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Integrating Care Managers
within Practices
MiPCT Team
May 17, 2012
Agenda
• MiPCT Complex Care Management Training
Update
• Geisinger evidence-based tools for CCMs, HCMs
• CCMs, HCMs – getting started
• MiPCT POs and Practices
▫ Integration of CCMs, HCMs, MCMs into practice
• MiPCT support for POs and Practices
MiPCT CCM Training Update
MiPCT Complex Care Management
Training Update
• CCM and HCM Training - 5 day course
• First 3 training sessions
▫ Geisinger faculty, MiPCT Master Trainers
• To date 3 training sessions completed
▫ 4/23/12 – 4/27/12 New Hudson
▫ 4/30/12 – 5/4/12 Grand Rapids
▫ 5/7/12-5/11/12
Ann Arbor
• MiPCT CCMs/HCMs trained to date = 73
Complex Care Management
Training Dates
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6/4-8, 2012
6/4-8, 2012
6/18-22, 2012
6/18-22, 2012
7/9-13, 2012
7/16-20, 2012
8/20-24, 2012
Grand Rapids
New Hudson
Lansing
Madison Heights
Lansing
Okemos/Marquette (virtual)
Lansing
MiPCT Complex Care ManagementGeisinger Partnership
• Background
▫ Train the trainer program for the MiPCT CCM
course
▫ Certification
 Master Trainers, Clinical Leads
▫ Geisinger ProvenHealth Navigator Model
 Evidence based tools
 Standardized interventions based on Geisinger
ProvenHealth Navigator model
MiPCT Complex Care Management
Curriculum
Day 1: Begins with MiPCT 101
Days 1,2,3 Geisinger
ProvenHealth Navigator (PHN)
model
• Standards of Practice for Case
Management
• Patient population
stratification
• Risk segmentation
• Right care, right place, right
time: criteria based level of
care determination
• Metrics
• Concept of Medical Home
• Population based case
management
• Need to know targeted
conditions
• Heart Failure
• COPD
• Population based care Path
• PHN 5 step case management
model
• PHN Time management
• Medical Home meeting
MiPCT Complex Care Management
Curriculum
Days 4, 5 MiPCT
• BCBSM PGIP PCMH
• Identification of high risk
MiPCT eligible patients
• Transitions of care
• Medication reconciliation
• Evidence - based care
• Chronic conditions
• Specific assessment tools
• Health Plan Payment Policy
BCBSM, BCN, Medicare
Advantage
• Medical Neighborhood
• Complex Care Manager
documentation tools
• Teamwork
• SWOT
• Case Studies
• Complex care manager – a
day in the life and getting
started
Geisinger Evidence Based Tools
For CCMs, HCMs
Geisinger Evidence-based Tools
Geisinger Standard Case management tools
• To be used by MiPCT CCMs and HCMs
• Licensed tools
• Includes
▫ CCM patient visit documentation tools
▫ Self Management Action Plans
▫ Care Manager Care Path
• CCM HCMs trained on tools during CCM course
▫ receives hard copy of tools
Geisinger Evidence Based Tools
• CCM patient visit documentation tools
▫ Comprehensive Patient Assessment (i.e. G9001)
▫ Return visit note
▫ Post discharge note (i.e. transition of care)
Geisinger Evidence-based Tools
• 10 Self Management Action Plans
• SMAPs -clinical topic specific
• Example of Heart Failure SMAP
▫ BP monitoring schedule, BP goal
▫ Patient education
 Monitoring symptoms
▫ Action plan (ex. eating right plan, daily weight,
medications)
▫ Who to call, when to call
Geisinger Evidence-based Tools
SMAPs
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After surgery
Asthma
Case Management (general)
COPD
HF Diabetes
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HF
HTN
Osteoporosis
Stop Tobacco Use
UTI
Geisinger Complex Care manager
Licensed Tools for MiPCT
• FAQ - specifies basic legal requirements
• PO Attestation letter
▫ MiPCT POs need to sign attestation letter
▫ Return signed attestation letter to [email protected]
• User agreement – micmrc.org
▫ CCMs and HCMs
 complete the MiPCT CCM course
 will receive a username and ID, to access Geisinger tools on
micmrc.org
PO, Practice Role - Use of
Geisinger tools
• Review Geisinger tools with clinical leaders, CCMs, HCMs
• If you have an EMR
▫ with care management documentation template
 compare your current complex care management
documentation templates to the Geisinger documentation tools
 add fields to EMR documentation templates as needed to
incorporate Geisinger content
▫ with out care management documentation template
 use Geisinger documentation tools
• If you have a paper medical record
▫ MiPCT team will form a work group to develop usable paper tool
version of the Geisinger documentation templates
 timeline: by 5/24/12 recruit participants, work group meets
following week
Geisinger Complex Care manager
Licensed Tools for MiPCT
• Distribution of tools
▫ CCMs and HCMs
 access electronic version of tools via password
protected micmrc.org web site
▫ POs
 first sign attestation letter
 provide request for Geisinger tools via
[email protected] and identify PO contact
information
 PO and practice - business need to know information
CCMs, HCMs – Getting Started
Initial Focus Areas for CCMs and
HCMs
• Build Complex patient caseload
• Transitions of care
 Post hospital discharge
 Transition from one setting to another – ex. SNF to
home
• Care coordination
• Medication reconciliation
• Build/expand the Medical Neighborhood
CCMs, HCMs - Screening Complex
Care Management Referrals
• High Risk, high demand
▫ MiPCT patient lists
▫ PCP, RN, health care team referrals
• Chronically ill – multiple chronic conditions or
poorly controlled
• Medically complex
• High utilizer of health system
▫ ER visits, hospitalizations
• Frail/Elderly
• “Cringe Factor”
CCMs and HCMs Daily Work
• Prioritizing daily work - complex patient case
load
▫ Review MiPCT eligible patient list with PCP
▫ MiPCT eligible complex patient with PCP visit
today
▫ Transitions of care
 from one setting to another
 hospital discharge patient list
▫ Referrals
▫ Follow up on patients in caseload
• Reminder - focus on MiPCT eligible patients
Care Manager Integration into
the Practice
Role of the PO, Practice Leadership, and MiPCT
Practice Leadership – Integration
of Care Management
• Identify a physician champion
• Practice leadership, physician champion, CCM HCM
MCM
▫ Identify consistent MiPCT care management goals
▫ Assess current processes
▫ Redesign processes as needed
Practice Leadership – Integration
of Care Management
▫ Provide education regarding MiPCT and care
management for all staff
▫ Team members roles
 define and communicate how each member contributes
to care management
▫ Introduction CCM, HCM, MCM to team members
 if transitioning from clinic RN role to MiPCT care
manager role; communicate Care Manager role
responsibilities and expectations with team members
Practice Leadership - Integration
of CCM, HCM, MCM into Practice
• Support communication, team building, and
education
▫ CCM, HCM, MCM schedule appointment with
each Physician to discuss role
▫ Team meetings
▫ Staff meetings
▫ Physician meetings
▫ Meet with practice leadership
▫ 1:1 meetings with key members of the health care
team
PO and Practice: Integration of
CCM HCM MCM into Practice
• Basic
▫ Work space
▫ Phone
▫ Providing the MiPCT attribution members list for
CCMs, HCMs
• Advanced
▫ Medical Home meeting
 Multidisciplinary – representation of team members
 Discuss Care management case studies
 Data, Process improvements
How MiPCT can help
• Work with POs to address hospital barriers
(timely discharge notifications, etc.)
• Provide resources and framework for enhancing
team functioning
▫ Support Learning Collaboratives, Lean workshops,
other team based learning
▫ More to come – soon!
• Care Management Resource Center
• MiPCT Care Manager regional infrastructure
Getting Started – Introducing
Complex Care Management to the
Practice
• What is your experience?
• What has worked?
• What has not worked?
Ideas to try. . .