2013 Practice FLASH

December 16, 2013

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 you are approached by the evaluation team to assist with the focus group recruitment, we encourage your cooperation with this important component of the evaluation. If you 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

Physicians’ Corner: Choosing Wisely
by Kevin Taylor MD

Recently, a physician organization in southeast Michigan conducted an evening meeting amongst their provider colleagues about Choosing Wisely guidelines.  One of the physician leaders, a pathologist, stood up and commented on the American Society of Clinical Pathology guideline regarding vitamin D testing. Specifically, the guidelines states,  “Don’t perform population-based screening for 25-OH-Vitamin D deficiency.”  The guideline continues, “Vitamin D deficiency is common in many populations, particularly in patients at higher latitudes, during winter months and in those with limited sun exposure. Over the counter Vitamin D supplements and increased summer sun exposure are sufficient for most otherwise healthy patients. Laboratory testing is appropriate in higher risk patients when results will be used to institute more aggressive therapy (e.g., osteoporosis, chronic kidney disease, malabsorption, some infections, obese individuals).”

The pathologist noted that he sees thousands of vitamin D serology tests in his lab on a monthly basis, and believes most of these tests add very little value to the overall care of the patient.

As I left this meeting, I was struck by 2 things. One was that I was not aware of this Choosing Wisely guideline and appreciated the information. The second lesson for me was the power of the conversation.

Choosing wisely is about creating conversations amongst our colleagues, and with our patients.

Daniel B.Wolfson, Executive Vice President and COO of the ABIM Foundation, noted these conversations are how we change the culture of our care delivery model.  In one of his blogs (Sept 17, 2013), Wolfson referenced Atul Gawande’s recent article in The New Yorker (07.29.13), “Slow Ideas.” Gawande makes several salient points that should be considered when discussing how to implement the Choosing Wisely recommendations on the ground.

While referring to ways the status quo was changed for childbirth practices in developing countries, or hand-washing practices in the USA in the 1800s, Gawande notes: “(N) either penalties nor incentives achieve what we’re  really after: a system and a culture where X is what people do, day in and day out, even when no one is watching.”

Wolfson states that that through Choosing Wisely, we develop a culture and a new norm of intolerance of wasteful tests and procedures. That culture would be developed by conversations among physicians about the altruistic reasons they entered the profession, rather than the financial ones, and the new “norm” would be not ordering a test, rather than automatically ordering one.

As Everett Rogers, author of Diffusion of Innovations, showed, people follow the lead of other people they know and trust when adopting an innovation. “We yearn for frictionless, technological solutions. But people talking to people are still the way that norms and standards change.”

In his piece, Gawande relays a story in which health care has been changed by high-touch solutions like local women talking to mothers about pregnancy and care of infants in developing countries. Easy-to-follow messages relayed on a person-to-person basis had more impact than official mandates and regulations.

Choosing Wisely promotes such one-on-one conversations among physicians, and between patients and physicians. It’s these conversations that are the important catalysts for change in both attitudes and norms in ordering tests and procedures without clear purpose.

What are you doing in your practice or physician organization to promote these conversations?

Quality Improvement Tools and Resources

Practice teams that have been successful in meeting MiPCT goals and objectives identify a culture-continuous quality improvement as a key element of practice transformation work. An important initial step when addressing a Quality Improvement strategy is to understand current processes, identify aims, and perform tests of change. This involves selecting and using a Quality Improvement (QI) model. The QI model is fundamental to making process and system-level changes, and to sustain the changes over time. The QI model supports all aspects of the Patient-Centered Medical Home (PCMH). There are many models for quality improvement. The Model for Improvement and Lean Methods are used commonly in health care settings.

Model for Improvement

The Model for Improvement focuses on steps to accelerate improvement. The model has two parts:

•    Three fundamental questions, which can be addressed in any order.

  • What are we trying to accomplish?
  • How will we know that a change is an improvement?
  • What changes can we make that will result in improvement?

•    The Plan-Do-Study-Act (PDSA) – is a cycle to test changes in real work settings. The PDSA cycle guides the test of a change:

  • Plan: Define problem, current state, future state, plan the test of change
  • Do: Implement the test of change
  • Study: Learn and observe consequences
  • Act: Determine if changes are needed to the test

A sample PDSA form is provided as an attachment to this edition of the FLASH.

For more information on the model for improvement, please go to the Institute for Healthcare Improvement website at http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx.

Lean Methods

Lean Thinking helps to identify the challenges that hinder effective and efficient delivery of health services. Lean Thinking provides teams of people doing the work, and using the tools to break these challenges down into smaller, manageable parts to map a tailored course of action toward improvement. The result is a better use of resources, less rework, and improved health outcomes for patients.
For more information on Lean methods please go to the Lean for Clinical Redesign Collaborative Project website at http://leanforclinicalredesign.org/.

Admission, Discharge, Transfer & ED Alerts (ADT) Update

Care Team Connect, now known as Crimson Care Management, partnered with MiPCT in 2012 to provide the MiPCT patient list directly on a web-based platform to care managers. As an enhancement to this partnership, the ability to receive near real-time alerts for admission, discharge and transfers and ED (ADT) visits is now available.

On an initial basis, ADT alerts are now flowing from Beaumont Hospital to St. John Providence Partners in Care. Henry Ford Health System, Trinity Health, and St. John Providence ADTs will be added in the first months of 2014. This will be expanded to other participating POs in January.   In conjunction, webinar trainings focused on timely response to alert notification, sharing of best practice processes and system tips, will be provided by MiPCT and CTC to Provider Organization (PO) identified PO CTC/leads. A CTC/ADT webinar presentation can be found at www.mipctdemo.org under the Resources tab.

Announcement of Upcoming MiPCT Webinars

A list of upcoming webinars can be found on the www.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 is updated monthly.

2014 MiPCT Care Manager Webinar Update

We will be moving to a once-a-month webinar schedule for all MiPCT Care Managers and Pediatric Care Managers. (Please see dates and times below to save the date in your calendar.  Topics for the webinars are TBD, unless identified below.) The second date of the month, identified below in the “All MiPCT Care Manager Webinar” table, will be used to provide education to care managers also. Additional updates will follow as things are finalized.

Upcoming MiPCT CM Webinars:
Adult Webinars: Wednesdays, 2:00 – 3:00 PM
Pediatric Webinars:  Fridays, 10:00 – 11:00 AM

  • December 25, 2013: No webinar scheduled. Happy Holidays!
  • January 22, 2014: CM Best Practice Daily Workflow and DM Care Mamagement, All MiPCT Care Managers
  • January 24, 2014: TBD, Pediatric Care Managers

2014 All MiPCT Care Manager Education Webinars
2nd and 4th Wednesday, 2:00 – 4:00 PM

  • January 22
  • February 12
  • February 26
  • March 12
  • March 26
  • April 9
  • April 23
  • May 14
  • May 28
  • June 11
  • June 25
  • July 9
  • July 23
  • August 13
  • August 27
  • September 10
  • September 24
  • October 8
  • October 22
  • November 12
  • November 26
  • December 10

 2014 Pediatric Care Manager Webinars
Occur 10:00 – 11:00 AM, the 3rd Friday of Every Month except April*.
*(April’s Webinar will be held on the 11th due to a holiday)

  • January 24
  • February 21
  • March 21
  • April 11*
  • May 16
  • June 20
  • July 18
  • August 15
  • September 19
  • October 17
  • November 21
  • December 12

Stories of Your Care Management Success:

Dawn Carroll, MSW, MBA
Hybrid Care Manager — Hampton Medical Center, MiPCT Clinical Lead

Dawn Carroll, RN, MSW, MBA, is a Hybrid Care Manager at Hampton Medical Center and a MiPCT Clinical Lead. She and the members of the practice team at Hampton Medical Center worked together to develop and implement group visits for some of their MiPCT patients. Members of the team who participated in the group visits included the Nurse Practitioner, Medical Assistants, Dietitian, Care Managers, and Behavioral Health Coach.

The practice team ran a group visit for diabetic patients, which involved the patients first seeing a Nurse Practitioner for an individual health check-up. The patient then met with the Care Managers for a group visit. Eight patients were part of the group visits. All of the patients had diabetes with an A1C greater than 7.

The group visits were divided into two sessions, two months apart. The practice provided gas cards as incentives for participating. Topics covered included, “Myths and Facts of Diabetes,” “Sweetened Beverages,” “Dining Out with Diabetes,” and “Stress Management.” The practice team believed that providing the patients with an opportunity to learn from each other in a group setting would benefit their health outcomes.

The patients reported becoming more aware of signs of worsening conditions related to diabetes, and they have demonstrated a better understanding of when to contact the Primary Care Provider (PCP) for same-day appointments.

Five of the eight patients reduced their A1C after the group visits were completed. Half of the participants continue to work with Care Managers individually to improve their health.
Group visit participants stated, “I am so glad to learn about how to deal with stress…Seeing the care managers helps me keep my blood sugars in check…The ladies are so nice and helpful; keep up the good work!”

Michigan Care Management Resource Center Care Manager Monthly Update

The November, 2013 edition of the Michigan Care Management Resource Center (MiCMRC) Care Manager Monthly Update contains a review of MiPCT project events and developments that occurred in November, and a resource list. The November resource list contains links to resources provided during the adult MDCH Resources Part IV: WIC and Children’s Special Health Care Services, and pediatric MiPCT Year 3 webinars.

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

Diabetes Mellitus Best Practices

Care managers from MiPCT participating practices presented best practices for Diabetes Mellitus management during the December 6, 2013 PGIP afternoon breakout session. The MiPCT team would like to thank these care managers, practices and POs for their willingness to share their expertise and knowledge with other members of the healthcare community. Presenters included Elizabeth Eaton, RN, MPH, Care Facilitator, Sparrow Medical Group North and MiPCT Clinical Lead;  Sherrie Damstra, LPN, Clinical Lead for Spectrum Health Medical Group; and Pam Szymanski, RN, Complex Care Nurse Navigator, University of Michigan Health System.  Each care manager presented the process used in their practice to engage diabetic patients and improve clinical outcomes using a team-based approach. The identified best practice processes, work flows and tools that were presented at PGIP can be accessed on the http://www.mipctdemo.org web site using the following link https://mipct.org/resources/presentations/.

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

NEXT ISSUE DATES:

•    Next MiPCT Practice FLASH Issue:  January 27, 2014

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

November 25, 2013

Your Help is 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 project. The council is comprised of patients serviced by MiPCT care managers. 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)

We are 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 MiPCT 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.

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. A webinar to introduce the Learning Collaboratives will be held on December 4 at 2:00 PM. Attendance is welcome to PO leaders and MiPCT care managers.

Conversation Ready

In 2012, IHI and a group of end-of-life experts and concerned health care organizations launched the “Conversation Ready” initiative. Together, this group committed to establishing what it means for a health care organization to be “Conversation Ready,” by developing and piloting processes to create systems that re-frame patient-provider relationships around the question, “What matters most to you?,” and, in some instances, break the silence between patient and provider.” (Institute for Healthcare Improvement web site, 2013. The Conversation Project found at http://www.ihi.org/offerings/Initiatives/ConversationProject/Pages/default.aspx).

IHI launches the Conversation Ready Health Care Community.  IHI is now organizing a broader Conversation Ready Health Care Community for organizations committed to working with IHI to develop reliable care processes informed by the following core principles:

  1. Engage with our patients and families to understand what matters most to them at the end of life
  2. Steward this information as reliably as we do allergy information
  3. Partner with our patients to develop appropriate goals of care
  4. Exemplify this work in our own lives so that we understand the benefits and challenges
  5. Connect in a manner that is culturally and individually respectful of each patient (IHI, 2013).

To access an IHI audio broadcast explaining the Conversation Ready project go to: http://www.ihi.org/knowledge/Pages/AudioandVideo/WIHIWhosConversationReadyHowHealthCareCanRespectEnd-of-LifeWishes.aspx

High-Risk, High-Cost Populations IHI Summary Report: January 31, 2013

Many organizations are concerned about managing the cost of providing health care to high-risk, high-cost patients. It is estimated that 5% of the patients account for 50% of the cost of health care (IHI, 2013). Insurance companies have addressed this through focusing of high cost populations and thinking about risk and prediction of future costs. It seems simple, controlling the cost of delivering care to this population and will decrease spending on health care significantly. How this is done effectively and efficiently takes a careful, thoughtful approach.

Developing effective interventions that are cost effective requires a comprehensive understanding of the problem. Review of a previous year’s claims demonstrates that patients fall into three groups: low, medium and high-cost. Initially, it would seem appropriate to focus interventions on the patients who fell into the high-cost group. Historically, this group changes from year to year. While the organization continues to have a group of high-cost individuals from year to year, the group does not remain static, complicating measures to impact the highest cost patients.

Developing effective, cost effective interventions to better manage high-risk, high-cost populations requires a systematic process that takes into account patient identification, impact ability, potential interventions and cost effectiveness (IHI, 2013). Considering the potential savings along with the cost of the intervention is the key to developing appropriate care delivery for this population. IHI has developed a 5-step process to assist organizations in the development of effective, cost effective interventions to improve the management of high-risk, high-cost populations. The five steps include the following:

1. Identification

  • Decide what high-risk population to focus on

2. Impactibility

  • Understand the needs of the population to develop cost-effective interventions that answer these questions:

              – Can we make a difference?

              – Can we improve care and do it in a cost-effective manner?

3. Potential interventions: Begin with five patients

4. Building from 5 to 25: Cost effectiveness

  • Build and work with 25 and consider whether this design has the potential to scale to much higher numbers

5. Building from 25 to 125: Cost effectiveness

  • The design and work at 125 is getting closer to the system that can be used to manage the total targeted population

For complete information regarding IHI’s 5-step process for developing effective, cost-effective interventions to manage high-risk, high-cost populations please see the articles High-Risk, High-Cost Populations “How To” Guide and IHI RD Report W26 High Risk High Cost, which are provided as attachments to this edition of the FLASH.

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. Registrations 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.

Placement of Upcoming Webinars

MiPCT Webinars:

Upcoming webinars can be found on the http://www.micpctdemo.org website. On the right side of the web page you will see a box containing the date, topic, intended audience, and presenter if known of future webinars. This list is updated monthly.

Upcoming MiPCT CM Webinars:

Adult Webinars: Wednesdays, 2:00 – 3:00 PM  |  Pediatric Webinars: Fridays, 10:00 – 11:00 AM

  • November 27, 2013:  No webinar scheduled. Happy Thanksgiving!
  • December 4, 2013:  Intro:Learning Collaborative Cohort 2
  • December 11, 2013:  Care Manager Essentials; core skills, MiPCT and MDC updates, and 2014 project metrics. Marie Beisel and Paula Amormino. (All MiPCT Care Managers)
  • December 25, 2014:  No webinar scheduled. Happy Holidays!

Michigan Care Management Resource Center Care Manager Monthly Update October 2013

 The October, 2013 edition of the Michigan Care Management Resource Center (MiCMRC) Care Manager Monthly Update contains a review of MiPCT project events and developments that occurred in October and a resource list. The October resource list contains links to resources provided during the MiPCT Annual Summit and the adult MDCH Resources Part I: Injury Prevention, Arthritis and Disability Health, MDCH Resources Part II: Cancer, Tobacco Control and Review of Asthma, Cardiovascular Disease, Diabetes, and Obesity and MDCH Resources Part III: Substance Abuse, Mental Health and HIV/AIDS webinars.

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

Stories of Your Care Management Success: Michele Niles RN, RNC-MNN, Care Manager, Gaslight Family Practice, Spectrum Health Medical Group

A True Story of Collaboration: This is a story about collaboration across the health care continuum provided by Michele Niles RN, RNC-MNN Care Manager at Gaslight Family Practice, which is affiliated with Spectrum Health Medical Group (SHMG). Successful collaboration resulted in favorable outcomes for a child and his family. A primary care physician (PCP) asked Michele to follow up on a child who had not shown up for several appointments. Michele contacted the child’s Medicaid case manager at Priority Health to assist the family with transportation. A few months later, the physician approached Michele because the child’s mother was requesting a refill for the child’s ADHD medication. The mother had cancelled the child’s one month ADHD follow-up visit. Michelle was asked to call the mom to assess the situation. She called the mom and explained the doctor would not refill the medication without an appointment. The mom stated transportation continued to be very difficult. The mom agreed to let Michele make another referral to the child’s Priority Health case manager to help her with transportation. The appointment was rescheduled.

The Priority Health case manager connected with the mom and called Michele back to report the mom had three other children in addition to the one seen at the practice. The other three children had been dismissed from their provider because of no-shows. The mom asked if all of her children could be seen in this office. The physician agreed to see the other children, and they were all scheduled for appointments. The mom admitted to Michele that she was sometimes overwhelmed and might need help with care for her son with ADHD. A social work referral was made to a SHMG social worker.

 The mom connected with Priority Health for transportation and brought the children in for their appointments. Michele met with the mom while she was in the office with her children. While Michele was talking to the mom, the child with ADHD fell asleep and was snoring abnormally. Michele asked the physician to come back into the room to assess the child. This child had a previous cleft palate surgery. The physician and Michele noted periods of apnea while the child was sleeping. The provider ordered a sleep study and Michele assisted the mom with telephone calls to Network 180 and Arbor Circle for mental health services. An appointment was made for her son that day.

The next month, the Priority Health case manager who was monitoring the family’s appointments noted the mom had not called to set up transportation for upcoming scheduled appointments, and the Priority Health care manager was unable to contact the mom with the telephone number she had on file. The Priority Health case manager contacted Michele to see if she had any other phone numbers. The office did not have any other phone numbers but Michele noted in EPIC that one of the four children was enrolled in the MOMS Program, and had a case manager (CM) and community health worker (CHW) seeing her regularly.

Michele called the CHW and asked if she had a better phone number. She stated the mom did not have a phone, but she agreed to visit them to see if they were planning to come in for the scheduled appointments, and if she had rides arranged or needed transportation. The CHW called back to tell Michele the family had been staying in a motel, did not have money for another night, and had no place to go. The MOMS Program case manager and CHW had been working with the family to get the mom to go to Salvation Army for housing assistance, but the mom had not followed through. Michele asked the CHW to keep her informed of what was happening with the family, and she would reschedule their PCP appointments when the family was more stable.

Michele saw in EPIC the oldest child had an appointment at the Cleft Palate clinic. She called the clinic to update them about the family’s situation. If they missed their appointment the clinic would know the family was homeless, and did not have a phone. After the family went to a shelter and was placed in temporary housing, the MOMS CHW called Michele back with a phone number. She then called the child’s Priority Health case manager to share the phone number.

The child with ADHD/sleep apnea went to his appointment for the sleep study. Because the results of the sleep study were very poor (SPO2 of 35%) the child had a tonsillectomy/adenoidectomy the very next day. The office tried to follow-up with the mom after the child’s hospital discharge, but there was still no working phone. Michele called the MOMS CHW again. Even though the child is not in the program, the CHW agreed to go out and check on the family and make sure the child was using his prescribed bipap appropriately, and that the mom was planning on keeping the child’s follow-up appointment with the physician. Michele noticed a note in EPIC that the case manager from the Cleft Palate Clinic was trying to follow up with the family after the surgery, but could not contact them. She called the Cleft Palate Clinic to update them on the family’s status, and asked the clinic if there was anything the office could do when the child came in for his appointment. The Cleft Palate Clinic gave Michele information to pass on to the mom.

The child was recently seen in the office for an appointment, and is doing well. He is sleeping better, and his school performance has greatly improved. The physician has noted a big change in the family and thanked Michele for the work she has done.

This is a great story about how collaboration across the continuum makes a difference. Those involved included the PCP and office staff, MiPCT Care Manager, SHMG Social Worker, Priority Health Case Manager, Community Agencies (Network 180 and Arbor Circle), MOMS Program Case Manager and CHW, Case Manager from the Cleft Palate Clinic, treatment teams from Peds Pulmonology, Sleep Study Clinic, Peds Otolaryngology, Helen DeVos Children’s Hospital surgical staff and ICU and Airway Oxygen for DME.

NEXT ISSUE DATES:

Next MiPCT Practice FLASH Issue: December 16, 2013

Next MiPCT Monday FLASH Issue: December 2, 2013

October 21, 2013

Embedding the Care Manager in the Physician Practice Team — What’s in it for YOU ???

Sometimes more isn’t better – a sixth digit doesn’t make a better piano player, an extra 3-year-old tugging at your leg in the grocery store, or an extra 3 inches of snow on top of a previous blizzard. But – your care manager should not feel like those scenarios. A MiPCT care manager should be a resource integrated to your team to help you navigate your day and deliver better care for your patients.

A care manager is an asset to your team to :

1.    Manage transitions for your patients coming from the hospital to home

2.    Follow up with patients after the emergency room

3.    Touch base with at-risk patients with new meds or a new diagnosis, both during and after the appointment. To check in with those patients that, when you leave the room, you worry about or wondered,  “Do they really understand what we just talked about?”

So – those are just a start of what your care managers can do – but providers need to communicate with the care managers, whom they would like them to see.  A simple and proven method is huddles. Yup – just like the football team – stand around (not sitting) a couple times a week, (daily is best !) for 5-10 minutes to talk about whom the fits the list above.  Make it a set time, include your clinical support person – they may also want to refer patients to the care manager.

Plan to scan the next few days’ schedule to see who may be coming in that could use a little help. So – what will that do?

1.    Will build team cohesiveness – you are not in this alone

2.    Allow a smoother day for the provider – less chaos in the work flow
3.    Most importantly – better care for your patients.

So – huddle up – welcome your care manager into the team!!

New Research on Population Health — from the PCPCC

Just released from the Patient Centered Primary Care Collaborative (PCPCC):

MANAGING POPULATIONS, MAXIMIZING TECHNOLOGY
Population Health Management in the Medical Neighborhood

Key Learnings:
Critical  Technologies —  Electronic health records, Patient registries, Health Information Exchange, Risk stratification, Automated outreach.

Referral tracking, Patient portals — Telehealth/telemedicine, Remote patient monitoring, Advanced population analytics
Key clinical factor –  team based care – emphasizing the impact of mental health integration

Essential  delivery  factors – access and continuity

-Care Coordination

-Quality and Safety

It outlines future challenges and policy imperatives. It finishes with three great case examples to learn from with extensive references.

Physicians’ Corner:  Choosing Wisely

Kevin Taylor MD

Starting in 2000, our health care community focused on health care quality and safety. This was inaugurated by the sentinel report from the IOM “Crossing the Quality Chasm”.
Since 2010, however, we have shifted our focus toward cost-consciousness. Several organizations, from the
AMA, JCAHO, ABIM Foundation and others are leading this discussion of being effective stewards of our healthcare resources. Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures,and to support physicians’ efforts to help patients make smart and effective care choices. The Choosing Wisely commitment to a just distribution of finite resources, specifically calls on physicians to be responsible for the appropriate allocation of resources and to scrupulously avoid superfluous tests and procedures.
In this campaign, over 50 professional medical societies have developed lists of top five activities in their profession where the quality of care could be improved. Within the State of Michigan, there are several organizations that are actively engaged in the Choosing Wisely Campaign. BCBS of Michigan developed the Healthcare Resource Stewardship Council (HRSC) that set as a goal to identify focus areas from Choosing Wisely guidelines. The criteria for selecting focus areas/metrics should be: measureable through claims; high impact on cost; evidence-based care decisions (based on Choosing Wisely Top 5 items), and easy-to-implement change.
Using these criteria the HRSC identified these guidelines for our health care teams to focus on in our efforts to be effective stewards of our resources:
  • Imaging of Uncomplicated Conditions
  • Don’t do imaging for uncomplicated headache
  • Don’t obtain back imaging studies in patients with non-specific low back pain
  • Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis
  • Cardiology Tests in Low-Risk Individuals
  • Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present
  • Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms
  • Women’s Health
  • Don’t perform pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease
  • Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors
Going forward, we encourage you to foster dialogue on these 7 Choosing Wisely guidelines with your colleagues. We will provide more information related to each of these items in our future Practice FLASH publications

Michigan Care Management Resource Center (MiCMRC) Care Manager Monthly Update: September 2013

The Michigan Care Management Resource Center (MiCMRC) has developed a monthly update for care managers participating in the MiPCT project. The September 2013 edition contains a review of MiPCT project events and developments that occurred in September and a resource list. The September resource list contains links to resources provided during the adult Beneficiary Medication Adherence and Managing Pharmacy Costs and Care Management Integration Using A Quality Improvement Process and pediatric Developmental Screening webinars.

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

Community Resource Tool Template

The Michigan Care Management Resource Center (MiCMRC) has prepared a community resource tool template for MiPCT care managers, practice teams and POs/PHOs. The tool is provided (attached) as an Excel file that can be customized with agency contact information, specific to the geographic region served within a particular organization.

Worksheets for specific resource topics are provided, as well as website links and contact numbers for some statewide and national resources. The Community Resource Tool Template is included as an attachment to this edition of The Practice FLASH.

MiPCT Webinars

Upcoming webinars can be found on the micpctdemo.org website.   On the right side of the screen, 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.  Here is a recap at-a-glance:

MiPCT Care Manager Fall Webinar Schedule*

October 30, 2013:     MDCH Resources Part III: Substance Abuse and Mental Health. (All MiPCT Care Managers).

November 13, 2013:     MDCH Resources Part IV: HIV/AIDS and Maternal/Child Health. (All MiPCT Care Managers).

*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 November 11th-14th, 2013 in Lansing.  Registrations is available at the following link: https://jodyooo.wufoo.com/forms/november-1114-2013-mipct-ccm-training/. The MiPCT CCM course consists of four training days:  November 11, 12, 13, 14.

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

Physicians’ Corner:  Choosing Wisely
by Kevin Taylor MD

Starting in 2000, our health care community focused on health care quality and safety. This was inaugurated by the sentinel report from the IOM “Crossing the Quality Chasm”.

Since 2010, however, we have shifted our focus toward cost-consciousness. Several organizations, from the AMA, JCAHO, ABIM Foundation and others are leading this discussion of being effective stewards of our healthcare resources. Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures,and to support physicians’ efforts to help patients make smart and effective care choices.

The Choosing Wisely commitment to a just distribution of finite resources, specifically calls on physicians to be responsible for the appropriate allocation of resources and to scrupulously avoid superfluous tests and procedures.

In this campaign, over 50 professional medical societies have developed lists of top five activities in their profession where the quality of care could be improved.

Within the State of Michigan, there are several organizations that are actively engaged in the Choosing Wisely Campaign. BCBS of Michigan developed the Healthcare Resource Stewardship Council (HRSC) that set as a goal to identify focus areas from Choosing Wisely guidelines. The criteria for selecting focus areas/metrics should be: measureable through claims; high impact on cost; evidence-based care decisions (based on Choosing Wisely Top 5 items), and easy-to-implement change.

Using these criteria the HRSC identified these guidelines for our health care teams to focus on in our efforts to be effective stewards of our resources:

  • Imaging of Uncomplicated Conditions
  • Don’t do imaging for uncomplicated headache
  • Don’t obtain back imaging studies in patients with non-specific low back pain
  • Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis
  • Cardiology Tests in Low-Risk Individuals
  • Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present
  • Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms
  • Women’s Health
  • Don’t perform pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease
  • Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors

Going forward, we encourage you to foster dialogue on these 7 Choosing Wisely guidelines with your colleagues. We will provide more information related to each of these items in our future Practice FLASH publications.

Palliative Care: MiPCT Annual Summit Key Points: Integration into Primary Care

Dr. Phil Rodgers, MD and Dr. Colleen Tallen, MD, both primary care physicians and palliative care specialists, presented an overview including key concepts of Palliative care during each of the MiPCT Summits.  The information presented supported the integration of palliative care in primary care provider (PCP) practices as a means to improve patient outcomes for those with serious and chronic conditions.

There are three types of palliative care; primary, secondary, and tertiary. Primary palliative care is provided by all clinicians caring for patients with serious illness, including (PCP) practices primarily focused on chronic disease management. Secondary palliative care is often provided by subspecialist  teams caring for higher volumes of patients with advanced illness, such as Oncology or Cardiology practices, though primary care teams  create an essential bridge for the care needs of  these patients and their families. Tertiary palliative care is provided by dedicated palliative care clinicians with specific training and expertise, and can be added when palliative care needs become more complex, much like a referral to any subspecialty team.  Common reasons for palliative care referral include pain and symptom management, discussions around treatment goals and preferences, transitions of care through advanced illness, end-of-life management, and bereavement.

Often palliative care consults are ordered during an inpatient hospital stay due to an exacerbation of a serious chronic disease. While a palliative care referral may be appropriate at this time, it is  recommended that palliative care options be discussed when a patient is first diagnosed with a serious chronic condition, and revisited at times of notable disease progression, or when functional decline is noted.

PCP practice teams can help make decision-making a process rather than an event by having conversations about treatment options and disease progression earlier. The palliative care discussion does not necessarily result in a referral to palliative care. It is an opportunity for the care team to learn what the patient’s goals of care are and to help develop a plan to assist the patient in achieving those goals. The PCP may be in the best position to engage in this type of discussion with the patient because the PCP typically knows the patient best and will follow the patient throughout the course of the disease.

Patients often make statements to their PCP practice team members that indicate they are ready to have a palliative care conversation. Statements such as ‘I don’t think I can do this much longer’ or ‘I don’t want to go back to the hospital’ provide an opportunity for PCP practice teams to discuss the patient’s goals, values, and beliefs regarding the treatment of their serious chronic disease. A document containing scripting suggestions provided during the MiPCT Annual Summit by Dr. Colleen Tallen, MD and Dr. Phil Rodgers, MD is provided as an attachment to this edition of the Practice FLASH. PCP practice teams may use this information to support the work of integrating palliative care delivery in PCP practices who serve patients with serious chronic diseases.

Next Practice FLASH Issue: November 25, 2013

September 23, 2013

Inaugural Practice FLASH Edition!

Welcome to the first edition of the MiPCT Practice Flash!  This newsletter will be sent out monthly to keep MiPCT practice teams informed on MiPCT events, provide you with information on the project’s status, and share tips and articles that can help you enhance your practice’s team-based care.

Since some practice team members may be new to MiPCT, we thought it might be helpful to provide a little background information on the project as well as a summary of current participants:

Background
The Michigan Primary Care Transformation (MiPCT) Project is a three-year, multi-payer, state-wide project aimed at reforming primary care payment models and expanding the capabilities of patient-centered medical homes (PCMH) throughout the state. The selection of Michigan as one of eight states in the Multi-Payer Advanced Primary Care Practice Demonstration (MAPCP), sponsored by the Centers for Medicare and Medicaid (CMS), was the catalyst for bringing together Medicare, Michigan Medicaid Health Plans, Blue Cross Blue Shield of Michigan and Blue Care Network to improve upon the strong PCMH foundation in the state and create a uniform, sustainable primary care platform. Priority Health also joined MiPCT in July 2013.  With over one million participating patients, Michigan is the largest PCMH demonstration project in the nation.

Breadth and Scope
•    Over 370 primary care practices
•    35 Physician Organizations (POs)
•    1,700 physicians
•    Over one million patients

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

A state-wide Care Manager training program was developed for MiPCT in partnership with Geisinger Health System.  To date, over 300 care managers have been trained and are working in participating practices.  Ongoing support is provided through MiPCT-sponsored webinars and Learning Collaboratives.

We hope you find this newsletter to be informative and helpful!  Comments/suggestions are welcome and can be submitted through your Physician Organization or directly to MIPCTDEMO@MICHIGAN.GOV.

Many thanks!
Your MiPCT Leadership Team

MiPCT 2013 Regional Annual Summits

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.  The morning conference 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, Gaylord
•     October 9:    Meijer Gardens, Grand Rapids
•     October 15:    U of M (NCRC), Ann Arbor

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 (TODAY!) Registration closes for the October 1 Northern Regional Summit in Gaylord.
•    September 30     Registration closes for both the October 9  & 15 Summits.

Choosing Wisely

The following is provided to you from Consumer Reports and the ABIM Foundation:

Think you need an EKG as part of your annual exam? Think again. How about an MRI or CT scan for your headache? Probably not. And antibiotics for that case of sinusitis that has been bugging you for 3 days? Sorry, that’s strike three.

Many common tests and treatments are often overused, both because patients too often ask for them, and because doctors are all too willing to order them.

More than a third of the primary-care doctors in a Consumer Reports survey, for example, said that their patients very frequently or quite often asked for unnecessary or duplicative medical tests. And two-thirds of the doctors said they had agreed to at least one such request. Other research suggests that up to a third of all medical care delivered in the U.S. may be unnecessary.

All that needless care can be harmful to your health—and your wallet. Unnecessary CT scans and X-rays, for example, expose you to potentially cancer-causing radiation. And any money spent on tests you don’t need is money down the drain.

How can physicians and patients have the important conversations necessary to ensure the right care is delivered at the right time? Choosing Wisely® aims to answer that question.

An initiative of the ABIM Foundation, Choosing Wisely is focused on encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.
To spark these conversations, leading specialty societies have created lists of “Things Physicians and Patients Should Question” — evidence-based recommendations that should be discussed to help make wise decisions about the most appropriate care based on a patient’s individual situation.

Consumer Reports is developing and disseminating materials for patients through large consumer groups to help patients engage their physicians in these conversations and ask questions about what tests and procedures are right for them.

More than 50 specialty societies have now joined the campaign, and 30+ societies will announce new lists in late 2013 and early 2014.

You can see summaries of the Choosing Wisely lists on the website of the ABIM Foundation, the organization spearheading the effort.

Developing Team-Based Care – Process Steps and Success at West Front Primary 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, served to strengthen the practice team, and resulted in transformed healthcare delivery. A workflow map depicting this approach provided as an attachment to this week’s edition of the FLASH.

Priority Health 101

Would you like more information about Priority Health’s Case and Disease Management Program?  Do you have a question for one of Priority Health’s case managers? Would you like to confirm if one of your patient’s is currently enrolled in our Priority Health Case Management program or refer a patient to work with one of Priority Health’s case managers?

Please call Priority Health’s Case Management Department at 1-800-998-1037, press option #4 to speak with one of their Health Care Coordinators who will be able to answer your questions or direct you to the Priority case manager who is working with your patient.

Finding Joy in Primary Care

Across the country, primary care practices are seeking to provide high quality care while maintaining high levels of satisfaction for patients, physicians and staff.  In May 2013, an article titled, “In Search of Joy in Practice:  A Report of 23 High-Functioning Primary Care Practices,” was published in the Annals of Family Medicine.  In this article, the authors described their findings from interviewing physicians and staff at 23 high functioning practices around the country.  In summary, the innovations identified as leading to the greatest job satisfaction included the following:

1.    Proactive planned care, with pre-visit planning and pre-visit laboratory tests
2.    Sharing clinical care among a team, with expanded rooming protocols, standing orders, and panel management
3.    Sharing clerical tasks with collaborative documentation (scribing), nonphysician order entry, and streamlined prescription management
4.    Improving communication by verbal messaging and in-box management
5.    Improving team functioning through co-location, team meetings, and work flow mapping

The complete article can be found at http://www.pcpcc.org/resource/search-joy-practice-report-23-high-functioning-primary-care-practices.

Michigan Care Management Resource Center Monthly Update
August 2013 (attached)

The Michigan Care Management Resource Center (MiCMRC) has developed a monthly update for care managers participating in the MiPCT project.

This edition contains a review of MiPCT project events and developments that occurred in August 2013, 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.

Stories of Your Care Management Success:
Novella Lanzanas, CM, Henry Ford Health System – Warren Clinic

Novella Lanzanas, RN, BSN, is a care manager for the Henry Ford Health System —  Warren Clinic. Novella began working with a BCN patient after identifying the patient on the clinic’s daily MiPCT appointment list. Prior to care management, the patient, ‘Betty’, had uncontrolled diabetes with a HbA1c of 9.5. ‘Betty’ had been on oral hypoglycemic medication for years. Her blood sugars were running mostly in the 200’s. She also had depression, which was managed with oral medications.

Novella knew care management interventions could be offered to help ‘Betty’ with the self-management of her diabetes, as it had been uncontrolled for a while. She huddled with the Primary Care Physician (PCP) to discuss the plan of care and enrollment for care management and possible Lantus initiation. The PCP was in agreement.

Novella met with ‘Betty’ during a PCP follow up appointment. She explained her role as a care manager and how she might be able to help ‘Betty’ get her diabetes under control.  Novella also initiated a discussion on Lantus and how it can help control blood sugars. ‘Betty’ agreed on care management and Lantus initiation with titration. She also agreed to be enrolled into Medical Nutrition Therapy and Diabetes Self-Management Education (DSME). Referrals were completed.

Initially, ‘Betty’ did really well on the insulin titration, and had early success with fasting blood glucose as demonstrated by readings between 100 and 120. She also completed her DSME classes and said she learned a lot and was thankful for the education. ‘Betty’ really tried to follow the recommendations of the Dietician and Diabetes Educators. However, after a while, her fasting sugars began to trend back up.

Novella and ‘Betty’ reviewed her diet and activities. Novella also evaluated ‘Betty’s’ depression at that time to see if it was playing a role in her difficulty. Even with oral medication, ‘Betty’ scored a 7 on the Depression Screening Tool. The idea of brief Problem Solving Therapy (PST) for treatment of her depression was introduced and she agreed to participate.
After the initial PST session, ‘Betty’ verbalized willingness to do it at home on her other listed problems. She found it to be really helpful. In fact, she reported successes often. She was working on problems between care management sessions. She realized how depression was affecting her ability to manage her condition and was motivated for change.

Setting goals with action planning really helped ‘Betty’. She started with going to the gym three times a week and then increased to daily. She was also really determined to control her diet by involving her family.

After four months of working on diet, regular exercise, medications, and addressing symptoms of depression ‘Betty’s’ HbA1c is 7.7 and her Depression Screening Score is down to 1.  Her HbA1c goal is it to continue trending down until it is below 7.0. She continues with her medications, lifestyle management and PST use in her journey to achieve this goal.

‘Betty’s’ physician has stated, “I am so pleased at how much she has improved and is still continuing to work on it. I have seen how she is taking control of her diabetes through proper education and medications, and by recognizing how depression affects her ability to manage it”.

In response to her experience with care management ‘Betty’ has stated, “I am really thankful that you [Novella] worked with me on my diabetes and depression. Now I feel that my goal is within reach”.

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.

MiPCT Webinars

Upcoming webinars can be found on the micpctdemo.org website.   On the right side of the screen, 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.  Here is a recap at-a-glance:

MiPCT Care Manager Fall Webinar Schedule*

  • October 2, 2013:     MDCH Resources Part I: Injury Prevention, Arthritis and Disability Health. (All MiPCT Care Managers).
  • October 16, 2013:     MDCH Resources Part II: Cancer, Tobacco Control and Review of  Asthma, Cardiovascular Disease, Diabetes and Obesity. (All MiPCT Care Managers).
  • October 30, 2013:     MDCH Resources Part III: Substance Abuse and Mental Health. (All MiPCT Care Managers).
  • November 13, 2013:     MDCH Resources Part IV: HIV/AIDS and Maternal/Child Health. (All MiPCT Care Managers).

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

Next Practice FLASH Issue: October 21, 2013