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2018 PCMH InitiativeANNUAL KICK-OFF WEBINAR
JANUARY 9, 2018 | 12:00 – 1:00PM
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Overview2017 RECAP, 2018 GOALS, YOUR PCMH INITIATIVE TEAM
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
MI-SIM Components
Supported by:
Stakeholder Engagement
Data Sharing and Interoperability
Consistent Performance Metrics
Care Delivery• Patient-Centered Medical Home
(PCMH) Initiative
• Advanced Payment Models
Population Health
• Community Health Innovation Region (CHIR)
Focused on:Clinical-Community Linkage
2017 A Year in Review
The PCMH Initiative experienced a number of accomplishments in 2017, many of which have been highlighted in previous presentations. For details on program accomplishments see slides from the 2017 Annual Summits, or from the 2017 Q4 Update Meeting!
With help from its integral partners, the PCMH Initiative has created a succinct document with an overview of 2017, and preview into the 2018 Initiative. Find the PCMH Initiative “Year in Review” document attached in the handouts section of the webinar toolbar, or posted on our website!
2018 PCMH Initiative: Big Picture Goals1. Champion models of care which engage patients using
comprehensive, whole person-oriented, coordinated, accessible and high-quality services centered on an individual’s health and social well-being.
2. Support and create clear accountability for quantifiable improvements in the process and quality of care, as well as health outcome performance measures.
3. Create opportunities for Michigan primary care providers to participate in increasingly higher level Alternative Payment Methodologies.
Your 2018 PCMH Initiative Team
MI-SIM Care Delivery Team
University of Michigan:
PCMH Initiative Daily Operations Support
Michigan Care Management
Resource Center
Clinical Values Institute
Michigan Data Collaborative
External Vendor Support
Michigan Health
Information Network
Institute for Healthcare
Improvement
Michigan Community
Health Worker Alliance
Self Management Training Support
Integrated Health Partners
Practice Transformation
Institute
Michigan Center for Clinical
Systems Improvement
PCMH Initiative Team: MDHHS Team Members
Yagna Talakola
Project Manager
Laura Kilfoyle
SIM Care Delivery Coordinator
Katie Commey, MPH
SIM Care Delivery Lead
Lyndsay Tyler
BusinessAnalyst
MI-SIM Care DeliveryGovernance Team
Kathy Stiffler Medicaid Care Management and Quality Assurance, Deputy Director
Brian Keisling Medicaid Operations and Actuarial Services, Bureau Administrator
Kim Hamilton Managed Care Plan, Division Director
Penny Rutledge Actuarial Division, Manager
Theresa Landfair Managed Care Plan Division,Specialist
Phillip Bergquist Policy and Strategic Initiatives, Manager
Tom Curtis Quality Improvement and Program Development, Section Manager
PCMH Initiative Team: UM Team Members
Diane Marriott
Director
Amanda First-Kallus
Analyst
Veralyn Klink
AdministratorMarie Beisel
Sr. Project Manager
Yi Mao
Analyst
Susan Stephan
Sr. System Analyst
Scott Johnson
Int. Project ManagerBetty Rakowski
Curriculum Designer
Jessie Chen
Application Systems
Analyst / Programmer
Alice Stanulis
Business Systems
Analyst
Marty Kosla
Sr. Business Systems
Analyst
Clinical Values Institute Michigan Data Collaborative MI Care Management Resource Center
2018 Participation Agreement • Bureau of Purchasing sent out Agreements on December 21st
• This is the version that should be signed and returned
• Participants have until January 19th to sign and return Agreements to [email protected]
•Questions can be emailed to [email protected]
Note: This is the memorandum of understanding used to signify participation in the 2018 PCMH Initiative, signed by both MDHHS and either a PO (on behalf of member practices) or an individual practice. There are two versions: PO Agreement and Practice Agreement. There is also a 2018 Participation Agreement Summary of Changes resource available to support identifying the changes from the 2017 to 2018 Participation Agreement.
Initiative Resources: SIM Care Delivery Website
Website Content:
• Newsletters
• Monthly Calendar
• Links to register for upcoming events
• Important deadlines
• Participation Guide
• Will be continuously updated to include important resources
• FAQs
• Webinar slides and recordings
www.michigan.gov/sim
Initiative Resources: New Website Features for 2018•All 2017 material is archived • Link at the bottom of Care Delivery Page
• The Participation Guide will be continuously updated to include most of the participant resources instead of providing them in separate documents
•We will be updating the look and feel of the website• When changes are made, information will be shared in
our newsletter
Initiative Resources: Partner WebsitesMichigan Care Management Resource Center
Michigan Data Collaborative
Michigan Health Information Network
Michigan Community Health Worker Alliance
Institute for Healthcare Improvement◦ IHI also offers access to the IHI Open school for all SIM PCMH Initiative participants, use the group
passcode DFDA8BE6 to access for free!
Practice Transformation Institute
Integrated Health Partners
Michigan Center for Clinical Systems Improvement
What’s Coming in 2018TECHNICAL ASSISTANCE & PARTICIPANT SUPPORT OPPORTUNITIES
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
Practice Support and Learning Opportunities: How to Engage with the Initiative in 2018Activity Purpose Occurrence Who Should Attend
Monthly Office Hours
Topic focused sessions to bring current health policy information, pertinent topics and operational details of the Initiative to participants.
Offered virtually around the 3rd Wednesday of the month
Open to all participants; under development: opportunities specifically geared towards pediatric practices
Care Coordination Collaborative
Network with payer partners and other SIM participants, supporting alignment in care coordination
To Be Announced: Currently in planning phase
Care Management and Coordination staff, including managers and administrators
Practice TransformationCollaborative
Focused learning activities to support systemic development and maintenance of Clinical Community Linkages and Population Health Management
To Be Announced: currently under redevelopment
To Be Announced: currently under re-development
Quarterly UpdateMeetings
Regularly scheduled Initiative updates, providing key information for successful participation.
Offered virtually:4/5/2018, 7/12/2018, and 10/4/2018
Required: Physician Organization Representatives, and key practice staff (for practices participating independently
Annual RegionalSummits
Provide an opportunity for participant to engage in learning and networking face to face, building on the foundation of regular learning opportunities throughout the year.
Fall 2018: Northern Lower Peninsula, Western Lower Peninsula, & South East or Mid-Michigan
Participant staff including but not limited to administrative staff, care managers and coordinators, quality improvement staff, and other leaders
Join the planning
Committee!
Join the planning
Committee!
Practice Support and Learning Opportunities: Join us in Planning 2018 EventsDo you have suggestions for other learning opportunities or events that would be helpful to you and your organization? Email us at [email protected]
Interested in helping plan the Care Coordination Collaborative events or the Annual Summits, shaping the themes, topics, identifying speakers and locations? Join a planning committee:
HOW TO JOIN A PLANNING COMMITTEE:
Care Coordination Collaborative Annual Regional Summits
1. Leave your contact information in the evaluation following this webinar
1. Leave your contact information in the evaluation following this webinar
2. Email the Initiative [email protected]
2. Email the Initiative at [email protected]
3. Complete the Care CoordinationCollaborative Planning Survey (sent out in late December)
Practice Support and Learning Opportunities: Monthly Newsletters
Distributed via GovDelivery & on our website!• To sign up for the distribution:
• Email us at [email protected], or
• Sign up for MDHHS subscriptions: when managing your “subscriptions” select State Innovation Model Patient Centered Medical Home Initiative”
Will released late month for the following month (ex. February Newsletter will be released in late January)
Designed to have upcoming events, training information, topics of interest, participant highlights, suggested resources and other pertinent information
Suggestions always welcome, please email them to [email protected]
Required Training CARE MANAGER AND COORDINATOR TRAINING REQUIREMENTS
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
Care Manager & Coordinator Learning: Required Initial Training for SIM CMCCs
Initial Required Training Care
CoordinatorCare
ManagerTime Required
MiCMRC Approved Self-Management Support Course X X* Varies by vendor
MiCMRC CCM Course X Click here for details
SIM Overview Recorded Webinar X X 30 minutes
PCMH, Chronic Care Model, and ACOs Recorded Webinar X X** 20 minutes
Team Based Care Recorded Webinar X X** 45 minutes
Introduction to Social Determinants of Health Recorded eLearning Module
X X*** 25 minutes
The Role of Care Managers & Care Coordinators in Developing and Maintaining Community Linkages eLearning Module
X X*** 30 minutes
Social Determinants of Health and the Implications for Care Management eLearning Module
X X*** 20 minutes
Social Determinants of Health Case Study eLearning Module X X*** 20 minutes
*Care Managers are strongly encouraged to complete the Self-Management course prior to enrolling in the MiCMRC CCM Course
**Recorded webinar content is included in the CCM course. If a care manager attends the CCM course after January 2017, they do not need to complete the PCMH, Chronic Care Model, and ACO or the Team Based Care recorded webinars. However, Care Coordinators do need to complete.
***SDOH eLearning modules are included in the CCM course content. If the care manager attends the CCM course after July 2017, they do not need to complete the eLearning Modules. However, Care Coordinators do need to complete.
Care Manager & Coordinator Learning: Self Management Training Options Cont.
To provide additional flexibility and convenience for SIM PCMH Initiative participants, three organizations will be available for self-management training for Care Managers and Coordinators whohave not been trained previously:
◦ Integrated Health partners (IHP)
◦ Michigan Center for Clinical Systems Improvement (MiCCSI)
◦ Practice Transformation Institute (PTI)
If self-management training is completed through one of these vendors, the PCMH Initiative will coverthe cost of the course. (Travel and any other related expenses are the responsibility of the attendee ortheir organization.)
Trainees must attest that they have not been previously been trained in self-management. Those whocompleted self-management training with a MiCMRC-approved vendor with MiPCT or anotherinitiative do not need to be retrained.
Care Manager & Coordinator Learning: Self Management Training Options Cont.
Class availability and the number of training slots may vary at each organization. If classes with aparticular vendor are full, you will be put on a wait list or can explore availability at the other organizations.
◦ Integrated Health Partners (IHP) - based in Battle Creek◦ Note: this is a 2 part series and participants must attend both session dates
◦ For more information, contact: Emily Moe | [email protected] | Phone: 269-425-7138.
◦ Michigan Center for Clinical Systems Improvement (Mi-CCSI) - based in Grand Rapids◦ For more information, contact: Amy Wales | [email protected] | Phone: 616-551-0795 ext. 11
◦ Practice Transformation Institute (PTI) - based in Southfield◦ For more information, contact: Yang Yang | [email protected] | Phone: 248-475-4839
For a summary of MiCMRC approved Self Management Support Courses (includes details for the above courses): www.micmrc.org
Care Manager & Coordinator Learning: Complex Care Management TrainingThe SIM PCMH Initiative partners with the Michigan Care Management Resource Center to offer Complex Care Management Training to all Care Managers supporting SIM PCMH Initiative patients, that have not been previously trained.
The MiCMRC Complex Care Management Course (CCM) curriculum provides the framework for the complex care management role, foundational elements of integration into the ambulatory care setting, and development of complex care management skills.
Course ScheduleDAY 1: Introduction, Live one-hour logistics webinarDay 2: Self-study, recorded webinars, post-tests, (approximately 6 hours of self-study)Day 3&4: In-person training, 8 hours each day
*Note: This course is required for Care Managers only
Check here course dates | For more information, contact: [email protected]
Care Manager & Coordinator Learning: Longitudinal Learning OpportunitiesCare Management Webinars offered monthly by MiCMRC. Check out: http://micmrc.org/webinars
Upcoming Live Webinars:
• Quality Metrics in Ambulatory CareWednesday January 17th 2-3 pmNatalie Pirkola, Pharm D, MBA, CCM, CPHIMS, BCACPREGISTER HERE
• Managing Hypertension Wednesday February 14th 2-3 pmKristina Dawkins, MPH, Clinical and Public Health ConsultantMichigan Department of Health and Human ServicesCardiovascular Health, Nutrition, and Physical Activity SectionHeart Disease and Stroke Prevention UnitREGISTRATION COMING SOON
Note: Several of the Live and recorded webinars provide CE Contact Hours for Nursing and Social Work
Care Manager & Coordinator Learning: Longitudinal Learning Opportunities Cont.
Basic Care Management Program – web based, interactive eLearning
Provide CE Contact Hours for Nursing and Social Work upon completion of each module• Module Topics
◦ Medication Reconciliation◦ Transition of Care◦ Introduction to Palliative Care and Advance Care Planning◦ Role of the Care Manager ◦ 5 Step Process◦ Care Planning◦ Patient engagement – available Feb/March 2018
Data CollectionPARTICIPANT DATA MAINTENANCE & REPORTING
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
Practice and Provider Changes❖Quarterly document sent for verification: February, May, August, November
❖Best way to send changes: Change Submission Website
❖Email submissions to be phased out
❖Coming soon to MDC Portal: Practice and Provider List as an easier way to see current practice
and provider list
Quarterly Progress Report (Q4 2017)Release: December 21, 2017
Due: January 31, 2018
Content:
• PO contacts and clinical champion, practice contacts and clinical champions
• Care Manager and Coordinator information
• MHP contracting information
• Infrastructure, practice, provider changes
• Participation Experience, Strengths and Challenges
Note:
Report will be formatted so that the PO can complete on behalf of all participating practices
Participant Key Contact will receive an email with supplemental excel document (similar to Q3 report)
Practice Self-AssessmentRelease: January 9, 2018
Due: February 6, 2018
Reminder: A self-assessment must be completed for each practice.
Dashboards & ReportsMEASURES/METRICS AND DASHBOARDS THROUGH MICHIGAN DATA COLLABORATIVE
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
MDC Reporting in 2017Monthly Patient Lists
Quarterly Patient Aggregate Reports
Monthly Care Management and Coordination Reports
Quarterly Care Management and Coordination Reports
Quarterly Dashboard Releases containing quality and utilization measures results
New Measures and Reports in 2018Monthly Provider Reporting
Revisions/Additions to Care Management and Coordination Reports
Utilization/Cost Measures
• Preventable ED Visits
• Ambulatory Care Sensitive Hospitalizations
• Per Member Per Month Costs
Quality of Care Measures
• Appropriate Testing for Children with Pharyngitis
• Appropriate Treatment for Children with Upper Respiratory Infection (URI)
New Measures Coming in 2018Quality of Care Outcome Measures Using EMR/QMI Data
• Adult BMI Assessment
• CDC: Blood Pressure Control
• CDC: Hemoglobin A1c Poor Control
• Controlling High Blood Pressure
• Screening for Depression and Follow-Up
• Tobacco Use Screening and Cessation Counseling
• Weight Assessment and Counseling
2018 Tracking CodesCARE MANAGEMENT AND COORDINATION
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
Care Management and Coordination: 2018 Tracking Codes • The PCMH Initiative requires all participating practices to track Care
Management and Coordination Service provision using a designated set of Healthcare Common Procedure Coding System (HCPCS) and the American Medical Association's Current Procedural Terminology (CPT) codes.
Code Quick Description
G9001 Comprehensive Assessment
G9002 In-person Encounter
98966, 98967, 98968 Telephone Services
99495, 99496 Care Transition
G9007 Team Conference
G9008 Physician Coordinated Care Oversight Services
98961, 98962 Group Education and Training
S0257 End of Life Counseling
See Appendix C: Care Management and Coordination Tracking Quick Reference in the 2018 Participant Guide for more complete details on each code
New codes added for 2018
Care Management and Coordination: Service DocumentationAll Services rendered should be documented in electronic Care Management and Coordination Documentations Tools (either a stand alone product or component of EHR), with information accessible to all care team members at the point of care.
Documentation should, at a minimum, include the following: • Date of Contact*• Duration of Contact • Method of Contact• Name(s) of Care Team Member(s) Involved in Service• Nature of Discussion and Pertinent Details• For G9001- Comprehensive assessment results and detailed, individualized care plan• For G9007- Update(s) and/or additions made to individualized care plan
* Date of service reported should be the date the care management and coordination service took place. In some cases, a service may take place over the course of more than one day, in such an event the date of service reported should be the date the service was completed
Care Management and Coordination: Claims Submission Guidelines
Submission of the Care Management and Coordination claims supports one of the SIM PCMH Initiative Care Management and Coordination Metrics:
All claims must be formally submitted to the appropriate payer (Medicaid Health Plan) directly at the practice’s customary charge to be included as a part of service provision tracking
• The Care Management and Coordination services outlined by the HCPCS and CPT codes must be provided under the general supervision of a primary care provider.
• Many of the services themselves or activities to support the service can be accomplished through coordinated team efforts, maximizing Care Manager and Coordinator skills to engage patients efficiently. While many team members may be involved in the provision of a single service (such as a care transition), the service may only be billed using the National Provider Identifier (NPI) of the primary care provider
Any patient who has had a claim with one of the applicable codes during the reporting period
Eligible Population
Mark Your CalendarUPCOMING EVENTS
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
Upcoming Events• January 17:
• January Office Hour: Integrated Service Delivery, Concepts and Plan for Statewide Implementation, 11:30-12:30
• MiCMRC Longitudinal Learning Activity: Quality Metrics in Ambulatory Care Webinar, 2:00-3:00PM
• January 19:
Q3 17 Care Coordination Report Release
• January 31:
Q4 17 Progress Report Submission Deadline
• February 6:
Practice Self Assessment Submission Deadline
• February 21:
February Office Hour: Michigan 2-1-1
• March 21:
March Office Hour: CMCC Service Tracking Codes
• March 26:
Q1 18 Progress Report Release Check out the calendar in our 2018 Participant Guide
2018 PCMH InitiativeANNUAL KICK-OFF WEBINAR
JANUARY 9, 2018 | 12:00 – 1:00PM