Download - Mipct 05 15_2013
Michigan Primary Care Transformation
Demonstration Project
May 15, 2013Webinar
Congratulations: URAC Accreditation!
Hampton Medical Center• Bruce Johnson, DO: Board Certified in Internal Medicine and Geriatrics; American Medical Directors Association as a Certified Medical Director of Long Term Care Facilities
• Susan Tam, DO: Board Certified in Family Medicine• Christie Schunemann, NP: Board Certified Family Nurse Practitioner
• Cyndi Jones• Janet Johnson, Office Manager• Dawn Carroll, RN, Hybrid Care Manager
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Sequestration
President Obama signed an order that imposes across‐the‐board Federal spending reductions (also known as sequestration) for Federal payments effective as of April 2013.
Congress did not take action to avert this, monthly payments to practices and POs are reduced by 2% beginning April 1, 2013 and this will continue until there is resolution about the Federal budget and Federal deficit.
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Metrics Year Three
Committee review of proposed Year Three Metrics
Metrics submitted to Clinical Sub‐committee
All proposed process and clinical outcome metrics approved by Steering Committee
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Pay for Performance Year End 2012
Not available
Fund release date is unknown
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Sharing Activities: Teams
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Spotlighting Practices
May 30
Detroit Branch Federal Reserve Bank
8:30am‐12 noon
National speaker
Volunteers?
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Physician Engagement
PCP involvement with care managers
PCP involvement with care team
Number of patients referred by PCP
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Team Learning Events
June 6, 2013 (9am‐3pm)
June 8, 2013 (9am‐3pm)
June 13, 2013 (4pm‐8pm) Teams participating in Learning Collaborative
Compulsory attendance of practice team members
Required component of MiPCT practices
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Best Practices for Care Coordination/Management
Implement self management, coaching and support with patient/family
Implement effective medication management plan
Manage care setting transitions
• Having a timely, comprehensive response to care setting transitions (esp. from hospitals and skilled nursing facilities)
Care Manager Training
Complex to be online after testing is complete
Moderate various opportunities
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Reflection
Don’t talk, just act.
Don’t say, just do.
Don’t promise, just prove.
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June: 20 Days Ultimate Challenge
20 new Blue Cross patients enrolled
10 new Blue Care Network patients enrolled
20 new Medicare/Medicaid patients enrolled
~ 50 new patients
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Refresher:What is Care Coordination?
“A person‐centered, assessment based, interdisciplinary approach to integrating health care and social support services in a cost‐effective manner in which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an evidence‐based process which typically involves a designated lead care coordinator.”
Refresher:What is the Problem?
Most health care dollars are spent on a small percentage of beneficiaries Those with complex chronic conditions
Causes of high utilization and costs: Deviations from evidence‐based care Poor communication among primary providers, specialists, health and community providers, patients, and families
Failure to catch problems early Failure to address psychosocial issues Lack of coordinated, longitudinal management Ineffective transitional management
What is Effective Care Coordination?
Intervention with rigorous evidence that:
• Improves outcomes
• Reduces total health care expenditures for participating beneficiaries
• Improved satisfaction or clinical indicators not sufficient
• Net savings require reduced hospitalizations
Promising Interventions
New care coordination and care management interventions being used by care managers
• Transitional care interventions • Care Transitions Intervention (Coleman)
• Transitional Care Model (Naylor)
• Enhanced Discharge Planning Program – RUSH (Perry)
Promising Interventions
Other promising care coordination and care management interventions are emerging
• Comprehensive Care Management ‐Medicare/ Duals
• Guided Care (Boult)
• GRACE (Counsell)
• Care Management Plus (Dorr)
• MCCD: Best Practice Sites (Brown)
Promising Interventions
However, promising care coordination and care management interventions are emerging Comprehensive Care Management – Medicaid/
Duals
Integrated Care Management (Douglas)
Community Based Chronic Care Management (Lessler)
Hospital to Home (Raven)
Health Care Management Program (Reconnu & Herndon)
What Distinguishes Successful Models?
MODEL SYNTHESIS LITERATURE REVIEWTargeting • Patients with select chronic conditions including
co-occurring serious mental health diagnoses and substance abuse• Those who were hospitalized in previous year or at time of enrollment
• Program targeting to identify the population who can most benefit from a given intervention
Intervention • Conduct comprehensive in-home initial assessment • Develop a mutually agreed upon “action plan” with goal• Frequent face-to-face contact (home, office) with patients (~1/month)
• Baseline and ongoing assessment of health and social needs• Multidisciplinary approach to allow providers to address a spectrum of health and social service needs• Flexible provision of services and service intensity
Primary care provider
• Strong rapport with primary careprovider/specialist/hospital/family/caregiver• Face-to-face contact through co-location, regular hospital rounds, contact with hospitalist•Assign all of a physician’s patients to the same care manager when possible
• Enhanced communication among providers, frequently including the primary care physician
What Distinguishes Successful Models?
MODEL SYNTHESIS LITERATURE REVIEW
PatientEducation
• Providing a strong, evidence based patient education/coaching intervention for managing health, symptoms, medications
• Evidence‐based protocols to assess health and social condition and develop care plan
Training • Initial comprehensive training of CareManagers and Care Teams• Performance feedback to CareManagers and Care Teams
• At least 15 percent of articles included for review report specialized training for service providers as intervention component
Community link • Coordinate communication among physicians, health/community providers and patient/family
• Connection to existing community health and supportive services
Best Practices for Care Coordination/Management
Follow evidence based practices/guidelines for care management
Address psychosocial issues• Staff with experts in social supports and community resources for patients with those needs
Being a communications facilitator• Care managers actively facilitate communications among providers and between the patient and the providers
Open Discussion
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