January 13, 2015

Care Management News

Today’s Topics

Learning events Maintenance of Certification How IHI views MNO care management activities Learning Community What’s new

2

Training

Who Should Register? MNO PCPs and members of the practice team

Prerequisites: Knowledge of medical terminology and anatomy

Clock Hours: 10 (Note: 10 clock hours accounts only for time spent in the online or in-person course, proficiency exam and not study time. Study time will vary widely per individual.)

Course Length: To be completed within a 3-month period or less

3

Training

Certificate of Completion: Yes Testing: A one-hour wrap up session followed by a

one hour competency exam is required Course Material: Workbooks and study guides

available after registration

4

Why Attend

Identify conventions and guidelines used in coding Describe signs, symptoms and ill-defined

conditions Explain rule out versus probable, possible,

differential, suspected terms relating to diagnosis

5

Why Attend

Explain CMS STAR ratings Illustrate how CMS STAR ratings are measured Identify the CMS STAR ratings data sources Demonstrate a strategy to improve STAR ratings Illustrate coding chronic illness conditions using

Medicare’s guidelines for correct coding Show the CMS Risk Adjustment Model and the

HCC Categories (Hierarchical Condition Categories)

6

Why Attend

Show examples of appropriate documentation and coding

Describe common documentation inadequacies Illustrate how to correctly incorporate the Chronic

Care Management (CCM) codes Identify a successful patient-centered care plan

document Explain transition care management codes

7

Cohort A: Instructor Led - Classroom

Wednesday, February 4 6:00pm-8:00pm Wednesday, February 11 6:00pm-8:00pm Wednesday, February 18 6:00pm-8:00pm Wednesday, February 25 6:00pm-8:00pm

8

Cohort B: Instructor Led - Classroom

Thursday, March 5 6:00pm-8:00pm Thursday, March 12 6:00pm-8:00pm Thursday, March 19 6:00pm-8:00pm Thursday, March 26 6:00pm-8:00pm

9

Cohort C: Instructor Led - Classroom

Monday, April 13 6:00pm-8:00pm Monday, April 20 6:00pm-8:00pm Monday, April 27 6:00pm-8:00pm Monday, May 4 6:00pm-8:00pm

10

Full Day: Instructor Led - Classroom

Wednesday, February 4 8:30am-4:30pm Saturday, February 7 8:30am-4:30pm Wednesday, February 11 8:30am-4:30pm Wednesday, February 18 8:30am-4:30pm Saturday, March 7 8:30am-4:30pm Saturday, March 14 8:30am-4:30pm Saturday, April 18 8:30am-4:30pm Monday, April 20 8:30am-4:30pm

11

Mandatory Wrap Up and Competency Exam

Thursday, April 16, 2015 9:00am-11:00am 6:00pm-8:00pm

Saturday, April 18, 2015 9:00am-11:00am 10:00am-12noon

Thursday, May 14, 2015 9:00am-11:00am 6:00pm-8:00pm

Saturday, May 16, 2015 9:00am-11:00am 10:00am-12noon

Tuesday, June 15, 2015 9:00am-11:00am 6:00pm-8:00pm

12

Other Approaches

On demand On-demand interactive Self paced learning

13

Why Attend Training

Contractual Agreement Documentation training Coding Preparation for ICD-10

14

A Guide For Caring For the Elderly

Two day training for team members Certificate upon completion Membership in learning community First training in May

15

Maintenance of Certification

Part IV module, ABMSF AF4Q Greater Detroit Area Health Council (GHAHC), was added to each Physician Portfolio

All MNO PCPs who successfully completed MLC III were awarded the CMEs for MOC – Part IV

16

MOC - Part IV and MLC

A payment is required to complete the process. Within the Physician Portfolio, you will see a

Pending Payment link on the Modules Page under the modules listed in-progress. Click the "Pending Payment" link will permit you to make this payment online.

Until payment has been made credit will not be awarded.

17

BCBSM, IHI and MNO

Target population• Medicare Advantage members with at least 6

chronic conditions who are attributed to a physician organization that is providing high intensity care model

18

BCBSM, IHI and MNO

Target population’s core challenges• Psychosocial needs• Mental health needs that are unmet• Polypharmacy• Managing 6+ chronic conditions• Geo location• Lack of practice and PCP buy-in

19

BCBSM, IHI and MNO

Integrated Care Team• Community-based multi-disciplinary care team with

heavy emphasis on psychosocial support• Integrated care team coordinates with dozens of

Primary Care Physicians in the community• PCPs sit outside the Integrated Care Team

20

MNO Team

Nurse Practitioner• Oversees HICM including developing policies and

procedures• Provides medical interventions as needed• Makes home visits, including doing initial

assessment with social worker when needed

Geriatrician• Assess interdisciplinary team activities• Reviews cases• Advises team on assessments

MNO Team

Registered Nurse• Assigned to Primary Care Provider to serve a panel

of patients• Does outreach to PCPs to recruit patients• Assists in patient recruitment• Provides home visits• Navigates care with patient/caregiver/family • Interacts with hospitalist, home care agency, DME• PCMH –N activities

MNO Team

Psychologist (PhD)• Supervises the masters level behavioral health

providers • Oversees psychosocial assessments• Provides home visits when necessary

Clinical Psychologist

Consults with the team around care plans as each patient is reviewed in the weekly huddle

Leads learning modules related to behavioral health factors (eg. depression, dementia, caregiver burden, chronic pain... and adds BH perspective to other modules)

Participates in the development of policies and procedures and clinical protocols from a BH perspective

24

Behavioral Health Care Management

BH CM goes beyond assessment, care planning, and linking to community resources• Provides brief behavioral health, evidence-

based interventions shown to be helpful with geriatric patients• Facilitates self-management support of mental

health and physical health symptoms through motivational interviewing, patient education, and brief action planning

25

Behavioral Health Care Management

Other kinds of interventions include• brief problem solving therapy• teaching relaxation techniques• supportive counseling to caregivers• brief cognitive-behavior therapy

26

MNO Care Team

Social Workers • Perform initial assessment with nurse practitioner or

RN• Co-create care plans with patient and other care team

members• Link patients to community resources

MNO Care Team

Dietitian and/or Certified Diabetes Educator• Co-create meal plans with patients/caregivers• Access community resources for patients and their

caregivers• Teach care team

Pharmacist• Provide medication education, management and

reconciliation• Meet with Primary Care Physicians• Teach care team

28

MNO Care Team

Medical Assistants• Provide back-up support and complete paperwork

Health Coaches: Certified Exercise Specialists • Trained in wellness, health, and injury prevention as

well as health coaching• Design exercise programs in the home

29

MNO Care Team

Primary Care Physicians• Provides primary care in various communities• Assesses care plans • Communicates with Integrated Care Team via

Protected Time

MNO Care Team coordinates with over 80 Primary Care Physicians

30

MNO Care Team

Caregiver/Family members• Interact directly with the care team• Partner in creating and carrying out the care plan

31

What Else…

32

Central Training and Education Hub: Comprised of Nurse Practitioner, Registered Nurse, Pharmacist and PsychologistProvide trainingLead team in a 4 hour weekly metingAssess team competencyLead Quality Improvement activitiesDevelop and share PDSAs

MNO Care Team Support

IT Support• Data capture• Maintain central electronic health record• Create templates• Repository

33

MNO Care Team Support

Coding and Billing• Interacts with payer• Coders and Billers• Revenue Cycle Consultant• Run reports on documentation completion by the

team• Advise on ways that team can increase efficiency

34

What We’ve Learned So Far

35

Behavioral health is the key component of the care team

Relationship between Primary Care Physicians (PCPs) and patients is very significant

Collaborating with PCPs requires finding the key person in each PCP office

What We’ve Learned So Far

36

Learning how PCP and practice team prefer to communicate, and using technology to communicate in real time (secure text & email)

PCPs are very responsive to Integrated Care Team including making same-day appointments available to Integrated Care Team patients

What’s New

SIM Grant Innovation Grant Clinical Team

37

Open Discussion

38