webinar july 31, 2012

The Michigan Primary Care Transformation (MiPCT) Project

Learning Collaborative Information Session

Webinar July 31, 2012

MiPCT Success to Date

– Launch meetings attended by 600 participants– Trained over 230

Complex Care Managers– Continued training of Moderate Care Managers – Payments flowing– Beginning of data sharing WAY TO GO

“Embedment”

• Verb – the act of effectively embedding care managers in primary care practices

• Critical to the success of MiPCT

What does Effective Embedded Care Management Look Like in

Your Day ???Team huddle kicks the day offCCM meets with post transition patient in the office –

reconciles med list, reassesses home needs – connects with community agency for the VNS services

MCM follows up on registry, and call backs. Indentifies patient that sugar is out of control , confers with CCM regarding protocol ,and works with front desk to bring patient in sooner for provider visit

Doctor stays on schedule Patients get better care Everyone goes home happy!

Learning Collaboratives

Learning Collaboratives

Participants Engage

Select Topic

Planning Group

Identify Change

Concepts

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

E-mail Visits Web-site

Phone Assessments

Senior Leader Reports

Outcomes

Congress

A D

P

S

(6-12 months time frame)

Embedment of Care managers in primary care practices

Late Fall 2012

Starting now

Framework for MiCPT Embedded Care Management Collaborative

• 3 one day sessions, 2 months apart • Monthly learning collaborative call for team

participants • Collaborative teams include representation for all

aspects of the office team • Monthly webinar calls for other office staff not

involved in the collaborative sessions• Monthly reporting on process measures related to

model elements • Team level meetings ~ 1 hour a month • 4 waves of regionally based collaboratives • Start monthly beginning in November, 2012

Waves of MiPCT Collaboratives

• Wave One begins November 2012

• Wave Two begins early December 2012

• Wave Three begins January 2013

• Wave Four begins February 2013

PRACTICETRANSFORMATION

CARE MANAGEMENTTRANSFORMATION

Transitions of Care,

Medication Reconciliation,

Advanced Directives

Quality Improvement

Strategy,Build Teams,Define Roles

Care Management Embedment Model

PRACTICETRANSFORMATION

Quality Improvement

Strategy,Build Teams,Define Roles

Care Management Embedment Model

Meetings for Quality Improvement

Sometimes gathering data can

bring new and

surprising knowledge!

Too Many Men on the Field?

Impact of Practice TransformationPhysician Organizations /Practices • Offers expertise on team development to

sustain change • Ability to sustain change by redesigning

how your team works together • Decrease the chaos • Improve the satisfaction for the team

delivering care management care.

Impact of Practice TransformationCare Managers

• Ability to build case load more effectively with the team

• Increased understanding of the care managers role in the team

• Decrease the chaos • Improved satisfaction with the delivery of

care

CARE MANAGEMENTTRANSFORMATION

Transitions of Care,

Medication Reconciliation,

Advanced Directives

Care Management Embedment Model

Impact of Transition of Care

•Enhanced communication across the care system,

•With seamless handoffs

•Recognition of the importance of the patient’s health experience

•Addresses and prevents the patient from “falling

through the cracks”

Impact of Medication Reconciliation

• Medication list will be accurate and complete at hospital transitions.

• Patients will be actively engaged to ensure the medication list is correct at all care provider encounters

• Decreased chaos for the care team • Decreased medication side effects and

complications for the patient

Impact of Advanced Directives

• Directives will be discussed with the patients.

• When obtained, they will be identified and accessible by the care team

• Patient wants and desires are honored across the care system

• Unwanted care and costs are avoided

Impact of Care Delivery TransformationPatients

• Improved engagement in their care • Improved patient satisfaction - “they really

do care about me” • Less chaos • Less frustration

ProcessMeasures1.2.3.4.

ProcessMeasures

1.2.3.4.

PRACTICETRANSFORMATION

CARE MANAGEMENTTRANSFORMATION

Transitions of Care,

Medication Reconciliation,

Advanced Directives

Quality Improvement

Strategy,Build Teams,Define Roles

Care Management Embedment Model

ProcessMeasures1.2.3.4.

ProcessMeasures

1.2.3.4.

PRACTICETRANSFORMATION

CARE MANAGEMENTTRANSFORMATION

Transitions of Care,

Medication Reconciliation,

Advanced Directives

Quality Improvement

Strategy,Build Teams,Define Roles

OUTCOMESReduced Hospitalizations for Ambulatory Care Sensitive Conditions

Reduced Emergency Department VisitsReduced Avoidable Readmissions

Care Management Embedment Model

What does Effective Embedded Care Management Look Like in

Your Day ???Team huddle kicks the day offCCM meets with post transition patient in the office –

reconciles med list, reassesses home needs – connects with community agency for the VNS services

MCM follows up on registry, and call backs. Indentifies patient that sugar is out of control , confers with CCM regarding protocol ,and works with front desk to bring patient in sooner for provider visit

Doctor stays on schedule Patients get better care Everyone goes home happy!

Come Join Us !!

• Register your practice team at:– https://jodyooo.wufoo.com/forms/mipct-

learning-collaborative-team-application/

• Dates will begin in November• CME and CEU will be available • Unique learning experience that helps you

know that your not alone • How can we help you recruit practices for this

opportunity ?

Thank You!