The Michigan Primary Care Transformation (MiPCT) Project

Care Management:MiPCT Tiers 3 and 4

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What is Care Management?

The Center for Health Care Strategies definition:

“Programs [that] apply systems, science, incentives, and information to improve medical practice and assist consumers and their support system to become engaged in a collaborative process designed to manage medical/social/mental health conditions more effectively.

The goal of care management is to achieve an optimal level of wellness and improve coordination of care while providing cost effective, non-duplicative services.”

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OK… WHAT is care management??

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Care Management Models (example)

• Complex care managers (Tier 4)▫1 per 5,000 MiPCT patients (active cases ~ 150)▫Target: patients with multiple co-morbidities and/or

high utilization▫Goal: coordinate care, maximize function

• Care managers (Tier 3)▫1 per 5,000 MiPCT patients (work with ~ 10%)▫Target: patients with moderate complexity illness▫Goal: mitigate risk factors, optimize chronic

conditions, provide self-management support

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IV. Most complex

(e.g., Homeless,Schizophrenia)

III. ComplexComplex illness

Multiple Chronic DiseaseOther issues (cognitive,

frail elderly, social, financial)

II. Mild-moderate illness

Well-compensated multiple diseases Single disease

I. Healthy Population

<1% of population Caseload 15-40

3-5% of population Caseload 50-200

50% of populationCaseload~1000

Targeting the Efforts of MiPCT Care Management

Care Management: Basic Principles•Care manager is a member of the PCMH team •Close partnership with patient’s physician

▫Help patients achieve health goals▫Coordinate care, provide follow up between

visits•Who can be an MiPCT care manager?

▫Complex care manager: Registered Nurse, Social Worker (MSW), Nurse Practitioner, Physician Assistant

▫Other team members can also provide care management services: Pharmacist, Registered Dietician, Certified Diabetes Educator, etc.

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Goal #1: Avoid Bad Outcomes

Goal #2: Avoid Unnecessary Care

Models for MiPCT Care Managers

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Role Comparison: Moderate Risk Care Manager (MiPCT Tier 3), Complex Care Manager (MiPCT Tier 4)

 Moderate Risk Care Manager (MCM) Complex Care Manager (CCM)

Patient Population

Moderate risk patients identified by registry, PCP referral for proactive and

population management.

High risk patients identified by PCP referral and input, risk stratification,

patient MiPCT list.

Patient Caseload

Caseload 500 (approx. 90 - 100 active patients); one MCM per 5,000 patients.

Caseload 150 (approx. 30 - 50 active patients); one CCM per 5,000 patients.

Focus of Care Management

Proactive, population management. Work with patients to optimize control of chronic conditions and prevent/minimize

long term complications.

Targeted interventions to avoid hospitalization, ER visits. Ensure

standard of care, coordinate care across settings, help patients understand

options.

Duration of Care

ManagementTypically a series of 1 to 6 visits

Frequency of visits high at times, duration of months

    

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Functions of a Care Manager

•Partners with practice leadership team to integrate care management

•Assesses healthcare, educational, and psychosocial needs of patient/family

•Provides self management support ▫ focus is typically on lifestyle and behavior change

•Provides patient/family education ▫ with teach back

•Implements evidence-based care▫ chronic disease protocols and guidelines

 •Assists with transitions between settings

▫ includes medication reconciliation •Assists with advance directives

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Additional Functions: Complex Care Manager Role

•Conducts comprehensive patient assessments (Functional status, fall risk, depression, etc.) ▫initial and periodically, over time

•Creates/maintains individualized, longitudinal plan of care

•Implements evidence-based care based on chronic disease protocols and guidelines▫intervene early during acute exacerbations▫analyze complex data sets ▫monitor patient/family response

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Hybrid Care Manager Model

Definition of hybrid model: one individual who fills both Complex Care Manager (CCM) and Moderate Risk Care Manager (MCM) role

▫Use only for special circumstancesPractices with significantly fewer that 5,000 MiPCT attributed patientsPractice that serve primarily pediatric patients and have fewer complex patients

▫Individual filling both roles must complete the MCM and CCM training requirements

▫Hybrid model will be evaluated during first year of intervention; continued if successful

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Features of Successful Care Management Models

•Close collaboration between care manager and PCP •High level of “in-person” contact between care

manager and patient•Close attention to transitions of care

▫“Handoffs” are where many errors occur▫Need timely information on hospital/SNF discharges

•Medication reconciliation is regularly performed▫Need access to patient record/EHR▫Assess adherence to medication regimens

•Target patients at high risk for hospitalization

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MiPCT Care Management Priorities•Care managers work in close proximity to PCP team

▫In PCP office as much as possible▫Work with PCP team to meet their needs▫Evidence supports this model as superior to vendor-

based•Ensure Complex Care Management coverage

▫Manage high-complexity, high-cost patients▫Patients selected based on risk score plus PCP input

•Focus on evidence-based interventions▫Medication reconciliation▫Care transitions▫In-person contact with patients whenever possible▫Comprehensive care plan for complex patients

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Funding for Care Management

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MiPCT Care Management Funding • Two sources of care management funding:

▫ Per Member Per Month payments Funding not directly tied to encounters Paid on a monthly basis $4.50 PMPM – Medicare patients $3.00 PMPM – Medicaid patients

▫ G codes and CPT codes Encounter-based payments for services Blue Cross Blue Shield of Michigan Blue Care Network

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G Codes/CPT codes

• BCBSM/BCN replacement for T-codes• Encounter-based reimbursement for care

management services provided by non-physicians• Advantages over T-codes

▫Patients will not receive a bill for services if not a covered benefit under employer group plan

▫Allow mechanism for POs/PHOs to bill for services• Specific codes and reimbursement details are

available at www.mipctdemo.org (webinar #6)

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BCBSM/BCN Billing Codes

CODE SERVICE FEE*

G9001 Initial assessment $112.67

G9002 Individual face-to-face visit (per encounter)

$56.34

98961 Group visit (2-4 patients) 30 minutes

$14.08

98962 Group visit (5-8 patients) 30 minutes

$10.47

98966 Telephone discussion 5-10 minutes

$14.45

98967 Telephone discussion 11-20 minutes

$27.81

98968 Telephone discussion 21+ minutes

$41.17

*Net of Incentive amount, plus E/M uplift

Self-Management Support

March 13th, 2012

Kevin Taylor MD, MSAssociate Medical Director MiPCT

The Impact of Improving Patients’ Self-Management

“Improving patient self-management of chronic diseases would have a far greater impact on the health of the population than any improvement in specific medical treatments.”

World Health Organization, 2003

Self-Management Support

Institute of Medicine definition:▫“the systematic provision of education and

supportive interventions to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support.”

IOM, Priority Areas for National Action: Transforming Health Care Quality 2003.

Self-Management Support1. Series of techniques or tools that encourage

patients to choose healthy behaviors2. Collaborative Decision Making (a fundamental

shift in the patient-caregiver relationship)

Techniques or Tools

•Engage Patients By ConnectingThem To Their Data▫Patient care notebook▫Graphic display of information▫Patient entry of data Blood Pressure, Blood sugar graphs

▫CHF TeleScale•Patient Visit Summaries▫Patient Instruction or Prescription Sheet

Collaborative Decision Making:Setting Action Plans

1.Begin with your patient’s interests2.Believe that your patient is motivated to live a

long, healthy life3.Help your patient determine exactly what they

might want to change• Identify and respect ambivalence

4. Develop a reasonable, detailed action plan

Unachievable Action Plans

• Unclear▫“I’m supposed to start exercising.”

• Unrealistic▫ “My doctor told me to lose 10 lbs before the next

visit.”▫“Taking care of my diabetes means I’m supposed

to eat perfectly and never cheat.”

Achievable Action Plans

1. Patients and the care team work together to set general goals for treatment that are important to the patients.

2. With the help of the care team, patients create a care plan or specific action plan for their own self-care.

3. Patients and the care team review the plan periodically to ensure that it is effective in reaching the desired goals.

Is Clear Information All That Patients Need for Good Self-Management?

Doctor

Patient

Is what I told you

to do clear?

Information Giving Only• Didactic patient education does not improve

health-related behaviors or clinical outcomes ▫Diabetes (Diabetes Care 24(3);561-87▫Asthma (Kaiser Permanente June 2003)▫Arthritis (JAMA 288 (19);2469-75

Collaborative Decision Making•Significant association between improved information giving, more participatory decision making, enhanced self-efficacy, healthier behaviors and better outcomes in patients with diabetes.

Heisler et al. J Gen Intern. Med. 17 (4);243-52)

Self-Management Support Video

•http://www.youtube.com/watch?v=Nb0Kikgieng

MiPCT Care Manager Training and Infrastructure

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MiPCT Complex Care Manager

Train the Trainer Program

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Current Statistics: Complex Care Manager Train the Trainer Model

• 4 Master Trainers • Adult CCM▫13 Clinical Leads • Pediatric Care Managers▫3 Pediatric Clinical Leads

2 open positions▫ In development – Pediatric Curriculum and Care

Manager job description ▫Physician Lead: Dr. Jane Turner (MSU)

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Master Trainer Complex Care Manager Role•Oversight of 3-4 Complex Care Manager (CCM) Clinical Leads

•Does not have a patient caseload

•Leadership role in providing CCM professional development • mentoring, coaching and education

•Gathers data, populates and analyzes specified CCM activity reports for region

•Collaborates with MiPCT leadership and MiPCT clinical subcommittee to assess, study, and refine CCM training and interventions as needed

•Presents educational offerings for CCMs in small group setting as well as a statewide audience

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Complex Care Manager (CCM) Clinical Lead Role•Preceptor for CCMs in a defined region, has reduced patient caseload

•Leads small group discussions, facilitates networking, sharing best practices

•Contributes to ongoing CCM curriculum development by assisting Master Trainers with CCM education, workflow support, and resources

•Collaborates with CCM Master Trainer, MiPCT leadership, MiPCT clinical subcommittee to assess CCM interventions

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Adult CCM Master Trainers, Clinical Leads Attend Geisinger Training

•First wave 2/6/12 – 2/24/12: ▫3 Master Trainers, 6 Clinical Leads

•Second wave 3/5 – 3/23: ▫1 Master Trainer, 5 Clinical Leads

•Both waves take place in Pennsylvania

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Adult CCM Geisinger Training for Master Trainer and Clinical Lead

location time line

1 week didactic, 2 weeks embedded with case Geisinger manager

PA MI trainees 9: 2/6/12 -2/24/12MI trainees 6: 3/5/12 -3/23 /12

Geisinger Preceptor & Practice Assessment

MI May 2012 – scheduling in progress

MiPCT Adult Clinical Leads and Master Trainers

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MiPCT Adult CCM Training - Michigan Roll outTo Be Held Regionally in Michigan:

•April 23, 2012 – New Hudson

•April 30, 2012 – Grand Rapids

•May 7, 2012 – Ann Arbor

•June 2012 and thereafter monthly or as needed based on demand

Required training for Adult MiPCT Complex Care Managers (CCM) and Hybrid Care Managers (HCMs)

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Training plan: Complex/Hybrid Care Managers

One-week Michigan MiPCT didactic training ▫ Three days - Complex Care Management

Fundamentals, based on Geisinger model▫ Two days - MiPCT curriculum

•MiPCT approved self-management support training • (see list on www.mipctdemo.org)

•On-going learning▫ Precepting: with local Clinical Lead (CL)▫ Case Study sessions: led by CL▫ Webinars: continuing education on special topics

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Training plan: Moderate-Risk Care Managers

•MiPCT approved self-management support (SMS) training (www.mipctdemo.org)

•Additional suggested topics as defined by MiPCT clinical subcommittee (www.mipctdemo.org) ▫Many MiPCT-approved SMS training

programs also include these additional topics•Ongoing education through MiPCT-sponsored webinars

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Michigan Care Management Resource Center• UMHS/BCBSM collaboration

• Goal is to help disseminate effective, evidence-based care management models throughout Michigan

• Initial focus is MiPCT practices -available to all Michigan PO/PHOs /practices

• Web-based resource for templates, tools, evidence-based information

• Webinars, workshops and mentoring in care management

• Personalized care management consultation service

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Getting Started

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Getting Started- Orientation suggestions for Care Managers

•Complete an MiPCT-approved self management training program

•Complete Orientation - guided by PO/Practice Leadership▫MiPCT Care Manager orientation outline

Content developed by MiPCT Clinical Leads

▫In progress - orientation checklist Development by Master Trainers

▫Available by April 1

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Getting Started- Orientation suggestions for Care Managers

•Become familiar with role and responsibilities of health care team members

•Navigating the Medical neighborhood Develop relationships: ex. Inpatient case managers, Home Health Agencies,

Behavioral health resources, - Meet and establish relationship with team

•Review the Clinical Guidelines used by PO/Practice•Identify/learn HIT used by Practice

▫EMR▫Registry (required by the end of 2012)▫Care management documentation (note: may be a work-in-

progress)

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Case Presentation

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Case Study: Post Hospital Follow up

• 59 year old male • s/p digit amputation, discharged from hospital• Diagnoses: DM, HTN, Hyperlipidemia, Neuropathy, RSD

• Pre-assessment• Right foot dressing, not weight bearing• I/D consult in the hospital• Appears that no medication changes during hospitalization• MRSA on inpatient culture (pending results at DC)• A1C 6.2, LDL 98, PB 132/78

• Caregiver support• At time of discharge lives with wife, who has macular degeneration

and DM• Unemployed, due to foot ulcer

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Case Study: Office Visit

CCM completes office visit with patient and wife

•Medication Reconciliation• Patient brought in all pills to visit• Reports taking bactrim for wound infection• Medication reconciliation identified

• On bactrim, with out known reason; not clear on discharge plan

•Care Coordination• I/D Specialist appointment in mid April• Questions on his follow up visits

•Self-Management Support• Patient had questions on control ranges• Patient self regulation Lantus doses based on his HS blood sugars

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Case Study

• Risk Assessment• Patient and wife report inability to “see” the wound• Uncomfortable with wound care, not confident in providing the

wound care• Fear of wound not healing

• Depression Assessment• PHQ 2 negative

What would the Complex Care Manager do next?

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Case StudyClosing the GAP

•CCM reviews inpatient hospital stay record and discharge plan•Determines

• bactrim doses will be out on Saturday• lab report shows MRSA• unknown to I/D Specialist, Hospitalist and PCP as culture report

was not available at time of discharge•Speaks with I/D Specialist

• Obtains order to continue bactrim through Monday• Schedules I/D Specialist appointment Monday - original plan was

RV in 3 weeks)•Schedules Home Health Agency – care giver not able to provide wound care

• Speaks directly with HHA RN – review history, meds, treatment plan

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Case Study

Self Management Support•CCM addressed patient and care giver’s concerns regarding wound care

•Education and teach back of ranges of blood sugar•Written materials provided showing target ranges

•Educated on contacting office for medication adjustment for blood sugar out of range

•Follow up phone visit scheduled in one week

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Case Study: CCM Week 1 Phone VisitPatient states he is doing better, still not ambulating:

• Worried about getting his medications as he is not able to drive and he is due for refills

• Still has questions about his meal planning and the best foods for he and his wife

• Mentions he has some swelling in his legs

• Homecare nurse has been out and visits are every 2 days—wound healing nicely

• Contacted I/D specialist to review treatment plan, ongoing ABX. Reinforced this plan with the patient.

What steps will CCM take?

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Case Study – CCM Care Planning, ongoing Ongoing Care Coordination

• More in-depth history on swelling

• Contacted Homecare to coordinate plan of care; arrange for collaborative call at the time of the home visit to review findings and discuss necessary treatment changes

• Reviewed with patient current diuretic meds and dosing

• Contacted pharmacy - arranged for home delivery of refills

• Contacted dietician - arranged for phone education to support healthier food choices

• Reviewed case with PCP, follow up CCM phone visit in one week

• Follow-up weekly phone visit planned in one week with patient

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Questions and Discussion