the michigan primary care transformation (mipct) project
DESCRIPTION
The Michigan Primary Care Transformation (MiPCT) Project . 2013 Annual Summit Sharing Care Management Best Practice & Building the Care Manager Caseload . MiPCT Care Manager Update Patient Panel Size. Mary Ellen Benzik,MD. Not what we had planned ---. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/1.jpg)
The Michigan Primary Care Transformation (MiPCT) Project
2013 Annual SummitSharing Care Management Best Practice & Building the Care Manager Caseload
1
![Page 2: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/2.jpg)
MiPCT Care Manager Update Patient Panel SizeMary Ellen Benzik,MD
![Page 3: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/3.jpg)
Hybrid59%
(248)
Mod-erate26%
(109)
Complex15% (63)
Care Manager RolesN=420
3
Not what we had planned ---
![Page 4: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/4.jpg)
4
2013 PO Report – 1st & 2nd Quarter Care Manager ActivitiesThe Mean increases are statistically significant.
25th
Perce
ntile
50th
Perce
ntile
75th
Perce
ntile
90th
Perce
ntile
050
100150200250300350
Face-Face En-counters/ FTE qtr 1Face-Face En-counters/ FTE qtr 2Phone Encounters/ FTE qtr 1Phone Encounters/ FTE qtr 2Unique Patients/ FTE qtr 1Unique Patients/ FTE qtr 2
![Page 5: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/5.jpg)
Care Manager Volume Quarter 2, 2013
EncountersUnique PatientsFace to
Face Phone
Total 15,250 32,709 22,237
Per CM FTE 63 112 82
5
![Page 6: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/6.jpg)
Care Management Breakdown-80/20 Rule
Complex
Well
Moderate
![Page 7: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/7.jpg)
Simple Math
•1,000,000 patients •20% = 200,000 patients potentially for
care management •22,234 in one quarter •Potentially over 100,000 patient
encounters a year at the current pace
![Page 8: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/8.jpg)
MiPCT Benchmark* for Care Manager Caseload
Care manager’s patient caseload – 2nd Quarter PO Data
8
Care Manager Role
90th Percentile Qtr 2 face to face/FTE
90th Percentile QTR 2Phone encounters/FTE
Encounters per day = Benchmark*
Complex 84 260 6 encounters per day
Hybrid 160 321 8 encounters per day
Moderate
193 238 7 encounters per day
![Page 9: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/9.jpg)
But this is NOT About NUMBERS
![Page 10: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/10.jpg)
Care Manager Survey Results
•Care Managers reported working with an average of 8.4 physicians
•On average, 83% of these physicians referred patients
10
Physician Interaction
![Page 11: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/11.jpg)
Care Manager Survey Results
Daily Weekly Every 2 weeks
> Every 2 weeks
Never0%
20%
40%
60%
42%35%
6% 8%3%
How Often Care Managers Converse with PCP Regarding MiPCT-Eligible
Patients
11
![Page 12: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/12.jpg)
Care Manager Survey Results
•The physician(s) I work with support the concepts of the MiPCT care management team.
12
Strongly
Disagree
Disagree
Neither Agree
nor Disagre
e
Agree Strongly Agree
![Page 13: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/13.jpg)
Care Manager Survey Results
•Physicians are available on a daily basis to address questions related to management of MiPCT patients.
13
Never Rarely
Sometimes
Frequently
Always
![Page 14: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/14.jpg)
Care Manager Survey Results•Physicians understand and are actively
involved in population management
14
Never Rarely
Sometimes
Frequently
Always
![Page 15: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/15.jpg)
Does Anybody Achieve Target CaseLoads?
Yes!
![Page 16: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/16.jpg)
How Do The Best Performing Practices Do It?• Front office staff screen member lists, confirm
current eligibility, identify gaps in care, etc.
• Office, PO and Nursing management support team-based care
• Backfilling occurs
• Physicians partner with the Care Manager and refer patients
• Team meets regularly as a team to discuss successes and opportunities for improvement
![Page 17: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/17.jpg)
Today is about Solutions
Sharing Best Processes
Engaging your care team
Letting go of patients when appropriate
![Page 18: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/18.jpg)
Henry Ford Medical Group (HFMG) MiPCT
HTN Initiative Juliann Testy RN, BSN
Henry Ford Health System
![Page 19: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/19.jpg)
New Initiative for HFMG: Measure Up, Pressure Down Campaign
Sponsored by AMGF
![Page 20: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/20.jpg)
CMs Participate in Blood Pressure Campaign80% BP Control Target by 2015
Case Managers and Diabetes Care Team Educators have BP related program goals as part of their Performance Management process- Disease management & RN BP re-check visit process
As self-management site champions, support staff with skill application following interactive self-management workshops for Medical Assistants and RNs
Developed collaborative protocols with Home Health Care: Telehealth Home Monitoring Process; calibration of BP cuffs
Pharm D’s share tips on medication reconciliation issue recognition
![Page 21: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/21.jpg)
New “Gimme 5” CampaignHelps Manage MiPCT Population
Campaign targets final gap in diabetes care Uses Registry & Epic to link meaningful info
to ProvidersBumped against MiPCT Attribution for Team
Care ◦Site/Physician based by component◦Identifies active point person/program◦Eligibility status◦Identifies patients with poor BP Control and
more…
21
![Page 22: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/22.jpg)
“Gimme 5” Campaign: A Twist on Diabetes Population Management
22
![Page 23: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/23.jpg)
Group Work – Care Management Processes
![Page 24: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/24.jpg)
Group Work Description Title of Work FlowA. Team Based Care – Care Manager Patient Engagement using HTN Registry
Henry Ford Health System – MIPCT Eligible HTN Registry
B. Building Care Manager Caseload – PO, Health System, Practice Support
McLaren Holt Family Practice: Building Care Management Integration Process
C. Team Based Care – Care Manager Daily Work Processes
McLaren Holt Family Practice: Team Based Care
D. Care Manager Processes – Case Closure
Lakeshore Health Network/Mercy Health Primary Care Network: Transitioning Care Management Patients
E. Team Based Care – Care Manager Daily Work Processes
Lakeshore Health Network/Mercy Health Primary Care Network Care Manager Warm Handoff
F. Team Based Care – Care Manager Daily Work Processes (includes case closure)
West Front Primary Care: Care Manager Work flow
![Page 25: The Michigan Primary Care Transformation (MiPCT) Project](https://reader036.vdocument.in/reader036/viewer/2022062811/568160f3550346895dd02b11/html5/thumbnails/25.jpg)
Report Out