webinar july 31, 2012
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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!