2013 PO FLASH

December 16, 2013

MDC’s December 2013 MiPCT All-Payer Patient Lists to be Released Next Week

The Michigan Data Collaborative plans to post the December 2013 MiPCT All-Payer Patient List the week of December 23, 2013. 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_2013_12.

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).

2013 Q4 Reporting

As noted in the Monday FLASH of November 11, 2013, POs will be asked to report on how their practices satisfied the 2013 MDCH Practice Learning Activity Requirement.    Attached are draft screen shots of the Excel file that will be used to report on Practice-led Learning Activities, contractual requirements and  performance incentives.  The Excel file also includes a section to report which hospitals provide admission and/or discharge notification.  POs will complete the web-based report for quarter 4 at https://mipct.mihealth.org/.  Please send questions about the 2013 Q4 reporting to MIPCTDEMO@michigan.gov.

Focus Groups by the National Evaluators of CMS MAPCP Demonstration

Michigan is one of eight states participating in the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration funded by the Centers for Medicare & Medicaid Services (CMS) – through the Michigan Primary Care Transformation Project (MiPCT). CMS has contracted with RTI International, the Urban Institute, the National Academy for State Health Policy, and The Henne Group to evaluate the impact of Medicare and Medicaid’s participation in MiPCT.

In late 2013 or early 2014, the evaluation team will conduct six focus groups with patients and caregivers of patients who receive care from practices participating in MiPCT. The purpose of the focus groups is to learn more about patients’ experience with care provided as part of MiPCT. Attached is a background document with more information about the focus groups, including who to contact with questions.

Focus group participants will be recruited using one of two approaches:

  • For Medicare and Medicare-Medicaid dual enrollees, the evaluation team will send letters directly to a random sample of beneficiaries that are receiving care at practices participating in MiPCT. Practices will not need to do anything to assist with recruitment for these focus groups.
  • For Medicaid only enrollees, the evaluation team will ask two practices to identify at least 100 and no more than 300 Medicaid patients that received care at their practices within the past 12 months and mail these patients a stamped, pre-formatted invitation letter provided by evaluation team. To thank practice staff for their assistance, the evaluation team will provide a $500 Amazon gift card. Detailed instructions and guidance will be sent directly to these two practices.

If one of your MiPCT practices is approached by the evaluation team to assist with the focus group recruitment, we encourage you to strongly support cooperation with this important component of the evaluation. If your MiPCT practices are not contacted by the evaluation team, there is nothing you need to do.

Thank you for your participation in the evaluation effort of the Michigan Primary Care Transformation Project.

MiPCT Complex Care Management Course – New Format Begins December 16, 2013

Beginning December 16, 2013 the MIPCT Complex Care Management Course will be offered in a new blended learning activity format.  We plan to continue this new format monthly in 2014.

The MiPCT Complex Care Management Course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs).

NEW Format:  Completion of the MiPCT CCM Course includes a live, 1-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.

To register for the January 6 – 9, 2014 MiPCT CCM course, visit: https://jodyooo.wufoo.com/forms/january-69-2014-mipct-ccm-training/

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

Clinical Data Submission Updates

As part of the MiPCT project, POs are required to submit clinical data to MDC to enhance the claims data in the MiPCT Dashboards and Reports. As a reminder, POs must submit Registry/EHR data on 30% of the applicable population for the following measures to receive points for the 24-month Performance Incentives:

  • Diabetes:  A1C, BP
  • Hypertension: BP
  • Asthma Action Plan/Self-Management

Plan: Yes, No

  • Tobacco use: Yes, No
  • Children > 3 years old: BMI Percentile
  • Adults: BMI

For additional information, see the 2013 and 2014 MiPCT Performance Incentive Technical Manuals on the MiPCT Website https://mipct.org/resources/mipct-documents-and-presentations/.

In addition, MDC has the following announcements about submitting your clinical data:

  • Several POs have not confirmed their BCN layout or submitted a test file with one month’s worth of data. If your PO has not completed these requirements, please contact Chris Reid before December 31, 2013 at reidcd@med.umich.edu or 734-615-7256. Unless you make other arrangements with Chris, these files are due by December 31, 2013.

For questions regarding the submission of clinical data, please contact Chris Reid at reidcd@med.umich.edu or (734) 615-7256.

Dashboard and Reports Release 6.0 Update

MDC plans to announce the 6.0 release during the week of December 30, 2013. This release will include Priority Health data, paid claims and eligibility data through July 2013, and an updated measurement period through April 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@med.umich.edu.

Happy Holidays, and
Happy New Year
from Your MiPCT Team!

NEXT ISSUE DATES:

•    Next MiPCT P.O. FLASH Issue:  January 13, 2014

•    Next MiPCT Practice FLASH Issue:  January 27, 2014

December 2, 2013

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 December 16, 2013 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

Federal Employee Program (FEP) Has Opted into Provider Delivered Care Management (PDCM)

Blue Cross Blue Shield of Michigan is pleased to announce that FEP has opted into the PDCM—care management services—program effective August 1, 2013. These members will NOT be on your patient list; rather, you will be able to identify them by their unique identification number. Their identification number will start with “R”. Below is an example of their identification card. Please also note that FEP members who are enrolled in Medicare (A&B or just B) are not eligible for the care management services program through Blue Cross Blue Shield of Michigan. Additionally, claims will be processed differently for this group. If you have rendered care management services to FEP members since August 1, 2013 and have not received payment or received a denial from BCBSM, please resubmit those claims. If you have questions please submit them through MiPCT, the Collaboration Site or to our mailbox at providerpartnerships@bcbsm.com.

Focus Groups by the National Evaluators of CMS MAPCP Demonstration

Michigan is one of eight states participating in the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration funded by the Centers for Medicare & Medicaid Services (CMS) – through the Michigan Primary Care Transformation Project (MiPCT). CMS has contracted with RTI International, the Urban Institute, the National Academy for State Health Policy, and The Henne Group to evaluate the impact of Medicare and Medicaid’s participation in MiPCT.

In late 2013 or early 2014, the evaluation team will conduct six focus groups with patients and caregivers of patients who receive care from practices participating in MiPCT. The purpose of the focus groups is to learn more about patients’ experience with care provided as part of MiPCT. Attached is a background document with more information about the focus groups, including who to contact with questions.

Focus group participants will be recruited using one of two approaches:

  • For Medicare and Medicare-Medicaid dual enrollees, the evaluation team will send letters directly to a random sample of beneficiaries that are receiving care at practices participating in MiPCT. Practices will not need to do anything to assist with recruitment for these focus groups.
  • For Medicaid only enrollees, the evaluation team will ask two practices to identify at least 100 and no more than 300 Medicaid patients that received care at their practices within the past 12 months and mail these patients a stamped, pre-formatted invitation letter provided by evaluation team. To thank practice staff for their assistance, the evaluation team will provide a $500 Amazon gift card. Detailed instructions and guidance will be sent directly to these two practices.

If one of your MiPCT practices is approached by the evaluation team to assist with the focus group recruitment, we encourage you to strongly support cooperation with this important component of the evaluation. If your MiPCT practices are not contacted by the evaluation team, there is nothing you need to do.

Thank you for your participation in the evaluation effort of the Michigan Primary Care Transformation Project.

Don’t Miss the Train! Call for Participants for Learning Collaboratives

Learning Collaborative sessions will continue in 2014, and will be hosted through Practice Transformation Institute. Don’t miss out on this learning opportunity! Continuing Medical Education credits will be awarded, and also Maintenance of Certification! Attached, please find an explanation sheet with full details.

12-Month Incentive Distribution Reporting

The 12-month incentive payments made to POs have been posted to the web-based quarterly report. Please complete this section to report how incentives were distributed to practices for Medicaid and Medicare only at your earliest convenience or no later than January 31, 2014.

Find the list of Incentive Distribution Reports on the Financial Reports page below the list of quarterly reports:

  • Click on Edit to open the Distribution of Incentives form.
  • Enter amount and date payment was made to each practice.
  • As with the quarterly reports, anyone who has a user account may enter and save the data. However, the person who has the authority to submit the financial report will also have to submit the Distribution of Incentives.
  • The submitter will complete the steps below.
    • Complete the check-box at the end of the page to indicate the report is ready to submit. (Checkbox only available to Submitter.)
    • Select the “Save and Continue” button at the end of the page.

 MiPCT Performance Incentive Update

Change in 2013 – 18 Month Performance Incentive Metrics and Points.

Due to the delay in beginning the collection of registry/EHR clinical data, the set of Clinical Quality Metrics based on EHR/registry data has been removed from the 18 Month (January 1 through June 30, 2013) performance incentive metrics and points have been adjusted. The attached document provides a summary of the performance metrics and point allotment for the 18 and 24 month performance incentive periods. Additional information is available in the new 2013 Performance Incentive Technical Manual posted on the MiPCT website

https://mipct.org/resources/mipct-documents-and-presentations/2014

Performance Incentive Technical Manual.

The new 2014 Performance Incentive Technical Manual was distributed last Monday. It is also posted on the MiPCT website https://mipctdemo.files.wordpress.com/2011/09/2014-perf_incen_tech_man-final.pdf

Questions about the Performance Incentive Program should be sent to the MiPCT mailbox mipctdemo@michigan.gov. Specific questions about submission of clinical data should be sent to MichiganDataCollaborative@umich.edu.

MDC’s November 2013 MiPCT All-Payer Patient Lists Released 11/26 with New Fields Added

The Michigan Data Collaborative posted the November 2013 MiPCT All-Payer Patient Lists on November 26, 2013. 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.

This month’s lists includes the Priority Health PPO population and the following new fields:

  • Medicare Dual Eligibility flag – Indicates if a member is dual enrolled in Medicare and Medicaid.
  • Priority Health HSA flag – Indicates if a Priority Health member is in a high-deductible plan.

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_2013_11.

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).

Enhancement 05.01 for the MiPCT Dashboards and Reports Released 11/25

MDC posted Enhancement 05.01 on November 25, 2013. This enhancement includes the following additions and updates:

  • New MiPCT and PO Population and Cost Trends Dashboards – These dashboards display the Standard Cost PMPM rates for each risk group over defined time periods. This can help you track long-term trending for standard costs.
  • New MiPCT and PO Quality Trends Dashboards
  • -These dashboards display the diabetes quality measure rates over defined time periods. This can help you track long-term trending for each diabetes quality measure.

Added the following ACSC Measures to the Utilization Dashboards:

  • Adult Acute ACSC Admission Rate (per 1000 Admissions)
  • Adult Chronic ACSC Admission Rate (per 1000 Admissions)
  • Pediatric ACSC Admission Rate (per 1000 Pediatric Admissions).

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

October 2013 G-Code Reports Released 11/27

New G-code reports for October 2013 were released on November 27, 2013 and are available on the Download PO Reports tab of the MiPCT Dashboards. These reports use November 2013 attribution for claims paid in October 2013. The reports are located in the <PO name>_G-Code_Reports_MiPCT_Overall_2013_10.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.

Register Your New Complex and Hybrid Care Managers for the MiPCT Complex Care Management Course

The MiPCT Complex Care Management course will be offered December 16-19, 2013 in Lansing. Registration is available at the following link: https://jodyooo.wufoo.com/forms/december-1619-2013-mipct-ccm-training/. The MiPCT CCM course consists of four training days: December 16, 17, 18, 19.

 Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

NEXT ISSUE DATES:

  • Next MiPCT Monday FLASH Issue: December 16, 2013
  • Next MiPCT Practice FLASH Issue: December 16, 2013

November 11, 2013

Medicare Care Coordination Payments Distributed

 POs should have received payment by November 1, 2013 for the third quarter Care Coordination Payment Invoice for Medicare claims paid through 09-30-2013. These payments are sent via check from the University of Michigan.

 Register Your New Complex and Hybrid Care Managers for the MiPCT Complex Care Management Course

The MiPCT Complex Care Management course will be offered December 16-19, 2013, in Lansing. Registration is available at the following link: https://jodyooo.wufoo.com/forms/december-1619-2013-mipct-ccm-training/. The MiPCT CCM course consists of four training days: December 16,17,18, and 19.

 Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

 Mi Care Management Resource Center Approved 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 Moderate Care Management (MCM) training. The programs listed in the attachment include information regarding course date/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 document titled “MiPCT Approved Self Management Support MCM Program Summary 9.5.13” at https://mipct.org/care-management-resource-center/

Call for Participants for Cohort Two Learning Collaboratives

 Learning Collaborative sessions will continue in 2014, and will be hosted through Practice Transformation Institute as a community partner with the MiPCT. Practices that did not participate in prior MiPCT Learning Collaborative waves are encouraged to participate. Attached, please find an explanation sheet with full details.

 2013 Learning Activities Requirement – Reminder on Tracking

 Consistent with earlier messaging, POs will be asked to report, and should be tracking how their practices satisfied the 2013 MDCH Practice Learning Activity Requirement (8 credit hours per year including at a minimum the physician and care manager), and the 2013 MDCH Care Manager Learning Activity Requirement (12 credit hours per year per Care Manager).

 As a reminder, the alternative options for satisfying the requirements are listed below:

 Care Managers may meet the education requirement by:

  • Participating in the MiPCT-led Care Manager webinars/sessions, on topics relating to care management, 3 hours per quarter for a total of 12 hours per year; or
  • Participating in PO-led Care Manager education up to 4 hours per year and the additional hours of MiPCT-led Care Manager webinars/sessions on topics relating to care management to equal a total of 12 hours of education per year.

Example: Care Manager attends 4 hours of PO-led Care Manager education and 8 hours of MiPCT-led Care Manager education sessions. The accrual of the 12 hours of education will be met by the Care Manager completing 3 hours of education per quarter. No preapproval is necessary for PO-led Care Manager educational activities.

Practices may meet the Practice Learning Activity Requirement by completing:

  • A MiPCT-led Activity:

             – Learning Collaborative

             – MiPCT Town Hall Dinners (counts as 2 hours toward the 8 hour requirement for practices with physician in attendance)

              – MiPCT Learning Collaboratives (satisfies the entire 2013 requirement for the practice).

              – MiPCT annual summit attendance (counts as 6 hours toward the 8 hour requirement for practices with physician in attendance)

  • Practice-led monthly medical home meetings (counts as 1 hour per month; if at least 8 monthly medical home meetings are completed per year, the entire requirement is satisfied for the year). NOTE: To receive learning activity credit, must include team participation in learning activities addressing the four functional tiers.
  • Another MiPCT-approved learning activity that directly addresses one or more MiPCT functional tiers that has been submitted and approved.

Webinar November 15 at 10 AM: Pediatrics in MiPCT, Year 3

 Since we were not able to hold a face-to-face meeting for pediatric care managers in 2013, I want to make this webinar as interactive as possible. I hope we can learn from each other so come prepared to talk about something that works well in your practice. Also, bring ideas and requests for pediatric webinar topics for 2014.

I will give a brief overview of highlights I heard at the fall summits. I will also talk a bit about things I have learned from colleagues in other states as they work to incorporate pediatrics in PCMH initiatives – we are not alone! Most of the hour will be open mic – an opportunity to learn from each other.

Release 5.0 of the MiPCT Dashboards and Reports is Now Available

MDC posted Release 5.0 on November 1, 2013. This release includes the following updates:

  • The data in the Dashboards and Reports have been updated using paid claims data from 1/1/2012 through 5/31/2013 for Medicare, Medicaid, BCBSM, and BCN.
  • For measures that MDC calculates, the measurement year includes dates of service from 3/1/2012 through 2/28/2013. This calculation allows for a three-month claims run-out.

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

 Clinical Data Submission Updates

 On October 31, 2013 MDC sent all POs an updated Clinical Data Specifications document. This document includes information about the file format, types of records to include, and the data submission due dates. You can access this document and the data submission examples on the MDC Website Support page (https://www.michigandatacollaborative.org/MDC/#/support). The documents can be found at the bottom of the page under the MiPCT Registry Data Submission heading.

 MDC requests that each PO confirm the format version they are using as soon as possible (if you haven’t done so already) and submit a test file with one month’s worth of data by November 30, 2013. In addition, an email was sent out on October 25, 2013 about including individual addresses in group emails. If you haven’t already responded, we’d greatly appreciate hearing from you as soon as possible.

 If you have any questions, please contact Christopher Reid at reidcd@med.umich.edu or 734-615-7256.

 Stories of Your Care Management Success:  Jackie Colwell, RN, CCP – Charlotte Medical Center

 Jackie Colwell, RN, CCP is a care manager at Charlotte Medical Center, which is affiliated with Sparrow Physician Health Network. Jackie worked with a patient covered by Medicare insurance who had been discharged from a sub-acute facility six weeks previously. Diagnoses for this patient include CHF, COPD, Acute Bronchitis, HTN and on-going unspecified constipation.

 Before Jackie was introduced to the patient, he was experiencing fatigue, lethargy, hypoxemia, depression and loss of appetite. He was having intermittent bouts of decreased functioning, and a general decline in his health. He was also experiencing decreased motivation to care for self or even get out of bed. He was living with his daughter who was becoming frustrated with his ups and downs. She expressed that she felt the patient’s condition was really declining at this time.

 The patient’s gradual decline in health, coupled with his daughter’s challenges in managing the ups and downs of his condition, and anticipating further decline in future, made him a perfect candidate for care management services. The patient’s daughter needed assistance in managing symptoms of the patient’s chronic conditions, yet wanted to respect the patient’s desire to remain comfortably at home. He also had several urgent care visits related to symptom management that could have been avoided. Due to his age and the marked decline in his functioning, per his daughter/caregiver, Jackie suggested palliative care.

 Jackie discussed the case with the patient’s primary care provider (PCP). The PCP was hesitant about the family’s understanding of palliative care and questioned whether the patient’s daughter would want this. Jackie and the PCP met with the patient and his daughter, to review palliative care service and the referral process, emphasizing that the PCP would remain the patient’s doctor and he could still maintain appointments with her. This was very important to the patient and his family. In addition, the PCP and Jackie explained to the patient that his symptoms would continue to be treated as usual, but that a specialized palliative care doctor would make visits and give recommendations on his plan of care.

 After the meeting, Jackie arranged for the referral from the PCP, and contacted a local home health company regarding palliative care services and what they had to offer. She also sent information regarding palliative care to the patient’s home so that he and his daughter could share the information with other members of the family. The palliative care doctor met with the patient and his family within a few days. Several medication changes and recommendations were made, as well as additional support brought in, such as physical therapy, skilled nursing and social work. The patient continues to be followed by the palliative care doctor monthly.

 When Jackie last spoke with the patient’s daughter, she was very pleased with the palliative care initiative, stating, “His mood is better and he has benefited from this process greatly. This was a really good thing.” The daughter also expressed thanks for additional support she has received from this initiative. The PCP expressed to Jackie that this was a very positive outcome for this patient. Jackie expressed that the successful integration of palliative care in the plan of care of this patient may improve utilization of the service for other patients with similar needs in the future.

 NEXT ISSUE DATES:

Next MiPCT Practice FLASH Issue: November 25, 2013

Next MiPCT Monday FLASH Issue: November 25, 2013

October 21, 2013

MDC’s October 2013 MiPCT All-Payer Patient Lists to be Released the Week of October 21st

The Michigan Data Collaborative plans to post the October 2013 MiPCT All-Payer Patient List the week of October 21, 2013. 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_2013_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).

Dashboard and Reports Release Updates

MDC plans to announce the 5.0 release during the week of October 28, 2013. This release will include updated data and measurement year dates. When the release is ready, we send an email to notify users and provide the release details.

We are also working to incorporate Priority Health data into the dashboards and reports, and we expect to include it in a release by the end of this year.
If you have any questions, or if you would like to provide feedback or suggestions, please contact MDC at MichiganDataCollaborative@med.umich.edu.

Medicaid Update

We expect POs to receive Medicaid Care Coordination payments by October 28th.  Most of the Practice Transformation payments should have been received on the 17th, with some not going out until the 24th.

Medicaid had a staffing issue this quarter, and extends their apologies for any inconvenience this may have caused.

NEXT ISSUE DATES:

  • Next MiPCT Monday FLASH Issue: November 11, 2013
  • Next MiPCT Practice FLASH Issue: November 25, 2013

October 7, 2013

2014 Incentive Metrics Approved!

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

Quarterly Reporting

Quarterly reports for 2013 Q3 will be completed entirely online, now that the narrative section has been incorporated into the website (https://mipct.mihealth.org/).

Quarter 4 will require collection of additional information in Excel related to contractual obligations and incentive criteria. Please see the “Streamlined Narrative Reporting” article in the September 23, 2013 edition of the Monday FLASH for more information on quarter 4 reporting.  Archived editions of the MiPCT Monday FLASH can be found on the Monday FLASH page of the http://www.mipctdemo.org website.

MiPCT Teams Score Well in Care Delivery

Care delivery is a team sport. To put the best team out on the field requires practice, coordination and planning. Significant investment in time, talent and monies are required to get a consistently winning team.

Convincing data is evident when you compare the Chicago Cubs with the New York Yankees – the result from investing in players and development strategies certainly has paid off.  So, how are we investing in our health care teams, and what is the payoff for that investment?

In the past year, 34 teams representing 12 physician organizations invested in Learning Collaboratives. The time investment was 3 full days out of the office for a representative team over a 6-month period. Team development and quality improvement infrastructure were indicated by monthly data reporting, as well as tracking of team huddles and team QI meetings.  Like the Yankees, the investment was significant.  We are happy to share their improvements below :

  • •    48 hour phone follow up post IP/ED
    –    Change of 20.1% from baseline
    –    59% increase in post follow up phone calls
  • •    96 hour in-person office after-hospital discharge
    –    6.0 % increase from baseline (76%) which represents a 7.9 % increase in hospital  discharge appointments
  • •    Discharge summary available at time of follow up
    –    increase in metric  7.3%  which is improvement from baseline  of 8.8 %
  • •    Medication reconciliation at post dc appointment
    –     Change is 10.6%  which represents a 38.9% increase since baseline
  • •    % of business days with daily huddle
    –    77.7%   (peak was 86%)
  • •    Number of QI meetings / month
    –    1.7 % (stable )
  • •    Average number of case reviews / month
    –    Current 15.5 (decrease from peak of 23.2)

The second cohort for learning collaboratives will begin in late 2013, early 2014.  Now is the time to utilize the MiPCT expertise to invest in your teams.

We will be working with collaborative PO partners to deliver this experience in a regional fashion. Please contact MiPCT at mipctdemo@michigan.gov with “LC-Cohort 2” in the Subject Line to get more information on the collaboratives.

MI Care Management Resource Center Approved 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 an MiPCT-approved self-management course.  Several of the self-management courses also include Moderate Care Management (MCM) training.  The programs listed in the attached table include information regarding course date/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 titled, “MiPCT Approved Self Management Support MCM Program Summary 9.5.13” at https://mipct.org/care-management-resource-center/.

Placement of Upcoming Webinars

Upcoming webinars can be found in the micpctdemo.org website.  Choose the Monday FLASH tab.  On the right side of the Monday FLASH web page you will see a box containing the date, topic, intended audience, and presenter if known of future webinars.  This list will be updated monthly with past webinars removed and future webinars added.

Upcoming MiPCT CM Webinars:
Adult Webinars (Wed. 2-3 PM) – Pediatric Webinars (Fri. 10-11 AM)

Oct. 16, 2013:     MDCH Resources Part II: Cancer, Tobacco Control and Review of Asthma, Cardiovascular Disease, Diabetes and Obesity. (All MiPCT Care Managers).

  • Oct. 30, 2013:     MDCH Resources Part III: Substance Abuse, Mental Health and HIV/AIDS. (All MiPCT Care Managers).
  • Nov. 13, 2013:     MDCH Resources Part IV: WIC and Children’s Special Health Services. (All MiPCT Care Managers).
  • Nov. 15, 2013:      Pediatric Webinar presented by Dr. Jane Turner: Topic to be determined.

*Please note: there will not be a Pediatric webinar in October

Register Your New Complex and Hybrid Care Managers for the  MiPCT Complex Care Management Course

The MiPCT Complex Care Management course will be offered October 21-24, 2013 in Lansing.  Registrations is available  at the following link: https://jodyooo.wufoo.com/forms/october-21-24-2013-mipct-ccm-training/.

The MiPCT CCM course consists of four training days: Oct 21, 22, 23 and 24.

Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

Clinical Data Request Plan Update

We know that several of you are anticipating a request from MDC to submit clinical data from your EMRs. MDC is currently working to clarify the specifics of the data request to ensure that it will meet all of the known requirements of the project. We expect to send a formal data request to each PO by the end of the month. It will include the specific kinds of records to send, including coding information and format.

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

Dashboard and Reports Release Updates

MDC plans to announce the 5.0 release during the week of October 28, 2013. This release will include updated data and measurement year dates. When the release is ready, we send an email to notify users and provide the release details.

We are also working to incorporate Priority Health data into the dashboards and reports, and we expect to include it in a release by the end of this year.

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

New G-Code Reports Released October 4, 2013

New G-code Reports were released on October 4, 2013 and are available on the Download PO Reports tab of the MiPCT Dashboards. The September 2013 attribution was used for claims paid in August 2013. The reports are located in the <PO name>_G-Code_Reports_MiPCT_Overall_2013_08.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.

Additional Opportunity for POs to Join Spotlight Direct Care Manager Member List with ADT Notifications

To support success in team-based care management, MiPCT made available the opportunity to obtain, at no cost to POs or practices, direct care manager web-based member list access.

Admission, Discharge, Transfer (ADT) notifications are in process of being added for the seventeen POs that chose to participate in this “MiPCT Spotlight Direct Care Manager Member List Access” offering.

POs that did not participate in the Spotlight MiPCT launch are now being offered a second opportunity to join.

To be added, a PO should complete and return the response form (attached) to Mipctdemo@michigan.gov by October 30th.   Upon receipt of your Response Form, you will receive an MOU from Carebridge to enable ADT transmission.

A webinar will be held on October 17th from 2:00 – 3:00 PM to answer any questions. Interested POs may find the attached Spotlight FAQ sheet helpful.  It addresses common questions about Spotlight.

Spotlight FAQs

Q:  If a PO chooses to participate in the MiPCT Spotlight offering, when will they be able to begin to see ADT alerts on their member lists?

A:  If a PO returns their completed response packet by October 30, and if their PO Spotlight lead (up to two per PO) identify their care manager/practice assignments by November 15th, their PO leads will be trained on Spotlight use with a “train the trainer” model to enable them to roll-out system use to their care managers.   By the December holidays, we look forward to adding ADT alerts into member lists for three major health systems.

Q:  If there is no cost to POs or practices, who is paying for Spotlight?

A:  The MiPCT project views the effective servicing of transitions of care to be key to demonstration project success.  Therefore, the funding for Spotlight comes out of the project’s administrative budget.

Q:   Is Spotlight the only way to get ADT notifications?

A:   Some physician hospital organizations now provide their primary care practices with ADT alerts within electronic medical record systems.  Other POs may have additional efforts to build long-term strategies for ADT incorporation.

However, Spotlight is the only MiPCT-funded alternative for POs to obtain ADTs for the members on their lists.  Furthermore, Spotlilght links the member list for a practice with ADT alerts, making it easier for the care managers to have timely notification of ADTs for MiPCT members.   Furthermore, Spotlight offers POs the opportunity to obtain health system ADTs quickly – we aim to provide participating POs with ADTs for at least three large health systems by late December, 2013.

Q: What happens after the demonstration period is completed (after December 31, 2014)?

A:  Though there is continued progress on a sustainability strategy to enable MiPCT’s continuation post-demonstration, and though this may contain funding for infrastructure  for items  such as ADT alerts, the effectiveness of MiPCT practices in reaching project goals also has an implication on project continuation.  Therefore, the MiPCT-funded ADT/direct member list access Spotlight made available in this offering will extend until the end of the demonstration period (December 31, 2014).       

Q: Will ADTs be available from every health system in the state?   
   
A: ADTs will be incorporated wherever available.  We expect this to be three large health systems by the end of 2013, with additional health system ADTs being added in MiPCT

Q: Who is CareBridge and why is there  an MOU with them?
 
A:  CareBridge is an organization that supports process and quality improvement affiliated with CIPA/MAG.   POs that participate in the Spotlight partnership are asked to sign a no-cost MOU with CareBridge because CareBridge has offered to act as the Virtually Qualified Organization (VQO) to enable ADT system feeds to be transmitted to MiHIN to enable ADT matching to the MiPCT member list.

Q: Will there be additional opportunities beyond the October 30 deadline to join Spotlight?
 
A:  Though we will try to accommodate requests from additional users after the October 30 deadline, we highly encourage interested POs to join now, so that they can be guaranteed participation.

National Evaluators to Visit in October and November

As you may know, the MiPCT is one of eight state programs that are part of the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration being sponsored by the Centers for Medicare & Medicaid Services (CMS).  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.  Aas part of this evaluation, researchers from these organizations plan to visit our state October 21st to October 23rd and November 12th to November 14th to interview key people involved in this initiative.

During these visits, the evaluation team will interview staff at practices and physician organizations.  A member of the evaluation team, Lexie Grove from RTI, 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.

The purpose of the interviews is to learn more about how you deliver care. For example, the researchers might ask you what your care coordinator does (if you have one), or how you use health IT (if you use it), or what changes you have recently made (if any) to your practice. They might also ask how you are using the Medicare payments you’re receiving, and about the impact you think any practice changes are having on your patients. Answers to other frequently asked questions appear in a background document included with this newsletter.

Thank you for your participation in the Michigan Primary Care Transformation Project evaluation effort. If you have any questions, please feel welcome to email Heather Kofke-Egger at hkofke@rti.org.

Stories of Your Care Management Success:
Diane McLeod, BSN, RN – Sparrow Medical Group West

Diane McLeod, BSN, RN, is a MiPCT care manager at Sparrow Medical Group West. Diane began working with a female patient, ‘Dorothy’, after receiving a referral from Dr. Monika Leitgeb, DO. Diane was asked to work with ‘Dorothy’ on diabetes education and glucometer teaching after experiencing and elevation in her HgA1c from 7.8 to 10.4.

‘Dorothy’ is 90 years old and has been married for more than 50 years. She was on numerous medications and has an extensive medical history. Diagnoses include lung and ovarian cancer, hypertension, type two diabetes mellitus, hypercholesterolemia, bullous pemphigoid, peripheral artery disease and mesenteric vascular insufficiency.

Diane’s initial assessment revealed a number of potential barriers for ‘Dorothy’, besides her multiple health issues. ‘Dorothy’ was not testing her glucose levels at all, was not taking her metformin as ordered and was adamant that she would never agree to use insulin. Her dietary habits were of concern because she did not eat regular meals and never ate breakfast. She also really likes baked goods (doughnuts, cakes, and cookies) and always has them available in her home. ‘Dorothy’ expressed she was tired of all the testing she has had to do in her life and she only eats when she feels hungry. Further challenges for ‘Dorothy’ include the fact that her husband is legally blind and she serves as the family matriarch and hosts most of the family gatherings. She also does most of the cooking for those gatherings. Diane considered all these factors as she began to work with ‘Dorothy’.

Diane began by providing teaching on how to use the glucometer. This required significant encouragement to receive ‘Dorothy’s’ agreement to test her glucose level even once a day.  Gradually she agreed to test three times a day and would only agree to begin testing “after the holidays”.  ‘Dorothy ‘had difficulty remembering the steps involved to test her glucose.  Although blind her husband encouraged her to test and verbally guided her during the testing process until she became independent.”

Diane then took slow and deliberate steps to present diabetes education in the areas of symptoms of hyperglycemia and hypoglycemia. She provided the rational for varied glucose testing times, medication management and education and nutrition, including the importance of carbohydrate/protein balanced foods. ‘Dorothy’ was reluctantly willing to learn and set goals. Although reluctant, the education previously provided helped ‘Dorothy’ learn new information and skills. Diane also engaged the patient’s husband and daughter in the process. Each was very supportive. Although ‘Dorothy’s’ husband is legally blind, he is very cognitively alert and able to provide her with verbal reminders and cues regarding her diabetes management.

Diane provided frequent telephone contacts. Initially ‘Dorothy’ lost weight, which was not desired. Her weight decreased from 120 pounds to 114 pounds. At that time Diane provided re-education on nutrition and the importance of regular meals.

Through self-management goal setting, education and care manager support, ‘Dorothy’ is now more engaged in the management of her diabetes and testing her glucose more regularly.  Her HgA1c has returned to 7.8, she feels better and has experienced an improvement in her memory. ‘Dorothy’ has also experienced financial savings by switching her metformin prescription to the Meijer pharmacy and now receives the medication at no cost.

‘Dorothy’ remains engaged in her diabetes management.  At her last PCP visit, she approached her PCP with a concern about remaining on Actos due to risk of bladder cancer. She requested to change medications in August, which is when she will have been on Actos for a year. ‘Dorothy’ is investigating alternative options (Januvia, Onglyza or Tradjenta) with her insurance company. Diane continues to call ‘Dorothy’ periodically for updates and to offer continued encouragement and support.

NEXT ISSUE DATES:

•    Next MiPCT Monday FLASH Issue: October 21, 2013

•    Next MiPCT Practice FLASH Issue: October 21, 2013

September 23, 2013

MiPCT 2013 Regional Annual Summit Registration Deadlines Approaching

Today (September 23rd) is the last day to register for our Gaylord Annual Summit (to be held on October 1st).  The registration period for the Grand Rapids (October 9th) and Ann Arbor (October 15th) Annual Summits will continue until September 30.

A link to the online registration form can be found at http://www.mipctdemo.org on both the home page, as well as on the Annual Summits page, where you can find general information, such as:

  • Links to the registration pages
  • Addresses of each of the conference facilities
  • Hotel listings with special MiPCT rates
  • FREE shuttles between hotels and conference sites
  • Agendas and other conference materials

In an effort to be environmentally conscious, MiPCT is going paperless.  The morning conference materials will be posted on the http://www.mipctdemo.org website on the MiPCT 2013 Regional Annual Summits page in time for all to preview. We will provide a paper copy of the agenda at each conference.  Attendees may wish to print materials in advance.  The materials will remain on the website, http://www.mipctdemo.org, under the “Resources/Presentations” tab for ongoing reference as well.

Announcing a New Practice FLASH Publication (TODAY)! (See the MiPCT Practice FLASH tab on this website!)

We are pleased to introduce the MiPCT Practice FLASH, to be published once each month, on the third Monday of every month.  Today we publish the inaugural issue!

The MiPCT Monday FLASH will continue to be published twice every month, provided there is ample material to cover in the second monthly issue.

We are very excited about this new initiative. The Practice FLASH will contain information relative to MiPCT practices, such as project updates, periodic MDC outcome results across PO’s (for example ED utilization), MiPCT payer updates when applicable, articles on Choosing Wisely, and links to relevant literature. It will also contain patient success stories, upcoming CM webinar topics and dates, and future CCM training dates.

We are requesting that all POs distribute this monthly practice FLASH edition to their participating MiPCT practices.  Please feel free to provide recommendations for additional subject matter and comments related to the Practice FLASH to MiPCTDEMO@michigan.gov, with “PRACTICE FLASH” in the subject line. Thank you for your continued partnership.

-The MiPCT Team
REMINDER: Need for Timely Submission  of Change Forms  for Provider File Updates

An additional reminder that change forms should be submitted by POs within five (5) days of learning of a change in a practice or provider directly to mipctdemo@michigan.gov.

Examples of changes that need to be reported include changes in identifiers such as NPIs and PTANs, changes regarding new and departing physicians at practices, and changes within the practice (such as a practice closing, or dropping from the MiPCT, etc.).

The change form is located at:https://mipctdemo.wordpress.com/resources/mipct-documents-and-presentations/physician-and-practice-change-form-v5-2/.   

Again, change forms should be returned to: mipctdemo@michigan.gov (and not individual MiPCT staff members).

BCBSM System Issues for PDCM Claims

Blue Cross Blue Shield of Michigan has identified some system issues you should be aware for PDCM claims:
1.  Some claims deny with a mental health or weight loss/obesity related diagnosis.

  • >    If possible, do not bill these types of diagnoses in the primary/first diagnosis position on the claim.
  • >    If one of these diagnoses is the only applicable diagnosis, we will reimburse through the PGIP Reward Pool.  This payment goes directly to the Physician Organization and if necessary, occurs only 4 times per year.

2.  Some telephone codes claims deny for maximum met.

  • >    We will reimburse through the PGIP Reward Pool.

3.      When an ASC group chooses to participate in MiPCT/PDCM, we add their members to the monthly patient list.  The group’s effective date for the change may be a future effective date.   These claims will deny until the effective date.

  • >    We will reimburse their claims through the PGIP Reward Pool until their effective date.

4.  If an ASC group that has not chosen to participate in MiPCT/PDCM was inappropriately added to the monthly patient list.

  • >    We will reimburse the claim through the PGIP Reward Pool (e.g. Teamsters) until we notify you of our error and provide you an end date.
  • >    Members of the Michigan Conference of Teamsters (Group #’s:  71549, 80975, and 80980) were added to the Patient List in error.  We will reimburse all claims through October 31, 2013.

5.  Some claims deny when billed with a “V” code diagnoses.  Some of these denials may be appropriate.  For example, V70 – General Medical Exam, should not be billed for care management services.  A non-medical issue must be billed in conjunction with a medical issue and medically necessary diagnosis in order to bill a claim.

  • >    If possible, do not bill these types of diagnoses in the primary/first diagnosis position on the claim.
  • >    If one of these diagnoses is the only applicable diagnosis, and it is not a non-medical issue diagnosis, we will pay out of PGIP Reward Pool.

Streamlined Narrative Reporting

Beginning with 2013 Q3 reporting (due Oct. 31st), the narrative portion of the Quarterly Report will be completed online instead of in Excel.  Items 1-17 (see Quarter 2 2013 worksheet from quarter 2 template) will be collected every quarter online.

Quarter 4 will require additional reporting in Excel related to the contractual obligations and incentive criteria.  In particular, you will need to report how each practice met its training requirement. Section D, item 18 in the contract states:

18. Assure that every participating Practice has at least one Provider-led Care Team (i.e., a physician, care manager, at least one other practice member, and a PO representative) participating in one or more of the following MiPCT-approved learning opportunities within the first three quarters of Year Two:

a. MiPCT Learning Collaborative

b. Other MiPCT-approved learning activity that         directly addresses one or more MiPCT functional tiers (see Appendix E). Requests for Approval from POs should be directed to “MiPCTDemo@michigan.gov” at least four weeks before the activity takes place. See Guidelines for MiPCT Approval in Appendix F.

MDC’s September 2013 MiPCT All-Payer Patient Lists to be Released the Week of September 23rd

The Michigan Data Collaborative plans to post the September 2013 MiPCT All-Payer Patient List the week of September 23, 2013. 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_2013_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).

Updated August 2013 All-Payer Patient Lists Posted on September 19, 2013

Updated August 2013 All-Payer Patient Lists were posted September 19, 2013. The lists were re-released with an updated BCBSM_HIGH_DEDUCT_PLAN field for each BCBSM entry. This field now appropriately includes a 0 (member is not in a high deductible plan) or 1 (member is in a high deductible plan). You can find the updated August 2013 lists on the Download PO Reports tab of the MDC MiPCT dashboards.

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

NEXT ISSUE DATES:

•    Next MiPCT Monday FLASH Issue: October 7, 2013

•    MiPCT Practice FLASH: October 21, 2013

September 9, 2013

Announcing:

MiPCT 2013 Regional Annual Summit Web Page is LIVE on www.mipctdemo.org & Registration is NOW OPEN!

 Once again this year, the MiPCT will convene a Stakeholder Annual MiPCT Summit in three statewide regional locations (Gaylord, Grand Rapids and Ann Arbor).

 Registration for all three Annual Summits is NOW OPEN, and a new webpage, “MiPCT 2013 Regional Annual Summits,” can be found on a tab of http://www.mipctdemo.org. Links to the online registration forms can be found on this page, as well as on the Featured Links sidebar of the homepage.

 Following is some general information about the Summits, such as:

  • Links to the registration pages
  • Addresses of each of the conference facilities
  • Hotel listings with special MiPCT rates
  • FREE shuttles between hotels and conference sites
  • Agendas and other conference materials

In an effort to be environmentally conscious, MiPCT is going paperless. All conference materials will be posted on the http://www.mipctdemo.org website on the MiPCT 2013 Regional Annual Summits page in time for all to preview. We will provide a paper copy of the agenda at each conference. Attendees may wish to print materials in advance. The materials will remain on the website, http://www.mipctdemo.org, under the “Resources/Presentations” tab for ongoing reference as well.

The Dates of the Summits are as Follows:

  • • October 1: Otsego Club Conference Center, Gaylord
  • • October 9: Frederik Meijer Gardens, Grand Rapids
  • • October 15: University of Michigan North Campus Research Center (NCRC), Ann Arbor, MI

All MiPCT stakeholders and participants are welcome to attend. The format has been changed from last year to maximize the opportunity of joint learning and discussion, while efficiently using participants’ time. Best practice-sharing is encouraged to build on and share the many successes of participants.

Morning Session for All:

The morning session is applicable to all stakeholders (POs, health plans, practice managers, multidisciplinary MiPCT practice teams, care managers, purchasers, members, etc.). The MiPCT team has prepared an exciting morning, including segments on evaluation findings to date, MiPCT sustainability plans, palliative care, and the Choosing Wisely campaign. The morning is intended to set the pace and identify the key areas and work to deliver success together in 2014.

Lunch for Everyone:

A box lunch will be served to bridge the day, and is available to all who are interested.

 Afternoon Session for Care Managers:

The afternoon session is for care managers, and focused on skill development. The MiPCT Summit Care Manager afternoon session activity (1:00 to 4:00 PM) 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 by the State of Michigan Board of Nursing.

 The Michigan Care Management Resource Center is preparing educational sessions to be held in the afternoon, and will focus on content applicable to the MiPCT care manager role. Topics include Palliative Care, Self-Management Support, and Building Best Practice and Care Manager Caseload Management. The sessions will provide opportunities for MiPCT care managers to learn and practice new concepts and skills, which may be used to improve individual practice and enhance care delivery in primary care.

For those who car pool in the morning with a care manager, we will have a space available for you to work at each of the three sites while your care manager is attending the afternoon session.

 Please select one (1) of the regional locations, and indicate whether you plan to come for the day, or part of the day in the space indicated on the registration form.

 Deadlines:

  • September 23 – Registration closes for the October 1 Northern Regional Summit in Gaylord.
  • September 30 – Registration closes for both the October 9 & 15 Summits.

The State Innovation Management Team Would Like Your Feedback!

Michigan is in the process of transforming the health system in our state. In April, Michigan was awarded $1.7M to design a State Innovation Model (SIM) that improves health outcomes, system performance, and reduces costs.

The SIM Management Team, under the direction of the Michigan Department of Community Health, has been hard at work developing a State Healthcare Innovation Plan (SHIP) to address the following goals:

  • Goal 1: Strengthen primary care and expand access for Michigan residents
  • Goal 2: Provide coordinated care to promote positive health
  • Goal 3: Build capacity within communities to improve population health
  • Goal 4: Improve systems of care to ensure delivery of the right care, by the right provider, at the right time, and at the right place
  • Goal 5: Design system improvements to reduce administrative complexity
  • Goal 6: Design system improvements that keep insurance premiums affordable

After six months of gathering and synthesizing feedback, MDCH will be presenting an initial working concept of the SIM at three upcoming regional meetings. We encourage POs to attend one of these meetings and provide feedback.

 Date & Time: Tuesday, Sept. 10, 2013, 6:00 – 8:00 p.m.

Location: Calvin College Prince Conference Center, 1800 East Beltline Ave. SE, Board Room, Grand Rapids

Sponsored By: Alliance for Health

Contact Info.: Jocelyn Burkett jburkett@afh.org, 616-248-3820

Date & Time: Friday, Sept.13, 7:30 am – 10:00 am

Location: Westin Hotel Southfield, 1500 Town Center, Southfield, MI 48075

Sponsored By: Greater Detroit Area Health Council

Register at http://www.gdahc.org

Contact Info.: Laurie Arora at 313-965-4123 or larora@gdahc.org

Date & Time: September 26, 2013, 6:00 – 8:00 p.m.

Location:  Comfort Suites, 2463 US 41 West, Marquette, MI

Sponsored By: Great Lakes Center for Youth Development

Contact Info.: Amy Quinn, acquinn@glcyd.org,906-228-8919

MiCMRC Care Manager Monthly Update: August, 2013

 The Michigan Care Management Resource Center (MiCMRC) has developed a monthly update for care managers participating in the MiPCT project. The August 2013 edition contains a review of MiPCT project events and developments that occurred in August and a resource list. The August resource list contains links to resources provided during the adult Balancing a Care Manager Caseload: Developing Team-Based Care and Leading Through Change and pediatric Pediatric Assessment Tools webinars.

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

Announcing a New Practice FLASH Publication!

 The MiPCT Monday FLASH is currently published bi-monthly on the first and third Monday of every month. Effective this month, the current MiPCT Monday FLASH will be published the first Monday of every month and a new publication called The Practice FLASH will be published on the third Monday of every month. The first Practice FLASH publication is coming September 23, 2013.

 We are very excited about this new initiative. The Practice FLASH will contain information relative to MiPCT practices, such as project updates, periodic MDC outcome results across PO’s, (for example ED utilization), MiPCT payer updates when applicable, articles on Choosing Wisely, and links to relevant literature. It will also contain patient success stories, upcoming CM webinar topics and dates, and future CCM training dates.

 We are requesting that all POs distribute this monthly practice FLASH edition to their participating MiPCT practices. Please feel free to provide recommendations for additional subject matter and comments related to the Practice FLASH to MiPCTDEMO@michigan.gov, with “PRACTICE FLASH” in the subject line. Thank you for your continued partnership.

-The MiPCT team

 Blue Cross Blue Shield of Michigan Case Manager Coordination and Referral

MiPCT care managers wishing to coordinate care with BCBSM case managers, or refer patients to BCBSM case managers may do so by calling the BCBSM case manager number: (1-800-845-5982).

MiPCT care managers will need to provide the BCBSM ase manager specialist with the member’s name and demographics to determine if they are already in case management; if so the BCBSM CM specialist can provide MiPCT care managers with the extension and name of the case manager and transfer them. If the patient is not in BCBSM case management, MiPCT care managers may request that the specialist do a referral into case management at that time.

Register Your New Complex & Hybrid Care Managers for the MiPCT Complex Care Management Course

The MiPCT Complex Care Management course is available September 16-19, 2013 in Lansing. Registration is available at the following link: https://jodyooo.wufoo.com/forms/september-1619-2013-mipct-ccm-training/ The MiPCT CCM course consists of four training days.

The MiPCT Complex Care Management course will be offered October 21-24, 2013 in Lansing. Registrations is available at the following link: https://jodyooo.wufoo.com/forms/october-21-24-2013-mipct-ccm-training/. The MiPCT CCM course consists of four training days.

Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

 MiCMRC- Approved Program Summary – Update

The adjacent table  CLICK HERE FOR 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 Moderate Care Management (MCM) training. The programs listed in the table include information regarding course date/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 document titled “MiPCT Approved Self Management Support MCM Program Summary 6.7.13” at https://mipct.org/care-management-resource-center/

Developing Team-Based Care

 Integrating care management services into primary care daily work is fundamental to practice transformation. The practice team at West Front Primary Care PLLC integrated the MiPCT moderate care manager role by using many of the essential elements of successful care management, such as collaboration with providers and practice staff to identify patients appropriate for care manager services, as well as facilitating in-person care manager visits with patients.

 The process has been effective in meeting the care management needs of this practice’s population, has served to strengthen the practice team, and has resulted in transformed healthcare delivery. A workflow map depicting this approach is provided as an attachment to this week’s edition of the FLASH.

Placement of Upcoming Webinars

Upcoming webinars can be found on the mipctdemo.org website. On the right side of the home page, you will see a box containing the date, topic, intended audience, and presenter (if known) of future webinars.

Upcoming MiPCT CM Webinars:

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

September 18, 2013:

Care Management Integration Using Quality Improvement Concepts. (All MiPCT Care Managers). Dr. R. Troy Carlson, MD and Debbie Mays, RN, Care Manager, Family Tree Medical.

October 2, 2013:

MDCH Resources, Part I. (All MiPCT Care Managers).

October 16, 2013:

MDCH Resources, Part II. (All MiPCT Care Managers).

October 30, 2013:

MDCH Resources, Part III. (All MiPCT Care Managers).

November 13, 2013:

MDCH Resources, Part IV. (All MiPCT Care Managers).

NOTE: There will not be a Pediatric Webinar in October

 Blue Care Network Resources

Blue Care Network (BCN) has provided the MiCMRC with a list of commonly used resources within the organization. The resource list contains contact numbers to use when determining coverage for BCN members for a variety of services. MiPCT Care Managers are encouraged to use this as a reference when assisting BCN members to access services.

BCN Website http://www.bcbsm.com

Behavioral Health Services 800.482.5982

Case Management Nurse Line 800.943-9744

Customer Service

PCP Changes 888.656.8276

Benefits & General Inquiries 800.662.6667

Durable Medical Equipment

Northwood (General Supplies & Eqpt.) 800.667.8496

J&B Diabetic Supplies 888.896.6233

Prior Authorization Inquiries 800.943.9744

Smoking Cessation Program (Quit the Nic) 800.811.1764

Stories of Your Care Management Success: Cheryl Ball, RN, CCM, Forest Hills Pediatrics Associates

Cheryl Ball, RN, is a complex care manager at Forest Hills Pediatrics Associates. Her main role is that of ED/Hospitalization/post-surgical – Care Management Coordinator. Cheryl accepts calls from parents in an effort to assess the current situation, immediate needs, provide direction in the management of the identified problem, and prevent an ED visit or in-patient admission.

 In May 2013, Cheryl received a phone call the mother of a 19 month old girl whom we shall refer to as “Ava.” Blue Cross Blue Shield of Michigan is Ava’s health insurance carrier. Ava’s insurance plan has the care management feature. Ava’s mother, “Jane,” called to inform Cheryl that her daughter had fallen on a playground platform and was having pain in her leg. Cheryl used her assessment skills to evaluate the severity of the injury, considering functional status, obvious distortion of Ava’s leg, circulation distal to the injury site and bleeding. Cheryl was able to determine that the child was not in need of an ED visit for a possible reduction or surgical repair of the injury, and made a same- day appointment for Ava. Her mother brought Ava to the office for examination. Ava was given an order for an out-patient x-ray. The Radiologist’s reading of this exam demonstrated that Ava had sustained a fractured tibia. Cheryl was notified of this finding. From the PCMH, Cheryl was able to send Ava to receive casting utilizing out-patient services, and avoided an ED visit. Cheryl coordinated care with the Orthopedic specialist for follow-up in 7-10 days.

 Cheryl called Ava’s mother the next day to ensure the transition of care encounter had gone well, and to answer any questions the mother may have regarding cast care and fracture management. Jane did have questions that Cheryl was able to address and clarify, regarding understanding of follow-up instructions and medical management of Ava’s fracture. Mother was able to demonstrate understanding by using the “teach-back” method.

 Jane stated her gratitude regarding Cheryl’s follow-up phone call the next day. Management of this unfortunate event was able to occur from the PCMH versus the Emergency Department due to the assessment skills and care coordination provided by the PCP and Cheryl in the primary care office. The mother expressed to Cheryl how pleased she was with the follow-up call the day after the event, improved communication and understanding, as a result of the follow-up call, and the concern shown for her child. Jane expressed her thankfulness in knowing the PCP office took the lead in her child’s care and directed the care of this event to the out-patient services available in the community. Cheryl’s actions avoided 1) an Emergency Department visit, 2) increased cost to family for co-pay liability, 3) decreased cost to manage this injury to the insurer, 4) emotional influence for a child from use of an Emergency Department and 5) increased trust and parental satisfaction as to the benefit of the role of the CM in the PCMH.

NEXT ISSUE DATES:

  • • Premiere Issue of MiPCT Practice FLASH: September 23, 2013
  • • Next MiPCT Monday FLASH Issue:  October 7, 2013

August 26, 2013

Comment Period Closing on September 6, 2013:

Post-Demonstration Complex Care Management CMS Proposed Funding & 2014 Proposed Physician Fee Schedule (see attachment, directly above)

As relayed earlier, a draft rule in the 2014 Physician Fee Schedule proposes payment starting in 2015 after the demonstration ends in all states for medical home type services to complex patients with multiple chronic conditions. In brief, the proposal (attached) allows practices to submit a bill once every 90 days for delivery of complex care management services for patients with multiple complex chronic conditions that place the patient at a significant risk of death, acute exacerbation/decompensation, or functional decline. To receive reimbursement, patients would have to agree to receive the services. The proposal does not include a payment level. The comment period began on July 8 and extended 60 days (until September 6, 2013). Operations Group members discussed the proposal at their August 7th meeting and suggested that the project submit comments to CMS. Should you have comments that you wish to be considered for inclusion, please send them to mipctdemo@michigan.gov with the Subject Line: CMS Complex Care Proposed Payment COMMENT. Comments will then be prepared for the Steering Committee’s submission to CMS by September 6th. In advance, the Operations Group will view the compiled response at their September 4, 2013 meeting.

In addition, any interested MiPCT stakeholder is encouraged to review the rule and provide comments to CMS independently if they wish. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions posted at the site for “submitting a comment” and refer to file code CMS-1600-P. Alternatively, written comments may be provided via overnight mail to:

Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS-1600-P, Mail Stop C4-26-05

7500 Security Boulevard

Baltimore, MD 21244-1850

Register Your New Complex & Hybrid Care Managers for the MiPCT Complex Care Management Course

 The MiPCT Complex Care Management course is available September 16-19, 2013 in Lansing. Registration is available at the following link: https://jodyooo.wufoo.com/forms/september-1619-2013-mipct-ccm-training/

The MiPCT CCM course consists of four training days: September 16, 17, 18 and 19. Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

 Stories of Your Care Management Success:  Pam King, RN, Royal Oak Pediatrics, PC

Pam King, RN, is a care manager at Royal Oak Pediatrics, PC. She has been working with a 10 year old patient covered by Blue Cross Blue Shield of Michigan insurance. When Pam met with the patient, “Lucy”, and her mother, the referral was for obesity and high cholesterol. As Pam worked with “Lucy” and her mother, she learned that Lucy had Attention Deficit Disorder (ADD) and her mother has Bipolar disorder, and has been widowed for four years. “Lucy” also has a brother, an underweight twelve-year-old with Attention Deficit Hyperactivity Disorder (ADHD).

“Lucy’s” mom was still mourning the death of her husband four years ago. She presented to the office looking very tired and she was also very overweight. She was easily overwhelmed by her children and their needs, and became depressed often. Because she had difficulty managing her household and family demands, she bought fast food for many of their meals.

Pam collaborated with Karen Samosiuk, MSW. Together they met with and assisted the family to develop a plan to improve their health. Through care management support, “Lucy’s” mom is not feeling as overwhelmed with taking care of her children, and has organized her life so that she plans some meals and does not resort to fast food as frequently. The whole family is eating healthier foods. “Lucy” and her brother are now helping their mom with household tasks, including assisting with meal preparation. Lucy had her medications from her psychiatrist adjusted and lowered. Side effects have decreased.

The family is more active and mom has recently found a new boyfriend that is involved with the whole family and supportive of their healthier lifestyle. “Lucy’s” mom is going to school and is very interested in nutrition classes. She has been cooking healthier food for the family. “Lucy” has lost weight and her brother has gained weight. Pam has been able to decrease the frequency of her phone calls and face to face meetings with the family now that “Lucy”s mom has demonstrated improved management of the health of her family.

“Lucy’s” mom was very happy to have someone like Pam spend time with her and help her with her daughter. Pam’s interventions assisted her to cope with being a single mom raising two children with health needs. She expressed, “I really enjoy talking with you and needed someone to help me organize my household. My daughter respects what you tell her when you encourage her to be more cooperative and eat healthier foods.

Placement of Upcoming Webinars

Upcoming webinars can be found on the mipctdemo.org website. On the right side of the home page, you will see a box containing the date, topic, intended audience, and presenter (if known) of future webinars.

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

  • September 4, 2013: Medication Adherence and Managing Medication Costs for Medicare Beneficiaries. (Adult). Presenter: Hae Mi Choe, Pharm.D, Director, Innovative Ambulatory Pharmacy Practices and Clinical Associate Professor of Pharmacy, Department of Clinical, Social, and Administrative Sciences.
  • September 6, 2013: Developmental Screening (Ped). Presenter: Jane Turner, MD, Pediatrician, MSU Health Team.
  • September 18, 2013: Care Management Integration Using Quality Improvement Concepts. (All MiPCT Care Managers). Dr. R. Troy Carlson, MD and Debbie Mays, RN, Care Manager, Family Tree Medical.
  • October 2, 2013: MDCH Resources, Part I. (All MiPCT Care Managers).
  • October 16, 2013: MDCH Resources, Part II. (All MiPCT Care Managers).
  • October 30, 2013: MDCH Resources, Part III. (All MiPCT Care Managers)
  • November 13, 2013: MDCH Resources, Part IV. (All MiPCT Care Managers).

MDC’s August 2013 MiPCT All-Payer Patient Lists Released on August 23, 2013

The Michigan Data Collaborative posted the August 2013 MiPCT All-Payer Patient List on August 23, 2013. 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 the PO, and a dropped patient list.

Note:  The BCBSM Medicare Advantage patient list is released as a separate file. The file is included in the PO’s patient list zip file and has the following name format: <POname>_All_Practice_BCBSM_MA_Patient_List_2013_08.

 This month’s list includes attribution information for Priority Health.

 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 Announces Enhancement 04.01 for the MiPCT Dashboards and Reports

MDC will release Enhancement 04.01 the week of August 26, 2013. Users will be notified via email. An announcement will also be posted on the MDC website: www.MichiganDataCollaborative.org.

Next Issue: September 9, 2013

August 12, 2013

BCBSM Update: Attachment on Desktop IVR webDENIS for PDCM (see attachment)

Attached is an update to the web DENIS/CAREN IVR slide deck BCBSM distributed a few weeks ago. Of note, additions include:

  • Disclaimer language
  • Web-DENIS-MOS Example for High Deductible Health Plan with HSA
  • Web-DENIS-MOS Example for no reference to High Deductible Health Plan with no HSA

Updated Timeline for Priority Health Member Servicing

Priority has been actively working toward the inclusion of members on the multipayer member list distributed in July, but experienced a few setbacks with test files. The release of the final production file is scheduled soon and HMO members in fully-insured plans will be included in MiPCT’s August member list.

 So as not to delay the provision of care management services to fully-insured Priority health members from all their product lines (HMO, POS, PPO) further, Priority advises that immediately, MiPCT practices may provide care management services as long as the practice confirms with Priority that the member is in a fully-insured plan. Physician, nurse or patient/caregiver referral to care management is encouraged. Details will be included on how to identify members in fully-insured plans on a webinar scheduled for Thursday, August 15 from 4-5pm. In addition, billing, reimbursement, and how Priority’s addition will be incorporated into the dashboards and member list will also be discussed. POs and practices will be able to ask questions as well. Until then, POs and practices can identify Priority members in fully-insured plans using the member benefit information in Priority’s Member Inquiry Tool located within Priority Health’s Provider Center. A log-in is required to access this portion of the Provider Center. If you do not have a log-in, this can requested from the main page, priorityhealth.com. To request a log-in select the “Create account” link.

Priority Health will reimburse care management G-codes for all members in HMO, POS and FF-PPO plans. (CPT care management codes offer coverage for a wider range of plans.) For a complete list of codes and coverage details, please visit http://www.priorityhealth.com/provider/manual/billing-and-payment/services/care-management-codes. Tune in on Thursday, August 15th from 4-5pm to provide further details and to answer any questions from POs and practices. Note that afterward, the webinar will be posted online at http://www.mipctdemo.org for those who have conflicts on Thursday afternoon or wish to share the session with others at the practice or PO.

Michigan Care Management Resource Center Care Manager Monthly Update (July 2013)

The Michigan Care Management Resource Center (MiCMRC) has developed a monthly update for care managers participating in the MiPCT project. The monthly update contains a review of project events and developments for the preceding month that impact care managers and a care manager resource list.

 The July 2013 edition contains a review of MiPCT project events and developments that occurred in July, and a resource list. The July resource list contains links to resources provided during the adult Care Managing Obesity in Adults and pediatric Educational Advocacy for the MiPCT Care Manager webinars, as well as links to the Member Eligibility Document, July 2013 Changes to All-Payer Patient List and MiPCT Care Manager Quarterly Activity Reporting Guidelines.

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

Register Your New Complex and Hybrid Care Managers for the MiPCT Complex Care Manager Course

The MiPCT Complex Care Management course is available September 16-19, 2013 in Lansing. Registration is available at the following link: https://jodyooo.wufoo.com/forms/september-1619-2013-mipct-ccm-training/ The MiPCT CCM course consists of four training days: September 16, 17, 18 and 19. Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

Placement of Upcoming Webinars

MiPCT Webinars:

Upcoming webinars can be found in the micpctdemo.org website. From the Home Page, on the right side you will see a box containing the date, topic, intended audience, and presenter, if known, for future webinars. This list will be updated monthly with past webinars removed and future webinars added.

Upcoming MiPCT CM Webinars: 

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

August 16, 2013:

Pediatric Assessment Tools (Ped). Presenter: Rose Seavolt, MiPCT Regional Clinical Lead.

 August 21, 2013:

Leadership, Transformation and Change Management (All MiPCT Care Managers). Kerrie Barney RN, BSN, CHPN, Hybrid Care Manager, Lakeshore Family Care at Millpoint Center, Mercy Health Partners- Primary Care Network.

September 4, 2013:

Medication Adherence and Managing Medication Costs for Medicare Beneficiaries. (Adult). Presenter: Hae Mi Choe, Pharm.D, Director, Innovative Ambulatory Pharmacy Practices and Clinical Associate Professor of Pharmacy, Department of Clinical, Social, and Administrative Sciences.

September 6, 2013:

Developmental Screening (Ped). Presenter: Jane Turner, MD, Pediatrician, MSU Health Team.

Stories of Your Care Management Success: Jamie Rivard, RN, BSN, HCM, MSU Health Team

Jamie Rivard RN, BSN is a Hybrid Care Manager for Michigan State University Health Team. In January she received a referral for a patient with Blue Cross Blue Shield insurance who wanted to work on his obesity and hypertension. The patient (Mr. P) had been struggling with his weight since coming to the clinic in 2008. At the time of the referral he had just turned 53 years old, was 71.5 inches tall, 227 lbs. and had a BMI of 31.4. His blood pressure was ranging between 146-154 systolic/ 67-82 diastolic with medication management. Mr. P was not checking his blood pressure at home on a regular basis. He was coming to the clinic for blood pressure checks between office visits. Mr. P. has a strong family history of cardiovascular disease and was frustrated with his blood pressure and weight.

The initial visit with Jamie lasted an hour and during that time Mr. P identified his frustrations, barriers and goals. Education was incorporated throughout the conversation. Mr. P’s initial goals were to begin monitoring his blood pressure three to four times each week. A blood pressure log with simple instructions from the American Heart Association was provided. He also wanted to try to exercise 30 minutes three times a week. In addition, he was going to try and incorporate additional walking throughout the day by using stairs and parking farther away in parking lots.

The DASH diet was introduced with the focus on making small changes to his diet. He identified that his long term weight loss goal was to be 185 lbs. Together, Mr. P and Jamie also identified barriers to his goals and strategies to work through them. Jamie encouraged him to not focus on his weight, but how often he was exercising. They agreed to follow up in two weeks. At the time of the follow up call, Mr. P stated he was “doing everything right” and wanted to schedule a return face to face visit to be weighed and evaluate his goals.

Mr. P returned to the office on February 22 and was very excited to be weighed. His weight at the time of the visit was 208 pounds and his BMI was now 28.7. His blood pressure was 161/77. Mr. P had lost 19 lbs. since the last visit. He had begun exercising on a regular basis and eating more fruits and vegetables. He increased exercising from three times per week to exercising daily. His healthy lifestyle changes were supported by his wife, who began exercising with him. He set a new goal to run a 5k. Together Mr. P and Jamie reviewed previously identified barriers and new barriers and strategies to overcome them.

At his most recent office visit in April, Mr. P’s weight was down to 197lbs. He has built up enough endurance to walk/run over 4 miles. He remains motivated and feels confident that he will be able to maintain his active lifestyle throughout the summer. He and Jamie agreed to discontinue care management through the summer months with a plan to touch base before the holiday season. Mr. P. felt that without the support and encouragement from the provider office, and the individual support he received from Jamie, he would not have been able make the changes that he did. He stated that, “everyone was offering to help me, and I decided to use it.”

Next Issue: August 26, 2013.

 July 22, 2013

Post-Demonstration Complex Care management CMS Proposed Funding — Comment Period on 2014 Proposed Physician Fee Schedule

(see attachment)

Just released in the Federal Register is a draft rule in the 2014 Physician Fee Schedule for a proposed payment starting in 2015 (after the demonstration ends in all states) for medical home type services to complex patients with multiple chronic conditions. Though a draft and in public comment stage right now, it proposes that practices bill (once every 90 days for patients meeting specific criteria) to receive reimbursement (patients would have to agree to receive the services.) The excerpt is attached for your review. The comment period began on July 8 and extends 60 days. This will be discussed with the Operations Group members at their next meeting (on August 7th), but all MiPCT stakeholders are encouraged to review the rule and provide comments to CMS.

You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions posted at the site for “submitting a comment” and refer to file code CMS-1600-P. Alternatively, written comments may be provided via overnight mail to: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1600-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

MDC’s Release 4.0 of the Dashboards and Reports Scheduled for July 29, 2013

The next release for MDC MiPCT Dashboards and Reports is scheduled for Monday, July 29, 2013. This release will include claims data for Blue Care Network (BCN) and will include data for all participating payers based on paid claims through March 2013. It will also include a new dashboard and reports for Inpatient visit measures and other features and updates. All features and updates will be detailed in the release notes that are posted with the release. We will send out an email to notify users about the expected downtime while we load the updated dashboards.

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 July 2013 MiPCT All-Payer Patient Lists to be Released the Week of July 22, 2013

The Michigan Data Collaborative plans to post the July 2013 MiPCT All-Payer Patient lists the week of July 22, 2013. 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 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_2013_07.

This month’s lists include the following major changes:

• The record layout has changed to move certain fields (columns) to the beginning of the record layout.

• The sort order of patient records has been updated to more quickly identify patients of interest for care management services.

These changes are detailed in the July 2013 Changes to the All Payer Patient List document posted on the Support page of the MDC website (https://www.michigandatacollaborative.org/MDC/#/support). If you have any questions please contact MDC at MichiganDataCollaborative@med.umich.edu.

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).

Financial Report Update –– Care Manager Activity Template Changes

With the recent updates to the financial reporting website and the addition of Priority Health, the template for uploading care manager activity has undergone some adjustments. The data type and new order are listed below.

Reporting for Priority Health encounters and patients would begin after Priority Health patients appear on your MDC Patient lists.

Please visit the website to obtain your template. We are sorry for any inconvenience this causes.

Practice

Practice ID (pre-populated)

Practice Name (pre-populated)

Care Manager

Last Name (pre-populated)

First Name (pre-populated)

Date of Birth (pre-populated)

Face-to-Face Encounters

BCBSM

BCN

Medicare

Medicaid

Priority Health*

Telephone Encounters

BCBSM

BCN

Medicare

Medicaid

Priority Health*

Unique Patients

BCBSM

BCN

Medicare

Medicaid

Priority Health*

*Reporting for Priority Health encounters and patients would begin after Priority Health patients appear on your MDC Patient lists.

MDC Webinar on July 24

to Announce Updates

to the MiPCT Dashboards

and All-Payer Patient Lists

MDC invites you to attend a webinar on July 24, 2013 at 12:00pm. In this webinar, we’ll discuss the recent changes to improve the All-Payer Patient Lists (APPL) and the MDC Dashboards and Reports. The APPL improvements include field order changes and the addition of a dropped patient list. The Dashboard improvements include the addition of inpatient data and reports and a PO comparison of utilization measures. There are several other additions and improvements that we are excited to show you. To learn more about how these upcoming changes will benefit your PO and patient population reporting, please join us!

Event Details:

Event:

Updates to MDC Dashboard & All-Payer Patient Lists – Summer 2013

Date:

Wednesday, July 24, 2013

Time:

12:00 PM Eastern Daylight Time

Event Number:

660 870 752

Event Password:

mipct

————————————————————–

To Join the Online Event & Teleconference

————————————————————–

1. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=660870752

2. Click “Join Now”.

3. Follow the instructions that appear on your screen.

——————————————————-

To Join the Teleconference Only

——————————————————-

Call-in toll number (US/Canada): 1-650-479-3207

Access code: 660 870 752

If you have any questions about the webinar or would like more information, please contact MDC at MichiganDataCollaborative@med.umich.edu

MiCMRC Webinar Power Point Slides & Supporting Documents

Webinar PowerPoint slides and supporting documents used during both adult and pediatric presentations are provided as an attachment to the webinar invitation received by care managers from the Michigan Care Management Resource Center (MiCMRC). To access these files and documents, please refer to the original webinar invitation email received prior to the webinar presentation date.

 Placement of Upcoming Webinars

Upcoming webinars can be found on the MiPCT website (http://www.mipctdemo.org). On the right side of the home page you will see a box containing the date, topic, intended audience, and presenter, if known, for future webinars. This list will be updated monthly with past webinars removed and future webinars added.

 Upcoming MiPCT CM Webinars:

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

July 24, 2013:

Updates to MDC Dashboard and All-Payer Patient Lists Summer 2013. Presenters: MiPCT Team

 August 7, 2013:

Balancing a Care Manager Caseload: Developing Team-based Care. (All MiPCT Care Managers). Lisa M. Nicolaou, MSNI, BSN, Care Manager, West Front Primary Care, P.L.L.C.

August 16, 2013:

Pediatric Assessment Tools (Ped). Presenter: Rose Seavolt, MiPCT Regional Clinical Lead.

August 21, 2013:

Leadership, Transformation and Change Management (All MiPCT Care Managers). Kerrie Barney RN, BSN, CHPN, Hybrid Care Manager, Lakeshore Family Care at Millpoint Center, Mercy Health Partners- Primary Care Network.

September 4, 2013:

Medication Adherence and Managing Medication Costs for Medicare Beneficiaries. (Adult). Presenter: Hae Mi Choe, Pharm.D, Director, Innovative Ambulatory Pharmacy Practices and Clinical Associate Professor of Pharmacy, Department of Clinical, Social, and Administrative Sciences.

September 6, 2013:

Developmental Screening (Ped). Presenter: Jane Turner, MD, Pediatrician, MSU Health Team.

MiCMRC – MiPCT Care Manager Monthly Update

The Michigan Care Management Resource Center (MiCMRC) has developed a monthly update for care managers participating in the MiPCT project. The monthly update contains a review of project events and developments for the preceding month that impact care managers and a care manager resource list. The resource list will contain items like chronic condition resources, patient education materials, and links to resources provided during adult and pediatric webinars. The MiCMRC Care Manager Monthly Update will be distributed to MiPCT care managers as an attachment to the FLASH each month.

The June 2013 edition contains a review of MiPCT project events and developments that occurred in June and a resource list. The June resource list contains the Care Manager Essentials Document, Standards of Practice for Care Managers, Care Management Definition and Framework, ‘What is Care Management?’ document, LACE tool, Chronic Disease Information Sources, and webinar resources provided during the adult Hypertension Part 1 and Part II and pediatric Part I: Education Rights for Children with Disabilities webinars.

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

Michigan Department of Community Health Primary Care Resources

The Michigan Department of Community Health (MDCH) has developed a web site to provide public health resources for care managers and practice teams. This is a great place for MiPCT care managers to find resources for their patients with chronic conditions. The web site contains information on local programs and resources appropriate for care managers to use as they support patients with lifestyle changes. Resources are provided on a number of topics including Arthritis, Asthma, Cancer, Cardiovascular Health, Diabetes and Kidney Disease, Disability Health, Injury & Violence Prevention, Obesity, Physical Activity & Nutrition and Tobacco. The web site can be found at www.michigan.gov/primarycare.

Register Your New Complex and Hybrid Care Managers NOW: MiPCT Complex Care Management Course

To accommodate PO interest in timely MiPCT Complex Care Management training, there will be a CCM course August 12-15, 2013. Registration is available at the following link:

https://jodyooo.wufoo.com/forms/august-1215-2013-mipct-ccm-training/

The MiPCT CCM course consists of four training days: July 15, 16, 17, 18, 2013. Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

The CCM course includes training for billing PDCM/MiPCT codes for the BCBSM commercial, BCN, and Medicare Advantage payers. This is key to increasing the volume of G and CPT code billing, a key focus area for this year.

Stories of Your Care Management Success:

Shirley Tinnon, RN, Hybrid Care Manager, Livonia & Novi Internal Medicine Clinics, HFHS

Shirley Tinnon, RN is a hybrid care manager at the Livonia and Novi Internal Medicine clinics, which are Henry Ford Health System practices.

Shirley identified a possible Medicare patient for care management services through the practice’s daily MiPCT discharge list. She contacted the patient within 48 hours of hospital discharge. Shirley spoke with the patient’s husband who reported that the patient had been in the hospital for hypertension and shortness of breath. Upon chart review, Shirley discovered the patient was 70 years old and had an admitting diagnosis of congestive heart failure exacerbation, and a medical history of congestive heart failure, as well as hypertension, stroke, atrial fibrillation, hyperlipidemia, intracerebral bleed, seizure disorder, and vitamin D deficiency. Shirley determined this patient would benefit from care manager services because of her multiple chronic conditions, age and recent hospitalization.

Shirley learned during the transition of care phone call that the patient’s husband was the primary caregiver and advocate for the patient. When the patient was discharged from the hospital, the patient could barely walk or lift her legs to get in and out of the car. Her husband was concerned that she was still not doing well after discharge from the hospital. He was contemplating taking her back to the emergency department. Home care was set up for her at discharge from the hospital, but the home care nurse had not arrived yet, and the patient’s husband had not received any communication from the home care agency.

Shirley addressed the husband’s concerns by coordinating directly with home care to inquire when the nurse was scheduled to come out, which was the next day. Shirley communicated this information to the patient’s husband and requested that he call her if the nurse did not arrive as scheduled the next day. The patient phoned the next day to inform Shirley that the home care nurse had made it out to her home. Physical therapy and Coumadin Clinic services were coordinated at that time.

Shirley identified a potential concern regarding the patient’s medications. The patient was discharged on Coumadin and ASA 81 MG. She huddled with the Primary Care Provider (PCP) to discuss the patient taking ASA and Coumadin at the same time, as well as to review the plan of care. Through collaboration with the PCP, it was determined that the patient continue the current plan of care. The patient would remain on Coumadin and ASA. Shirley updated the caregiver on this determination. Shirley also worked with the patient’s husband to set short term and long term goals.

At the next follow up call, the husband verbalized that his wife was doing great. He and the patient were pleased to inform Shirley that the patient was beginning to ambulate independently with her walker and cane. The patient’s husband was very grateful that Shirley had expedited the home care nurse’s visit.

Shirley’s care management interventions helped to avoid an unnecessary emergency room (ER) visit. The husband did not take the patient to the ER the following day because the home care nurse was able to come out and assess the patient and physical therapy was initiated. The patient began to ambulate with her walker without feeling like her legs were going to give out. The patient continues to receive care management services. She continues to do well with her ambulation, and her breathing has improved.

The husband verbalized at the care manager’s last encounter that the patient is ambulating without any problems.

He stated, “I would like to thank you so much for calling my wife and checking up on her, because I would not have known who to call to see if the home care nurse was still coming out, and my wife would have not received the prompt care that she did before you intervened.”

Next Issue: August 12, 2013.

 July 8, 2013

Register Your New Complex and Hybrid Care Managers NOW: Summer MiPCT Complex Care Management Courses

To accommodate PO interest in timely MiPCT Complex Care Management training, there will be a CCM course July 15-18, 2013, and another CCM course August 12-15, 2012. The MiPCT CCM course consists of four consecutive training days.

Registration is available at the following links:

Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

 The CCM courses include training for billing PDCM/MiPCT codes for the BCBSM commercial, BCN, and Medicare Advantage payers. This is key to increasing the volume of G and CPT code billing, a key focus area for this year.

Priority Health Joins MiPCT as a Participating Payer

MiPCT is tremendously excited about Priority Health’s addition as a participating payer. This will bring approximately 150,000 additional new members to the MiPCT, all of whom are in fully-insured Priority POS, PPO and HMO products. Though Priority has existing programs that satisfy the MiPCT funding requirements for the Practice Transformation and Incentive components, reimbursement for care management services will occur via G- and CPT-codes. Importantly, though a large percentage of the new Priority members are in high-deductible health plans with Health Savings Accounts, Priority has engineered an approach to allow first dollar coverage (without patient financial obligation for satisfying a deductible) for care management services.

 The Operations Group has helpfully provided input on care manager staffing considerations, testing of the proposed payment mechanisms, etc. The MiPCT greatly appreciates their partnership in informing policy that serves to effectively provide team-based care.

The target date for Priority members to show on the multipayer patient list is with the July 2013 list, which the MDC expects to distribute to POs by July 26. A conference call for PO leaders will be scheduled for late July to provide fuller details. Please note that:

  •  Work is underway on the number to determine the counts of new Priority members for each PO and practice and these counts will be distributed as soon as they are available. These counts will be distributed in advance of the late July conference call.
  • Priority’s billing and reimbursement guidelines for MiPCT are in final review there and will also be distributed in advance of the call.
  • Care manager staffing sufficiency ratios and the lead time that should be provided to meet such ratios for the incremental new members are being revisited to fairly balance patient need and new funding.
  • The need for additional Care Manager training sessions will be assessed and scheduled after the practice level distribution counts are available

Remaining 2013 MiPCT Target Payment Dates by Payer

The following table contains the target payment dates for the MiPCT funding to practices and POs from participating payers. Note that Priority Health is included in the table and that further details about their addition will be provided in an upcoming late July conference call that will soon be scheduled. Updates to the table will be provided in upcoming editions of the FLASH as they are available.

Remaining Target 2013 MiPCT Payment Dates (By Payer)

 Financial Report Update –– 2013 Quarter 2

Updates are under way for the financial website and should be deployed early in the week of July 8. If you have started your report, you will soon see differences in the appearance of the web pages, but all of your data are saved. The changes you will see are:

Priority Health added to the Care Manager Activity reporting (for 3 & 4Q 20B reporting).

  •  Care Manager Detail Page:
  1. Added a field to report who employs the care manager.
  2. Eliminated “Overtime” as a separate field. Please include overtime in the “Compensation” field.
  • Practice Transformation is removed.
  • Only Medicaid revenue will be loaded quarterly. A new year-end report will be produced after we obtain revenue amounts from all payers.
  • New section to report how incentives were distributed to practices for Medicaid and Medicare only.

(See the 6/10/2013 edition of the FLASH, below, for more details.)

MiPCT Webinars

Upcoming webinars can be found on the mipctdemo.org website. On the right side of the home page, you will see a box containing the date, topic, intended audience, and presenter (if known) of future webinars. This list will be updated monthly with past webinars removed, and future webinars added.

 Upcoming MiPCT CM Webinars:

Adult Webinars: Wednesdays, 2-3 PM

Pediatric Webinars: Fridays, 10-11 AM

  • July 10: Care Managing Obesity in Adults (Adult). Presenters: Maureen E. Irwin, RD, PA-C, Care Manager; Dawn Rodman, MS, CWHC, CPT, Michigan Health & Wellness 4×4 Plan Coordinator, Michigan Department of Health; and Annemarie Hodges, MA, Public Health Consultant-Arthritis Program, Michigan Department of Community Health.
  •  July 19: Part II: Educational Advocacy for the MiPCT CM (Pediatric). Presenter: Kelly Orginski, Michigan Alliance for Families
  •  July 24: Updates to MDC Dashboard and All Payer Patient Lists Summer 2013. Presenters: MiPCT Leadership
  •  Aug. 7: Balancing CM Case load: Developing Team-Based Care (Adult). Presenter: Lisa M. Nicolaou, MSNI, BSN, Care Manager, West Front Primary Care, P.L.L.C.
  • Aug. 16: Pediatric Assessment Tools (Pediatric). Presenter: Rose Seavolt, MiPCT Regional Clinical Lead
  • Sept. 6: Screening (Pediatric). Presenter: Jane Turner, MD, Pediatrician, MSU Health Team

 CORRECTION: MiPCT Care Manager Success Story Correction

The care manager success story published in the June 24, 2013 FLASH incorrectly identified Jane Ruhl, RN, BSM, as a complex care manager at Battle Creek Community Physicians and that Dr. David Lambrix is a provider at that practice.

 Jane is a Complex Care Manager who provides care management services at Dr. David Lambrix’s practice, which is affiliated with Integrated Health Partners. We’re sorry for any inconvenience this may have caused you.

Member Eligibility Document Attached (see link above in title block)

A document that shows how to identify members’ eligibility for the MiPCT/PDCM benefit in web-DENIS or CAREN IVR is now available on the MiPCT website. This document is also attached to this issue of the MiPCT Monday FLASH for your convenience.

 MiPCT-Approved Self-Management Programs – Update

The adjacent 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 Moderate Care Management (MCM) training. The programs listed below include information regarding course date/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 document titled “MiPCT Approved Self Management Support and MCM program” at https://mipct.org/care-management-resource-center/

Self Management Table for 7 8 2013 FLASH

2013 Changes to the All-Payer Patient Lists July  2013  

MDC is implementing two major changes to the July 2013 All-Payer Patient Lists that will make them easier for MiPCT Care Managers to use.

 The changes include:

  • Changing the record layout to move certain fields (columns) to the beginning of the record layout.
  • Changing the sort order of patient records to more quickly identify patients of interest for care management services.

These changes are detailed in the July 2013 Changes to the All Payer Patient List document posted on the Support page of the MDC website (https://www.michigandatacollaborative.org/MDC/#/support). If you have any questions, or if your programmers would like a sample file to work with, please contact MDC at MichiganDataCollaborative@med.umich.edu.

 MDC plans to post the July 2013 All-Payer Patient Lists the week of July 22, 2013. An email will be sent to users to announce their availability.

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.

 Annual MiPCT Summit Dates

 Once again this year, the MiPCT will convene a Stakeholder Annual MiPCT Summit in three statewide regional locations. We wanted to share the dates and locations as early as possible. They are:

  • October 1

– Ostego Club Conference Center (Gaylord)

  • October 9

– Frederik Meijer Gardens (Grand Rapids)

  • October 15

– University of Michigan North Campus Research Center (NCRC), Building 18, Dining Hall (Ann Arbor)

 Again this year, all MiPCT stakeholders and participants are welcome to attend. At this point, we anticipate a morning session that would be applicable to all stakeholders (8:00-noon), and an afternoon session specific to care managers (1:00-4:00 p.m.). A joint lunch that bridges the day would be available to all who are interested. Best practice-sharing would be encouraged to build on and share the many successes of participants.

 Watch the FLASH for additional details and a registration link soon to come!

MDC Webinar on July 24th to Announce Updates to the MiPCT Dashboards and All-Payer Patient Lists

MDC invites you to attend a webinar on July 24, 2013 at 12:00 p.m.. In this webinar, we’ll discuss the recent changes to improve the All-Payer Patient Lists (APPL) and the MDC Dashboards and Reports. The APPL improvements include field order changes and the addition of a dropped patient list. The Dashboard improvements include the addition of inpatient data and reports and a PO comparison of utilization measures. There are several other additions and improvements that we are excited to show you. To learn more about how these upcoming changes will benefit your PO and patient population reporting, please join us!

 Event Details:

Event:     Updates to MDC Dashboard & All-Payer Patient Lists – Summer 2013

Date:     Wednesday, July 24, 2013

Time:     12:00 PM Eastern Daylight Time

Event Number:     660 870 752

Event Password:     mipct

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To Join the Online Event and Teleconference

————————————————————–

1. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=660870752

2. Click “Join Now”.

3. Follow the instructions that appear on your screen.

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To Join the Teleconference Only

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Call-in toll number (US/Canada):     1-650-479-3207

Access code:     660 870 752

 If you have any questions about the webinar or would like more information, please contact MDC at MichiganDataCollaborative@med.umich.edu.

Stories of Your Care Management Success:

Diane Scarpace, NP, Complex Care Manager, Taubman Center General Medicine Clinic, University of Michigan Health System

Diane Scarpace, NP, is a complex care manager at the Taubman Center General Medicine Clinic, which is part of the University of Michigan Health System. She recently provided care management to a Medicare recipient experiencing frequent falls.

 ‘Sally’ is an older female with uncontrolled diabetes, uncontrolled hypertension, chronic pain, depression, anxiety and interpersonal psychosocial issues who came to the clinic with good-intentioned goals, but always a “reason” for non-adherence.

 Diane conducted an in-clinic fall assessment with the patient and PCP. They developed immediate strategies to reduce falls. These included medication changes, and patient counseling on methods to reduce divided attention. Over a series of phone calls and clinic visits, Sally eventually revealed feeling overwhelmed and lacking self-confidence, which was a life-long pattern. This led to emotional eating, frustration, and giving up on diet, medication adherence and physical activity.

 Diane received support and assistance from other members of the team. She collaborated with the PCP, clinical pharmacist, social worker, as well as endocrinology and mental health services, to meet the needs of this complicated patient. This team approach increased Sally’s sense of trust, self-efficacy, coping and decision-making. This led to further mutual goal-setting, identifying successes and strategies to overcome barriers.

 During clinic visits, Sally is more engaged with her care and smiling. She feels more in control of her life, and has fewer negative thoughts. She has learned strategies to delay giving in to her food cravings. Most importantly, she feels hope, and is inspired to improve control of her health. She feels invigorated with a lightened spirit, stating, “The dark cloud has passed,” and, “I now care enough to take care of myself”.

Sally continues to have some difficulty maintaining her diet and insulin regimen, and struggles with interpersonal issues. She also experienced a fall and fractured her ankle. Through her ups and downs, she feels grateful for the support of her health care team, and the fact that she has learned more about managing her chronic conditions. She reports she is addressing issues she didn’t want to address before, and indicated that setting small goals. keeping a log of blood pressures and a food journal inspires hope and reminds her of her successes. These activities encourage her to be as well as she can be.

 Next Issue: July 22, 2013.

June 24, 2013

MDC Announces Enhancement 03.02 for the MiPCT Dashboards and Reports

 MDC posted Enhancement 03.02 on Friday, June 21st. This enhancement includes the following additions and updates:

  • Added report details and descriptions on the View PO Reports and Download PO Reports tabs
  •  Added the Adolescent Immunization Measure to the PO Comparison – Quality dashboard and the PO Quality Measure Comparisons Report
  •  Added drill-down updates to the PO Comparison – Quality dashboard
  •  Added collapsible section headers on the PO Comparison – Quality dashboard, View PO Reports tab, and Download PO Reports tab.
  • Changed the Quality Measure Dashboard names to the following:
  1. – MiPCT Quality Summary
  2. – PO Quality Summary
  3. – PO Comparison – Quality
  • Updated the Facility Field in the ED Detail Report so that it now includes the correct facility name on The Quality Summary dashboards, added “N/A” for measures that are not calculated for given Payers
  • Updated documentation, including the Release Notes and User Guide, can be found on the Support page of the MDC 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.

 Weight-Related Claims Denials

Based on our review of submitted claims, we determined that certain claims are being denied when billed with an obesity (278.0 to 278.03) or body mass index (V85.0 to V85.54) diagnosis. As a workaround to the denial, please do not bill these diagnoses as the primary diagnosis. Remember you should be billing all active diagnoses for the patient on each claim. You may resubmit these claims.

MDC’s June 2013 MiPCT All-Payer Patient Lists to be Released the Week of June 24, 2013

 The Michigan Data Collaborative plans to post the June 2013 MiPCT All-Payer Patient lists later 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 files include a list of all patients for the PO and formatted lists for each Practice within your PO.

  •  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_2013_06.

 This month’s lists include two new fields to help care managers quickly identify new patients who need to be reviewed. The two new fields are titled:

  • “New to PO Flag,” and
  • “New to Practice Flag,”

 and they will indicate if a patient is new on the current month’s Patient List for the PO or Practice. These fields will be added to the end of the records.

 Also, be advised that the following two major changes will occur in the July 2013 patient list:

  1.  The record layout will change to move certain fields (columns) to the beginning of the record layout, and,
  2. The sort order of patient records will change to more quickly identify patients of interest for care management services.

These changes are detailed in the July 2013 Changes to the All Payer Patient List document posted on the Support page of the MDC website (https://www.michigandatacollaborative.org/MDC/support.jsp).

If you have any questions, or if your programmers would like a sample file to work with, please contact MDC at MichiganDataCollaborative@med.umich.edu.

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

 MiPCT Webinars

 Upcoming webinars can be found in the mipctdemo.org website. Choose the Monday FLASH tab. On the right side of the Monday FLASH webpage, you will see a box containing the date, topic, intended audience, and presenter if known, of future webinars, This list will be updated monthly with past webinars removed and future webinars added.

UPCOMING MiPCT CM WEBINARS:

(Adult Webinars – Wednesdays, 2-3 PM; Pediatric Webinars – Fridays, 10-11 AM)

  •  June 26, 2013 – Hypertension – Part II (Adult),  Presenters: Lisa Tobias, Practice Administrator, and Swanee Kooistra, RN, Hybrid Care Manager
  •  July 10, 2013 – Obesity (Adult), Presenters: Maureen E. Irwin, RD, P-AC, Care Manager; Dawn Rodman, MS, CWHC CPT, Michigan Health and Wellness 4 x 4 Plan Coordinator, Michigan Department of Health; and Annemarie Hodges, MA, Public Health Consultant – Arthritis Program, Michigan Department of Community Health
  • July 19, 2013 – Part II Educational Advocacy for the MiPCT CM (Pediatric), Presenters: Michigan Alliance for Families
  • August 16, 2013 – Pediatric Assessment Tools (Pediatric) Presenter: Rose Seavolt, MiPCT Regional Clinical Lead
  • September 6, 2013 – Behavioral Screening (Pediatric) Presenter: Jane Turner, MD, Pediatrician, MSU Health Team.

 Register Your New Complex and Hybrid Care Managers NOW: Summer MiPCT Complex Care Management Courses

To accommodate PO interest in timely MiPCT Complex Care Management training, there will be a CCM course July 15-18, 2013, and another CCM course August 12-15, 2012. The MiPCT CCM course consists of four consecutive training days.

 Registration is available at the following links:

 Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

 The CCM courses include training for billing PDCM/MiPCT codes for the BCBSM commercial, BCN, and Medicare Advantage payers. This is key to increasing the volume of G and CPT code billing, a key focus area for this year.

 DUE June 28: CTC / MiPCT Care Manager Mapping & User Access Spreadsheet

 MiPCT is working with Care Team Connect (CTC) to provide care managers access to member lists using CTC Spotlight upon PO consent, at no cost to POs. The CTC Member List Distribution option is an effort to reduce the PO administrative burden of member list distribution in a timely way. Recently, MiPCT and CTC held webinars to provide an overview of this option, and to date, we have received a 53% response from our POs.

 Each PO participating in the MiPCT/CTC partnership for member list distribution designated two people who will serve as the PO CTC Leads. These Leads serve an important role in the partnership and provide CTC with information about which Care Managers (and associated practices) lists should be available for (at launch and afterwards in continuing operations). Designated PO CTC Leads will be involved in product and user testing, provide user feedback, and desired improvements.

 Leads will receive an MiPCT Care Manager Mapping and User Access Spreadsheet today to complete and return to CTC by June 28, 2013, per the instructions on the email.

 Stories of Your Care Management Success: Jane Ruhl, Complex Care Manager, Battle Creek Community Physicians

 Jane Ruhl is a care manager working with Dr. Lambrix at Battle Creek Community Physicians.

 Jane was working with a BCBS patient who has diabetes and chronic abdominal pain. The patient’s abdominal pain was from multiple abdominal surgeries including gastric bypass and numerous hernia repairs. She also suffered from chronic nausea and vomiting.

 The patient was frequenting the emergency department (ED) for pain management and anti-emetics (12 visits in 8 months). Patient had several workups at well-known regional medical centers in the past. Despite these best efforts, no effective treatment plan had been developed.

 Jane met with the patient to offer care management services. After conducting a needs assessment and speaking with the patient extensively, the patient stated she felt she was not getting the care she needed at the ED, and really wanted her PCP to be the one to take care of her pain needs and her condition. Jane worked with the PCP and patient to develop a plan. If the patient experienced abdominal pain or nausea/vomiting for more than 24 hours, she would contact Jane. Jane would then arrange for the patient to be seen at the office by the PCP, and an appointment would be made in outpatient surgery, if indicated, for the patient to receive a liter of fluids, an antiemetic and IV pain medications.

 The patient has had no further ED or inpatient admissions since she has been in care management. She has called Jane five times since the plan was developed and has been treated on an outpatient basis at the PCP office and outpatient surgery, avoiding emergency room admissions.

The patient reports she feels ‘better cared for’ by working with the care manager and physician who know her and her needs.

 Care Manager Activity Reporting Guidelines – Group Visits

 POs began reporting care manager activity across payers in 1 Q 2013. To help to guide consistency of reporting for 2Q 2013 and beyond, the June 10, 2013 FLASH contained answers to queries about reporting that have been received by the mipctdemo mailbox. To this, we add the following guideline for reporting of in-person group visits:

  •  In-person group visits should be counted as a face-to-face (for each patient that attended) providing that there has been documentation of the visit for each patient. (For example if there were a group visit with five patients where time was spent with each, it would count as five encounters).

If you have questions, please contact us at mipctdemo@michigan.gov and type “CTC CM Mapping & User Access Spreadsheet” in the subject line.

Next Issue: July 8, 2013

June 10, 2013

Upcoming MiPCT Care Management Billing Seminars

 We invite you to attend a MiPCT Care Management Billing Seminar, facilitated by Blue Cross Blue Shield of Michigan, Blue Care Network, and Medicare Advantage, on billing care management codes for MiPCT.

 The session will be interactive and informative, and there will be opportunities to have any of your questions about the program answered. Billers, coders, care managers, Physician Organization representatives, and others involved in the coding and billing process are encouraged to attend.

 Here are the available dates and times:

 June 18 – 1:00 p.m. to 4:00 p.m.

Kalamazoo/Battle Creek, Lawrence Education Center (LEC) 1521 Gull Road, Kalamazoo

 July 22 – 9:00 a.m. to 12:00 noon –

Traverse City, Northwestern Michigan College, The Haggerty Center, 715 E Front St, Traverse City

It would help us prepare for the meeting if you would send us your specific questions in advance of the meeting. Please send them to mipctdemo@michigan.gov using the subject line “G/CPT Code Billing Forum Question/Issue”, and indicate which region of the state you would likely attend (Kalamazoo/Battle Creek or Traverse City).

 If you plan to attend, please respond to kvogelei2@bcbsm.com no later than June 14, 2013. Please include the following information in your response, for each person who is attending:

 Contact Name:

Title:

Physician Organization Name:

Office Name (if applicable):

City, State, Zip:

Phone Number:

Email:

Desired Session Date/Location:

CORRECTION: BCBSM Quarterly PGIP Meeting is June 14, 2013

 In the May 13 issue of the FLASH, we inadvertently published the wrong date for the PGIP meeting in the

“Important Dates” sidebar on the first page (see below). The correct date is Friday, June 14, 2013. We’re sorry for any confusion or inconvenience this may have caused you.

 Register Your New Complex Care and Hybrid Care Managers NOW: June MiPCT Complex Care Management Course

 To accommodate PO interest in timely MiPCT Complex Care Management training, there will be a CCM course June 17-20, 2013. Registration is available at the following link: https://jodyooo.wufoo.com/forms/june-1720-2013-mipct-ccm-training-course/.

 The MiPCT CCM course consists of four training days: June 17,18,19 and 20, 2013. Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

 The CCM course includes training for billing PDCM/MiPCT codes for the BCBSM commercial, BCN, and Medicare Advantage payers. This is key to increasing the volume of G and CPT code billing, a key focus area for this year.

 Watch the http://www.mipctdemo.org website for other Summer 2013 CCM Training dates.

MiPCT/Care Team Connect (CTC) Care Manager Member List Distribution Option

Webinars were held over the last two weeks to provide an overview of the option that will be made available at no cost to POs in an effort to reduce their administrative burden of member list distribution to care managers in a timely way. A PowerPoint presentation that overviews the option and advantages is available at: https://mipct.org/resources/presentations/

Under this approach, upon PO consent, care managers would have web-based access in a user-friendly format to member lists for their practices.

Please note that:

• This is an option (not a requirement) for POs

• There is no fee to POs or practices for participating (covered in the MiPCT administrative budget)

• POs that participate would continue to receive their member list and other products from the MDC as well as any future MDC reports

• The due date for response forms for POs who wish to have their practices participate in the launch of the product is June 17th. The response form is available at: https://mipct.org/resources/mipct-documents-and-presentations/mipct-ctc-member-list-response-sheet-v-2/

If you have any questions, or wish to have a discussion with the MiPCT implementation team to answer questions specific to your PO, please email them to mipctdemo@michigan.gov with the subject line: MiPCT CTC Question.

Care Manager Activity Reporting Guidelines

POs began reporting care manager activity across payers in 1 Q 2013. To help to guide consistency of reporting for 2Q 2013 and beyond, following are reminders:

• Care manager activity reporting is intended to capture information about the patients who actually received care management (phone or in-person) over a given quarter.

• If a patient did not receive care management services via a phone call or in-person visit with the patient, they should not be reflected in that quarter’s count. (Even if they are considered an “active” patient, unless they actually received phone or in-person services, they should not be “counted” in reporting.)

• If a patient received services from two different care managers at the same PO, then the patient should be counted as a unique patient serviced by each care manager. Thus, if the same patient received two phone call sessions with Care Manager A, and one in person session with Care Manager B, then:

  • Each care manager would report the patient as a “unique patient” for their reporting.
  • Care manager A would report two phone encounters with the patient during the quarter.
  • Care manager B would report one in-person encounter with the patient during the quarter.

• If a phone or in-person care management service was delivered in a quarter, the patient and encounter should be reported, even if it is not known whether the patient will continue to receive care management services in the subsequent quarter.

• Coordination or other work that took place on behalf of the patient, but in which the patient was not directly involved (i.e., did not receive an in-person or telephone service that quarter) should not be counted in reporting.

• Outreach attempts to engage patients in care management that were not successful (did not result in a patient receiving care management services during the quarter) should not be counted.

Financial Report Update

Revenue

Changes are being made to the financial reporting website. Effective January 1, 2013, only Medicaid revenue will be loaded on a quarterly basis. A new year-end report will be produced after we obtain revenue amounts from all payers.

We expect to receive final revenue data for 2012 from all payers by June 14, 2013. The report for each quarter in 2012 will be updated once all revenue data are received. POs can review each quarter and print an updated version. However the revenue for each quarter may not align with POs records for various reasons. It is recommended you use the Year-to-Date totals to reconcile.

Reporting of Incentive Distributions

The financial website now includes a new reporting section on the Financial Reports page below the list of quarterly reports. POs will use this area to report how incentives were distributed to practices for Medicaid and Medicare only.

• Click on Edit to open the Distribution of Incentives form. The form lists each practice.

• Enter amount and date payment was made to practices.

• As with the quarterly reports, anyone who has a user account may enter and save the data.However, the person who has the authority to submit the financial report will also have to submit the Distribution of Incentives.

• The submitter will complete the steps below.

  • Complete the checkbox at the end of the page to indicate the report is ready to submit. (Checkbox only available to Submitter.)
  • Select the “Save and Continue” button at the end of the page. The Status on the Financial Reports page changes from Draft to Submitted.

Please complete the 6 Month Incentives report with your Quarter 2 Financial Report by July 31, 2013.

BCBSM PGIP Quarterly Meeting 6/14/2013: MiPCT Update Session Features Successful Strategies for Moderate Care Management

The BCBSM PGIP Quarterly Meeting June 14, 2013 MiPCT Update session at 11:15 am highlights Successful Moderate Care Management strategies and processes. Presentations include a Moderate Care Management panel discussion and also “a view” from the practice and PO level with a presentation by Dr. Troy Carlson, Debbie Mays at Family Tree Medical Associates and Keith Deans, Physicians Organization of Michigan. The Moderate Care Management panel presenters are MiPCT Care Managers and a MiPCT Clinical Lead: Hae Mi Choe Pharm D, UMHS; Lisa M. Nicolaou, MSNI, BSN West Front Primary Care; Lynn King MSN, WHNP-BC Lake Shore Health Network/ MiPCT Clinical Lead. We are excited to offer this interactive session and look forward to the opportunity to learn about the presenters experience and insight regarding implementation of Moderate Care Management.

MiPCT Webinars

Upcoming webinars can be found on the http://www.mipctdemo.org website. From any of the webpages on the site, you will see a sidebar (box) containing the date, topic, intended audience, and presenter if known, of future webinars. This list will be updated monthly, with past webinars removed and future webinars added.

UPCOMING MiPCT CARE MANAGER (CM) WEBINARS:

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

June 12, 2013:

Hypertension – Part I (Adult). Presenters: Dr. Zorica Kauric-Klein, PhD Nursing, MSN, BSN and Kristina Dawkins, MPH.

June 21, 2013:

Part I – Education Rights for Children with Disabilities (Pediatric.) Presenter: Mark McWilliams, Attorney.

June 26, 2013:

Hypertension: Case Study: A Practice Process – Part II (Adult). Presenters: Lisa Tobias, Practice Administrator and Swanee Kooistra, RN, Hybrid Care Manager.

July 10, 2013:

Obesity (Adult). Presenter: Maureen E. Irwin, RD, PA-C, Care Manager.

July 19, 2013:

Part II – Educational Advocacy for the MiPCT CM (Pediatric). Presenters: Michigan Alliance for Families

August 16, 2013:

Pediatric Assessment Tools (Pediatric). Presenter: Rose Seavolt, MiPCT Regional Clinical Lead.

September 6, 2013:

Developmental Screening (Pediatric). Presenter: Jane Turner, MD, Pediatrician, MSU Health Team.

MDC Announces Changes to the All-Payer Patient Lists

In response to the needs of the Care Manager users, MDC is planning to make significant changes to the All-Payer Patient Lists (APPL) over the next two months. These changes were identified by MiPCT clinical leadership to make it easier for MiPCT care managers to use the list.

In June, we will add two new fields to help care managers quickly identify new patients who need to be reviewed. The two new fields are titled “New to PO Flag” and “New to Practice Flag,” and they will indicate if a patient is new on the current month’s APPL for the PO or Practice. These fields will be added to the end of the records. (POs have requested that all new fields be added to the end of the record layout to make it is easier for their load and processing programs.)

In July we will modify the sort order to more quickly identify patients of interest for care management services. We will also change the record layout to move certain fields (columns) to the beginning of the record layout.

For more information about these changes, please review the July 2013 Changes to All Payer Patient List document, which you can find on the Support page of the MDC Website:(https://www.michigandatacollaborative.org/MDC/support.jsp).

 We are announcing these changes now to give programmers enough time to make the necessary updates to the load and processing programs. If you have any questions, or if you would like a sample file to work with, please contact MDC at MichiganDataCollaborative@med.umich.edu.

MDC Announces Enhancement 03.01 for the MiPCT Dashboards and Reports

MDC posted Enhancement 03.01 on Friday, May 31st. This enhancement includes:

• Added standard cost data to the Population Summary dashboards and reports.

Notes about standard cost:

  •  Members with claims for which standard cost could not be assigned are not reflected in standard costs on this dashboard.
  • Standard costs are assigned to inpatient and outpatient services only and exclude pharmacy costs.
  • Standard Cost PMPM is blank if there are no members with sufficient standard cost data to produce the PMPM calculation.

• Added ED benchmark data to the Utilization dashboards and reports. These benchmarks are for viewing and comparing purposes only; they are not used for calculating performance incentives.

• Added timeframe information to graph and table titles in the dashboards. The timeframe information is now included when you print or export a table or graph.

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

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

 Stories of Your Care Management Success:

Laurisa Cummings, LMSW, Hybrid Care Manager, Saginaw Township Family Physicians

 Laurisa Cummings, LMSW, is a hybrid care manager at Saginaw Township Family Physicians. Recently, Laurisa was working with a five year old boy, “Ethan”, and his family. Blue Cross Blue Shield of Michigan is their insurance carrier. “Ethan’s” mom brought him in for a visit with the primary care provider (PCP). She explained her concerns about her son, including the extent of his behaviors, relaying her frustration and need for assistance. The PCP asked Laurisa for help in getting ‘Ethan’ the necessary referrals to get him evaluated and his parents the resources they needed to care for him.

 The PCP and Laurisa’s assessment of “Ethan” revealed that he had not been enrolled in preschool or kindergarten. He exhibited delayed development, learning and behavioral difficulties, including speech and language, sensory issues, angry outbursts, and poor social interactions with family and others. ‘Ethan’ had been physically violent towards his parents and siblings, throwing toys and other items at them. His temper tantrums were so intense he would put holes in the walls. “Ethan’s” parents were at their wits’ end, as they had tried multiple interventions, nearly all of which proved unsuccessful.

 After meeting with “Ethan” and his mother, a plan of action was established. He was referred to his school district for testing and appropriate placement recommendations. “Ethan” was referred to a Pediatric Neuropsychologist, who later ruled out Asperberger Syndrome and Autism, as originally diagnosed. He was diagnosed as having a Speech Delay and Behavior Causing Concern in Biological Child. “Ethan’s” parents were unable to afford the costs of traditional therapy, and met criteria for services through Community Mental Health, where “Ethan” is followed by a Psychiatrist and Therapist. He was enrolled in school and is now in kindergarten. He also receives occupational therapy for his speech difficulties. “Ethan” has a daily plan that his teachers follow, including planned time out to prevent angry outbursts.

 “Ethan’s” mom is his primary care giver. She expressed appreciation for the help Laurisa provided in putting a plan of action in place, as she felt overwhelmed, and did not know which issue to tackle first. She verbalized gratefulness for the continued guidance in getting her son what he needed, especially well enough so that he could attend school. She knows every day is not going to be a good day, but she is thankful for those days that are.

 MiPCT-Approved Self-Management Programs Update

 The link to the chart below 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 Moderate Care Management (MCM) training.

The programs listed below include information regarding course date/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 document titled “MiPCT Approved Self Management Support and MCM program” at https://mipct.org/care-management-resource-center/

chart for FLASH 6 10 2013

Next Issue: June 24, 2013

May 20, 2013

12-Month Incentive Score Calculation and Payout Update

The 12 month metric score calculation is almost complete. We anticipate that scores will be released to POs prior to the end of May for a one-week review, allowing payments to be distributed mid-June. Scores will be released for review in the MDC portal site and an email advising of their availability will be distributed.

MDC Announces Release 3.0 for the MiPCT Dashboards and Reports

MDC posted Release 3.0 on Monday, May 13th. This release included the following additions and enhancements:

• Updated dashboards and reports using paid claims data through December 2012 for Medicare, Medicaid, and BCBSM.\

• New PO Quality Measure Comparisons dashboard and reports to compare quality measure rates across all POs in the MiPCT project.

• On the Population Summary Dashboard, when you drill down to the members list, the # of ED visits in newest 6 months of data column is now populated.

• On the View PO Report tab, the ED Summary and ED Detail reports are now initially sorted by practice and then by physician.

• On the View PO Report tab, removed the Multi-Payer Attribution List and Risk Stratification report. To view attribution data, see the All-Payer Patient Lists on the Download PO Report tab.

• On the View PO Report tab and the Download PO Report tab, the corrected Medicaid plan is populated in the Payer column of the ED Summary and ED Detail reports.

• On the Download PO Report tab, the Number of ED Visits column is now populated in the All-Payer Patient Lists.

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 May 2013 MiPCT All-Payer Patient List Released to POs

The Michigan Data Collaborative will post the May 2013 MiPCT All-Payer Patient lists this week (the week of May 20, 2013). An email announcing the release will be sent to Dashboard users.

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_2013_05.

MDC plans to release the MiPCT All-Payer Patient lists every third week of each month.

The All-Payer Patient lists can be found on the Download PO Reports tab of the MDC MiPCT dashboards. 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.jsp).

Register Your New Complex and Hybrid Care Managers NOW:

June MiPCT Complex Care Management Course

To accommodate PO interest in timely MiPCT Complex Care Management training, there will be a CCM course June 17-20, 2013. Registration is available at the following link: https://jodyooo.wufoo.com/forms/june-1720-2013-mipct-ccm-training-course/.

The MiPCT CCM course consists of four training days: June 17,18,19 and 20, 2013. Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

The CCM course includes training for billing PDCM/MiPCT codes for the BCBSM commercial, BCN, and Medicare Advantage payers. This is key to increasing the volume of G and CPT code billing, a key focus area for this year.

MiPCT Care Manager Webinars: Upcoming Webinar Topics:

Care Managers are invited to attend the upcoming MiPCT webinars:

  • 5/29/13: Motivational Interviewing
  • Presenter: Monica Brunetti, RN, ADN, CCM, CCP
  • 6/12/13: Hypertension
  • Presenters:  Dr. Zorica Kauric-Klein, PhD, MSN, BSN, Assistant professor at Wayne State University, will present HTN management and life style modification. Kristina Dawkins, MPH, Clinical and Public Health Consultant, Michigan Department of Community Health, will present resource information for HTN.

The National Choosing Wisely Campaign (see link above) 

One of the keys to our success in MiPCT is our ability to be effective stewards of our health care resources. Recognizing that patients sometimes ask for tests and treatments that are not necessarily in their best interest, and that physicians often struggle with decisions about prescribing tests and procedures as a way of covering all possible bases, the ABIM Foundation has joined with leading medical specialty societies to develop evidence-based lists of tests and procedures for patients and physicians to question as part of a national Choosing Wisely campaign (described further at http://www.choosingwisely.org/). The goal is to help physicians, patients and other health care stakeholders think and talk about overuse of health care resources in the United States. The campaign is part of the ABIM Foundation’s goal of promoting wise choices by clinicians in order to improve health care outcomes, provide patient-centered care that avoids unnecessary and even harmful interventions, and reduce the rapidly-expanding costs of the health care system.

You may have already read about Consumer Reports’ work with Choosing Wisely and their interest in resources for consumers and physicians to engage in these important conversations about the overuse or misuse of medical tests and procedures that provide little benefit and in some cases harm. First launched with the contributions of nine medical societies in April 2012, the campaign was joined by more than a dozen additional societies in February 2013, each with their own lists of tests and procedures that physicians and patients should question. The PDF attachment to this FLASH contains the complete list of Choosing Wisely recommendations. MiPCT is exploring how the Choosing Wisely work may be helpful in better reaching project goals.

Stories of Your Care Management Success:

Jennifer Young, Hybrid Care Manager, Pine Medical Group

Jennifer has been working with a patient covered by Medicaid insurance who has uncontrolled type II diabetes. The patient’s A1C was between 9 and 10.5 most of the time. The patient is insulin dependent, blind in one eye, has severe neuropathy, HTN, hyperlipidemia, depression and short term memory impairment. This patient had many barriers; one of them was transportation which allowed her to only come to the PCP office once a month. She also had financial limitations and she seemed to be constantly ill.

Common complications for this patient included skin infections, UTIs, URIs, pyelonephritis, sinus infections, abscesses and gout flares. Besides her medical complications, the patient also experienced multiple family tragedies. These included a house fire and murder/suicides. She experienced several tragic and devastating events in a short period of time. Understandably, the patient had a high level of stress. This made managing her diabetes difficult. The patient was not taking her meal time insulin with every meal, she was not consistently taking her Lantus at night or calculating it properly, and she was not checking and writing down her blood sugars. Management of her diabetes was not her top priority.

The patient was referred to Jennifer by the PCP to assist with the patient’s multiple issues. The PCP was unable to address her issues fully in a once a month office visit. The patient’s short term memory impairment required that she receive consistent follow up over the phone in between appointments by the same person. Jennifer was able to provide consistent individualized patient education, re-education and reinforcement of what was being taught. The patient often just needed a listening ear as well. Jennifer was able to provide that.

The PCP worked with Jennifer and a medical assistant (MA) specifically assigned to the patient to establish a consistent care team for the patient. The PCP kept Jennifer up to date on the patient’s medical condition and never hesitated to contact her for assistance. The MA was paired with Jennifer to serve as a resource person to the patient if Jennifer was out of the office or unavailable.

Jennifer struggled initially to identify what she could do to help this patient. She provided education, gave the patient handouts to take home, followed up frequently over the phone, reinforced education every time she came to the office, and communicated regularly with her PCP. Despite Jennifer’s efforts to educate and support the patient, she was not able to consistently calculate her insulin dose correctly. After about four months her A1C came down to 8.6, but her blood sugar was still spiking into the 300s at times and getting hypoglycemic at other times.

The PCP or Jennifer would write out the insulin instructions and self-management plan for the patient at every office visit. The patient expressed that while they were explaining it to her it made sense, but as soon as she got home, and every time she went to use the directions, it was like she was looking at it for the first time. The patient would just give up and take a flat 10 units of Apidra at every meal or none at all. Instructions such as “Apidra with meals – 2u per 5g carbs plus 2 units for every 50 her blood sugar was over 200 and Lantus 10u am, 50u pm”, were clear to the PCP and Jennifer, but did not make sense to the patient. As they developed a rapport, the patient opened up more to Jennifer. She asked Jennifer to write all the instructions as detailed and simple as she could, stating, “Dumb-it-down. Write it for a kindergartner, I don’t care if its three pages long”.

Jennifer provided the patient with the instructions written as she had requested. She typed out an entire day’s insulin schedule with directions completely spelled out. For example, ‘this is what you do before breakfast, at breakfast, lunch, supper, before bed’, and wrote out the entire sliding scales with every meal’s individual directions, ‘200-249 2 units, 250-299 4 units, 5 grams carbs 2 units, 10 grams carbs 4 units, etc. With every meal, check blood sugar, calculate and take insulin, this is how you calculate, write down, eat’. Jennifer also included a picture of a food label with the total carb value circled next to the mealtime calculation.

These interventions worked. The patient loved it, understood it and was able to use it. She keeps it on her refrigerator and uses it every day. One month later her A1C was 7.4, the lowest it has been since she starting coming to the practice. Jennifer has worked with the patient over the last 10 months. In that time, the patient has experienced many little successes in every area of her life, including the management of her diabetes.

The patient expressed to Jennifer, “Thank you for spending so much time on me.” And “Thank you for being so patient, I know I’m a pain.” Jennifer’s favorite quote from the patient was hearing her say, “I think I finally get it.”

MiPCT-Approved Self Management Programs – Update (see link above)

The adjacent 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 Moderate Care Management Training. The programs listed below include information regarding course date/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 document titled “MiPCT Approved Self Management Support and MCM program” at https://mipct.org/care-management-resource-center/

Pediatric Care Manager Webinar Schedule Changes 

Our September pediatric webinar has been re-scheduled for September 6 (instead of Sept. 20).

Next Issue: June 3, 2013

May 6, 2013

May Regional Biling/Coding BCBSM, BCN and Medicare Advantage Forums

 Invitations were sent out by BCBSM for the upcoming MiPCT Care Management Billing Seminars. Please check your email boxes for the invitations and respond as quickly as possible. If you RSVP’d you should receive a confirmation e-mail with details specific to the time and location you selected. However, we have included the location and parking details for each session below. We look forward to seeing you. Sessions will be three hours long and consist of both morning and afternoon repeating sessions. If you have not received a meeting invitation and wish to attend, please contact Kristin Vogelei at kvogelei2@bcbsm.com.

  • Refreshments: We plan to have coffee, water, and soft drinks available.
  • The session locations and dates are:

             May 7 – Lansing

             Blue Cross Blue Shield of Michigan

             232 South Capitol Avenue

             Lansing, Michigan 48933

             Please bring your driver’s license or state-issued ID.

             Parking: Directly across the street from the main entrance, off Capitol Avenue, there is a surface lot. Please bring the ticket to BCBSM security to be validated.

              May 8 – South Lyon

              Blue Cross Blue Shield of Michigan

               Lyon Meadows Conference Center

               53200 Grand River Avenue

                New Hudson, Michigan 48165

                Aqua Room

                Parking: Free surface lot parking is available.

                May 9 – Grand Rapids

                Grand Rapids Masonic Center

                233 Fulton Street East, 4th Floor

                Grand Rapids, Michigan 49503

                Parking: There is limited parking in the lower level of the Masonic Center parking ramp, but ample parking at the Grand Women’s City Club lot on Lafayette Street (less than ½ blocks away). There is no fee for parking.

                  May 21 – Marquette

                  Video Conference

Billers, coders, Care Managers, PO representatives, and others involved in the coding and billing process are invited to attend. If you have specific issues that you would find helpful to address, please send them to mipctdemo@michigan.gov using the subject line “G/CPT Code Billing Forum Question/Issue”.

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Release 3.0 of the Dashboards and Reports

 To ensure all data has been properly tested and verified, MDC is rescheduling the 3.0 Release for the week of May 6, 2013. This release will update the dashboards and reports using paid claims data through December 2012 for Medicare, Medicaid, and BCBSM. It will also include a new dashboard and reports for PO Comparisons on Quality Measures. All features and updates will be detailed in the release notes that are posted with the release.

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

Provider File

A Provider File update email will be sent this week. Please document all practice and provider changes and send your response by Wednesday, May 15th, for inclusion in the July – September Medicare beneficiary assignments. You do not need to fill out a separate form for every change; please summarize the changes you made on one form and return to the MIPCT mailbox at mipctdemo@michigan.gov.

If there are no current changes, please respond with a confirmation email. You can copy my email: tyrrellj@med.umich.edu on the response to expedite the update.

Register Your New Complex and Hybrid Care Managers NOW: May MiPCT Complex Care Management Course

To accommodate PO interest in timely MiPCT Complex Care Management training, there will be a CCM course May 20-23, 2013. Registration is available at the following link: https://jodyooo.wufoo.com/forms/may-2023-2013-mipct-ccm-training-in-lansing/. The MiPCT CCM course consists of four training days: May 20, 21, 22, and 23, 2013. Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

The CCM course includes training for billing PDCM/MiPCT codes for the BCBSM commercial, BCN, and Medicare Advantage payers. This is key to increasing the volume of G and CPT code billing, a key focus area for this year.

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Stories of Your Care Management Success: 

Ann Shoop, RN, MSN, Care Manager, Neighborhood Family Health Center

Ann Shoop, RN, MSN, is a care manager at Neighborhood Family Health Center. She recently was working with a patient covered by Medicare insurance who had experienced frequent hospitalizations for exacerbation of CHF and Diabetes. These hospitali-zations were occurring nearly every week. The patient was receiving limited health oversight from a home care agency. The agency was providing some assistance with transportation.

 Ann received a referral for case management for this patient by the physician. She met the patient at the office and explained her role to the patient. The patient agreed to care management. Initial assessment revealed that the patient had no family support system and memory loss. Ann also identified during the visit that the patient did not understand how to take her medications.

 Ann provided education, support and symptom monitoring to this patient for over a year. Interventions included home visits and regular office visits. The moderate care manager in the office is also a social worker, and she provided assistance with connecting the patient with agencies to provide more support in the home and transportation. The office manager at the practice supported care management intervention by allowing Ann the flexibility to visit the patient in the hospital, which helped to strengthen Ann’s relationship with the patient. Because of care management, the patient had fewer hospitalizations and was eventually transitioned to hospice care.

 The patient called Ann her ‘advocate and angel’. Through all of the hospital stays and agencies involved with her care, Ann was able to be the consistent presence that provided her medical history and preferences in care. The physician expressed that managing this patient was very difficult before care management was involved. Care management improved the patient’s quality of life. The patient recently passed away peacefully with the support of Hospice. Ann was able to visit with the patient the day before she died.

Childhood Obesity– Effective Interventions Webinar:  May 10, 10AM

The next scheduled Pediatric Care Management webinar is planned for May 10, 10-11am. There will be open discussion with a focus on effective interventions for childhood obesity. Dr. Jane Turner will lead the webinar, introducing scenarios for discussion. Participants will be encouraged to describe some of their encounters, and care managers will have an opportunity to share their knowledge and experiences.”

Webinar Information:

  • Event: Childhood Obesity –Effective Interventions
  • Date: Friday, May 10th, 2013
  • Time: 10:00am Eastern Daylight Time
  • Event Number: 663 388 318
  • Event Password: mipct
  • ——————————————————
  • To join the online event
  • ——————————————————-
  • 2. Click “Join Now”.
  • 3. Follow the instructions that appear on your screen.
  • ——————————————————-
  • Top join the teleconference only
  • ——————————————————-
  • Call-in toll number
  • (US/Canada): 1-650-479-3207
  • Access code: 663 388 318

Next Issue:  May 20, 2013

April 22, 2013

May Regional Billing/Coding BCBSM, BCN, and Medicare Advantage Forums

Invitations were sent out last week by BCBSM for the upcoming MiPCT Care Management Billing Seminars. Please check your email boxes for the invitations and respond as quickly as possible. We look forward to seeing you. Sessions will be three hours long and consist of both morning and afternoon repeating sessions. If you have not received a meeting invitation and wish to attend, please contact Kristin Vogelei at kvogelei2@bcbsm.com. The session locations and dates are:

  • May 1 – South Lyon
  • May 7 – Lansing
  • May 8 – South Lyon
  • May 9 – Grand Rapids
  • May 21 – Marquette

Billers, coders, Care Managers, PO representatives, and others involved in the coding and billing process are invited to attend. If you have specific issues that you would find helpful to address, please send them to mipctdemo@michigan.gov using the subject line “G/CPT Code Billing Forum Question/Issue”.

 Childhood Obesity Training

As part of Governor Snyder’s Michigan Health and Wellness 4 x 4 effort, the Michigan Department of Community Health (MDCH) and the United Dairy Industry of Michigan (UDIM) recognized an opportunity to deliver tools and training to provide early intervention in impacting childhood obesity. The training is targeted at health professionals who are trying to manage childhood obesity and offers Motivational Interviewing techniques to help children and their families reach optimal success. Whether you are in a health care, school or community setting, you’ll receive tools and resources that can be adapted to your setting.

The training is FREE (please see details attached to this issue). In addition to the training itself, participants will walk away with:

  • Resource Manual
  • Cue Cards Motivational Interviewing (MI) Training Folder

If you have questions, call Michelle Hart at UDIM at 1-800-241-6455 or Krystal Quartermus at MDCH at 517-241-0947.

MDC Announces Release 3.0 for the MiPCT Dashboards and Reports

The MiPCT Dashboards and Reports Release 3.0 is scheduled for April 26, 2013. The release will include updated claims and eligibility data through the end of December 2012 for Medicare, Medicaid, and BCBSM. It will also include other enhancements, which will be detailed in the release notes. When the release is posted, MDC will send an email message and include an announcement on the MDC website (https://www.michigandatacollaborative.org/).

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

 MDC’s April 2013 MiPCT All-Payer List Released to POs 

The Michigan Data Collaborative will post the April 2013 MiPCT All-Payer Patient lists the week of April 22, 2013. An email announcing the release will be sent to Dashboard users.

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_2013_04.

MDC plans to release the MiPCT All-Payer Patient lists every third week of each month.

The All-Payer Patient lists can be found on the Download PO Reports tab of the MDC MiPCT dashboards. 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.jsp).

Register Your New Complex and Hybrid Care Managers:  May MiPCT Complex Care Management Course

To accommodate PO interest in timely MiPCT Complex Care Management training, there will be a CCM course May 20-23, 2013. Registration will be available by Monday, April 29.

The MiPCT CCM course consists of four training days: May 20, 21, 22, and 23, 2013. Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

The CCM course includes training for billing PDCM/MiPCT codes for the BCBSM commercial, BCN, and Medicare Advantage payers. This is key to increasing the volume of G and CPT code billing, a key focus area for this year.

MiPCT Care Manager Webinars: Announcing Topics for April-May, 2013

Care Managers are invited to attend the upcoming MiPCT webinars:

April 24, 2013, 2-3 PM

“Transition of Care – LACE Tool to Stratify High Risk Patients”

May 1, 2013, 2-3 PM

Moderate Care Management 5 Step Process: Referral, Screening, Enrollment

May 8, 2013, 2-3 PM

Moderate Care Management 5 Step Process: Management, Case Closure

May 15, 2013, 2-3 PM

Moderate Care Management Case Studies – Presented by MiPCT Care Managers

The April 24, 2013 Webinar topic is “Transition of Care – The LACE tool to stratify high risk Patients”. The webinar presentation will include a summary of the work of the MiPCT Transition of Care (TOC) workgroup and introduction of the LACE tool. The LACE tool may be used by a care manager to stratify MiPCT patients discharged from the hospital, to identify the patients at high risk of hospital readmission. Use of the LACE tool is optional and the PO/Practice Leaders can decide if it would be beneficial to use.

To view the LACE tool: http://tc.nphhi.org/Archive/NSN-Readmissions-Templates/LACE-Index-Scoring-Tool.aspx

The May 1, May 8 and May 15, 2013 webinars will consist of a three part series on Moderate Care Management. The series on Moderate Care Management is designed to be informative for both Moderate and Hybrid Care Managers.

In year one of MiPCT, we focused heavily on transition of care and complex care management. The MiPCT clinical model is based on population management and as we progress in year two it is critical to include the delivery of care management to moderate risk patients. Providing care management for moderate risk patients will result in avoidance or delay of complications for patients who have a chronic condition. Additionally, the MiPCT participating health plans provide funding for delivery of care management to their members. MiPCT practices will achieve this goal by ensuring care management addresses both complex and moderate risk patients.

 In the Literature:  Improving Medication Adherence

The attached article from the Journal of Family Practice outlines suggestions for both providers and care managers in improving medication adherence in those with chronic illnesses, as discussed at the Summit on Improving Patient Adherence. Example interventions include motivational interviewing, implementing the medication interest model, and using the Adherence Estimator. Citation: Brunton, Stephen. Journal of Family Practice. April 22 2011, volume 60 (No 4 suppl: S1-S8).

Stories of Your Care Management Success:  Karen L. MacWilliams, RN, Hybrid Care Manager

Lakeshore Medical Center-Shelby

Karen L. MacWilliams, RN is a Hybrid care manager at LakeShore Medical Center in Shelby, Michigan. Karen is working with a 63-year-old woman diagnosed with Type 2 Diabetes/Uncontrolled, Hypertension, Hyperlipidemia, Morbid Obesity, CAD with CABG X4 in 4/2011, Breast CA/Bilateral Mastectomy, Cellulitis/Staph Breast Infection, Goiter, Leg Swelling, and Basal Cell Carcinoma. Her HgbA1C went from 6.3 in May of 2011 and continued to climb every three months until November 2012 when it was 11.1. Her PCP requested care management services because medications and counseling were not working and the PCP verbalized fear of another heart-related incident.

The patient agreed to talk with Karen about barriers in managing her diabetes and “what bothered her about her DM” starting the end of November 2012. The first three weeks Karen worked with her, the patient’s blood sugar ranges were 140-227, 114-208, and 180s. The first week she verbalized a long term goal of getting better control over her blood sugars. Her short term goal was to get a battery for her glucometer and test her blood sugar three to five times in the next week. She then decided that a new glucometer was needed since she was unsure if she has ever owned one other than the one she currently has.

Every week she has met the goals she has set, except one. She has developed a new awareness of her control over her diabetes and with each small goal attained she has added new goals including blood pressure monitoring, weight monitoring, and increased blood sugar checks. She is becoming more empowered to make a positive change over that control. As the care manager, Karen has had the privilege to watch this transformation and participate in it by asking questions, making gentle suggestions and providing education like, “when might be the best time for you to test you blood sugar if you are only testing once a day?”

This past week the patient stated she was excited to see how much her changes will affect her HgbA1c now that her fasting blood sugars are consistently below 150.

Next Issue: May 6, 2013

April 8, 2013

Plan On Attending! Regional Billing/Coding BCBSM, BCN, and Medicare Advantage Forums

During the month of May, regional meetings will be held throughout the state, facilitated by BCBSM, BCN, and Medicare Advantage on G and CPT care management codes. The sessions will be approximately three hours long (morning or afternoon). Billers, coders, care managers, PO representatives, and others involved in the coding and billing process are invited to attend. If you have specific issues that you would find helpful to address, please send them to mipctdemo@michigan.gov using the subject line “G/CPT Code Billing Forum Question/Issue”, and indicate which region of the state you would likely attend (west, east, central, north). The tentative dates and regions include:

  • May 1 – Detroit
  • May 7 – Lansing
  • May 8 – South Lyon
  • May 9 – Grand Rapids
  • May 21 – Marquette

Both morning and afternoon sessions will be offered, if possible. Look for more information soon! In the interim, if you save the date, it would be much appreciated!

MDC to Release G-Code Reports Soon

MDC is in the final stages of producing a set of G-code summary reports for each PO to help monitor and improve the billing and reimbursement process for BCBSM G-code claims. The reports will reflect one month’s worth of claims data for each practice, as well as YTD totals. It will show the number of patients eligible for care management by practice and by PO along with the percentage of patients for whom care management services are billed to BCBSM. It will also show the volume of G-code claims paid and denied.

MDC plans to release the first G-code reports in April and will release subsequent versions on a monthly basis.

To announce the G-code report release, MDC will send an email and post articles the MiPCT Monday FLASH newsletter and on the MDC Website.

If you have any questions or would like further information, please contact MDC at MichiganDataCollaborative@med.umich.edu.

Working for Success: 2013 Performance Metrics

As we progress into 2013, we thought it would be helpful to recap the 2013 performance metrics (attached with complete documentation). These 2013 metrics were presented to and approved by the MiPCT Steering Committee on November 19, 2012, and were included in a previous edition of the FLASH. As a recap, they are as follows:

MDC Announces the All-Payer Patient List FAQ Guide

MDC has received several inquiries about the data included in the All-Payer Patient lists that we release each month. To help answer your questions, MDC compiled a frequently asked questions guide. This guide supplements the All-Payer Patient List Information document that we update with each release. The All-Payer Patient List FAQ Guide is posted on the MDC Support Page in the All-Payer Patient List section (https://www.michigandatacollaborative.org/MDC/support.jsp). We encourage you to review this guide if you have any questions and to contact MDC at MichiganDataCollaborative@med.umich.edu if you have additional questions that you’d like to see included.

Medicare Care Coordination Payments

The PO Medicare Care Coordination Payment which covers paid claims from February 1, 2013 through March 31, 2013 will be distributed to POs by April 26, 2013.

Register Your New Complex and Hybrid Care Managers NOW: April MiPCT Complex Care Management Course

To accommodate PO interest in timely MiPCT Complex Care Management training, there will be a CCM course:

April 15th-18th – Lansing .

Registration is available at the following link: https://jodyooo.wufoo.com/forms/april-1518-2013-mipct-ccm-training-in-lansing/. Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training.

The CCM course includes training for billing PDCM/MiPCT codes for the BCBSM commercial, BCN, Medicare Advantage payers. This is key to increasing the volume of G and CPT code billing, a key focus area for this year.

Please keep in mind that development of the pilot self-paced CCM course is in early stages and will not be offered in the near future. Hence, it is key to register for in-person training in a timely way.

Financial Report Update:

  • Practice Transformation Expenses

As announced in the Monday FLASH on March 25, 2013, POs no longer have to report practice transformation expenses. However, there was insufficient time to remove this page from the website. Since these fields are required to submit your report, please enter 0 (zero) for all practice transformation expense categories this quarter.

  • Care Manager Activity

Development of the Care Manager Activity reporting form is complete. Instructions (below) from the website outline the options for loading your data. If downloading the PO specific template from the website, it is best to first verify that all care managers are included in the list on the Care Managers page.

  • Care Manager Activity Instructions

Practice and Care Manager fields are populated from the Care Manager staff page. If additional care managers should be listed here, please return to the previous section.

Two options are available for reporting care manager activity.

1. Enter information directly into the fields below. All fields are required. Enter a zero if a field is not applicable.

2. Upload a tab-delimited file created in one of two ways AFTER all care managers have been entered in the previous section.

a. Select Download Template link to obtain a tab-delimited text file that includes all current care managers and practices.

• Complete all required fields, taking care NOT to change any data in the first 5 columns.

• Save file as a tab-delimited text file. Select Browse to identify the file and Select Upload.

• Verify that all data are imported. Any records in your upload file that do not have a corresponding care manager in the financial report will not be imported. An error message will identify these records.

b. Upload a file generated from your system that matches the format and existing care manager data of the template from step “a.” above.

• Verify that all data are imported. Any records in your upload file that do not have a corresponding care manager in the financial report will not be imported. An error message will identify these records.

Questions about the financial website may be submitted to mipctdemo@michigan.gov.

BCBSM Medicare Advantage Updated PDCM Billing Guidelines

BCBSM has produced updated billing guidelines for the Medicare Advantage product. The new guidelines are attached and also in the http://www.mipctdemo.org site (under the Documents tab). Please see Attachment.

 MiPCT Care Manager Webinars: Announcing Topics for April-May 2013

Care Managers are invited to attend the upcoming MiPCT webinars, held at 2 PM on select Wednesdays. The April and May webinars will focus on the underserved population, and a three-part series on Moderate Care Management. The series on Moderate Care Management is designed to be informative for both Moderate and Hybrid Care Managers.

In year one of MiPCT, we focused heavily on transition of care and complex care management. The MiPCT clinical model is based on population management, and as we progress in year two it is critical to include the delivery of care management to moderate risk patients. Providing care management for moderate risk patients will result in avoidance or delay of complications for patients who have a chronic condition. Additionally, the MiPCT participating health plans provide funding for MiPCT to deliver care management to their members and this requires population management.

  • April 17, 2013, 2:00 PM

Care Management and the Underserved – Presented by MiPCT Care Managers

  • May 1, 2013, 2:00 PM

Moderate Care Management 5 Step Process: Referral, Screening, Enrollment

  • May 8, 2013, 2:00 PM

Moderate Care Management 5 Step Process: Management, Case Closure

  • May 15, 2013, 2:00 PM

Moderate Care Management Case Studies – Presented by MiPCT Care Managers

Stories of Your Care Management Success: Susan Maddox, RN Hybrid Care Manager, Henry Ford Medical Group-Lakeside

Susan Maddox, RN is a hybrid care manager working at the Henry Ford Medical Group Lakeside. She had the opportunity to provide care management for the following patient after a recent hospitalization.

This female patient was admitted to hospital with dyspnea, blood pressure 190/100, found to have myocardial infarction, heart failure, exacerbation and new onset atrial fib. Patient had a past medical history of diabetes, hypertension, chronic kidney disease, overweight and severe osteoarthritis. The patient was using a fentanyl patch and Norco for pain control and taking 17 other medications, including 2 types of insulin. She had difficulty with transportation, reading, understanding disease management, diet, and self-management.

Upon hospital discharge, the patient was enrolled in Case Management and found to have GFR of 11, on enoxaparin and Lasix. Susan huddled with covering provider and orders were obtained to hold enoxaparin and Lasix check labs end of week. She attempted to contact patient, called multiple numbers with no answer and no voice mail set up. Susan contacted the emergency contact and home care nurse. She experienced extra challenges in coordinating lab draws and results from multiple health care networks, as the home care provider was not part of Henry Ford Health System.

The patient experienced an early hospital readmission due to bradycardia with HR in the 30’s and being hypokalemic. Susan followed the patient while hospitalized and the patient was discharged home the following week. She contacted the patient’s son, and discussed importance of having contact numbers with voice mail, and followed up on scheduled appointments.

Susan worked closely with the patient and family, PCP, specialists, home care nurse, and the transportation company. She coordinated with each frequently via phone, email, and huddling in clinic throughout the week. The patient has now been stable with no additional emergency department visits or admissions over past 4 months. Insulin was recently discontinued due to stable blood sugars, A1C has gone from 9.1 to 6.6, weight is stable at 175 lbs (203.5 at enrollment), blood pressure is now controlled at 110/60 and kidney function has improved per labs! Patient is taking occasional Tylenol for pain.

Both the patient and her daughter were very appreciative of the care and coordination Susan provided. The patient said with a smile and laugh, “Thank you Ms. Susan, I love you.” Her daughter said, “Thank you so much for taking such good care of my Mother.”

Next Issue: April 22, 2013

 

 

March 25, 2013

GOOD NEWS: Streamlining Financial Reporting!

Thank you for your efforts in reporting PCMH expenditures during the first year of MiPCT. These data have been very helpful for us to understand what is involved in implementing the project at the practice and PO levels. We have also listened to your feedback on the difficulty of reporting and tracking some of these items. Therefore, to balance information need with reporting burden, POs will no longer have to report practice transformation expenses. This is effective immediately as of the Q1 financial quarterly report that is due on April 30. As you may already be familiar from last year’s webinars, POs are not responsible for populating MiPCT revenue received (as we receive this data directly from the payers).

Please DO continue to collect Care Management expenses and Care Manager detailed information. Accurate information on care manager staffing and other expenses is critical and will be used in determining whether you have met your 80% required care manager staffing sufficiency requirement.

Also, as a reminder, beginning with your Q1 2013 report, you will be required to report Care Manager activity (number of phone visits, number of face to face visits, and number of unique patients served by practice, by Care Manager and by payer) on the financial quarterly report template. Please submit questions you have about this process to mipctdemo@michigan.gov.

Reminder: Practices Must Enroll in CHAMPS

Please remember that any practice that wishes to receive Medicaid MiPCT payments needs to ensure they are enrolled in the CHAMPS system within MDCH. Medicaid cannot send practice transformation payments until that process is completed.

Stories of Your Care Management Success:

Rebecca Joostens, Hybrid Care Manager, Spectrum Health Grand Rapids Family Medicine

Rebecca Joostens, RN, is a Hybrid Care Manager at Spectrum Health Medical Group, Grand Rapids Family Medicine. Rebecca has been working with a couple insured by Blue Care Network. The provider referred their case to Rebecca. Both patients have been seen at the practice for a long time and have diabetes, HTN, and hyperlipidemia and are obese. The husband also has arthritis and GERD. He is 60; she is 59. When care management services started the husband’s A1C was 8.4 and the wife’s was 11.3. The husband was struggling with vertigo, headaches and extreme fatigue (sleeping most of the day). He was having a difficult time concentrating on lifestyle changes to improve/manage his blood sugars. His diabetes was being treated with oral medications and he was very resistant to the idea of insulin. The wife was even more poorly controlled and already prescribed a-mix insulin. She was very non-adherent to this medication, often skipping or decreasing doses. They struggled to afford medications and would cut down on frequency of medication dosing to decrease quantity/cost.

Rebecca was aware of the couple’s history of poor medication compliance secondary to multiple side effects from medications, along with their health literacy needs and financial restrictions. She was able to identify the couples’ health literacy needs related to the importance of diet, exercise and weight loss to better manage their chronic illness. The couple initially lacked a readiness to change. Rebecca considered these issues as she developed interventions to engage the couple in their own health care. She began by discussing with them the connection between better blood sugar control and prevention of future complications. She worked with their practice’s on-site pharmacist to identify cost effective medication options for both patients and referred them to other pharmacies with cost effective drug plans to assist with medication costs. Rebecca made many contacts with the patients to assist in goal making regarding managing arthritis pain, addressing lack of energy by increasing physical activity, improving food choices and med adherence. She used motivational interviewing to initiate insulin therapy as both patients were strongly resistant to moving forward from oral agents to insulin therapy.

The improved health outcomes realized by both these patient include improvements in A1C, LDL, and blood pressure. His A1C is 6.6 (down from 8.4) and her A1C is 6.7 (down from 11.3). His LDL cholesterol dropped 30 points. Both have demonstrated a 10 point drop in their systolic blood pressure. They are both more active. His dizziness and extreme fatigue have resolved and he feels very good about himself because of the physical activity. They both take all their medications nearly 100% of the time. They do not skip medications because of cost issues (most of their medications are now on the $4 dollar plans at various pharmacies). The husband threw away all the sweets out of the house and the wife now grocery shops for healthy, low carb foods. They have stopped their evening snacking on potato chips and ice cream. Their progress has been slow and steady. Both of the patients and Rebecca believe they have made long term changes in their lives.

The husband stated to Rebecca, “I told you this last time we spoke but I have to say it again today. I know that we are here [at a controlled A1C and feeling very good] because of you. You didn’t give up on calling us to follow up on how we were doing and your persistence made me throw away my ice cream and snicker bars and get on track”. Rebecca has demonstrated through the success of this case that care management activities improve the lives of patients by assisting them to manage their health care more effectively.

MDC’s March 2013 MiPCT All-Payer Patient Lists Released to POs

The Michigan Data Collaborative posted the March 2013 MiPCT All-Payer Patient lists the week of March 18, 2013. An email announcing the release was sent to Dashboard users.

The All-Payer Patient lists can be found on the Download PO Reports tab of the MDC MiPCT dashboards. The zip file for your PO includes an all-practice patient list and individual lists for each practice in your PO.

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_2013_03.

MDC plans to release the MiPCT All-Payer Patient lists every third week of each month.

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.jsp).

MDC Announces Enhancement 2.02 for the MiPCT Dashboards

MDC plans to release enhancement 2.02 of the MiPCT Dashboards on Tuesday, March 26th. This enhancement includes:

  • Population Summary dashboards – Added a Risk Group Range column to the Member Risk Levels table. This column provides the numerical risk score range for each risk category (Very High, High, Medium, etc.)
  • Quality Measures Summary dashboards – Changed column heading in the Quality Measures by Payer table from “Comm” to “Commercial.” This column includes data for all commercial payers.
  • Quality Measures Summary dashboards – Changed the Quality Group label from “Diabetes Overall” to “Diabetes.”
  • Utilization Summary dashboards – Updated the measures order in the graph to match the order in the table.

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.

Register Your New Complex and Hybrid Care Managers NOW: April MiPCT Complex Care Management Course Available

 To accommodate PO interest in timely MiPCT Complex Care Management training, there will be a CCM course April 15 – 18, 2013 in Lansing.

Registration is available at the following link: https://jodyooo.wufoo.com/forms/april-1518-2013-mipct-ccm-training-in-lansing/. Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in the MiPCT CCM training session.

The CCM course includes training for billing PDCM/MiPCT codes for the BCBSM commercial, BCN, Medicare Advantage payers. This is key to increasing the volume of G and CPT code billing, a key focus area for this year.

Please keep in mind that development of the pilot self-paced CCM course is in the early stages, and will not be offered in the near future. Hence, it is key to register for in-person training in a timely way.

MDCH Seeking MiPCT Volunteers for NICU Follow-Up Statewide Workgroup

The Michigan Department of Community Health (MDCH) is moving forward with plans for a statewide coordinated perinatal system. Implementation of a Regional Perinatal System is the first strategy in the State of Michigan Infant Mortality Reduction Plan released in 2012.

Using recommendations from the Perinatal Guidelines (Perinatal Regionalization: Implications for Michigan, 2009; AAP’s Levels of Neonatal Care, 2012), MDCH is establishing a subcommittee to determine a statewide system to facilitate NICU graduate follow-up. NICU follow-up care involves home visitation, developmental assessment, care coordination, linkages to community services, medical services for acute and chronic conditions and preventive services in the medical home.

MDCH is seeking one or two volunteers from MiPCT to participate in the statewide NICU follow-up workgroup. We are specifically looking for a pediatrician and a family physician involved in the development of a medical home as part of MiPCT with a good sense of the role of the medical home in providing care to NICU graduates.

If you want more information or you would like to volunteer, please contact Trudy Esch at escht@michigan.gov. We welcome and look forward to participation from MiPCT.

For a copy of Perinatal Regionalization: Implications for Michigan from 2009 see:

http://www.michigan.gov/documents/mdch/1116_04_01_09_274917_7.pdf.

For a copy of the State of Michigan Infant Mortality Reduction Plan see:

http://www.michigan.gov/documents/mdch/MichiganIMReductionPlan_393783_7.pdf

For a copy of the AAP’s 2012 Levels of Neonatal Care see:

http://pediatrics.aappublications.org/content/130/3/587.full.html

 Care Management Staffing Levels

Last week, all POs received communication about where each stands in relation to meeting the 80% care management sufficiency ratio required in the 2013 MDCH/PO/Practice contracts. Many POs continue to meet and exceed the 80% ratio, and on behalf of the project we applaud them! Other POs are working hard to close the gap and many have already conveyed that they will have good progress to report soon (and several had corrections to the way that they reported staffing in their 4 Q 2012 reporting). We look so forward to the good progress that is occurring and know that all understand the importance of meeting the 80% level by June 30, 2013, as POs who do not meet the 80% level as of this date will not be able to continue to participate in the project.

Next Issue: April 8, 2013

March 11, 2013

WANTED! Two New Members for the MiPCT Performance Incentive Committee

The Performance Incentive Subcommittee is seeking nominations for 2 positions:

1. PO Medical Director

2. Physician from an MiPCT Practice

The Performance Incentive Subcommittee will be meeting 1-2 times per month this spring at MPHI in Okemos to select the 2014 Performance Incentive Metrics.

Please use the following link and complete the online nomination form for yourself or another candidate who agrees to be nominated: https://jodyooo.wufoo.com/forms/performance-incentive-nomination-form/

Contact Dana Watt through the MiPCT Demo mailbox MIPCTDEMO@michigan.gov or (517) 373 4246 for further information about the Performance Incentive Subcommittee.

 Correction: Quarterly Financial and Narrative Reports Due by April 30, 2013

In the MiPCT Monday FLASH, we published the wrong due date for Quarterly Financial and Narrative reports. Please note that while Quarter 1 2013 ends on March 31, the due date is April 30, 2013. We are sorry for any confusion this may have caused. The templates will be available on March 22.

MiPCT Data and MDC Dashboards Webinar Recording Posted

On February 27, 2013, MDC hosted a webinar to provide an update about recent and future MDC deliverables including data updates, new dashboards and reports, and the all-payer patient lists. To listen to the webinar, view the slides used in the presentation, or review the related Q&A document, click the following link: https://mipctdemo.wordpress.com/resources/presentations/.

Potential Effect of Sequestration on Monthly Payments to Practices and POs

 As you know, President Obama signed an order that imposes across-the-board Federal spending reductions (also known as sequestration) for Federal payments effective as of April 2013. Though Congress and the President continue discussions and action could still be taken to prevent the need for such reductions, we are sharing information prospectively about the likely impact on MiPCT. If Congress does not take action to avert this, monthly payments to practices and POs will be reduced by 2% beginning April 1, 2013 and this will continue until there is resolution about the Federal budget and Federal deficit. We will continue to monitor the situation and share updates.

 BCBSM 2013 MiPCT Care Management/Coordination Funding Statement

 Appropriately servicing and billing G and CPT codes for BCBSM and BCN patients who would benefit from care management is a major initiative for 2013 and 2014. As discussed at the March 8, 2013 PGIP Quarterly meeting, BCBSM has issued a statement that outlines the approach and requirements that qualify an organization for “make-whole” funding, should it be needed. The full statement is attached. Highlights include:

 • POs must have hired and trained at least 80% of the care managers needed to meet the MiPCT standards for number of care managers

 • Every MiPCT-participating practice in the PO must have begun submitting PDCM claims

 • Engaging at least 10% of eligible adult members (i.e., members on their monthly lists) will be eligible for make-whole payments. (For POs that have not engaged at least 10% of eligible adult members, BCBSM will consider overall program experience and evidence of concerted, good faith effort in determining eligibility for make-whole payments)

 • The $3pmpm is not a cap; providers may bill PDCM codes equivalent to more than $3pmpm.

BCBSM MiPCT/PDCM Update Webinar Announced 

BCBSM is holding a third MiPCT/PDCM Update Webinar on Monday, 3/18 from 3:00 to 4:30 p.m. During this webinar, we will provide MiPCT/PDCM program updates and present the new PDCM billing codes. In addition, we will address any questions related to the MiPCT/PDCM program.

If you were not able to attend one of the two prior webinars (held on 2/21 and 2/25), please make every effort to participate this webinar, as we will be providing important updates and seeking provider feedback.

Here are the webinar details:

Login: https://www.webmeeting.att.com

Meeting number: 8774119748

Access Code: 5884739

Call number: 877-411-9748

Access code: 5884739

Stories of Your Care Management Success:

Cathy Healy-Steggerda, Care Manager, Spectrum Health Sparta Family Medicine

Cathy Healy-Steggerda is a care manager at Spectrum Health Sparta Family Medicine. During her work, Cathy came in contact with a patient who had struggled with uncontrolled diabetes for many years. The patient indicated she was ready for a change in her diabetes treatment, and asked for help.

Cathy initiated a discussion with the patient. She reviewed the basics of diabetes treatment with the patient. When healthy food choices and amount of meals to be eaten per day were presented, the patient smiled and stated:

 “I have heard this for years and never paid any attention to it. It makes sense the way you just presented it. I have only eaten one meal for years. I can change this now.”

Cathy worked with the patient and communicated updates to the nurse practitioner, who responded by making adjustments in the patient’s insulin to improve blood sugar control. A follow-up call was made one week later, and the patient reported her blood sugars were less than 200 for the first time in 10 years!

Cathy’s patient was appreciative of the education and support she received stating:

 “I thank you for explaining what happens to me when I don’t eat right. It makes sense to me now.”

Cathy’s interventions, collaboration with the provider, and engagement with the patient has set the stage for positive health outcomes for this patient for years to come, and the potential to avoid diabetes related complications.

 MDC Announces Enhancement 2.01 for the MiPCT Dashboards

MDC released enhancement 2.01 of the MiPCT Dashboards on Thursday, March 7th. This enhancement includes:

• Two new Utilization dashboards:

o MiPCT ED Utilization Dashboard –

Shows ED Utilization data for all payers

o PO ED Utilization Dashboard –

Shows ED Utilization data for only your PO

• Two new ED Utilization reports:

 o ED Summary Report –

Includes a summary of the number of ED visits for each patient during the reporting period

 o ED Detail Report –

Includes detailed information about each ED visit by a participating patient

 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@umich.edu.

Register Your New Complex and Hybrid Care Managers NOW: April MiPCT Complex Care Management Course Available

 To accommodate PO interest in timely MiPCT Complex Care Management training, there will be a CCM course April 15 – 18, 2013 in Lansing.

Registration is available at the following link: https://jodyooo.wufoo.com/forms/april-1518-2013-mipct-ccm-training-in-lansing/

Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in the MiPCT CCM training session.

The CCM course includes training for billing PDCM/MiPCT codes for the BCBSM commercial, BCN, Medicare Advantage payers. This is key to increasing the volume of G and CPT code billing, a key focus area for this year.

Please keep in mind that development of the pilot self-paced CCM course is in the early stages, and will not be offered in the near future. Hence, it is key to register for in-person training in a timely way.

Next Issue: March 25, 2013

February 25, 2013

Patient Advisory Council Member Nominations Close This Week

A Patient Advisory Council (PAC) is being convened as an advising resource to the Steering Committee, subcommittees and other MiPCT groups (PO Advisory Council, etc.). The goal is to ensure that the patient voice is incorporated in the implementation and operations of the MiPCT. The council will be comprised of patients serviced by the MiPCT. We are recruiting nominations for a state-wide PAC which is expected to meet approximately three to four times per year. In-person attendance is preferred, though phone participation can be accommodated. Members will be eligible for mileage reimbursement.

Members should be:

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

b. Able to use their own experience constructively

c. Able to see beyond their own experience

d. Able to listen to and hear differing opinions

Member nominations can be submitted at: https://jodyooo.wufoo.com/forms/patient-advisory-council-nomination-form/

The nomination period will extend until February 28.

Now Available: 2013 Learning Activity and Care Manager Education Requirements– A User’s Guide

To provide greater understanding and clarity around the practice learning activity requirement and the care manager education requirement in the 2013 MDCH PO/Practice contractual agreements, a user guide is now available (copy attached). In summary, the guide clarifies that:

• Each Care Manager must complete a total of twelve hours of Care Manager education per year. This can be satisfied either through twelve hours of MiPCT-led Care Manager webinars/sessions, or through eight hours of MiPCT-led Care Manager webinars/sessions and four hours of PO-led Care Manager training per year. No preapproval is necessary for PO-led Care Manager education sessions.

• Each Practice Team (including at least one physician from the practice, and at least one other practice team member) must complete eight hours of learning activity requirements during calendar year 2013. The following activities require no additional preapproval to be counted toward the Learning Activity practice requirement: 1) Town Hall dinners, 2) MiPCT Learning Collaboratives (existing waves are full but additional sessions will begin again in October 2013), 3) monthly practice Medical Home meetings, and 4) attendance at the annual MiPCT Summit (in planning for Fall 2013). Alternatively, POs and practices may elect to apply for other non-MiPCT led activities. These require preapproval using the form available at: https://mipctdemo.wordpress.com/resources/mipct-documents-and-presentations/mipct-learning-activity-approval-form/ and should be submitted at least four weeks prior to the event at mipctdemo@michigan.gov.

Register Your New Complex and Hybrid Care Managers NOW: March MiPCT Complex Care Management Course 

To accommodate PO interest in timely new Complex Care Management training, MiPCT team is offering a two-part March CCM session:

• Session I – Lansing – March 4, 5, and 7, and

• Session II – Lansing – March 13

 (Keep in mind that completion of both sessions, one and two, is required.)

There are many available openings for the March session. Registration is on a first-come, first-served basis and is available at the following link:https://jodyooo.wufoo.com/forms/march-2013-mipct-ccm-training-in-lansing/

Please remember that POs are responsible for timely enrollment of new complex and hybrid care managers in MiPCT CCM training. The CCM course includes training for billing PDCM/MiPCT codes for the BCBSM commercial, BCN, Medicare Advantage payers. This is key to increasing the volume of G and CPT code billing, a key focus area for this year.

Please keep in mind that development of the pilot self-paced CCM course is in early stages and will not be offered in the near future. Hence, it is key to register for in-person CCM course training in a timely way.

MDC’s February 2013 All-Payer Patient List Released to POs

The Michigan Data Collaborative (MDC) posted the February 2013 All-Payer Patient Lists the week of February 18, 2013. An email announcing the release was sent to Dashboard users.

Note: The BCBSM Medicare Advantage group is not included in the February 2013 All-Payer Patient List. MDC will release the BCBSM Medicare Advantage patient list as a separate file when it becomes available.

MDC plans to release the All-Payer Patient List every third week of each month.

The All-Payer Patient List can be found on the Download PO Reports tab of the MDC MiPCT Dashboards. For information about the All-Payer Patient List, 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.jsp).

Now Available: MiPCT Patient list Webinar on mipctdemo.org Website

Did you ever wonder why a patient that you think should be on the member list is not? To help answer questions and to spread understanding of the criteria used by each payer to include a patient on the MiPCT patient list distributed each month by the MDC to POs, a webinar is now recorded and available at: https://mipctdemo.wordpress.com/resources/presentations/

The streaming recording and download recording are listed as the first two bullets under “Meetings, Q&As and Webinars” at the top of the page.

MiPCT Data and MDC Dashboards Update Webinar Scheduled for February 27 

On February 27th from 2:00PM-3:00PM, a webinar will be held to provide an update about recent MDC activities and deliverables including:

• Version 2.0 release of the MDC MiPCT dashboards

• When to expect ED Utilization dashboards

• What to expect in future releases and enhancements

• BCN data timing

• All-Payer Patient Lists

Event Details:

Event: MiPCT Data and

MDC Dashboards Update

Date: Wednesday, February 27, 2013

Time: 2:00 PM Eastern Daylight Time

Event Number: 668 119 534

Event Password: mipct

To Join the Online Event and Teleconference:

1. Go to https://mphievents.webex.com/mphievents/onstage/g.php?t=a&d=661960973

2. Click “Join Now”.

3. Follow the instructions that appear on your screen.

To Join the Teleconference Only:

Call-in toll number (US/Canada): 1-650-479-3207

Access code: 668 119 534

CMS Emphasizes Timeliness of Provider File Updates

CMS has communicated that they want to reaffirm the importance of timely reporting of changes in practice information. CMS expects better cooperation from POs and practices for submission of this important information. Examples include changes in identifiers such as NPIs and PTANs, changes regarding new and departing physicians at practices, and changes within the practice (such as a practice closing, etc.). POs are required to submit change forms within 5 days of learning of the change (located at: https://mipctdemo.wordpress.com/resources/mipct-documents-and-presentations/physician-and-practice-change-form-v5-2/). Change forms should be returned to: mipctdemo@michigan.gov.

Update from the MiPCT Transition of Care (TOC) Workgroup

The MiPCT Transition of care workgroup formed in late November 2012 to:

• Identify the current state of implementation of the following transition of care MiPCT standard intervention: MiPCT Care Manager conducts post discharge phone call 24-48 hour post hospitalization, and subsequent phone call weekly times four.

• Develop recommendations to share with MiPCT Clinical Leaders based on understanding of current state implementation of the TOC intervention.

Members of the TOC work group include MiPCT PO Leaders, MiPCT Care Managers, Managers of MiPCT Care Managers, Master Trainers and Clinical Leads. Initially, the work group focused on gaining an understanding of the successes and challenges experienced by MiPCT care managers as they implement the TOC standard intervention.

The work group confirmed that the MiPCT standard intervention (described above) is working for many practices and care managers. However, a subset of care managers and practices are experiencing challenges when the volume of patients discharged in one day is high. Based on this understanding, the work group determined the next step was to conduct a review of the literature related to transition of care and stratification of patients at high risk for hospital readmission. The literature review reflects lack of consensus on methodology/tools to risk stratify patients at risk for hospital readmission.

The work group reviewed existing patient risk stratification tools and TOC initiatives such as BOOST, STARR, and RED.

The workgroup identified the importance of selecting a tool which has been in use and has initial findings of validity. Criteria also included “ease of use” by the MiPCT care manager to review the patient discharge summary in a timely manner, apply the tool, and determine patients who are high risk for hospital readmission. With the ability to identify the high risk TOC patients, the Care Manager will be able to prioritize work and conduct the post hospital phone call within 24 to 48 hours for the high risk TOC patients.

The TOC work group members have identified the LACE Modified tool, and the next step is to pilot this tool with a small number of MiPCT care managers. For review of the LACE Modified tool, please go to: http://tc.nphhi.org/Archive/NSN-Readmissions-Templates/LACE-Index-Scoring-Tool.aspx

Welcome & Introduction: Three New MiPCT Clinical Team Members

Please welcome three new MiPCT clinical team members. The new team members joined MiPCT early February, 2013. Paula Amormino RN, MSA, CCM, is a MiPCT Central Clinical Coordinator. Rose Seavolt, RN, is a MiPCT Regional Clinical Lead for the Lansing/Saginaw area. Maureen Koval, RN, is a MiPCT Regional Clinical Lead for the Grand Rapids/Muskegon area.

They are fully dedicated to supporting the implementation of care management within MiPCT. The following is a brief description of the positions:

Regional Clinical Lead:

This position has preceptor responsibility for new Care Managers in a defined geographic region, and provides support to MiPCT physician organization leaders in the assigned region. Preceptor responsibilities include individual Complex Care Manager (CCM), Hybrid Care Manager (HCM), and Moderate Care Manager (MCM) coaching/mentoring, and facilitation of care manager group discussions, networking and sharing best practices.

 The Regional Clinical Lead collaborates with the Master Trainers to identify Care Managers’ training needs, and to develop ongoing Care Manager curriculum, tools and resources. In collaboration with Master Trainers, this position contributes to the development of ongoing curriculum for MiPCT Care Managers, and provides training at a regional, and occasionally statewide, level.

Central Clinical Coordinator: The Central Clinical Coordinator will provide day-to-day support for the development of care management capabilities in the MiPCT primary care practices.

With the MiCMRC Senior Project Manager, MiPCT Medical Director, and MiPCT Clinical Leadership Team and Master Trainers, the Central Clinical Coordinator assists physician organizations with embedding care management in the MiPCT primary care practices. In addition, this position provides education, mentoring, and coaching of Regional Clinical Leads, Clinical Leads and Care Managers, as assigned.

 Quarterly Financial Report Revenue

Many comments have been made that revenue amounts on the Quarterly Financial Report website are inaccurate and that there is a desire to reconcile the online amounts with those of the POs. The revenue online is obtained from the payers and may not align with PO records for various reasons. MiPCT leadership is working with payers to obtain all revenues attributed to the project. We are expecting to have the revenue data for Quarter 1 completed by April 30, 2013 for all payers. The delay in reporting revenue data is attributable to funds paid through claims which require a 90 day run-out for completion. We appreciate your patience and cooperation with the delay in posting revenue to your reports.

February 11, 2013

Monthly Release Schedule for the Multi-Payer Patient List

 The Michigan Data Collaborative (MDC) plans to release the Multi-Payer Patient List the third week of each month.

 The exact release date may vary depending on when MDC receives the monthly patient list from each Payer. If the Payer lists are received earlier in the month, MDC will create and post the Multi-Payer Patient List earlier.

To announce the availability of the lists, MDC will send an e-mail notification and include a notice in the FLASH newsletter.

 If you have any questions, please send an email to MichiganDataCollaborative@umich.edu.

Medicaid Member List 101

In order for a Medicaid patient to be attributed to a MiPCT practice, members must have full Medicaid managed care coverage, with no other public or private insurance, and be assigned to a participating PCP as of the first of the month. If, during any month, a member does not fulfill the criteria above, he or she will not appear on a MiPCT practice patient list. If you have a patient that meets that criteria but does not appear on the list, please write the mipctdemo@michigan.gov mailbox with the subject line: Medicaid Member List Question.

Nomination Period Closes February 28th for Patient Advisory Council Member Recommendations

A Patient Advisory Council (PAC) is being convened as an advising resource to the Steering Committee, subcommittees and other MiPCT groups (PO Advisory Council, etc.). The goal is to ensure that the patient voice is incorporated in the implementation and operations of the MiPCT. The council will be comprised of patients serviced by the MiPCT. We are recruiting nominations for a state-wide PAC which is expected to meet approximately three to four times per year. In-person attendance is preferred, though phone participation can be accommodated. Members will be eligible for mileage reimbursement.

Members should be:

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

b. Able to use their own experience constructively

c. Able to see beyond their own experience

d. Able to listen to and hear differing opinions

Member nominations can be submitted at:

The nomination period will close on February 28.

MDC Announces Release 2.0 for the MiPCT Dashboards

MDC is excited to announce the upcoming release of the MiPCT Dashboards. Version 2.0 will be released on Friday, February 15th. This release will include:

• Updated claims and eligibility data through July 2012 for Medicare and Medicaid

• Addition of BCBSM claims and eligibility data for January 2010 – July 2012

• Addition of a Well Child Visits 15-months metric to the Quality Measures dashboards

• Grouped Quality Measures into the following three categories: Diabetes Overall, Adult Preventative, and Pediatric Preventative

• Updated Member Risk Level chart on the Population Summary dashboards

Prior to the release, there will be a short time period when the dashboards are unavailable. MDC will email users to let them know when the site will be down and when the updated dashboards and reports are available.

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@umich.edu.

BCBSM Care Management G-Code and CPT Code Billing for MiPCT Practices

The G9001 code may be billed for complex or moderate risk patients. Here are a few excerpts from the BCBSM PDCM Frequently Asked Questions document 10.8.12 update:

Who is eligible for care management services?

• Active BCBSM coverage that includes the BlueHealth Connection program

• One or more conditions that indicate that care management services have the potential to improve patient well-being

• A referral for care management services from a physician, certified nurse practitioner or physician assistant in a participating MiPCT practice at which the patient has an established care relationship

• Patient agrees to actively participate in an individualized plan of care

Are there any specific criteria associated with the G9001 code?

The G9001 code is the initial patient evaluation for moderate or complex patients. The G9001 may be billed only once per year, and must be conducted by an RN, PA, CNP, or licensed MSW; and may also encompass multiple visits, at least one of which must be face to face.

To access the PDCM FAQ document, please see:

https://mipctdemo.wordpress.com/resources/mipct-documents-and-presentations/pdcm_faq_2012-10-08-3/

 MiPCT CCM Course -Upcoming Dates

The MiPCT team recommends registering CCMs and HCMs for the March 2013 Complex Care Management Course if the individual has not previously completed the course.

The Complex Care Management Course will be provided in two sessions.

• Session I – Lansing – March 4, 5, and 7

• Session II – Lansing – March 13

• Completion of session one and two are required

The MiPCT March 2013 CCM course registration is available online starting 2/14/13: https://jodyooo.wufoo.com/forms/march-2013-mipct-ccm-training-in-lansing/

In March 2013, the MiPCT team will be piloting a self-paced version of the CCM course. More details will be shared as we progress with this pilot.

Care Manager Activity Reporting

Beginning with the financial report for 2013 Quarter 1 (due March 31), a new feature will be added to collect care manager activity data. Care Manager Activity reporting will require that the information listed below be reported for every care manager at every practice and by payer.

Two reporting options will be available:

1. Manual data entry directly into the financial reporting template.

2. Upload of standardized files.

a. Download a template from the website that includes a list of the care manager and practices for the current quarter. Upload a tab-delimited file after completion.

The second option will only work if the PO is able to generate a file that conforms to specific file requirements (e.g., tab-delimited text file) and contains practice unit and care manager IDs. Beginning this month we seek to work with POs who would like to test their ability to generate the appropriate file. While it may take some time to work with your system(s) to generate such a file, it could be much easier and more accurate than typing the information into the web application. Please contact Joan Moore, jmoore@mphi.org, if you are interested in working on the file upload option.

Care Manager Activity Fields (all fields are required)

• Practice

o Practice ID (prepopulated)

• Care Manager

o Last Name (prepopulated)

o First Name (prepopulated)

o Date of Birth (prepopulated)

Face-to-Face Encounters

o Medicaid

o Medicare

o BCBSM

o BCN

Telephone Encounters

o Medicaid

o Medicare

o BCBSM

o BCN

Unique Patients

o Medicaid

o Medicare

o BCBSM

o BCN

Town Hall Dinners

The MiPCT Town Hall dinners are intended to bring physicians and care managers together to share stories and experiences of the MiPCT transformation journey, as well as to share best practices and find solutions for challenging issues related to implementing care management into the workflow of MiPCT practices. Flyers are available for recruitment of teams.

The Learning Objectives include:

• Describe common challenges related to embedment of practice care management

• Describe the key components of successful care management

• Utilize shared experiences related to embedment of care managers in primary care practice.

The Practice Transformation Institute has designated this activity for a maximum of two (2) AMA PRA Category 1 Credits™.

The registration site can be found at:

https://jodyooo.wufoo.com/forms/registration-for-town-hall-dinner-meetings/

Attendees must register in advance. Dates and meeting locations are listed below for your convenience:

Tuesday, 3/19 Muskegon / Mia and Grace

Thursday, 3/21 Grand Rapids / Mangiamo! Italian Restaurant

Tuesday, 4/23 Livonia / Sweet Lorraine’s

Wednesday, 4/24 Troy / TBD

Thursday, 6/06 Okemos / Dusty’s Cellar

Care Management Corner: Stories of Success!

Terri Carmichael, RN, Hybrid Care Manager, Internal Medicine Pediatrics

 Terri Carmichael, RN, is a Hybrid care manager at Internal Medicine Pediatrics 1300 Michigan. She has been working with a patient covered by Medicare insurance who is 65 years old and a Vietnam Veteran. He lives alone. His diagnoses include COPD, underweight, chronic cervical pain, OA of the spine, depression, anxiety, constipation, ETOH abuse, a history of IV drug abuse and renal cell carcinoma in 2010.

 He was anxious and has PTSD issues from his experience in the military. He spent time in prison as a result of his IV drug abuse in his youth. When he comes in for an appointment he always sits in the farthest chair in the waiting room next to a window. He does not like to have the door closed ever when he is in the exam room. Closed and confined areas remind him of time in Vietnam and in prison. His former PCP would see him monthly to assist with pain control and to prescribe the appropriate medications.

 His PCP left the practice and he needed to be transitioned to a new PCP. The new PCP recommended the patient work with a care manager and initiated a warm handoff to Terri. The PCP felt that the patient needed someone to spend more time developing a relationship with him and asked Terri to see the patient. He weighed 80 pounds when Terri first started working with him. He does not drive. He frequently did not show for appointments. When he did show up for appointments, he was often agitated or angry and demonstrated this through outbursts and yelling obscenities. His PCP had wanted him to have an MRI and a colonoscopy, but the patient cancelled them several times. Terri began working with him and found out he was terrified that his cancer had returned and spread.

 Previous to care management interventions the patient would call the ambulance or go to the ED several times a year to address his chronic health conditions. Terri investigated possible reasons for this by reviewing the patient history and through interviews. She discovered that the patient was on narcotics and had no regular bowel program, which was a frequent reason for ED visits. Terri arranged transportation for the patient as well as assistance with getting meals. She offered education on dietary supplements and provided nutritional counseling. Terri communicated the patient’s individualized needs to office staff to make them aware of his anxiety about being in an exam room with door shut. The PCP, office staff and medical assistants go out of their way to make him feel welcome and are sensitive to his specific requests such as keeping the door open a crack. They always room him in an exam room with a window in it so he doesn’t feel so enclosed. He now sees Terri prior to the PCP appointment. Pain meds are being titrated by the PCP regularly, which is providing better pain control. The patient agreed to the MRI and colonoscopy. The results indicated no evidence of cancer spread. He is now pleasant to office staff and has gained trust in his new PCP and in Terri.

 Since working with Terri and developing a more positive relationship with his care team, the patient has not missed any appointments. He has had only one trip to the ED in the past five months. He has gained weight and is participating in his plan of care. He is also pleasant to speak with and always polite. He stated to Terri, “I feel like you really care about me and you are concerned about me as a person and not just a number.” Terri took the time to get to know her patient and sought to understand the reason behind his behavior. This allowed her the opportunity to get to know him better and to engage him in managing his own health care.

Do you have a Care Manager Success Story to share with us? We would love to hear from you!

 Please go to https://jodyooo.wufoo.com/forms/stories-of-your-care-management-success/

Next Issue: February 25, 2013

January 28, 2013

Your Help Needed: Patient Advisory Council Member Nominations

A Patient Advisory Council (PAC) is being convened as an advising resource to the Steering Committee, subcommittees and other MiPCT groups (PO Advisory Council, etc.). The goal is to ensure that the patient voice is incorporated in the implementation and operations of the MiPCT. The council will be comprised of patients serviced by the MiPCT. We are recruiting nominations for a state-wide PAC which is expected to meet approximately three to four times per year. In-person attendance is preferred, though phone participation can be accommodated. Members will be eligible for mileage reimbursement.

Members should be:

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

b. Able to use their own experience constructively

c. Able to see beyond their own experience

d. Able to listen to and hear differing opinions

Member nominations can be submitted at: https://jodyooo.wufoo.com/forms/patient-advisory-council-nomination-form/The nomination period will extend until February 28.

Medicaid Care Coordination Payments

Medicaid care coordination payments are issued on a quarterly basis and the billing cycle follows the calendar year (CY).

 During Year 1 of the demonstration, the third quarter (July 1 – September 30) care coordination payments were issued on October 4, 2012 for most POs. However, due to a processing error, some POs did not receive their payment on that date.

 Care coordination payments for the fourth quarter of CY 2012 were released on January 17, 2013. The POs that did not receive their third quarter payments in October received their third and fourth quarter payments as a lump sum in January.

 Please be aware that the remittance advice received by POs for the third quarter payments inadvertently omitted the date range identifying the quarter for which the payments were made. On behalf of Medicaid, the MiPCT Team would like to apologize for any confusion this may have caused.

 Q4 Narrative and Financial Reports and Registry Data Due January 31, 2013

Reminder: The Quarterly Narrative and Financial Reports for fourth quarter 2012 are due January 31, 2013 and should be submitted to the MiPCT demo mailbox. Financial data should be submitted here: https://mipct.mihealth.org. To the extent possible, payer data has been pre-loaded. When data is not yet available from payers (e.g., G/CPT code payments), data will be loaded retrospectively as it is made available to us.

 The POs should also submit the registry/EHR data specified in the 12-month incentive metric document along with the report. Further information is available at the following link: https://mipctdemo.wordpress.com/resources/mipct-documents-and-presentations/12-month-metrics-final/ Contact MDC directly with registry/EHR data questions at michigandatacollaborative@med.umich.edu.

 Six Month Incentive Payment Reports Available

Your Six Month MiPCT Performance Incentive Scoring and Payment Reports are now available and posted on the MiPCT Reporting web portal (www.MichiganDataCollaborative.org). The MiPCT web portal users in your organization can access the reports by logging in to the web portal and clicking on the “Download PO Report” tab at the top of the screen. They will see a zip file with “Performance Incentive Reports” and your PO’s name in the title. This file will contain PDFs of your PO’s scoring summary, payment summary and an FAQ document explaining the six month metrics and incentive payment calculation and distribution. If you are a MiPCT web portal user and are having trouble logging in or accessing the reports, please contact MDC-Accounts@med.umich.edu.

The updated scores include any changes resulting from PO inquiries following the first round of score distribution and also updated required care manager numbers that result from a using updated member count information from BCBSM that excludes self-insured groups that have not yet opted in to the MiPCT. This resulted in decreases in the number of care managers required for some POs.

 Medicare payments are currently being processed are expected to be distributed to your PO by January 31st. This allows for POs to receive the incentive funds prior to the close of their 4Q financial closings for many POs. The Medicaid payments will be released in February. POs should look for their six-month Incentive payments around February 7, 2013.

 As we obtain payment date information for BCN, we will post it in the FLASH.

 We’d like to thank you for your assistance and patience during this first incentive calculation process! Much care was taken to ensure accuracy and equity to set up robust processes for this first distribution. The lag time between the receipt of the data necessary to calculate incentives and distribution of incentives will be much shorter in the upcoming periods.

CCM Course Offering in March

 The MiPCT Complex Care Management (CCM) Course Sessions I and II, Jan 22, 23, 24 and Feb 12, 13, 2013, are at capacity, with 35 Complex and Hybrid care managers attending this offering.

 We are actively planning for the future Complex Care Management courses. This week the MiPCT team will send an e-mail to MiPCT PO leaders to request information about the CCM/HCMs currently hired who need to complete the MiPCT CCM course. Once we understand the number of CCM/HCMs who need to complete the CCM training we will announce the plan to offer future MiPCT CCM courses. Our goal is to provide the CCM course in a timely manner to meet the training needs of the Complex and Hybrid Care Managers.

 Town Hall Dinners 

The MiPCT Town Hall dinners are intended to bring physicians and care managers together to share stories and experiences of the MiPCT transformation journey, as well as to share best practices and find solutions for challenging issues related to implementing care management into the workflow of MiPCT practices. Flyers are available for recruitment of teams.

The Learning Objectives include:

• Describe common challenges related to embedment of practice care management

• Describe the key components of successful care management

• Utilize shared experiences related to embedment of care managers in primary care practice.

The Practice Transformation Institute has designated this activity for a maximum of two (2) AMA PRA Category 1 Credits™.

 The registration site can be found at:

https://jodyooo.wufoo.com/forms/registration-for-town-hall-dinner-meetings/

Attendees must register in advance. Dates and meeting locations are listed below for your convenience:

Tuesday, 2/5 Okemos Dusty’s Cellar

Tuesday, 3/19 Muskegon Mia & Grace

Thursday, 3/21 Grand Rapids Mangiamo!

Tuesday, 4/23 Livonia Sweet Lorraine’s

Wednesday, 4/24 Troy TBD

Thursday, 6/06 Okemos Dusty’s Cellar

MDC Multi-Payer Patient List Released to POs Today

As a part of the new streamlined approach to MiPCT patient list distribution across all four (BCN, BCBSM, Medicare, Medicaid) payers on a monthly basis from the Michigan Data Collaborative (MDC), the updated Multi-Payer Patient List will be released to POs today. (This list replaces the previous list from December 2012).

Please keep in mind that the MiPCT patient lists distributed by the MDC each month are the best way to identify MiPCT patients who are eligible for MiPCT care management services. In 2013, you will see further improvements to the lists as additional fields are populated that may provide you with additional insight to help to identify patients who would most benefit from care management.

Note: The BCBSM Medicare Advantage (MA) group is not included in the January 2013 Multi-Payer Patient List. We will release the BCBSM MA patient list as a separate document when it becomes available.

Going forward, MDC plans to release the Multi-Payer Patient List every third week of each month.

 The Multi-Payer Patient List can be found on the Download PO Reports tab of the MDC MiPCT Dashboards

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

 Four New Steering Committee Members 

MiPCT has four new Steering Committee members in 2013: Ted Makowiec, Roger Prong, MD, Paul Szilagyi, and Felicia Williams, MD. Ted is joining us from the University of Michigan Benefits Office as an employer representative. Dr. Prong, MD, is joining us from OPNS and represents the Michigan Primary Care Consortium. Paul joins us from Henry Ford Medical Group and is a PO representative. Dr. Williams, MD, joins us from BCN and is a payer representative.

Care Management Corner: Stories of Success!

Robin Boonstra, LPN, Moderate Case Manager, Wexford Mercy PHO

 Robin works with providers at Great Lakes Family Care in Cadillac, Michigan. A patient was referred to Robin by Gayla Finstrom, RN, the complex case manager in the practice. The patient had frequent ED visits for ambulatory sensitive conditions. Most often he presented to the ED via ambulance, complaining of constipation. Prior to working with a case manager he was seen ten times in the ED over the course of five months.

 The patient’s behavior did not demonstrate understanding of how to manage his own care or how to access the appropriate health care services at the appropriate time (i.e. contact his PCP for constipation issues during normal business hours).

 Robin began communicating with the patient multiple times a day to address his health concerns and to assist him in identifying the appropriate actions to take to address these issues. During her frequent patient contacts, and a conference with the provider, it was determined that the patient was experiencing anxiety which was contributing to his reactions to health symptoms. As the patient’s health concerns decreased and his coping and decision making improved, Robin’s contact with the patient decreased to daily and currently he calls into the office to review his symptoms approximately once a week. Robin’s frequent contact, teaching, and support have resulted in the patient avoiding an ED visit since case management services began.

 Robin worked closely with the patient’s PCP to identify the key areas of concern and to develop a care plan in partnership with the patient. This included the addition of anti-anxiety medications.

The patient has expressed appreciation to Robin and the care team at Great Lakes Family Care for his improved health and independence.

 —

Do you have a Care Manager Success Story to share with us? We would love to hear from you! Please go to https://jodyooo.wufoo.com/forms/stories-of-your-care-management-success/

Next Issue: February 11, 2013

January 14, 2013

Medicaid Payments to be Released January 17

The fourth quarter (October – December 2012) Medicaid care coordination and practice transformation payments are scheduled to process on Thursday, January 17, 2013.

Medicare Care Coordination Payments Released

Medicare MiPCT care coordination payments were mailed out last week. This payment includes funds received from Medicare through November 30, 2012. As you may recall, a payment was not made in November because CMS was delayed in making the payments for October 2012. So this payment includes a bulk of the care coordination payments made for the October and November months of service. However, during this time, U of M was also able to process overpayment recoveries (take backs) from Medicare. Due to a processing error made by Wisconsin Physician Services (the Medicare administrative contractor), a very large number of MiPCT Medicare claims were recouped erroneously for the month of February. These claims for February were repaid around September 2012 (and POs received these extra February payments at the end of October). To date, most POs have been paid twice for many of their beneficiaries for the month of February. In this payment, U of M will be recouping the payments from POs that have been recouped by CMS (the take backs will be subtracted from the amount that was to be paid to each PO). The take backs will be reflected on the EOP that the POs receive, and in addition, the PO will receive an Excel file that details the payment that has been taken back by CMS. Please note that in addition to the large percentage of erroneous take backs for February, there are a few ‘legitimate’ take backs that may appear on your EOP for members that were paid for initially, but CMS subsequently found out that they were not eligible for payment (they may have passed away prior to the date of service, or dropped out of Medicare fee for service).

Good News: MiPCT Practices Eligible for New CMS Codes for Discharge Planning

We have received and researched PO queries regarding whether or not MiPCT practices are eligible to bill for the two new Medicare Physician Fee Schedule codes introduced on 1/1/13 for care transition services (99495 and 99496) that allow community based providers (including non-physician providers) to bill for non-face to face services involved in post discharge planning. These codes require that there also be a face to face visit within 7 (99496) or 14 (99495) days of the discharge. The new codes are intended to supplement hospital discharge management and can only be billed by one provider during a 30 day period. Information on these codes is attached in the briefing from Woodcock and Associates.

CMS has clarified that although this is included in expectations for the care coordination work that medical homes are expected to be doing and are getting paid for with the CMS monthly fee, providers can still bill for any FFS Medicare service that they would otherwise be eligible to bill for in the absence of the demonstration. Thus, providers are not penalized for participating in the demonstration and are entitled to bill for all services covered under the physician fee schedule.

Your Help Needed: Patient Advisory Council Member Nominations

A Patient Advisory Council (PAC) is being convened as an advising resource to the Steering Committee, subcommittees and other MiPCT groups (PO Advisory Council, etc.). The goal is to ensure that the patient voice is incorporated in the implementation and operations of the MiPCT. The council will be comprised of patients serviced by the MiPCT. We are recruiting nominations for a state-wide PAC which is expected to meet approximately three to four times per year. In-person attendance is preferred, though phone participation can be accommodated. Members will be eligible for mileage reimbursement.

Members should be:

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

b. Able to use their own experience constructively

c. Able to see beyond their own experience

d. Able to listen to and hear differing opinions

Member nominations can be submitted at: https://jodyooo.wufoo.com/forms/patient-advisory-council-nomination-form/

and the nomination period will extend until February 28.

Care Management: What’s in it for a Patient?

Care Management steps include referral, screening, enrollment, intervention/management and case closure. Enrollment occurs once the Care Manager and Primary Care Physician have identified the patient meets the criteria for moderate or complex care management and will benefit from this service. A critical step in enrollment is engaging the patient and describing the “Why” and “What” of care management; essentially sharing with the patient and care giver “What’s in it for the Patient”. A one page patient Care Management handout does just that. This hand out is designed as a template and a practice can add their address, logo and adapt the tool to meet their needs. This Care Management handout template is attached, and it will be posted on Wednesday on the http://www.mipctdemo.org website on the Care Management dropdown menu.

Town Hall Dinner Flyers

Flyers are now available to assist POs in recruiting physician/care manager teams to attend the MiPCT Town Hall Dinners. The dinners are intended to bring physicians and care managers together to share stories and experiences of the MiPCT transformation journey, as well as to share best practices and find solutions for challenging issues related to implementing care management into the workflow of MiPCT practices.

The Learning Objectives include:

• Describe common challenges related to embedment of practice care management

• Describe the key components of successful care management

• Utilize shared experiences related to embedment of care managers in primary care practice.

The Practice Transformation Institute has designated this activity for a maximum of two (2) AMA PRA Category 1 Credits™.

Learning Activity Forms Available

As you know, every MiPCT practice must have at least one Provider-led Care Team (i.e., a physician, care manager, at least one other practice member, and a PO representative) participating in either the MiPCT Learning Collaborative or other MiPCT-approved learning activity that directly addresses one or more MiPCT functional tiers. POs can now request approval for their learning activities by filling out the attached form and sending it to MiPCTDemo@michigan.gov at least four weeks before the activity takes place. The form can also be found on the mipctdemo.com website under Documents > Forms > Learning Activity Approval Form (https://mipctdemo.wordpress.com/resources/mipct-documents-and-presentations/mipct-learning-activity-approval-form/).

Q4 Narrative and Financial Templates Available

The financial template remains available for POs to enter 4th quarter financial reports (it is continuously available at: https://mipct.mihealth.org). The authorized users should use the same login credentials as last quarter. We have made only minor modifications to the template. As before, MiPCT will obtain and enter revenue and membership data for you. These data may or may not be populated by the time you begin data entry.

The narrative template is being disseminated under separate cover as an Excel spreadsheet. Fields have been added to capture practice level contract requirements (infrastructure and registry functionality) and performance incentive metrics (hospital discharge notifications and quality performance reporting). As in the past, the narrative report will be submitted to the MiPCT demo mailbox. When submitting the narrative report, also submit the reports from the practice registry/EHR as described in the 12-month incentive metric document, available here: https://mipctdemo.wordpress.com/resources/mipct-documents-and-presentations/12-month-metrics-final/

Should you have any questions, please direct them to the demo mailbox at: MIPCTDEMO@michigan.gov

Next Issue: January 28, 2013.