014 Introductory Webinar June 9. Total six hour self-study modules and post- tests June 9-10. In person training June 11-12.
  • July 7-10, 2014 Introductory Webinar July 7. Total six hour self-study modules and post- tests, June 7-8, 2014. In person training July 9-10, 2014.
  • August 18-21, 2014 Introductory Webinar August 18. Total six hour self-study modules and post- tests, August 18-19, 2014. In person training August 20-21, 2014.

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

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: June 16, 2014
  • Next MiPCT Practice FLASH Issue: June 30, 2014

May 5, 2014

MDC Hosting May 8th Webinar to Introduce New Dashboard Format

The Michigan Data Collaborative (MDC) is excited to roll out new and improved Dashboards to display the MiPCT data. This new Dashboard format is based on the Tableau platform and will provide a more intuitive and flexible environment for our users. The new Dashboards will launch with Enhancement 8.01, which is scheduled for this week. The new Dashboards will contain the same data as the existing Dashboards (currently, release 8.0 data), but presented in a streamlined and easier-to-use format. The existing Dashboards will remain available until Release 9.0 is posted (early June 2014).

On May 8th at 9:00 AM, MDC will host a webinar to introduce you to and help you transition to the new Dashboards. This webinar requires all individuals to register for participation. To register, please follow this link (also listed below in the instructions) and select one of the “register” options to complete the registration in full: https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=669340017

. Once you have registered, a confirmation email with instructions for joining the meeting will be sent to you by messenger@webex.com . The email subject line will state: Registration approved for Web seminar: MDC Dashboards. Please be sure to save the confirmation email to access the webinar.

Topic: MDC Dashboards

Date: Thursday, May 8th, 2014

Time: 9:00am, EST (New York, GMT-04:00)

Instructions to register for this meeting:

1. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=669340017

2. Register for the meeting.

If you have any questions about logging into this webinar, please contact Jody Fisher fishjody@umich.edu . If you have questions about the Dashboards, please contact MDC at MichiganDataCollaborative@med.umich.edu .

Save the Date! Next PO Webinar May 14

On May 14 from 11-12:30 our next PO webinar takes place. The discussion is open to all MiPCT participants. Topics will include:

  • Palliative Care Curriculum Overview for MiPCT.-Presenter: Dr. Phil Rodgers;
  • An Update on MiPCT Sustainability and Continuity by MiPCT leadership; and
  • An open question-and-answer session.

To register, please follow this link (also listed below in the instructions) and select one of the “register” options to complete the registration in full: https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=667251156 . Once you have registered, a confirmation email with instructions for joining the meeting will be sent to you by messenger@webex.com. The email subject line will state: Registration approved for Web seminar: Palliative Care Curriculum Overview, an Update on MiPCT Sustainability/Continuity and Q&A. Please be sure to save the confirmation email to access the webinar.

Topic: PO Webinar Series: Palliative Care Curriculum Overview, An Update on MiPCT Sustainability/Continuity and Q&A

Date: Wednesday, May 14, 2014

Time: 11:00am, EST (New York, GMT-4:00)

Instructions to register for this meeting:

1. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=667251156

2. Register for the meeting.

If you have any questions about logging into this webinar, please contact Jody Fisher fishjody@umich.edu.

An Update on MiPCT Sustainability and Continuity

We are midway into our third and final year of our demonstration project (barring extension of the demonstration by CMS). When we began our work in 2012, the MiPCT was envisioned as a program aimed at strengthening and continuously improving team-based, patient-centered primary care. That vision has not changed and we have come so far together! Almost 400 care managers have been centrally trained and are embedded in practices across the state. For the first time in the state, multipayer data is flowing to improve care for patients in Michigan. A community of trust and great expertise has been created that is working hard to make a difference in 360 practices across the state.

We have also learned a great deal from our sister demonstration states, such as Vermont and Minnesota, whose efforts will continue with the state as the convener. Like Michigan, New York is engaged in discussion with each participating payer (maintaining the central role of the state as to evolve the programs past the demonstration period into ongoing programs). Other states are beginning this outreach with their payers. Michigan’s discussions with payers to date have been constructive overall, and will continue over the next few months. As one PO Leader described it on the ROI Subgroup, “we are together working for ‘MiPCT v.2’.”

It is natural that POs, practice teams and Care Managers are concerned about the opportunity to continue embedded care management after the demonstration period of the project, and we are working hard at delivering sustainability commitments from payers as soon as possible. That said, demonstrating success for payers, in terms of the number of patients served by Care Managers and prevention of adverse events through timely care management intervention and patient engagement, is more important than ever. You can help by focusing on the following keys to success:

  • Improving Care Management Activity Volumes
  • Reducing Avoidable ED and Inpatient Visits
  • Improving Clinical Metrics Performance (e.g., on diabetes measures)

Some practices have also expressed an interest in advocating with their legislative representatives and with participating payers to encourage support for care management and central MiPCT operations funding. Your continued and focused efforts now are important to support the case for an ongoing project.

MDC Expects to Post the Second Set of RTI Practice Feedback Reports This Week

MDC is currently waiting to receive all of the Practice Feedback reports from RTI. After we receive them, we will finish preparing the PO summary spreadsheets and the zip files with the RTI Practice Feedback reports for each PO’s Practices, and then post them. An email announcing the release will be sent to Dashboard users and posted on the MDC website (www.MichiganDataCollaborative.org ). If you have any questions in the meantime, please contact MDC at MichiganDataCollaborative@med.umich.edu .

 The Michigan Data Collaborative posted the April 2014 MiPCT All-Payer Patient Lists on April 28, 2014. An email announcing the release was sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports tab of the MDC MiPCT dashboards. The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_04.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support ).

Your Help Needed: Patient Advisory Council Member Nominations

The 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 the implementation and operations of the MiPCT. The council is comprised of patients serviced by the MiPCT. We are recruiting additional nominations for this state-wide PAC, which meets quarterly via conference call.

Members should be:

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

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

The dates of the 2014 PAC Conference Calls are as follows:

  • Friday, June 6, 2014 at 1:00 PM
  • Friday, September 5, 2014 at 1:00 PM
  • Friday, December 12, 2014 at 1:00 PM

Upcoming CM Webinars & Conference Calls

NEW: Calendar of CM Webinars and Conference Calls!

A listing of all care manager webinars and conference calls has been compiled into a calendar on the mipctdemo.org  website for your easy reference.

Visit the FEATURED LINKS sidebar on the right side of the home page. Click on the first item in the list: “To see a calendar of CM Webinars and Conference Calls Click Here”. The link will take you to the Care Manager Webinar/Conference Call Calendar tab. Go to the blue “CLICK HERE” text to open the calendar. The calendar is updated on the website monthly.

Upcoming MiPCT CM Webinars:

  • Adult Webinars: Wednesdays, 2-3 PM
  • Pediatric Webinars: Fridays, 10-11 AM

May 14, 2014: TBD (All MiPCT Care Managers)

May 16, 2014: Managing Obesity Within the Practice Team (Pediatric Care Managers)

May 28, 2014: Depression Care – Medication Management; presented by Nicole M. Simpson, PharmD, Clinical Pharmacist (All MiPCT Care Managers)

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. The programs listed below include information regarding course date/criteria to schedule.

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

Stories of Your Care Management Success: Lynn Czech, RN, BSN, HCM, Henry Ford Sterling Heights Pediatrics, HFHS

Lynn Czech, RN, BSN is a Hybrid Care Manager at Henry Ford Sterling Heights Pediatrics within Henry Ford Health System. Lynn was working with an 11 year old patient “Gavin” who is covered by Priority Health insurance. Gavin had a diagnosis of poorly controlled, moderate-persistent asthma. Lynn received the referral to work with Gavin and his family after he was seen by his Primary Care Physician (PCP), Dr. Sybil Rodrigues, in August of 2013. The PCP expressed that the patient and his mom had a poor understanding of his disease process, medications and triggers. At the first visit, Gavin’s mom reported frequent night waking due to uncontrolled asthma, and Gavin was unhappy because he was unable to play with his friends due to asthma symptoms. Mom and son were both eager to learn how he could sleep better, play longer, and be “happier.”

During their initial contacts, Lynn learned that Gavin had night-time awakenings 3-5 nights weekly and missed 3-4 days of school during the previous school year due to asthma symptoms. He stated he was “always sleepy.” He reported limited active play time due to his shortness of breath. He verbalized his sadness because he was always out of breath playing with his friends.

Gavin had seen an allergist when he was four and completed allergy testing, but never followed up. He had been using his Albuterol MDI with a spacer every three hours and had not been using his Pulmicort regularly, as was prescribed. Both Gavin and his mom were frustrated because the Albuterol helped him breathe, but only for a couple hours. He refilled his Albuterol MDI prescription three times in less than one month.

Gavin and his mom were receptive to education and care management interventions. His mom stated their first goal was to learn about his medications. Lynn provided education to Gavin and his mother about the disease process of asthma and the actions of his prescribed medications. They reviewed the signs and symptoms of asthma exacerbation and discussed appropriate actions to take. Adjustments were made on his MDI technique. Lynn huddled with the PCP, who agreed to change his medication regimen to relieve night-time symptoms. Gavin was taught to use a peak flow meter for self-monitoring at home and learned to adjust his medications using his asthma action plan. He and his mom were taught about his asthma triggers and how to avoid them.

Gavin was seen by the allergist, who further adjusted his medications and reinforced his progress. Carpeting was removed from his bedroom at the recommendation of the allergist.

In December, 2013, after four encounters with care management, his mom reported Gavin was “great.” She reported he is using his maintenance medications as directed and has not needed his Albuterol since his maintenance medications were adjusted in August. He continues to monitor his peak flows twice daily. He plays outside after school without any shortness of breath and can keep up with his friends. He is well-rested, has not missed any school, and has not had any night-time awakenings since care management interventions started in August. Dr. Rodrigues expressed to Lynn, “Good job helping them achieve their goals.” Gavin’s mom stated, “Thank you so much for helping Gavin. He has his asthma under control for the first time in his life. He is sleeping all night and so much happier because he has energy and can breathe, and play with his friends now. We both see how much he can do with his asthma controlled and want to keep it that way.” Gavin stated, “Thank you so much for teaching me all this stuff. I’m so happy because I can keep up with my friends now. I can’t wait to play tennis in the spring because it will be so much easier to breathe.”

Michigan Care Management Resource Center Care Manager Monthly Update

The April, 2014 edition of the Michigan Care Management Resource Center (MiCMRC) Care Manager Monthly Update contains a review of MiPCT project events and developments that occurred in April, and a resource list. The April resource list contains links to resources provided during the Depression Revisited and Care Manager Survey Results webinars.

The MiCMRC Care Manager Monthly Update for April is provided as an attachment to this edition of the Practice FLASH.

MiPCT Complex Care Management Course

The 2014 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 the four day period and includes:

  • Day One: A live, one-hour introductory webinar
  • Day Two: Total 6-hours of self-study modules and post-tests which are completed prior to the in-person training
  • Days Three and Four: Two in-person training days in Lansing, MI.

Register for the May 12-16 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/may-1215-2014-mipct-ccm-training/

NEXT ISSUE DATES:

• Next MiPCT P.O. FLASH Issue: May 19, 2014

• Next MiPCT Practice FLASH Issue: May 19, 2014

April 28, 2014

Save the Date! Next PO Webinar Scheduled for May 14

On May 14 from 11:00 AM -12:30 PM our next PO webinar takes place. We hope that you and your stakeholders can join us. The discussion is open to all MiPCT participants. Topics will include:

  • Palliative Care Curriculum Overview for MiPCT.-Presenter: Dr. Phil Rodgers;
  • An Update on MiPCT Sustainability and Continuity by MiPCT leadership; and
  • An open question-and-answer session.

MiPCT Clinical Focus Areas for 2014

The MiPCT approach to population management encompasses patients at all stages of health. The goal of the Transformation Project is to improve overall population health through risk reduction for healthy individuals, self-management support for patients with moderate chronic disease, care coordination and support for patients with complex chronic diseases and appropriate, coordinated end-of-life care.

For 2014, MiPCT Leadership has identified specific Clinical Areas of Focus, in the MiPCT Clinical Focus Areas article on page 3. By focusing on these areas and maintaining the current work of population management, MiPCT will be positioned to achieve success. The 2014 MiPCT Clinical Areas of Focus align with the program evaluation measures: to decrease utilization and positively impact quality improvement metrics. The Centers for Medicare & Medicaid is conducting the national evaluation. The CMS evaluation includes diabetes metrics and ER and hospitalization utilization. To access the “MiPCT State & National Evaluation Metrics,” visit: https://mipct.org/resources/presentations/. The 2014 MiPCT clinical focus areas can also be found at this link.

Second Set of RTI Practice Feedback Reports to be Posted the Week of 4/28

The Michigan Data Collaborative (MDC) received the next set of RTI Practice Feedback Reports and is currently preparing the Practice-level and PO total data. We plan to post the reports the week of April 28, 2014. An email announcing the release will be sent to Dashboard users.

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

MDC’s April 2014 MiPCT All-Payer Patient Lists Posted 4/28

The MDC plans to post the April 2014 MiPCT All-Payer Patient Lists on April 28, 2014. An email announcing the release will be sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports tab of the MDC MiPCT dashboards. The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_04.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).

MDC Rolling Out a New Dashboard Format

The Michigan Data Collaborative (MDC) is excited to roll out new and improved Dashboards to display the MiPCT data. This new Dashboard format is based on the Tableau platform, and will provide a more intuitive and flexible environment for our users. The new Dashboards will launch with Enhancement 8.01, which is scheduled for the week of May 5th. The new Dashboards will contain the same data as the old Dashboards (currently, release 8.0 data), but presented in a streamlined and easier-to-use format.  The old Dashboards will remain available until Release 9.0 is posted (early June 2014).

Save the Date! MDC Dashboards Webinar May 8

On May 8th at 9:00 AM, MDC is hosting a webinar to introduce you to and help you transition to the new Dashboards (see above).

To attend this webinar, you must register using the following instructions:

This webinar requires all individuals to register for participation. Please follow this link (also listed below in the instructions) and select one of the “register” options to complete the registration in full: https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=669340017.

Once you have registered, a confirmation email with instructions for joining the meeting will be sent to you by messenger@webex.com. The email subject line will state: Registration approved for Web seminar: MDC Dashboards. Please be sure to save the confirmation email to access the webinar.
Topic: MDC Dashboards
Date: Thursday, May 8th, 2014
Time: 9:00am, Eastern Standard Time (New York, GMT-04:00)

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To register for this meeting
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1. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=669340017
2. Register for the meeting.

If you have any questions about logging into this webinar, please contact Jody Fisher fishjody@umich.edu. If you have questions about the Dashboards, please contact MDC at MichiganDataCollaborative@med.umich.edu.

18 Month Incentive Payment Amounts to be Released

The 18 month incentive scores have received final approval and the payment amounts for Medicare and Medicaid incentive funds will be released May 1, 2014. Medicare incentive payments are scheduled to be released in the first half of May. The 18 month incentives are based on the time period 7/1/2012 – 6/30/2013 with baseline period 7/1/2011 – 6/30/2012. Please contact mipctdemo@michigan.gov with any questions.

Your Help Needed: Patient Advisory Council Member Nominations

The 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 the implementation and operations of the MiPCT. The council is comprised of patients serviced by the MiPCT. We are recruiting additional nominations for this state-wide PAC, which meets quarterly via conference call.

Members should be:

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

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

The dates of the 2014 PAC Conference Calls are as follows:

  • Friday, June 6, 2014 at 1:00 PM
  • Friday, September 5, 2014 at 1:00 PM
  • Friday, December 12, 2014 at 1:00 PM

MiPCT Clinical Focus Areas for 2014

The 2014 MiPCT clinical areas of focus have been identified, and are outlined below. Note that the required strategies for the focus areas require ongoing attention be given to the maintenance of essential PCMH infrastructure supports such as clinical registries, team-based care and enhanced access to care.

1. Improve Clinical Indicators for Individuals with Diabetes
Rationale: Diabetes is a common, high-cost chronic illness. Improvement in control of A1C, BP, and LDL-c has been associated with lower healthcare costs. Diabetes is a focus of the CMS evaluations, which includes four diabetes clinical quality measures among the evaluation metrics.
Strategies:

  • Encourage practices and care managers to develop processes and protocols to identify and reach out to patients with diabetes who need office visits, lab work, or eye exams.
  • Target patients who do not meet clinical indicators of control for case management and/or self-management support services.

2. Target the Right (High-Risk) Patients
Rationale: Five percent of a patient population typically generates about fifty percent of the healthcare costs. While it is possible to retrospectively identify individuals who have been high utilizers, only a portion remain in the high utilization group year after year. Additional methods are needed to screen potential high-risk individuals and identify those whose clinical outcomes may be improved through team-based clinical care and/or enrollment in care management.
Strategies:

  • Target individuals with high-risk scores for case management.
  • Develop criteria to identify additional individuals who may benefit from case management and/or self-management support, e.g. complex children with special healthcare needs and individuals with poorly controlled chronic conditions such as congestive heart failure, chronic obstructive pulmonary disease, and asthma.

3. Behavioral Health and Depression
Rationale: Depression is a debilitating condition commonly experienced by individuals with chronic disease. Primary care practitioners are encouraged to screen adults and adolescents with chronic illness for depression and to treat/refer those who are diagnosed.
Strategies:

  • Identify and share best practices for implementing depression screening.
  • Many patients stop medications early on due to side effects. Promote referral of newly diagnosed patients to care management for assistance with medication management.

4. Palliative Care
Rationale: Palliative care has been shown to relieve pain and other symptoms of patients with serious illnesses, help patients complete their prescribed treatments, assist in making difficult decisions, and ultimately improve clinical outcomes.
Strategies:

  • Work with subject matter experts to develop and launch a year-long training curriculum for care managers and other professionals.
  • Provide best practices and other resources to assist MiPCT practices in developing processes for discussing advanced directives with patients

The Focus for Pediatric Population:

1. Target the Right (High-Risk) Patients
Rationale: Similar to the adult population.
Strategies:

  • Ten Percent of children account for seventy-two percent of expenditures and one percent of children account for twenty-six percent of expenditures.
  • The task is similar to adults; develop criteria and methods to identify children and youth with complex medical conditions.
  • Target the NICU graduate. Assist practices with development of systems for smooth transition from NICU to home and primary care.

2. Behavioral Health and Depression
Rationale: The AAP Bright Futures just published new guidelines for preventive care and depression screening for all adolescents (beginning at age 11 years) and is now on the list as recommended (reference Bright Futures Periodicity Schedule). It is recommended that practices screen with the PHQ2. If positive, follow up with the PHQ9 and a more in depth interview.
Strategies:

  • Assist practices to incorporate screening into their practice flow, with positive screens (positive after the PHQ9) going to the care manager to link to community resources.
  • Provide active monitoring of those adolescents with identified mild to moderate depression
  • Although medications are used and useful in adolescents with depression, our first step is usually counseling. Focus for pediatrics differs from adults: “assistance with medication management” mentioned for adult depression is not the focus for pediatrics. Adolescent depression frequently has a major social component.

NEXT ISSUE DATES:

• Next MiPCT P.O. FLASH Issue: May 5, 2014

• Next MiPCT Practice FLASH Issue: May 19, 2014

April 7, 2014

Your Opportunity to Join the MiPCT Steering Committee!

Nomination Period Closes on April 30th

The MiPCT is soliciting nominations for two new MiPCT Steering Committee members; a physician practice representative, and a PO representative. The purpose of the Steering Committee is to provide strategic direction to MiPCT Leadership and monitor progress toward the goals and objectives of MiPCT. The Steering Committee meets bi-monthly in Okemos from 1:00 to 3:00 PM on the following dates:

  • May 19, 2014
  • July 21, 2014
  • September 15, 2014, and
  • November 17, 2014

Practice Nominees:

Each Practice nominee must be a participating physician at an MiPCT practice. The goal of adding a practice representative is to represent an “on-the-ground” clinical perspective and insight in shaping program development and operations. Nominees may self-nominate or be nominated by their PO.

Please submit nominations for the Practice Representative to https://jodyooo.wufoo.com/forms/steering-committeenominations/by April 30, 2014.

PO Nominees:

The PO nominees should have substantial experience with MiPCT implementation and operations for their member practices as well as leadership responsibility within their POs.

Please submit nominations for the PO Representative to https://jodyooo.wufoo.com/forms/steering-committeenomination-form-for-pos/ by April 30, 2014.

Your Help Needed: Patient Advisory Council Member Nominations

The 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 the implementation and operations of the MiPCT. The council is comprised of patients serviced by the MiPCT. We are recruiting additional nominations for this statewide PAC, 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-advisorycouncilnomination-form/

The dates of the 2014 PAC Conference Calls are as follows:

  • Friday, June 6, 2014 at 1:00 PM
  • Friday, September 5, 2014 at 1:00 PM
  • Friday, December 12, 2014 at 1:00 PM

Seeking Input & Your Experience: PO or Practice Patient Advisory Councils

In preparation of a document that is a user support tool for the new Learning Activity option of Practice or PO Patient Advisory Councils, we are interested in talking to any PO or practice that has an active patient advisory council or patient advisor program. If you have such a program, please contact Diane Marriott at bechel@umich.edu to arrange for a short phone discussion.

Release 8.0 for the MiPCT Dashboards and Reports Posted 4/1

MDC posted Release 8.0 on April 1, 2014. This release includes the following additions and changes:

  • For measures that MDC calculates, the measurement year includes dates of service from 9/1/2012 through 8/31/2013 based on paid claims through 11/30/2013. This calculation allows for a three-month claims run-out.
  • Priority Health PPO data is included.
  • Standard Cost values have been updated for new claims from the newest version of the Truven Health Analytics Commercial MarketScan® data.
  • Added Inpatient utilization trend data to the MiPCT and PO Utilization Trends dashboards.
  • Added Inpatient utilization data to the PO Comparison Utilization dashboard.
  • Added new PO Inpatient Utilization Comparison Reports (one comparing all POs and one comparing all Practices within your PO).
  • Changed the titles of the Comparison Reports in the <POName>_Reports_YYYY_MM.zip file to better reflect the reports included.

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.

MDC’s April 2014 MiPCT All-Payer Patient Lists to be Released the Week of 4/21

The Michigan Data Collaborative plans to post the April 2014 MiPCT All-Payer Patient lists the week of April 21, 2014. An email announcing the release will be sent to Dashboard users. The MiPCT All-Payer Patient lists are located on the Download PO Reports tab of the MDC MiPCT dashboards. The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_04.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).

December 2013 and January 2014 G-Code Reports Update

G-code Reports for December 2013 are available on the Download PO Reports tab of the MiPCT Dashboards. The reports are located in the <PO name>_G-Code_Reports_MiPCT_Overall_2013_12.zip file.

We anticipate posting the January 2014 G-Code reports the week of April 7, 2014. MDC will send an email to notify users when they are available. We apologize for the delay in getting these reports to you and appreciate your patience and understanding as we worked to resolve an issue with incoming data. A Quick Reference Guide for these reports is available in the User Guides section of the MDC Support Page (https://www.michigandatacollaborative.org/MDC/assets/GCode_Report_Quick_Reference.pdf).

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

Second Set of RTI Practice Feedback Reports to be Posted the Week of 4/14

MDC expects to receive the next set of RTI Practice Feedback Reports on or before April 12, 2014. We will then work to prepare the Practice-level and PO total data. We plan to post the reports the week of April 14, 2014. An email announcing the release will be sent to Dashboard users. If you have any questions in the meantime, please contact MDC at MichiganDataCollaborative@med.umich.edu.

BCBSM PDCM Reimbursement Policy and Billing Guidelines

The BCBSM PDCM Reimbursement Policy and Billing Guideline-Commercial was recently updated. Also, the BCBSM Medicare Advantage Reimbursement Policy and Billing Guideline – Medicare Advantage was updated January 2014. Access these documents at the website: https://mipct.org/resources/mipct-documentsandpresentations/

Upcoming CM Webinars & Conference Calls

NEW: Calendar of CM Webinars and Conference Calls! A listing of all care manager webinars and conference calls has been compiled into a calendar on the mipctdemo.org website for your easy reference.

Visit the FEATURED LINKS sidebar on the right side of the home page. Click on the first item in the list: “To see a calendar of CM Webinars and Conference Calls Click Here”. The link will take you to the Care Manager Webinar/Conference Call Calendar tab. Go to the blue “CLICK HERE” text to open the calendar. The calendar is updated on the website monthly.

Upcoming MiPCT CM Webinars: (Adult Webinars: Wednesdays, 2-3 PM / Pediatric Webinars: Fridays, 10-11 AM)

  • March 26, 2014: Palliative Care Part II (All MiPCT Care Managers)
  • April 11, 2014: Depression, Revisited (Pediatric Care Managers)
  • April 23, 2014: Care Manager Survey Results (All MiPCT Care Managers)
  • May 16, 2014: Managing Obesity Within the Practice Team (Pediatric Care Managers)

Centers for Medicare & Medicaid Services (CMS) Transitional Care Services Fact Sheet

The CMS Transitional Care Management (TCM) services Fact Sheet includes:

  • Health care professionals who may furnish TCM services;
  • TCM services settings;
  • Components included in TCM;
  • Billing TCM services;
  • Frequently Asked Questions; and
  • Resources

Access the CMS TCM Service Fact Sheet: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

MiPCT Complex Care Management Course

The 2014 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 (1 hour)
  • 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 Day 4 – In-person training Register for the May 12-15, 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/may-1215-2014-mipct-ccm-training/

May 12-15, 2014 – Introductory Webinar May 12. Total six-hour self-study modules and post- tests, May 12-13. In person training May 14-15.

June 9-12, 2014 – Introductory Webinar June 9. Total six-hour self-study modules and post- tests, June 9-10. In person training June 11-12.

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

Michigan Care Management Resource Center Care Manager Monthly Update: March, 2014

The March, 2014 edition of the Michigan Care Management esource Center (MiCMRC) Care Manager Monthly Update contains a review of MiPCT project events and developments that occurred in March and a resource list. The March resource list contains links to resources provided during the Depression in the Adolescents:

Identification, Screening, Community Resources, and Follow Up and Palliative Care Part II webinars. Also included in the March resource list is a web link to be discussed during the April 11, 2014 Pediatric Care Manager conference call titled ‘Depression Revisited’.

The MiCMRC Care Manager Monthly Update for March is provided as an attachment to this edition of the Practice FLASH.

Stories of Your Care Management Success

Dorothy Carlson, RN, HCM, Mercy Health Physician Partners – Northshore Family Practice

Dorothy Carlson, RN is a Hybrid Care Manager at Mercy Health Physician Partners-Northshore Family Practice, which is part of Lakeshore Health Network.” Mary”, is a 56 year old female with BCN insurance. She has been a patient at Northshore Family Practice for five years. When her care manager, Dorothy, met her last year, her A1C was 13.4 (the highest it had ever been). Mary admitted that she was not checking her blood sugar regularly, taking her insulin or following her diet.

Mary was anxious to work with the Dorothy because she knew her diabetes was out of control and she really wanted to be healthier. Mary has a very active life with a lot of family. She has a full-time job that often requires she get up at 2:00 am. Mary knew that as a diabetic she needed to avoid sugar, but that seemed to be the extent of her knowledge.

Dorothy provided Mary with diet education including specific information on carbohydrates (what they are and how they affect blood sugar) and asked Mary to write down everything she ate each day in a food diary. Mary met that challenge head on. Not only did she write down what she ate, but the time, what her blood sugar was, and how much insulin she took.

At the next care management appointment, Mary and Dorothy looked through the food diary and Dorothy was able to explain the correlation between food types and changes in blood sugar. Mary was able to see which foods affected her blood sugar the most and agreed to start making very small, manageable changes in her diet.

In six months, her A1C had decreased to 8.7. Mary continues to receive care management services to implement additional healthy habits. She has found when she meets with Dorothy regularly and keeps her food diary her blood sugar stays low. However, if she does not meet with Dorothy regularly her blood sugars start to increase. Mary is due to have her A1C checked again in May. She is hoping her A1C will be 7.0 or below.

NEXT ISSUE DATES:

  • Next MiPCT Practice FLASH Issue: April 28, 2014
  • Next MiPCT P.O. FLASH Issue: April 28, 2014

 March 24, 2014

RTI Practice Feedback Reports Posted on 3/14

The RTI Practice Feedback Reports were posted on March 14, 2014. You can access the reports on the Download PO Reports tab of the MiPCT Dashboards. The initial reports cover Jan 2012 – Jun 2013.

After you log into the MiPCT Dashboards, navigate to the Download PO Reports tab, and scroll down to the Medicare Practice Feedback Reports section. There is one .zip file for each PO containing a report in PDF format for each Practice and a Report Summary in Excel, which lists the results for each Practice in the PO. You can use the Report Summary to compare Practice rates or to conduct additional analysis.

Notes about the Reports

  • When creating the reports, RTI used an older Practice list. As a result, the data for some Practices were not included in this round of reports and show up as a blank row on the report. MDC is working to update this and will send out notice when updated reports are posted. Watch for an update the week of March 24th.
  • RTI did not provide PO-level totals. MDC is working to backward calculate this data; however, we need additional data points from RTI to do so. MDC is working on it with RTI and will send a notice when we post updated Report Summaries with these totals.

The support documentation can be found on the MDC Website’s Support page (https://webappstest.med.umich.edu/MDC/#/support). Click the User Guides link and scroll down to the Medicare Practice Feedback Reports Section.

If you have any questions that are not answered in the support documentation, please contact MDC at MichiganDataCollaborative@umich.edu.

Enhancement 7.02 and Release 8.0 Update

Enhancement 7.02 of the Dashboards and Reports was posted on March 12, 2014. This enhancement included the following additions and updates:

  • Added a fourth trend point (July 2012 – June 2013) to all trend dashboards.
  • Added the MiPCT and PO Utilization Trends dashboards, which contain trend data for the ED utilization measures. (IP utilization measures will be added in a future release or enhancement.)
  • Fixes to known issues.

Release 8.0 of the Dashboards and Reports is scheduled to be available the week of March 24, 2014. It will include the following:

  • Paid claims and eligibility data through November 2013
  • An updated measurement period through August 2013
  • Adding Inpatient utilization data to the PO Comparison – Utilization dashboard
  • Adding a PO Inpatient Utilization Comparison Report

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

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

MDC’s March 2014 MiPCT All-Payer Patient Lists Released 3/20

The Michigan Data Collaborative posted the March 2014 MiPCT All-Payer Patient Lists on March 20, 2014. An email announcing the release was sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports tab of the MDC MiPCT dashboards. The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_03.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support). Please note that the document includes an updated description for the “Payer Specific Member ID” field, which provides information about how this field is populated for each Payer.

November and December 2013 G-Code Reports Update

In January 2013, MDC was notified of a data issue that has delayed the release of the December 2013 G-Code reports. The November 2013 G-Code reports were also affected and will be re-released. We anticipate receiving the data in time to post them by the end of this month. MDC will send out a notice when they are available on the Dashboards. We apologize for the delay and appreciate your continued patience and understanding as we resolve this issue.

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

MiPCT Complex Care Management Course

The 2014 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 (1 hour)
  • 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.)
  • Day 3 and Day 4 – In person training

Register for the April 7-10, 2014 MiPCT CCM Course at the following site: (https://jodyooo.wufoo.com/forms/april-710-2014-mipct-ccm-training/)

Upcoming 2014 MiPCT CCM course dates:

  • April 7-10, 2014 (with Introductory Webinar on April 7). Total six-hour self-study modules and post-tests April 7-8. In-person training, April 9 & 10.
  • May 12-15 2014 (with Introductory Webinar May 12). Total six-hour self-study modules and post-tests, May 12-13. In person training, May 14-15.
  • June 9-12 2014 (with Introductory Webinar June 9). Total six-hour self-study modules and post-tests, June 9-10. In person training, June 11-12.

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

Coming in May: Pediatric Obesity Care Management Conference

The following conference about pediatric obesity may be of interest to MiPCT care managers and others in practices that work with children and youth. The conference is sponsored by the Michigan Chapter of the American Academy of Pediatrics and the Michigan State Medical Society Foundation. It is a one day conference, May 15, in Dearborn. The target audience includes physicians, administrators, office managers and others, such as MiPCT care managers.

Please visit this link for more information: http://origin.library.constantcontact.com/download/get/file/1102494410259-206/Childhood+Obesity+Brochure.5.2014.pdf
Your Opportunity to Join the MiPCT Steering Committee! Nomination Period Closes on April 30th

The MiPCT is soliciting nominations for two new MiPCT Steering Committee members; a physician practice representative, and a PO representative.
The purpose of the Steering Committee is to provide strategic direction to MiPCT Leadership and monitor progress toward the goals and objectives of MiPCT. The Steering Committee meets bi-monthly in Okemos from 1:00 to 3:00 PM on the following dates:

  • May 19, 2014
  • July 21, 2014
  • September 15, 2014, and
  • November 17, 2014

Practice Nominees: Each Practice nominee must be a participating physician at an MiPCT practice. The goal of adding a practice representative is to represent an “on-the-ground” clinical perspective and insight in shaping program development and operations. Nominees may self-nominate or be nominated by their PO.

Please submit nominations for the Practice Representative to https://jodyooo.wufoo.com/forms/steering-committee-nominations/ by April 30, 2014.

PO Nominees: The PO nominees should have substantial experience with MiPCT implementation and operations for their member practices as well as leadership responsibility within their POs.

Please submit nominations for the PO Representative to https://jodyooo.wufoo.com/forms/steering-committee-nomination-form-for-pos/ by April 30, 2014.
Your Help Needed: Patient Advisory Council Member Nominations

The 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 the implementation and operations of the MiPCT. The council is comprised of patients serviced by the MiPCT. We are recruiting additional nominations for this state-wide PAC, 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/

The dates of the 2014 PAC Conference Calls are as follows:

  • Friday, June 6, 2014 at 1:00 PM
    Friday, September 5, 2014 at 1:00 PM
    Friday, December 12, 2014 at 1:00 PM

Seeking Input & Your Experience: PO or Practice Patient Advisory Councils

In preparation of a document that is a user support tool for the new Learning Activity option of Practice or PO Patient Advisory Councils, we are interested in talking to any PO or practice that has an active patient advisory council or patient advisor program. If you have such a program, please contact Diane Marriott at dbechel@umich.edu to arrange for a short phone discussion.

NEXT ISSUE DATES:

  • Next MiPCT P.O. FLASH Issue: April 14, 2014
  • Next MiPCT Practice FLASH Issue: April 28, 2014

March 10, 2014

Revised Timing of 18-Month Incentive Score Release

The release of the 18-month incentive scores has been revised to the week of March 10. We apologize for the inconvenience. You will receive an announcement from the MiPCT mailbox when the scores are ready for release. A one-week review period for PO comments or questions on scores will follow. We anticipate that this will still permit payment of the Medicare portion of incentives by the end of March or early April at the latest.  Medicaid incentives will be incorporated in the quarterly payment cycle, as per the standing process.

Your Opportunity to Join the MiPCT Steering Committee!  Nomination Period Closes on April 30th

The MiPCT is soliciting nominations for two new MiPCT Steering Committee members; a physician practice representative, and a PO representative.

The purpose of the Steering Committee is to provide strategic direction to MiPCT Leadership and monitor progress toward the goals and objectives of MiPCT.  The Steering Committee meets bi-monthly in Okemos from 1:00 to 3:00 PM on the following dates:

  • March 17, 2014
  • May 19, 2014
  • July 21, 2014
  • September 15, 2014
  • November 17, 2014

Practice Nominees:   Each Practice nominee must be a participating physician at an MiPCT practice.  The goal of adding a practice representative is to represent an “on-the-ground” clinical perspective and insight in shaping program development and operations.   Nominees may self-nominate or be nominated by their PO.

Please submit nominations for the Practice Representative to https://jodyooo.wufoo.com/forms/steering-committee-nominations/  by April 30, 2014.

PO Nominees:  The PO nominees should have substantial experience with MiPCT implementation and operations for their member practices as well as leadership responsibility within their POs.

Please submit nominations for the PO Representative to https://jodyooo.wufoo.com/forms/steering-committee-nomination-form-for-pos/ by April 30, 2014.

Making the Business Case for Payment and Delivery Reform

I just read a document that provides a step-wise approach to identifying changes in health care delivery, and clarifies the financial impact. I thought this was relevant given the POs’ concerns related to continuity and sustainability of care management funding post-2014.  The MiPCT’s Return on Investment (ROI) Subgroup has used this approach in its work to quantify the value of care management embedded within the primary care practice.

The full article is attached to this issue of the FLASH , and can be found at http://www.chqpr.org/.- Kevin Taylor, MD

The report is the Center for Healthcare Quality & Payment Reform’s new guide, Making the Business Case for Payment and Delivery Reform.

The report identifies 10 steps that industry leaders can take to redesign healthcare and payment systems to improve quality and efficiency, while saving billions of dollars by avoiding unnecessary tests, procedures, emergency room visits and hospitalizations.

Here are the 10 steps:

  1. Define the planned change in care and the expected results. Consider the patient population, types of patient care changes, which payers and purchasers the changes will involve, the expected timeframe and any transition costs.
  2. Estimate how the type and volume of services will change. Consider whether the changes will provide a service that isn’t currently paid for, whether the changes will provide more or less of a service than is currently paid for and whether providing the current service in a different way changes its costs.
  3. Determine how payments and revenue will change under the current payment system. For this step, assume that only the current payment system in place. Then separately determine the payments/revenue for each provider organization and purchaser/payer.
  4. Determine how the costs of services will change. Use a cost model to identify the fixed costs, semi-variable costs associated with the service and how they will change based on the number of patients served or the number of services delivered.
  5. Calculate the changes in operating margins for providers. Based on the previous steps, determine whether the plan will provide equal or better operating margins, lower the positive operating margins or will mean negative operating margins.
  6. Calculate the changes in payment that providers need. If the operating margin is lower or negative under the proposed change in care, you must then determine what type of payment change is necessary to restore the margin.
  7. Determine whether a business case exists for both purchasers and providers. Consider whether the plan results in no payment changes, whether it lowers total spending or whether it would increase spending but achieve better outcomes.
  8. Refine the changes in care to improve the business case. If necessary, improve the business case by eliminating unnecessary or low-value components of the proposed sets of services, reducing the cost of delivering the proposed services or targeting the services to a different patient population.
  9. Analyze the impacts of deviations from planned care and expected outcomes. Consider the impact on services, outcomes and payments, and whether there is a potential harm scenario that indicates a change is necessary.
  10. Design a payment model to pay adequately for desired services, desired outcomes, and controls variation and risk. Make sure a payment plan provides adequate payment so the provider has the flexibility and ability to deliver the planned services, offers accountability to successfully achieve the intended outcomes, as well as protects the provider against inappropriate financial risk.

Your Help Needed: Patient Advisory Council Member Nominations

The 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 the implementation and operations of the MiPCT. The council is comprised of patients serviced by the MiPCT. We are recruiting additional nominations for this state-wide PAC, 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 via this link:
https://jodyooo.wufoo.com/forms/patient-advisory-council-nomination-form/

The dates of the 2014 PAC Conference Calls are as follows:

  • Friday, June 6, 2014 at 1:00 PM
  • Friday, September 5, 2014 at 1:00 PM
  • Friday, December 12, 2014 at 1:00 PM

Enhancement 7.02 for the MiPCT Dashboards and Reports Scheduled to be Released the Week of 3/10

MDC plans to post Enhancement 07.02 the week of March 10, 2014. This enhancement includes the following additions:

  • Added a fourth trend point (July 2012 – June 2013) to all trend dashboards.
  • Added the MiPCT and PO Utilization Trends dashboards, which contain trend data for the ED utilization measures. (IP utilization measures will be added in a future release or enhancement.)
  • Fixes to known issues.

When the enhancement is ready, we will send an email to notify users. If you have any questions, or if you would like to provide feedback or suggestions, please contact MDC at MichiganDataCollaborative@med.umich.edu.

MDC’s March 2014 MiPCT All-Payer Patient Lists to be Released the Week of 3/17

The Michigan Data Collaborative plans to post the March 2014 MiPCT All-Payer Patient Lists the week of March 17, 2014. An email announcing the release will be sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports tab of the MDC MiPCT dashboards. The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_03.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).

November and December 2013 G-Code Reports Update

In January 2013, MDC was notified of a data issue that has delayed the release of the December 2013 G-Code reports. The November 2013 G-Code reports were also affected and will be re-released. We anticipate receiving the data in time to post them by the end of this month. MDC will send out a notice when they are available on the Dashboards. We apologize for the delay and appreciate your continued patience and understanding as we resolve this issue.

If you have any questions, please contact MDC at MichiganDataCollaborative@med.umich.edu
Michigan Care Management Resource Center Webinar and Conference Call Schedules

MiPCT Care Manager and Pediatric Care Manager webinars and Regional or Specialty Care Manager Conference Call schedules are now available on the www.mipctdemo.org website, in the form of a calendar.  The calendar, containing the title, dates and times for these educational offerings, is found at https://mipct.org/care-manager-webinar-conference-call-calendar/. A link to this calendar is also available on the Care Manager page of the www.micmrc.org website under the Resources heading.

Topic details to be presented during the webinars or conference calls will be provided in the MiPCT PO and Practice FLASH publications as soon as subject matter experts and available resources are secured for each scheduled webinar and conference call. Concurrently, the title will be added to the Care Manager webinar and conference call schedule.

MiPCT webinars are designed with all care managers in mind. These will continue to occur once a month on a Wednesday from 2pm-3pm. MiPCT pediatric webinars are designed specifically for care managers who serve pediatric patients and occur once a month on a Friday from 10am-11am.

The Care Manager Conference Calls are approved MiPCT learning activities as are the MiPCT CM webinars. Care Manager participation is dependent on each PO/PHO/Medical Group’s decision to have their designated Care Managers attend these regional/specialty conference calls. Regional conference calls are designed for care managers serving primarily the adult population and are divided into North, West and Southeast Michigan. Specialty conference calls are designed for social workers and pediatric care managers. Each scheduled region and specialty conference call title, date and time are noted on www.micmrc.org, as noted above.

Registration is required for MiPCT webinars and conference calls. Care managers will receive an invitation to register for the events.They will receive an email with login instructions for the day of the event once they have registered. The events are facilitated by WebEx technology and are best accessed by using a computer and phone to login.

Upcoming CM Webinars & Conference Calls

NEW: Calendar of CM Webinars and Conference Calls!  A listing of all care manager webinars and conference calls has been compiled into a calendar on the www.mipctdemo.org website for your quick reference.

On the home page, visit the FEATURED LINKS sidebar on the right side of the page.  Click on the first item in the list:  “To see a calendar of CM Webinars and Conference Calls Click Here”.  The link will take you to the Care Manager Webinar/Conference Call Calendar tab.  Simply go to the blue “CLICK HERE” text to open the calendar.  We have provided the calendar as an attachment to this issue of the FLASH, and will update the calendar on the website monthly.

Upcoming MiPCT CM Webinars:

MiPCT CM Webinars: Wednesdays, 2:00 – 3:00 PM
Pediatric CM Webinars:  Fridays, 10:00 – 11:00 AM

  • March 21, 2014:     Depression in the Adolescents: Identification, Screening, Community Resources, and Follow Up (Pediatric Care Managers)
  • March, 26, 2014:    Palliative Care Part II (All MiPCT Care Managers)
  • April 11, 2014:    Depression Revisited (Pediatric Care Managers)
  • April 23, 2014:     TBD (All MiPCT Care Managers)
  • May 16, 2014:     Managing Obesity within the Practice Team (Pediatric Care Managers)

Seeking Input & Your Experience: PO or Practice Patient Advisory Councils

In preparation of a document that is a user support tool for the new Learning Activity option of Practice or PO Patient Advisory Councils, we are interested in talking to any PO or practice that has an active patient advisory council or patient advisor program.  If you have such a program, please contact Diane Marriott at  dbechel@umich.edu to arrange for a short phone discussion.

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

The attached table is a summary of 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. The programs, listed on the attached table, include information regarding course date/criteria to schedule.

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 2014 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 Day 3 and Day 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 April 7-10, 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/april-710-2014-mipct-ccm-training/.

Upcoming 2014 MiPCT CCM Course Dates:

  • April 7-10, 2014    Introductory Webinar April 7. Total 6-hour self-study modules and post-tests April 7-8. In-person training – April 9 & 10.
  • May 12-15, 2014    Introductory Webinar May 12. Total 6-hour self-study modules and post-tests May 12-13. In-person training – May 14-15.
  • June 9-12, 2014    Introductory Webinar June 9.  Total 6-hour self-study modules and post-tests June 9-10. In-person training – June 11-12. Please submit questions regarding the MiPCT CCM course to: micmrc-requests@med.umich.edu

Stories of Your Care Management Success
Susan Maddox, RN, BSN, Care Manager – Lakeside Internal Medicine, HFHS

Susan Maddox, RN, BSN is a care manager at Lakeside Internal Medicine within Henry Ford Health System. Susan began working with a Blue Care Network patient who is a 47 year old male. “Billy” has a history of uncontrolled diabetes, hypertension, and hyperlipidemia (triglycerides 561). Susan identified during chart review that the patient had difficulty with medication adherence due to stress and fatigue. “Billy” was working many overtime hours and often fell asleep before taking his insulin. He had past success when he was able to follow recommendations.

Susan engaged “Billy” by phone following his Primary Care visit and after identifying him on the daily MiPCT office visit list. He agreed to Moderate Case Management, but was very stressed and overwhelmed. He reported working six days per week and over 12 hours a day. This left only one day for time with his family. During the initial contact with Susan his work phone went off multiple times in the background even though he was on vacation. He was managing multiple buildings and got a lot of exercise running between buildings daily. However, he often was too exhausted to take his insulin at night and had run out of his fenofibrate months prior and never refilled it. He was managing to check his fasting blood glucose most days, stating, “It is usually in the 200’s.” Susan praised him for regularly checking his fasting blood glucose and administering his morning insulin. He recognized his health was important and agreed to action planning.

Susan provided very basic disease education for “Billy” regarding his chronic diseases. His reaction was, “I had no idea that could happen to me. I just thought some day when I’m old I might lose a leg. I had no idea diabetes can affect my heart, eyes and kidneys.” Susan also pointed out once his diabetes was better controlled he may have more energy.

Over the next few months Susan had brief calls with “Billy.” Calls were kept short and focused on one small action at a time. His first goal was to begin taking his Metformin twice daily as prescribed instead of once in the morning. His action plan included setting an alarm on his Smart Phone to remind him of the evening dose.

On another call “Billy” had still been unable to pick up his fenofibrate from the pharmacy. While on the call he told Susan he could not remember the pharmacy hours and it was a challenge to get to the pharmacy when it was open. Working together Susan and “Billy” made an action plan for him to take a picture of the pharmacy business card and save it to his Smart Phone contacts so he would have the hours stored and available. At the end of this call, his wife texted him and he told Susan he needed to go because his wife was texting him. Susan casually suggested to him to maybe text back to his wife to pick up his prescription at the pharmacy. On the next call “Billy” reported he had resumed taking the fenofibrate after his wife had picked up his prescription for him.

“Billy” continues to take his medications correctly, has joined weight watchers, and has signed up for Medical Nutrition Therapy. His A1C is now 6.0. His triglycerides improved greatly from 561 to 219. His blood pressure is controlled. He states, “I feel happier, have more energy and feel lighter.”

He also saw a need to make additional lifestyle changes and went for a new job with one of the major auto corporations in the area. He now has a job that is 40 hours per week and he has much more time to enjoy his family. This has greatly reduced his stress level. He continues to walk regularly for exercise. He told Susan he was not quite ready for discharge from care management and would like to talk with her again after he meets with the dietician at Medical Nutrition Therapy. “Billy” consistently thanks Susan for calling him.

NEXT ISSUE DATES:

  • Next MiPCT Practice FLASH Issue:  March 24, 2014
  • Next MiPCT P.O. FLASH Issue: March 24, 2014

February 24, 2014

18 Month Incentive Scores to be Released

The draft scores for the 18 month incentives will be released this week. Data is based on the time period 7/1/2012 – 6/30/2013 with baseline period 7/1/2011 – 6/30/2012. As usual, POs will have one week from the release date to review and comment on the results. Please contact mipctdemo@michigan.gov  as soon as possible if any concerns arise. Once the scores receive final approval, POs will receive a report with the amount of Medicare and Medicaid incentive funds they can expect to receive.

BCBSM MiPCT Webinar – Calculating Uplifts

Blue Cross Blue Shield of Michigan is holding an informational webinar session for all MiPCT participating PO’s. The purpose of the webinar is to provide information on calculating the amount of uplift owed to practice units for their participation in MiPCT. If this applies to your PO, please join us. The agenda is below:

  • Accessing web-DENIS to obtain the base fee
  • Finding the uplift amounts on Portico, by practitioner
  • Calculating the uplift amount using vouchers
  • Q&A

The webinar will be made available twice, first on Monday, March 3, 2014 from 9:00 am until 11:00 am, and then again on Friday, March 7, 2014 from 2:00 pm until 4:00 pm. Pick the one date/time that works best and mark your calendars. Also, feel free to share this article with any interested staff in your organization.

Below is information to connect to the meeting:

Please e-mail LaTonya Davis at ldavis7@bcbsm.com if you have any questions.

New PDCM Billing Code: Advance Care Planning and End of Life Counseling

A new billing code has been defined by BCBSM, the S0257 code for Advance Care Planning and End of Life Counseling. Beginning January 1, 2014, BCBSM will be accepting and paying claims for advance care planning and end of life counseling. This code should be used to bill for individual face-to-face or telephonic conversations regarding end-of-life care issues and treatment options conducted by qualified allied health personnel on the care management team with patients enrolled in care management. It may also be used for conversations with the patient’s caregiver/family about developing or revising a documented advance care plan.

Each encounter should be billed on its own claim line, and all active diagnoses should be reported in each claim. The S0257 code should be listed separately, in addition to the code for appropriate evaluation and management service as applicable.

Documentation associated with S0257 that must be recorded and maintained in the patient’s record should include:

  •  Enumeration of each encounter including:
    • Date of service
    • Duration of contact
    • Name and credentials of the allied professional delivering the service
    • Other individuals in attendance (if any) and their relationship with the patient
  • Pertinent details of the discussion (and resulting advance care plan decisions), which, at a minimum, must include the following:
    • A person designated to make decisions for the patient if the patient cannot speak for him or herself
    • The types of medical care preferred
    • The comfort level that is preferred
  • Advanced care planning discussions/decisions may also include:
    • How the patient prefers to be treated by others
    • What the patient wishes others to know
  • Indication of whether or not an advance directive or Physician Orders for Life-Sustaining Treatment (POLST) document has been completed

Complete details, including documentation requirements, can be found in the most recent BCBSM Medicare Advantage PDCM Billing Guidelines 01.2014, and BCBSM Commercial PDCM Payment Policies 02.2014, which are provided as attachments to this edition of the FLASH, and posted at https://mipct.org/resources/mipct-documents-and-presentations/.

Please Note: BCN does not pay for the S0257 code.

Open Position for the MiPCT Steering Committee: Remember to Make Your Nominations!

The MiPCT is soliciting nominations for a PO representative on the MiPCT Steering Committee.

The purpose of the Steering Committee is to provide strategic direction to MiPCT Leadership and monitor progress toward the goals and objectives of MiPCT. The Steering Committee meets bi-monthly in Okemos from 1:00 to 3:00 PM on the following dates:

  • March 17, 2014
  • May 19, 2014
  • July 21, 2014
  • September 15, 2014
  • November 17, 2014

PO nominees should have substantial experience with MiPCT implementation and operations for their member practices as well as leadership responsibility within their POs.

Please submit nominations for the PO Representative to https://jodyooo.wufoo.com/forms/steering-committee-nomination-form-for-pos/by March 10, 2014.

Your Help Needed: Patient Advisory Council Member Nominations

 The 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 the implementation and operations of the MiPCT. The council is comprised of patients serviced by the MiPCT. We are recruiting additional nominations for this state-wide PAC, 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 through March 14, 2014 at: https://jodyooo.wufoo.com/forms/patient-advisory-council-nomination-form/

The dates of the 2014 PAC Conference Calls are as follows:

  •  Friday, March 7, 2014 at 1:00 PM
  •  Friday, June 6, 2014 at 1:00 PM
  •  Friday, September 5, 2014 at 1:00 PM
  •  Friday, December 12, 2014 at 1:00 PM

Seeking Input & Your Experience: PO or Practice Patient Advisory Councils

In preparation of a document that is a user support tool for the new Learning Activity option of Practice or PO Patient Advisory Councils, we are interested in talking to any PO or practice that has an active patient advisory council or patient advisor program. If you have such a program, please contact Diane Marriott at dbechel@umich.edu by March 14, 2014 to arrange for a short phone discussion.

 NEW PO/Practice Webinars to be Offered Every Other Month Beginning March 2014

A webinar on the impact of health reform on MiPCT practices and POs has been confirmed for March 12, 12:30 to 1:30 PM. Presenters from Medicaid, BCBSM, BCN and Priority Health will recap important aspects from each payer’s perspective.

INSTRUCTIONS FOR WEBINAR REGISTRATION:

Please follow these instructions to register for the webinar:

The following webinar requires all individuals to register for participation. Please follow the link below, and select one of the “register” options to complete the registration in full.

Once you have registered, a confirmation email with instructions for joining the meeting will be sent to you by messenger@webex.com. The email subject line will state: “Registration Approved for Web Seminar: PO Webinar – The Effect of Health Reform on MiPCT”.

Please be sure to save the confirmation email to access the webinar.

Other webinars will be held every other month in May, July, September and November of 2014. The dates, topics and login information will be published in the FLASH closer to their dates.

NOTE:  For the MiPCT Care Management Webinar Series, please refer to the 2.24.2014 issue of the Practice FLASH on page 5, for the article entitled: “Placement of Upcoming Webinars”.

Care Team Connect (CTC)- Spotlight Training Webinar Recording

A CTC/Spotlight recorded training webinar is now available on the mipctdemo.org website at https://mipct.org/resources/presentations/. This webinar includes an overview of CTC/Spotlight functionality, Admission, Discharge and Transfer (ADT) alerts and corresponding Care Manager work- flows.

BCBSM Available for your Claims Questions Related to PDCM at PGIP

At the March 14th PGIP Quarterly Meeting, BCBSM staff will be available to answer any claims questions related to PDCM. Please bring your questions and examples (voucher or contract number, date of service, and member). BCBSM staff will be available after the General Morning Session for the remainder of the day. The location will be announced at the meeting.

MDC’s February 2014 MiPCT All-Payer Patient Lists to be Released this Week

The Michigan Data Collaborative plans to post the February 2014 MiPCT All-Payer Patient Lists the week of February 24, 2014. An email announcing the release will be sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports tab of the MDC MiPCT dashboards. The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_02.

 For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).

2014 MiPCT Due Dates & Action Steps Document Attached 

Attached to today’s issue of the Practice FLASH is a new 2-sided document which summarizes important program deadlines, and lists large group meetings, webinars and MiPCT/MDC incentive timing.

A few examples of items included in this document are:

  • Deadlines for quarterly report submissions
  • Annual Summit dates
  • Bi-monthly MiPCT webinars

We hope you will find this document helpful.

NEXT ISSUE DATES:

  • Next MiPCT Practice FLASH Issue: March 24, 2014
  • Next MiPCT P.O. FLASH Issue: March 10, 2014

February 10, 2014

Open Positions for the MiPCT Steering Committee:  Remember to Make Your Nominations!

The MiPCT is soliciting nominations for two new MiPCT Steering Committee members; a physician practice representative, and a PO representative.

The purpose of the Steering Committee is to provide strategic direction to MiPCT Leadership and monitor progress toward the goals and objectives of MiPCT.  The Steering Committee meets bi-monthly in Okemos from 1:00 to 3:00 PM on the following dates:

  • March 17, 2014
  • May 19, 2014
  • July 21, 2014
  • September 15, 2014
  • November 17, 2014

Practice Nominees:   Each Practice nominee must be a participating physician at an MiPCT practice.  The goal of adding a practice representative is to represent an “on-the-ground” clinical perspective and insight in shaping program development and operations.   Nominees may self-nominate or be nominated by their PO.

Please submit nominations for the Practice Representative to https://jodyooo.wufoo.com/forms/steering-committee-nominations/  by February 28, 2014.

PO Nominees:  The PO nominees should have substantial experience with MiPCT implementation and operations for their member practices as well as leadership responsibility within their POs.

Please submit nominations for the PO Representative to https://jodyooo.wufoo.com/forms/steering-committee-nomination-form-for-pos/ by March 10, 2014.

YOU’RE INVITED:
Register Now for a February 25 Webinar on Using Evidence to Improve Clinical Care

Please mark your calendar now to join a free Web conference on using evidence to improve patient care, hosted by the Michigan State Medical Society, Michigan Primary Care Transformation Project and the Federal Agency for Healthcare Research and Quality (AHRQ) from noon – 1 pm ET Tuesday, February 25, 2014. Physicians can receive 1 AMA PRA Category 1 CreditTM upon completion of the program.

The webinar, titled “Improving Health Care Decisionmaking: Comparative Effectiveness Research,” will:

  • Describe what is comparative effectiveness research
  • Summarize how comparative effectiveness research can be used to help improve clinical practice
  • Identify free AHRQ comparative effectiveness research resources for physicians and other clinicians

AHRQ, which is part of the U.S. Department of Health and Human Services, funds comparative effectiveness research (CER) to improve the quality of treatment decisions among clinicians and their patients. CER highlights the effectiveness, benefits, and risks of different treatment options for common health conditions. These free, unbiased resources help improve health outcomes and clinical quality, while engaging patients.

The main presenter is Stephanie Chang, MD, MPH, who is a board-certified general internist and pediatrician. She has worked at the Agency for Healthcare Research and Quality on the Effective Health Care Program and with the Evidence-based Practice Center Program since 2006. She was appointed director of the Evidence-based Practice Center Program in 2010. Dr. Chang completed undergraduate and medical school at the University of Michigan and continued postgraduate residency training in internal medicine and pediatrics at the University of Minnesota. She earned a master’s degree in public health at the Johns Hopkins Bloomberg School of Public Health and a general internal medicine fellowship at Johns Hopkins University in 2006.

REGISTRATION
To register for the webinar, please CLICK HERE and select “Attend Event,” no later than FEBRUARY 24, 2014. Although the Web conference is free, participants must register ahead of time. Details on accessing the Web conference will be communicated via email to registered participants.

STATEMENT OF ACCREDITATION
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Michigan State Medical Society and Agency for Healthcare Research and Quality (AHRQ).  The Michigan State Medical Society is accredited by the ACCME to provide continuing medical education for physicians.

AMA CREDIT DESIGNATION STATEMENT
The Michigan State Medical Society designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM.  Physicians should claim only credit commensurate with the extent of their participation in the activity.

DISCLOSURE
The planners and presenters for this activity have no relevant financial relationships.  This activity has received no commercial support or sponsorship.

For more information and questions about the Web conference, please contact Karen Costa at karen.costa@ahrq.hhs.gov.

Calculation for Care Manager Ratio Requirement  to Remain Unchanged

As promised in 2013, the MiPCT Care Management calculation has been reviewed to assess the effect of Priority Health members distribution on overall Care Management staffing sufficiency.  The analysis has been completed, and the current staffing sufficiency ratio for affected POs was found to still meet or exceed an 80% level across all participating payers.  As a result, the Care Management ratio requirements will remain unchanged (e.g., each PO must obtain at least an 80% level of two care managers per 5000 BCN, BCBSM, Medicare and Medicaid members on the member list).

November and December 2013 G-Code Reports Update

MDC was recently notified of a data issue that will cause a delay for the December 2013 G-Code reports. The November 2013 G-Code reports, which were already released, were also affected by this issue. After we receive the additional data to include in the reports, we will re-run the November reports and generate the December reports.  We anticipate posting them by the end of the month, and will send out a notice when they are available on the Dashboards.

We apologize for the delay and appreciate your patience and understanding as we resolve this issue.
If you have any questions, please contact MDC at MichiganDataCollaborative@med.umich.edu

Enhancement 7.01 for the MiPCT Dashboards & Reports Scheduled to be Released the Week of 2/10

MDC plans to post  Enhancement 07.01  the week of February 10, 2014. This enhancement includes the addition of the 30-Day All-Cause Readmission Rate measure for IP utilization.

When the enhancement is ready, we will send an email to notify users.

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

MDC’s February 2014 MiPCT All-Payer Patient Lists to be Released the Week of 2/17

The Michigan Data Collaborative plans to post the February 2014 MiPCT All-Payer Patient Lists the week of February 17, 2014. An email announcing the release will be sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports tab of the MDC MiPCT dashboards.  The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_02.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).

Placement of  Upcoming Webinars

MiPCT Webinars:  Upcoming webinars can be found on the mipctdemo.org website.  On the home page, you will see a box on the right containing the date, topic, intended audience and presenter, if known, of future webinars.  This list is updated monthly.

Upcoming MiPCT CM Webinars:
MiPCT CM Webinars: Wednesdays, 2:00 – 3:00 PM
Pediatric CM Webinars:  Fridays, 10:00 – 11:00 AM

  • February 26, 2014: Palliative Care Introduction,
  • (All MiPCT Care Managers)
  • March 21, 2014: TBD (Pediatric Care Managers)
  • March 26, 2014:  Palliative Care, Part II
  • (All MiPCT Care Managers)
  • April 23, 2014: TBD (All MiPCT Care Managers)

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

The attached table is a summary of the Michigan Care Management Resource Center (MiCMRC)-approved self-management support training programs.  MiPCT Moderate, Complex and Hybrid care managers are required to complete an MiCMRC-approved self-management course.  The programs listed below include information regarding course date/criteria to schedule.

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 – NEW 2014 Format

The 2014 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).

MiPCT Complex Care Management Course NEW 2014 Format:  Completion of the MiPCT CCM Course includes a live, one-hour Introductory webinar, 6 hours of self-study modules, post tests and 2 in person training days in Lansing, MI.  This entire course is completed during a four day period. The kickoff of the training begins with the Live MiPCT CCM Course Introduction Webinar on day  1.  Register for the March  10-13 2014 MiPCT CCM course at the following site: https://jodyooo.wufoo.com/forms/march-1013-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM course dates:

  • March 10-13, 2014
  • April 7-10, 2014
  • May 12-15, 2014
  • June 9-12, 2014

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

Stories of Your Care Management Success:
Elaine Hudson, RN, BSN, CCM, Detroit Internal Medicine, Henry Ford Health System

Elaine Hudson, RN, BSN, CCM is a care manager at Detroit Internal Medicine, a practice in the Henry Ford Health System. Elaine was working with a patient covered by Medicare insurance. The male patient, ‘Henry’, had been diagnosed with diabetes, hypertension, hyperlipidemia, s/p cerebral vascular accident, memory problems, leg ulcers and s/p cataract removal.

During her first encounter with ‘Henry’, Elaine assessed that ‘Henry’ had a knowledge deficit regarding his chronic conditions, uncontrolled diabetes, uncontrolled hypertension, and poor medication management. He also had missed appointments, frequent ER visits, and lack of motivation for self-care. Elaine and ‘Henry’ developed a plan of care, including care manager interventions and self-management goals, to address his identified needs.

‘Henry’ was in need of reliable transportation to appointments; contact information was given to patient to schedule transportation to medical appointments via his health insurance company. He reported several high blood sugar levels and fluctuating blood pressure readings. Elaine provided education on maintenance and proper use of glucose monitor and blood pressure monitor.

‘Henry’ is making efforts to adhere to dietary modifications including reducing sodium intake and practicing portion control after receiving education and support from Elaine. He calls Elaine with questions regarding making appropriate food choices when planning weekly meals, and uses diabetic materials as a reference. He reports increasing his activity level by performing yard work and walking to the local market and nearby pharmacy.

‘Henry’ admits to memory problems from his previous stroke in 1999, but has improved with reminders to take/refill medication, monitor blood glucose and  now keeps a written blood glucose log as well as scheduling and attending Primary Care Physician (PCP) and specialty care appointments consistently.

‘Henry’ has had no further ER visits, no hypo/hyperglycemic events, and no hypertensive emergencies since he enrolled in care management services. He has a better understanding of his chronic conditions and participates in care by monitoring his blood glucose and blood pressure and regularly takes medications, including insulin as prescribed. He has an improved understanding regarding medication use. These actions have resulted in improved blood sugar and blood pressure readings and overall better control of his chronic conditions. ‘Henry’s’ lab values have improved with a downward trend noted in the past 10 months since he has been receiving care management services. His A1c has gone from 14.1 to 10.3 and his LDL from 145 to 112. It is expected that ‘Henry’ will continue to demonstrate improvements because of the lifestyle changes he has committed to and the support of his PCP team.

‘Henry’ is in agreement with the plan of care and actively participates in realistic goal setting with Elaine and his PCP, Dr. Daniel Moore. Dr. Moore stated, “Since ‘Henry’ has started working with Elaine he has an improved insight into his chronic conditions”. ‘Henry’ stated, “It has been very helpful to have a person to call with questions about foods to purchase for meal planning. Also, to have someone patiently explain the reason my medications were prescribed in terms that made sense to me”.

NEXT ISSUE DATES:

•    Next MiPCT PO FLASH Issues:
February 24, 2014 (if enough material)
March 10, 2014

•    Next MiPCT Practice FLASH Issue:
February 24, 2014 2014

January 27, 2014

Practice Representative for MiPCT Steering Committee: Nominating Period Ends February 28

The MiPCT is soliciting nominations for one slot for a physician practice representative to sit on the MiPCT Steering Committee. The purpose of the Steering Committee is to provide strategic direction to MiPCT Leadership and monitor progress toward the goals and objectives of MiPCT.   The Steering Committee meets bi-monthly in Okemos.  The nominee must be a participating physician at an MiPCT practice.  The goal of adding a practice representative is to represent an “on-the-ground” clinical perspective and insight in shaping program development and operations.   Nominees may self-nominate or be nominated by their PO.

Please submit nominations to https://jodyooo.wufoo.com/forms/steering-committee-nominations/ by February 28, 2014.

Seeking Input & Your Experience:  PO or Practice Patient Advisory Councils

In preparation of a document that is a user support tool for the new Learning Activity option of Practice or PO Patient Advisory Councils, we are interested in talking to any PO or practice that has an active patient advisory council or patient advisor program.   If you have such a program, please contact Diane Marriott at dbechel@umich.edu by February 14, 2014 to arrange for a short phone discussion.

Join a Webinar on Using Evidence to Improve Clinical Care on February 25, 2014

Hosted by the Michigan State Medical Society, Michigan Primary care Transformation Project and the Agency for Healthcare Research and Quality

Interested in learning more about evidence-based resources to improve your patients’ health?  Join the Michigan State Medical Society, Michigan Primary Care Transformation Project and the Federal Agency for Healthcare Research and Quality (AHRQ) for a free Web conference from noon – 1 pm ET Tuesday, February 25, 2014.  Physicians can receive 1 AMA PRA Category 1 CreditTM upon completion of the program.

The webinar, titled “Improving Health Care Decisionmaking:  Comparative Effectiveness
Research,” will:

  • Describe what is comparative effectiveness research
  • Summarize how comparative effectiveness research can be used to help improve clinical practice
  • Identify free comparative effectiveness research resources through the Agency for Healthcare Research and Quality (AHRQ) for physicians and other clinicians

AHRQ conducts comparative effectiveness research (CER) to improve the quality of treatment decisions among clinicians and their patients.  CER highlights the effectiveness, benefits, and risks of different treatment options for common health conditions, such as diabetes, heart disease, cancer and mental health.  When integrated into clinical practice, these free, unbiased resources help improve health outcomes and clinical quality, while engaging patients.

In addition to the Michigan State Medical Society and the Michigan Primary Care Transformation Project, other organizations throughout Michigan already partner with AHRQ on this initiative, including the Michigan Academy of Family Physicians, Michigan Association of Osteopathic Family Physicians, Blue Cross Blue Shield of Michigan, Michigan Primary Care Association, Michigan Council of Nurse Practitioners and American Nurses Association – Michigan, among others.

SPEAKERS
Stephanie Chang, MD, MPH, is a board-certified general internist and pediatrician.  She has worked at the Agency for Healthcare Research and Quality on the Effective Health Care Program and with the Evidence-based Practice Center Program since 2006. She was appointed director of the Evidence-based Practice Center Program in 2010. Dr. Chang completed undergraduate and medical school at the University of Michigan and continued postgraduate residency training in internal medicine and pediatrics at the University of Minnesota.  She completed a master’s degree in public health at the Johns Hopkins Bloomberg School of Public Health and a general internal medicine fellowship at Johns Hopkins University in 2006.

Pamela Montagno, MA, is the lead of the Chicago Regional Partnership Development Office of AHRQ, which is part of the U.S. Department of Health and Human Services.  As an AHRQ contractor, Ms. Montagno  has served in various health care roles for most of her career.  She worked at Cincinnati Children’s Hospital Medical Center and Loyola University Medical Center in Maywood,  Ill., and consulted at the University of Chicago Medical Center, Joint Commission International and the University HealthSystem Consortium, among others.  She earned a bachelor’s and master’s degree at Loyola University Chicago.

REGISTRATION
To register for the webinar, please go to https://improving-healthcare-decisionmaking.eventbrite.com/ and select “Attend Event,” no later than FEBRUARY 24, 2014.   Although the Web conference is free, participants must register ahead of time.  Details on accessing the Web conference will be communicated via email to registered participants.

STATEMENT OF ACCREDITATION
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Michigan State Medical Society and Agency for Healthcare Research and Quality (AHRQ).  The Michigan State Medical Society is accredited by the ACCME to provide continuing medical education for physicians.

AMA CREDIT DESIGNATION STATEMENT
The Michigan State Medical Society designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM.  Physicians should claim only credit commensurate with the extent of their participation in the activity.

DISCLOSURE
The planners and presenters for this activity have no relevant financial relationships.  This activity has
received no commercial support or sponsorship.

For more information and questions about the Web conference, please contact Karen Costa at
karen.costa@ahrq.hhs.gov.

MDC’s January 2014 MiPCT  All-Payer Patient Lists  to be Released this Week with Additional Fields Populated

The Michigan Data Collaborative plans to post the January 2014 MiPCT All-Payer Patient Lists the week of January 27, 2014 with the following clinical fields populated:

  • # of Inpatient visits in newest 6 mo of data
  • # of visits to any PCP in newest 6 mo of data
  • Most recent PCP visit date
  • # of maintenance drug prescriptions in newest 6 mo of data

An email announcing the release will be sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports tab of the MiPCT Dashboards.  The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_01.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).
December 2013 G-Code Reports to be Released this Week with Improved PO Assignments

New G-code Reports for December 2013 will be posted the week of January 27, 2014. These reports use January 2014 attribution for claims paid in December 2013. As a result of MDC’s work with a couple POs to investigate claims not appearing on previous G-Code Reports, we have identified a way to assign a PO to more claims. This will result in a small increase in the number of claims attributed to your PO in the new reports.

They will be available on the Download PO Reports tab of the MiPCT Dashboards and are located in the <PO name>_G-Code_Reports_MiPCT_Overall_2013_12.zip file.

A Quick Reference Guide for these reports is available in the User Guides 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.

NEXT ISSUE DATES:

•    Next MiPCT Practice FLASH Issue:  February 24, 2014
•    Next MiPCT P.O. FLASH Issue:  February 10, 2014

January 13, 2014

MI Care Management Resource CenterApproved Program Summary – Update

The attached table is a summary of the MiPCT-approved self-management programs. MiPCT moderate, complex and hybrid care managers are required to complete a MiPCT-approved self-management course. Several of the self-management courses also include information regarding course date and criteria to schedule. Due to the low volume of MiPCT care managers needing this training, several of the programs have provided “criteria to schedule a course”.

 For additional detail about the MiPCT-approved self-management programs, please see the document entitled, “MiPCT Approved Self-Management Support MCM Program Summary 9.5.13” at http://www.mipctdemo.org/care-management-resource-center/

 Save the Date: Feb. 25 Web Conference on Using Evidence to Improve Clinical Care

Please mark your calendars to join a Web conference from Noon to 1 PM ET on Tuesday, Feb. 25, 2014, to learn how using evidence can improve patient care and clinical outcomes, while engaging patients. The webinar is hosted by the Michigan Primary Care Transformation Project (MiPCT), Michigan State Medical Society (MSMS) and the Agency for Healthcare Research and Quality (AHRQ).

 Entitled, “Improving Health Care Decision-making: Comparative Effectiveness Research,” the free webinar will review the role of comparative effectiveness research (CER) in improving the quality of treatment decisions, and will introduce physicians and their clinical teams to free evidence-based resources. A federal agency that is part of the U.S. Department of Health and Human Services, AHRQ conducts CER to highlight the effectiveness, benefits, and risks of different treatment options for common health conditions and has created free, unbiased resources for clinicians and their patients based on research results.

Webinar participants will learn the following:

  • Describe what is comparative effectiveness research
  • Summarize how comparative effectiveness research can be used to help improve clinical practice
  • Identify free AHRQ comparative effectiveness research resources for physicians and other clinicians

In addition to MiPCT and MSMS, key organizations throughout Michigan already partner with AHRQ on this initiative, including the Michigan Academy of Family Physicians, Michigan Association of Osteopathic Family Physicians, Blue Cross Blue Shield of Michigan, Michigan Council of Nurse Practitioners, Michigan Primary Care Association, and American Nurses Association – Michigan, among others.

SPEAKERS

Stephanie Chang, MD, MPH, a board-certified general internist and pediatrician, is the director of the AHRQ Evidence-Based Practice Center Program.  Dr. Chang completed undergraduate and medical school at the University of Michigan and continued postgraduate residency training in internal medicine and pediatrics at the University of Minnesota, as well as a general internal medicine fellowship at Johns Hopkins University.

Pamela Montagno, MA, is the lead of AHRQ’s Chicago Regional Partnership Development Office.  An AHRQ contractor, Ms. Montagno has served in various health care roles for most of her career.  She worked at Cincinnati Children’s Hospital Medical Center and Loyola University Medical Center in Maywood, Ill., and consulted at numerous health care organizations.  She earned a BA and MA at Loyola University-Chicago.

REGISTRATION

Stay tuned. Registration details to follow shortly.

New G-Code Reports Released January 8, 2014

New G-code Reports for November 2013 are available on the Download PO Reports tab of the MiPCT Dashboards. These reports use December 2013 attribution for claims paid in November 2013. The reports are located in the <POname>_GCode_Reports_MiPCT_Overall_2013_11 .zip file.

A Quick Reference Guide for these reports is available in the User Guides 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.

Release 7.0 for the MiPCT Dashboards and Reports Scheduled to be Released the Week of January 13

Due to data issues that needed to be corrected, MDC postponed the 6.0 release and will combine it with the 7.0 release to take advantage of the availability of more recent data. The 7.0 release is scheduled to be available the week of January 13, 2014. It will include the following:

  • Data from the newest participating payer, Priority Health.
  • Paid claims and eligibility data through September 2013.
  • An updated measurement period through June 2013.

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

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

 MDC’s January 2014 MiPCT All-Payer Patient Lists to be Released the Week of January 20

The Michigan Data Collaborative plans to post the January 2014 MiPCT All-Payer Patient Lists the week of January 20, 2014. An email announcing the release will be sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports tab of the MDC MiPCT dashboards. The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

Note: The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in your PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2014_01.

For information about the All-Payer Patient Lists, including a description of the fields, see the All-Payer Patient List Information document on the MDC Support page (https://www.michigandatacollaborative.org/MDC/#/support).

BCBSM Reports Additional System Issues RE PDCM Claims

 Blue Cross Blue Shield of Michigan has identified additional system issues regarding PDCM claims:

  •  Some claims for procedure codes G9007, G9008, 99487 and 99489 may deny with B526 (This service is not payable because this patient is not a member of Blue Cross Blue Shields coordinated care management or case management program), which is member liable. We are in the process of correcting the system; however, in the interim please do not bill the member. We will pay these claims through the PGIP Reward Pool until the system is correctly processing.

As a reminder, you must check eligibility for each patient through Web-DENIS or CAREN-IVR. Do not solely rely on the patient list that is received each month for eligibility and to determine if these members are enrolled in a High Deductible Health Plan (HDHP) with an Heath Savings Account (HSA).

Please refer to the complete information on this article, originally published in the 9.23.2013 issue of the PO FLASH.  All past FLASH publications can be found on http://www.mipctdemo.org under the PO and Practice FLASH tabs.  The CAREN-IVR / Web-DENIS slide deck is attached for your convenience.

 Quarterly Report Update

Quarterly reporting for 2013 Q4 will include completion of the web-based report, https://mipct.mihealth.org/, and a supplemental narrative report using an Excel template that will be distributed via email from the demo mailbox. Both are due no later than January 31st. Please return the Excel report to MIPCTDEMO@michigan.gov.

This quarter, additional validation has been added to the Care Manager Activity section. The additional validation will run after it is determined that all required fields have a value. This will check that the items listed below are true. The application does not advance to the next section if errors exist from this validation, but the data are saved. Look for a listing of errors to display above Face-to-Face Encounters. Errors do not have to be corrected before advancing to another section. However, the errors do need to be corrected before the report can be submitted.

  • The sum of Face-to-Face and Phone Encounters by payer/care manager/practice is equal to or greater than the number of Unique Patients.
  • The number of Unique Patients is equal to or greater than one (1) if encounters are reported.

Incentive Distribution Reports

The 12-month incentive payments made to POs have been posted to the web-based quarterly reporting, which can be found at https://mipct.mihealth.org/. Please look for the heading “Incentive Distribution Reports”, below the list of quarterly reports on the Financial Reports page. Please complete it (and the 6-month if not already submitted) by January 31st.

Stories of Your Care Management Success:

Julie Turk, RN, BSN, CCM – Bronson Internal Medicine-Downtown

Julie Turk, RN, BSN is a CCM at Bronson Internal Medicine Downtown. She had the opportunity to work with Dr. Albert Cabala, MD’s patient, who was covered by Medicare insurance.

The patient, ‘Hank’, was 88 years old and had severe Heart Failure and Chronic Kidney Failure. He was in the ED and hospitalized many times for HF exacerbation and kidney failure. He had a very supportive spouse, but Hank’s progressive decline and frequent exacerbations were taking their toll on her. ‘Hank’ had a minimal support system in the area, but was receiving services from a home health care agency. His sons live out of town and were unable to help support their mother and father during times of crisis.

Julie identified ‘Hank’ as being appropriate for care manager services due to his frequent ED visits and hospital admissions as well as his poorly controlled chronic conditions. She also identified that ‘Hank’ might be appropriate for palliative care services or hospice due to his progressive decline, uncontrolled symptoms and limited social resources. Julie discussed this with Dr. Cabala and he agreed that palliative care or hospice care might be appropriate and requested Julie assess ‘Hank’s’ understanding and openness to this support.

‘Hank’ and his wife did not understand palliative or hospice care. Julie provided them with information on each of these services and what their options were. ‘Hank’ stated he never wanted to go back to the hospital. Julie communicated this wish to Dr. Cabala who wrote orders for palliative care and social work services to discuss end of life concerns with ‘Hank’ and his wife. These orders were added to the existing home health care plan of care. Julie coordinated the referrals and followed up with ‘Hank’ and his wife to ensure the orders were carried out and to provide support.

‘Hank’ was transitioned from traditional home health care to their palliative program. He learned to better manage his HF at home. During ‘Hank’s’ last trip to the PCP office, his wife hugged Julie and stated, “I would have never been able to do this without you, thank you so much.” ‘Hank’ stated, “Thank you for following my wishes, which will allow me to stay home and out of the hospital”.

When ‘Hank’ and his family were ready, he transitioned to hospice care. Julie maintained contact with ‘Hank’ and his wife providing coordination between services and support, especially near the end of his life. ‘Hank’ died peacefully at home as he wished.

‘Hank’ and his family were very satisfied with the wonderful care they received. They were able to manage him at home as he wished until the end of life. His quality of life was maintained and his wish of no more hospitals and to die at home with dignity was respected. His wife benefited from the great services provided by the home care/palliative care/hospice agency and care management support to coordinate the care. ‘Hank’ and his wife appreciated being able to maintain their close relationship with Dr. Cabala as end of life decisions were made and ‘Hank’s’ wishes were respected and carried out.

MiPCT Complex Care Management Course – NEW 2014 Format

The 2014 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).

MiPCT Complex Care Management Course NEW 2014 Format: Completion of the MiPCT CCM COurse includes a live, one-hour introductory webinar, 6-hours of self-study modules, post-tests, and 2 in-person training days in Lansing, MI.  This entire course is completed during a 4-day period.  The kickoff of the training begins with the live MiPCT CCM Course Introduction Webinar on Day 1.

 Register for the February 10-13, 2014 MiPCT CCM course at: https://jodyooo.wufoo.com/forms/february1013-2014-mipct-ccm-training/

Upcoming 2014 MiPCT CCM Course Dates:

  • February 10-13, 2014
  • March 10-13, 2014
  • April 7-10, 2014
  • May 12-15, 2014
  • June 9-12, 2014

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

 NEXT ISSUE DATES:

  • Next MiPCT PO FLASH Issue:  January 27, 2014 (if enough material)
  • Next MiPCT Practice FLASH Issue:   January 27, 2014

HAPPY NEW YEAR!

Looking for an older issue?

Check out the MiPCT PO and Practice FLASH archives pages.  There is a page for each year for the PO and Practice FLASH newsletters.