Transcript Most Improved - MiPCT Demonstration Project

The Michigan Primary Care
Transformation (MiPCT) Project
WELCOME TO THE
2015 MiPCT SUMMIT!
MiPCT Payers, Patients and Providers
As of March 2015:
• 1814 providers
▫ 1,577 physicians
▫ 237 mid-level providers
• Over 500 care managers
• 346 PCMH practices
• 1,158,650 members
Medicare
Medicaid
BCBSM
BCN
Priority
Total
# Patients % Patients
186,997
16.1%
214,745
18.5%
361,802
31.2%
275,316
23.8%
119,990
10.4%
1,158,850
100.0%
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MiPCT Synergy with Blueprint Pillars
Vision: MC system that maximized
health status through evidence and
value-based care delivery
MiPCT
Population
Health
Management
-Registry skillbuilding
-Role of panel
managers
-Training specific to
each role as well as
team-wide sessions
MiPCT Pay
for Value
-Competitive
Incentives to Drive
Behavior
-Commercial G
and CPT Code
Care Management
Billing
MiPCT
Integration of
Care
MiPCT
Structural
Transformation
-Patient
identification and
Engagement
-Dashboards;
Incorporation of
Registry Data
-Team-based care
focus
-Support for
Health IT and
Analytics
-Transition
coordination
-ADT alerting
The Michigan Primary Care
Transformation (MiPCT) Project
Evaluation and Program Updates
8:40-9:10 AM
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Evaluation Update
• Overall Evaluation Results to Date
• Patient Experience Results
• Care Manager Survey Results
• Care Manager Activity
• MiPCT Utilization & Quality Trends
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Overall evaluation results to date
• Cost savings for Medicare beneficiaries
▫ Caveat: quarter to quarter variation
• All-payer utilization, 2011 - 2013
▫ Increase in ED rates
▫ Moderate decline in hospitalizations
• Patient experience (2015)
▫ MiPCT Adults generally more positive than
non-MiPCT
▫ MiPCT parents about the same as non-MiPCT
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Overall evaluation results to
date
• Provider/staff survey reveals satisfaction with
Care Management model
• Care Management survey and PO data
collection reveal progress on embedment
• Care Manager activity leveling off:
25,000 – 30,000 unique patients per
quarter
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Methods
• Stratified random sample
▫ MiPCT and comparison group status
▫ Payer
▫ High/very high risk concurrent risk category
• Multi-modal (mail with phone follow-up)
• Response rates
▫ Medicare
▫ Medicaid
▫ Commercial
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Adult survey results: MiPCT
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Adult survey results: MiPCT
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Child survey results: MiPCT
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Child survey results:
MiPCT
Reported occurrence
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Analysis
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•
•
•
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Regression: Generalized Linear Model
IBM SPSS v. 19
Independent Variable: MiPCT status
Controlled for: risk category, payer
Interactions with MiPCT status (e.g., does
MiPCT/PCMH have a different relationship
with patient experience for some groups
based on):
▫ High/very high risk score
▫ Payer type (Medicare, Medicaid, Commercial)
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Adult survey results
*
*
*
* Statistically significant difference
*
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Adult survey results
*
*
*
*
* Statistically significant difference
*
*
17
Child survey results: MiPCT
versus comparison groups
*
• MiPCT patients were not significantly
different
than other PCMH patients across domains
• MiPCT patients were not significantly different
than non-PCMH patients across most domains
▫ Exception: MiPCT patient ratings of provider
attention to growth and development 11.6% higher
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Average Total Patients in Caseload
(at the time of survey):
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Protocols
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Team members understand which
patients might benefit from care
management
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Practice Support
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PO Quarterly Reporting
CARE MANAGER ACTIVITY
2013 Q1 to 2015 Q2
45,000
30,000
15,000
0
Q1
Q2
Q3
Q4
2013
Face-to-Face Encounters
Q1
Q2
Q3
2014
Phone Encounters
Q4
Q1
Q2
2015
Unique Patients
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2011, 2012, & 2013
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Estimated Average MiPCT ED and Inpatient
Rates (#/1,000 member years)
450
449
400
411
395
350
300
All ED
All Inpatient
250
200
146
150
130
133
100
Baseline Rate
2012 Rate
NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color.
2013 Rate
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Estimated Average MiPCT Diabetes Rates
0.90
0.85
0.872
0.882
0.80
0.828
0.821
0.75
0.70
0.739
0.757
0.877
0.805
0.758
HbA1c
0.65
LDL-C
0.60
0.55
Eye Exam
0.546
0.50
Baseline Rate
0.536
2012 Rate
0.529
2013 Rate
NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color.
Neph
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Estimated Average MiPCT Adult Preventive Rates
0.75
0.716
0.70
0.65
0.715
0.732
0.726
0.696
0.631
0.60
Breast cancer
Cervical cancer
Chlamydia
0.55
0.50
0.440
0.45
0.40
0.379
0.35
Baseline Rate
0.395
2012 Rate
2013 Rate
NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color.
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Estimated Average MiPCT Peds Preventive Rates
0.95
0.900
0.90
0.905
Lead
0.85
0.80
0.75
0.70
0.790
0.769
0.763
0.731
0.775
0.760
0.682
0.65
0.60
0.55
0.785
0.775
Childhood
Immu
0.701
Adolescent
immu
0.616
0.573
0.582
Well Child
3-6 yrs
0.50
0.45
0.480
0.40
Baseline Rate
Well Child
15 Mon
0.442
0.436
2012 Rate
2013 Rate
NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color.
Adolescent
Well Care
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MiPCT Clinical Update
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The Care Management Resource Center:
Helping our Practices to Help Our Patients
CMRC Care Manager Training
Growth Over Time
Year
# CM Trained
2012
273
2013
165
2014
70
2015 to date
73
TOTAL
581
• Almost 600 CMs have been
trained and supported with
continuing education since the
MiPCT began
• As health plans (Priority,
BCBSM) have expanded the
care management benefit
beyond MiPCT practices, the
CMRC has expanded training
sessions (link at:
http://mipct.org/caremanagement-resourcecenter/ccm-online-registrationpage/
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The Higher the Risk, the More
Likely Patients are to Receive CM
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Progress Recap 2015-16 Clinical
Focus Areas
• Addressing social determinants of health and
overcoming barriers
▫ Mary Ellen Benzik, Tiger Team Lead
▫ Toolkit and white paper in development
• Integrating behavioral health
▫
▫
▫
▫
Kevin Taylor, Tiger Team Lead
Tiger Team tookit and white paper in development
Advocacy: proposed CMS collaborative care model
Coordinating with BCBSM/Priority Health work
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Progress Recap 2015-16 Clinical
Focus Areas
• Patient registry and data support for population health
▫ Registry and EHR User groups being formed for systems
most-used by MiPCT practices
▫ CMRC site visits to better understand and spread
processes highly linked to HEDIS and STAR
improvement
• Integrating palliative and end-of-life care
▫ Advocacy for CMS proposed advance care planning codes
▫ Ongoing work with Palliative Care subject matter experts
• Addressing appropriateness of care (e.g., Choosing Wisely
program, etc.)
▫ To launch in 2016
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Preparing for Sustainability: Never
Too Early!
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Strategy Avenue 1: CMS and State Policy
• CMS Policy
▫ Potential 2017 Expansion of Comprehensive Primary
Care Program (CPC) (our “sister” program)
▫ CPC milestones are very similar to the MiPCT





Enhanced patient access and continuity of care,
Planned chronic and preventive care,
Risk-stratified care management,
Patient and caregiver engagement, and
Coordination of care across a “medical neighborhood”
• State Policy
▫ SIM synergy
▫ Medicaid Managed Care Plan Rebid and Care
Management
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Strategy Avenue 1: CPC Milestone
Comparison to MiPCT Activity
CPC Milestone
I. Budget
II. Care Management
for High Risk
Patients
MiPCT
Mandatory CM salary and benefit PO reporting
MiPCT Multipayer Member List; MDC dashboards with risk score and quality/cost/use measures;
Self-management support and patient engagement are an additional 2015-16 focus area for the MiPCT; care managers are required
to have self-management and motivational interviewing education, and an all-care-manager half day training in Fall 2015 will
provide in-depth training on Brief Action Planning (BAP)
III. Access and
Continuity
IV. Patient
Experience
V. Quality
Improvement
VI. Care
Coordination Across
the Medical
Neighborhood
VII. Shared Decision
Making
VIII. Participate in
Learning
Collaborative
Medication reconciliation is a mainstay of care manager training in the MiPCT; Further, the program has partnered with the state
information backbone (MiHIN) to add detail on medications to the Admission, Discharge, Transfer (ADT) notifications that the
program currently provides when members experience ED, inpatient, home health or SNF admissions or discharges
24/7 care team access; practices encouraged to achieve PGIP PCMH capability 5.2 for real time access; Project monitors CM
sufficiency for an 80% minimum level
CG-CAHPS survey; Partnered with the Institute for Patient and Family-Centered Care to train MiPCT practices in patient and
family advisor programs
MDC registry data collection; webinars, focused learning collaboratives; quarterly learning webinars
Centralized CM Training and Continuing Education; ADT notifications; Transition of Care and other care guidelines and protocols
Potential application to Choosing Wisely focus area
MiPCT practices (the PCP, care manager and at least one other practice team member) must satisfy eight practice learning credits
per year; Behavioral Health and Social Determinant Tiger Teams; Medication Management competency in CM training
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Strategy Avenue 1, cont.
Section 115A of the Social Security Laws
• (c) Expansion of models (phase ii).—Taking into account the evaluation under
subsection (b)(4), the Secretary may, through rulemaking, expand
(including implementation on a nationwide basis) the duration and the
scope of a model that is being tested under subsection (b) or a demonstration
project under section 1866C, to the extent determined appropriate by the
Secretary, if—
• (1) the Secretary determines that such expansion is expected to—
• (A) reduce spending under applicable title without reducing the
quality of care; or
• (B) improve the quality of patient care without increasing spending;
• (2) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies
that such expansion would reduce (or would not result in any increase
in) net program spending under applicable titles; and
• (3) the Secretary determines that such expansion would not deny or limit the
coverage or provision of benefits under the applicable title for applicable
individuals. In determining which models or demonstration projects to expand
under the preceding sentence, the Secretary shall focus on models and
demonstration projects that improve the quality of patient care and reduce
spending.
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Strategy Avenue 2: Meeting Each Payer’s
Goals
 Payer Leadership Meetings to understand what is
important to each payer group so that we can better
service their members – and deliver value that can
help to sustain the program in the longer term




HEDIS and STAR Measure Improvement
Cost Savings
Improved Coordination with Proactive Outreach
Admission, Discharge, Transfer alert follow-up
 Servicing patients from all payers -- Medicaid,
Medicare, BCBSM, Priority Health and BCN – who
are likely to benefit from Care Management
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Strategy Avenue 3: Leveraging Care
Management Billing Codes
• Billing and Coding Collaborative
offers support to practices and POs (in
Resources tab of mipctdemo.org)
• G and CPT Codes - Billing for
commercial members with proactive
eligibility checking
• Codes are Payable by Medicare (e.g.,)
▫ Complex Care Management Code
(99490)
▫ Transition of Care Codes (99495,
99496)
The Michigan Primary Care
Transformation (MiPCT) Project
The State Innovation Model and
Population Health in Michigan
Elizabeth Hertel, Director of Health Policy
Innovation, State of Michigan
9:20-10:20 AM
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State Innovation Model
October 29, 2015
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Context: Centers for Medicare and Medicaid Services
Payment Reform Targets
Planned percentage of Medicare FFS payments linked to quality
and alternative payment models
2016
2018
30%
85%
50%
90%
All Medicare Fee for
Service
Fee for Service linked to quality
Alternative payment models
*Adapted from Centers for Medicare & Medicaid Services, January 26,
44
Round 2 Model Test States
New York - $99.9 million
Ohio - $75 million
Michigan - $70 million
Colorado – $65 million
Tennessee - $65 million
Washington - $64.9 million
Connecticut - $45 million
Iowa - $43.1 million
Idaho - $40 million
Delaware - $35 million
Rhode Island - $20 million
Round 1 Test States
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Michigan State Innovation Model
Proposal Overview
• Michigan Blueprint for Health Innovation
developed with broad stakeholder engagement
in 2013
• Model Test proposal submitted July 2014
▫ Closely follows Blueprint
• Proposal presentation at Center for Medicare
and Medicaid Innovation: October 2014
• $70 Million award announcement: December
2014
• Project begin date: February 1, 2015
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Phased Model Test
Wave I Regions
 Have all model components and capabilities
 Prior experience with pay for value
 May include Level I and II Accountable
Systems of Care
Wave II Regions
 Have some, but not all, model components
and capabilities
 Could benefit from additional planning,
investment, community convening, before
implementation
 May include Level I and II Accountable
Systems of Care
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Michigan’s Model Test Timeline
2018
2019
2020
2017
2016
2015
Model
Test:
Wave I
PreImplementation
Model Test:
Waves I
and II
Model
Test
and
spread
State-wide
dissemination
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Michigan’s Blueprint
Raises the Bar
Patient Centered Medical
Home
+ Accountable Systems of
Care
+ Population health
capacity
+ Payment reform
Patient Centered Medical
Home
+ Systems of Care
Policy
Infrastructure for a Learning Health System
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Accountable Systems of Care
▫ Physician organizations
 Cover all of Michigan: both
provider and health system led
 Contracting and credentialing
support
 Practice coaching and quality
improvement
 Support for patient centered
medical home transformation
▫ Medicaid managed care
▫ Emphasize whole-system
transformation, anchored by
strong primary care and
effective care management
▫ Create systems that
coordinate care within and
beyond health care system
(e.g., improved transitions
in care)
▫ Better leverage health
information technology and
health information exchange
▫ Link with Community
Health Innovation Regions
for better outcomes
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State Innovation Model
Performance Measures
▫ Drive adoption of a core set of measures
▫ Align payment and core set of measures
across payers to reduce administrative
complexity and provider burden
 Michigan State Medical Society has developed a
common clinical measure list across several
Michigan payers
 State Innovation Model Performance
Measurement and Recognition Committee will
establish additional process and population
health measures
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Payment Reform
• Align with trend toward payment for
population level performance, moving away
from fee-for-service
▫ Level I: Shared savings (upside risk)
▫ Level II: Capitation models
• Designed to drive:
▫ Consistent delivery of high-quality,
person/family-centered care
▫ Reductions in low-value care
▫ Reductions in avoidable acute care utilization
• Provide for investments in community
health
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Community Health Innovation Regions
▫ Work together for collective
impact on population
health:
▫ Multipurpose collaborative
bodies
▫ Chartered Value Exchanges
▫ Health Improvement
Organizations
▫ Community Benefit
▫ Assess community need
▫ Define common priorities
▫ Adopt shared measures of
success
▫ Pursue mutually reinforcing
strategies towards common
priorities
▫ Implement systems to
coordinate health care,
community services, and
public health
▫ Invest in prevention
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Health Information Exchange/
Health Information Technology
• Key functions of Health Information Exchange in State
Innovation Model:
▫ Support care coordination within Accountable Systems
of Care and across the health care system
▫ Support community linkages to better address social
determinants
▫ Allow real-time performance monitoring, rapid-cycle
improvement processes
▫ Infrastructure components
▫ Electronic Medical Record functionality
▫ Connection to sub-state Health Information Exchange
▫ Data aggregator
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State Innovation Model Target
Populations
• Healthy babies
• Emergency Department super-utilization
(8+ visits/year)
• Multiple chronic conditions
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Medicaid Managed Care Rebid
• Managed Care Rebid
▫ Plans and regions announced October 15, 2015
▫ Requires health plan participation in the State
Innovation Model
▫ Specifically promotes key components of
delivery system transformation:
 Patient-centered medical homes
 Support for care management
 Community health workers
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Pre-Implementation Update
• Complete
▫ Accountable System of Care and Community Health
Innovation Region capacity assessments reviewed
• To Do
▫ Region and site selection
▫ Develop key program materials for feedback
• Looking ahead
▫ Finalize programs
▫ Develop operational plans with Model Test participants
▫ Execute agreements with Model Test participants
▫ Launch Model Test learning system
▫ Implement payment reform
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Pre-Implementation: February 2015 – January 2016
Quarter 1
Quarter 2
Quarter 3
Quarter 4
(Feb - April)
(May - July)
(Aug - Oct)
(Nov - Jan)
•Hiring and
orientation
•Tool and
model
development
•Stakeholder
engagement
plan
•ASC capacity
assessment
•CHIR capacity
assessment
•Continued
model
development
•Timeline
development
•MDHHS
workgroups
launched
•Develop CMS
Operational
Plan
•Convening:
Performance
Measurement
and
Recognition
Committee
•Regional
selection
announced
•Program
policy public
comment
period
•CMS
Operational
Plan submitted
Implementation Year 1: February 2016 – January 2017
Quarter 1
Quarter 2
Quarter 3
Quarter 4
(Feb - April)
(May - July)
(Aug - Oct)
(Nov - Jan)
•ASCs and
CHIRs submit
operational
plans and
requests for
funding
•Participation
agreements
signed
•Collaborative
learning
networks
launch
•CHIRs
undertake
strategic
planning for
population
health
•ASCs, MHPs,
and MDHHS
test
administrative
information
systems
•ASCs and
MHPs sign
contracts to
begin October
1, including:
•Shared
savings
•Pregnancy
bundle
•Partial and
global
capitation
options
•Michigan
completes
Population
Health
Improvement
Plan
The Michigan Primary Care
Transformation (MiPCT) Project
Celebrating Best Practices!
10:50-11:50 AM
Celebrating Success in MiPCT
Practices!
Practice Awards-Categories
• Best Overall – Adult and Family Medicine
Practices
• Most Improved – Adult and Family Medicine
• Best Overall – Pediatric Practices
• Most Improved – Pediatrics
• Best Overall - Diabetes
• Diabetic Metric Improvement
Risk Adjustment (for top overall
awards)
• Purpose
To level the playing field so that practices are
recognized for performance, not for the
underlying characteristics of their population
• Considerations
 Health status
 Demographics
 Payer mix
Practice average risk score
(concurrent)
% Medicare, % Medicaid, %
Commercial
Risk Adjustment (continued)
• Methods
▫ Implemented by MPHI and approved by the
Stewardship and Performance Committee
▫ Involves comparing how the practice actually
performed to how we would have expected it to
perform if we knew nothing other than these
population characteristics
• Application
▫ Best overall adult, diabetes and pediatric awards
▫ Not applied to award categories for most improved
Best Overall – Adult and Family Practices –
Risk Adjusted*
• Composite score based on practices’ rankings in the
following MDC Measures, risk adjusted by MPHI:
▫
▫
▫
▫
▫
▫
Inpatient Admissions
ED Visits per 1000 Patients
PCS ED Visits
Acute ACSC Admission Rate
Chronic ACSC Admission Rate
Diabetes Overall
Most Improved – Adult and Family
• Greatest difference in Overall Ranking between
baseline (calendar year 2011) and current
measurement period as of the April, 2015 release
(claims incurred October, 2013 – September,
2014). For example, a practice that moved from
rank 200 to rank 100 would count as “more
improved” than one that moved from rank 50 to
rank 1.
Diabetes Overall - Risk Adjusted*
• Composite score based on practices’ rankings in
the following MDC Clinical (non-supplemented)
measures; composite (not components) are risk
adjusted by MPHI:
▫
▫
▫
▫
Diabetes Eye Exam
Diabetes HbA1c
Diabetes LDL-C
Diabetes Nephropathy
Diabetes Metric Improvement
• Greatest percent difference in Diabetes Overall
Score between baseline (calendar year 2011) and
current measurement period (claims incurred
October, 2013 – September, 2014) for all nonPediatric practices.
• Note that for this measure we are looking at
improvement in Score NOT improvement in Rank.
Best Overall – Pediatric Practices - Risk Adjusted*
• Pediatric Practices are defined as those where >= 85% of attributed
patients (based on current measurement period patient attribution)
are <= 21 years of age.
• Note that in cases where we filter to include only “pediatric” patients
we will use <18 as the cutoff age for Pediatrics. This only comes into
play where MPHI has requested demographic data be filtered by age
for risk adjustment. All MDC measures have age limits built into
their calculations (e.g. Well Child visits for different age groups only
look at members in those age groups, Adult ACSC utilization
measures only look at members >= 18)
• Composite score based on pediatric practices’ rankings for the
following MDC Measures, risk adjusted by MPHI:
▫ Pediatric Inpatient Visit Rate with Previous Asthma Diagnosis
▫ Pediatric ED Visit Rate with Previous Asthma Diagnosis
▫ Pediatric Preventive Overall
Most Improved – Pediatric
• Greatest change in ranking between baseline and
current measurement period. See Most
Improved – Adult and Family description for
change in measurements period definitions.
The 2015 Winning Practices!
Best Overall – Adult and Family
Medicine Practices
• Marquette Internal Medicine Pediatric
Associates
• Fenton Medical Center, P.C.
• Jane Castillo, MD
• Dhiraj Bedi, DO
• Lifetime Family Care, PLLC /A Division
of Michigan Healthcare Professionals PC
Winning Category: Best Overall Adult and Family
Practice Name: Fenton Medical Center
• WHAT MADE A DIFFERENCE (Process Change, etc.):
▫ Improved communication among departments for care management
referrals
▫ Hospital admissions and urgent care appt. notifications
▫ Staff assistance with checking MiPCT eligibility
▫ Improved Advanced Directives discussions
▫ Daily checking of the schedule for hospital, ED, or urgent care follow ups
▫ Resource document compiled by Clinical Leads
▫ Addition of a full time care manager has improved continuity,
communication, and timely follow up
▫ Increased staff education of the MiPCT program and purpose
• HINTS FOR OTHER PRACTICES
▫ Ensure all staff understand the value of the MiPCT program and their
part in achieving outcomes
Winning Category: Best Overall Adult and Family
Practice Name: Jane Castillo, MD
WHAT MADE A DIFFERENCE
• Daily Huddles (Dr. Castillo/CM/Staff)
▫ Include MiPCT care management candidates
▫ Identify scheduled patient gaps in care
▫ Physician access throughout the day to address patient needs
• Office uses Epic as a universal communication tool before, during and after clinic
• Reputation and Trust
▫ Patients are encouraged to call the office first (unless life-threatening) to
discuss needs and concerns
▫ Portion of daily schedule dedicated to same day appointments
• Timely Transition Care
▫ Dr. Castillo performs daily rounds on her hospital patients
▫ Patient follow up appointments are scheduled with the physician within 7 days
of the discharge date
▫ CM calls the patient within 48 hours of discharge to review patient knowledge
and understanding of discharge plan; intervention as appropriate
Winning Category: Best Overall Adult & Family Practice
Practice Name:
Dhiraj Bedi.DO
WHAT MADE A DIFFERENCE:
• Patient education about PCMH
• Health Navigation ED follow up calls post visit to
Genesys Regional Medical Center and Hurley Medical
Center
• Utilization Management follow up calls to out of network
inpatients at McLaren - Lapeer
• Care team approach to patient care (Primary Care
Physician, Health Navigator, Utilization Nurses, Medical
Assistant, Etc)
• Utilization of population management tools such as but
not limited to Utilization reports, or PMR reports
• Chronic Care planned visits to reduce gaps in care.
Winning Category: Best Overall Adult & Family Practice
Practice Name:
Dhiraj Bedi, DO
Genesys PHO Utilization Summary
Bedi, Dhiraj, DO
Insco/Cat:
BCN COMM Membership
Data Thru:
Drno:
Member Statistics
Provider
Group
Provider PYTD
Group PYTD
Provider
Group
Provider PYTD
Group PYTD
Provider
Group
Provider PYTD
Group PYTD
Provider
Group
Provider PYTD
Group PYTD
Member Months
Members Seen Last 12 Months
Members Seen YTD
Members With EEHR PCP
Inpatient Statistics
Use Rate/1000
Average LOS
Admits/1000
GRMC %
Non-GRMC %
After Hours / Emergency Department
AH Visits/1000
ED Visits/1000
ED GRMC %
ED Non-GRMC %
Referrals
Rate/1000
Avg Aprv Svcs/Ref
Pref Provider %
Non-Pref Provider %
Winning Category: Best Overall Adult & Family Practice
Practice Name:
Dhiraj Bedi, DO
Diabetes Population Management Registry Report
Patients age 18 thru 75
Provider: Bedi, Dhiraj, DO
Patient ID Patient FullName
HbA1C Last Visit
Exam Date
HbA1C <= 8 HbA1C LDL Last Dilated Retinal Depression Nephropath Last BP BP Med
result 12
Eye Exam
Screening y Screening Reading
Last Pneum Member Of Composite In Health
Vac Date
Measure
Navigation
Yes 2015-09-16
Met
6.4
Not Met
No
Met
Met
140/80
Met
SMHT TPA
Not Met
No
Yes 2015-04-27
Met
7.9
Met
Yes
Met
Met
148/80
Met
BCN COMM
Met
Yes
Yes 2015-03-23
Met
6.5
Met
No
Met
Met
122/68
Met
MR MR
Not Met
Yes
Yes 2015-06-04
Met
6.0
Met
Yes
Met
Met
148/80
Met
MR MR
Met
No
Yes 2015-05-18
Met
5.8
Met
No
Met
Met
128/60
Met
2012-10-04 BCBS MR
Not Met
No
Yes 2015-07-14
Met
7.3
Met
Yes
Met
Met
130/84
Met
MR MR
Met
Yes
Yes 2015-08-20
Not Met
8.5
Met
No
Met
Met
150/82
Met
BCBS COMM
Not Met
Yes
Yes 2015-08-14
Not Met
9.4
Met
Yes
Met
Met
120/72
Met
2007-10-12
BCBS COMM
Not Met
Yes
Yes 2015-08-28
Met
5.7
Met
Yes
Met
Met
132/66
Met
BCN COMM
Met
Yes
2008-10-27
Physician Totals
2015
Diabetes Diagnosis
HbA1C Exam
HbA1C <= 8
HbA1C >= 9
LDL Exam
Dilated Retinal Eye Exam
Depression Screening
BP Reading
Last BP Reading Elevated
BP Medication
Nephropathy Screening
Pneumovax Vac
Composite Measure
2014
September
September
Total
Patients
Total
Patients
Eligible
Provider
GPHO
Population Percentage Percentage
Eligible
Provider
GPHO
Population Percentage Percentage
Winning Category: Best Overall Adult & Family Practice
Practice Name:
Dhiraj Bedi, DO
• HINTS FOR OTHER PRACTICES
▫ Development of a team culture within the practice
▫ Efficient usage of technology – real time charting
and documentation within the electronic medical
record to avoid fragmentation.
▫ Accessibility to patients 24/7 via cell phone to
ensure the patient receive the most appropriate
care in the appropriate setting.
▫ Develop a network of specialists
Winning Category: Best Overall- Adult and Family
Practice Name: Lifetime Family Care
• WHAT MADE A DIFFERENCE (Process Change, etc.):
▫ Daily morning all-team huddle the first fifteen minutes of each
day (identify who is complex, etc.)
▫ Scheduling chronic patients on the day that the Care Manager is
in the office
▫ Active use of Welcentive registry – one FT staff member enters
data, identifies gaps in care for team, patients who have not been
in with chronic illness, etc.
▫ Drop-down shortcuts and information codes in EHR
▫ Having a “start” physician in Dr. Keu
• HINTS FOR OTHER PRACTICES
▫ Document policy and enforce it – don’t let it exist just on paper
▫ Use screening toolkit in the EHR
▫ Agreement on protocols among physicians in practice
Winning Category: Best Overall- Adult and Family
Practice Name: Lifetime Family Care
•
•
WHAT MADE A DIFFERENCE (Process Change, etc.):
▫
Communication! Communication! Communication!
 Monthly staff meeting
 Daily huddles (First 15 minutes of the day with all staff to discuss workflow, ADT, and meetings for the
day.)
 Impromptu daily meeting
 Administrative meeting
 Clinical Management meeting
▫
Physician lead Practice
▫
Maximize use of Technology:
 Wellcentive (Active Data Entry, Care Summaries, Alerts, and etc..)
 EMR (Shortcuts, Reminders, CDS, and Reports)
▫
Patient Focus Practice:
 Patient surveys reviewed monthly and changes made accordingly.
 Monthly staff training on building patient and staff relationships.
 Emphasize efforts to help patients feel valued.
HINTS FOR OTHER PRACTICES
▫ Get everyone involved in all office process.
▫ Develop policies as a team and enforce it-don’t let it exist just on paper.
Lifetime Family Care: Our Culture
Make work fun!
Lifetime Family Care: Team Huddle Agenda
Lifetime Family Care: Our Patient/Provider MOU
Lifetime Family Care: Our Patient/Provider MOU,
cont.
Most Improved – Adult and Family
Medicine
• East Ann Arbor Adult Medicine and
Pediatrics Clinic
• Rivertown Internal Medicine and
Pediatrics
• Campustowne Family Medicine
• Grand Rapids Internal Medicine and
Pediatrics
• Alpine Internal Medicine and Pediatrics
Winning Category: Most Improved – Adult and Family Practice
Practice Name: East Ann Arbor Adult Medicine and Pediatrics
Clnic
• WHAT MADE A DIFFERENCE:
▫ A Multidisciplinary Workgroup Approach
The Chronic Care Team. Membership consists of Clinic
Physicians, Navigator Team (Care Managers), PharmD (co-lead),
Registered Dietitian, Social Worker, Nursing, Practice
Management, Panel Manager, Medical Assistants, and Clerical
staff)
Winning Category: Most Improved – Adult and Family Practice
Practice Name: East Ann Arbor Adult Medicine and Pediatrics
Clnic, cont.
WHAT MADE A DIFFERENCE – Chronic Care Team
The team huddles for 15 minutes each Thursday to:
 Review Quality Management Programs (QMP) reports
 Set goals and review progress
 Divide the responsibility
 Medical Assistants play a significant role to assure Best
Practice Alerts are ordered/pended for their providers,
foot exams completed, etc.
Winning Category: Most Improved – Adult and Family Practice
Practice Name: East Ann Arbor Adult Medicine and Pediatrics
Clnic, cont.
The Care Navigation Team
•
•
•
Jennifer Smith, NP
Deborah Dahlgren, RN
Carol Carnell, MAS Panel
Manager
Navigators Jennifer and Deb
• Follow up on all the inpatient discharges
• Manage patients with multiple complex diagnoses
Coordination – The team meets weekly to focus on areas to
accomplish. Lists are worked daily.
Winning Category: Most Improved – Adult and Family Practice
Practice Name: East Ann Arbor Adult Medicine and Pediatrics
Clnic, cont.
HEALTH CENTER LPN TEAM
Have key roles in assuring plans
are in place for asthma and
controlled substances.
HEALTH CENTER RN TEAM
Follow up patients recently
discharged from Emergency
and Urgent Care settings.
Winning Category: Most Improved – Adult and Family Practice
Practice Name: East Ann Arbor Adult Medicine and Pediatrics
Clnic, cont.
Adult Medicine & Pediatrics Clinic
The Medicine Pediatric physicians (including 14 residents) partner with
medical assistants, the clinic LPN, Patient Service Assistants, RNs and the
Navigator Team to assure the best care for their patients.
Winning Category: Most Improved – Adult and Family Practice
Practice Name: East Ann Arbor Adult Medicine and Pediatrics
Clnic, cont.
HINTS FOR OTHER PRACTICES
Flexibility is key to working with and
meeting the needs of the team
Collective Approach all clinic staff are
responsible for meeting goals toward
excellent patient care
Diabetes Overall
• Family Tree Medical Associates
• St Johns Professional Associates
• SMG DeWitt
• Grand Blanc Family Medicine
• Jane Castillo, MD
Winning Category: Diabetes Overall
Practice Name: Jane Castillo, MD
WHAT MADE A DIFFERENCE
• Dedicated staff member manages registry to focus on obtaining test
results and closing gaps in care
• Dr. Castillo calls patients with test results – even if normal
• Focus is on patient self-management of blood sugar levels
▫ Dietary and exercise management
▫ Education and reinforcement on oral medication/insulin administration
options
Diabetes Metric Improvement
• Cherry Street Health Center
• SMG Holt
• St Johns Professional
Associates
• Premier Family Physicians
• New Day Family Medicine
Winning Category: Most Improved-Diabetes
Practice Name: New Day
• WHAT MADE A DIFFERENCE:
▫ A Flexible and “Eager to Adopt New Things” Culture -- The team takes care
to make sure that everyone has “bought in” to a proposed change
▫ “Whole Practice Team” (coach, CM, physician, front desk lead) meets twice
a month to go over their performance on measures, discuss gaps in care,
etc.) and uses IHP online registry
▫ Sustaining the Gains of the IHP Diabetes Collaboratives – Integrated
successes into the practice workflow as expectations, and have spread the
approach to asthma, hypertension
▫ Diabetic Eye Exam Excellence– Practice initiates and faxes the referral to
the ophthalmologist. Two weeks later they follow up with the
ophthalmologist and follow up if the patient has not gone using a referral
tracking form they developed
▫ In-Office Diabetic AIC Testing – The practice has its own machine and can
give the patient instantaneous testing and results
Winning Category: Most Improved-Diabetes
Practice Name: New Day, cont.
• HINTS FOR OTHER PRACTICES
▫ Everyone must be vested in a change (if the front
desk, MA, etc. is not “bought in”, the change won’t
work)
▫ Develop trust in your team –everyone is busy and
needs a team that they can trust
▫ Incorporate prompts as cues – for example, when
a chronic disease patient visits, the appointment
system labels as a chronic disease visit, prompting
the team to see if they need tests, etc.
Best Overall – Pediatric Practices
• Pediatric Specialists of
Bloomfield Hills PC
• Pediatric Consultants of Troy
PC
• Joseph B. Luna, M.D., P.C.
• Cereal City Pediatrics PC
• Moazami Pediatrics
Winning Category: Best Overall Pediatric
Practice Name: Pediatric Consultants of Troy
WHAT MADE A DIFFERENCE
• Access – Our Patients Know We Will Be Here for Them
▫ We are open SEVEN DAYS A WEEK (including Sat 8-11 and Sunday 5-8)
▫ Phones are personally answered (we don’t use an automated attendant), giving
parents of asthmatics confidence about reaching the practice at times of need
• Preparation and Scheduling
▫ We prepare charts the day before the visit
▫ Asthmatics get an initial 45 minute visit and we insert an asthma packet (with
an asthma navigator and history, etc.) with every pediatric asthmatic visit
▫ We use a Google calendar for dietician and social worker appointments
▫ Patients can’t get fills on their medications if they have not been seen in six
months
Winning Category: Best Overall Pediatric
Practice Name: Pediatric Consultants of Troy
WHAT MADE A DIFFERENCE
• Tracking Process – Our Checklist and our Tracking Book
▫ Our Checklist – The practice team designed a patient checklist that goes to the
physician to make sure everything is done (self-management goal, etc.), and is
returned to the front staff for follow-up and gap closure if needed; also entered
in Wellcentive
▫ Tracking Book – Contains things that require follow-up (e.g., call to a no-show
patient for rescheduling, etc.)
▫ If there is an ER visit, the patient gets a letter with information about how to
reach the practice and their office hours
▫ Good test tracking; we MCIR every patient who comes to the office (not just at
the physical but at all appointments)
HINTS FOR OTHERS
• Take tracking seriously
• Consider offering weekend hours – it makes a difference for our patients
98
Extended Hours
Awareness
99
Pediatric Asthma
Tools: Self Mgt
Goal Form and
Checklist
Checklist:
100
Pediatric Asthma
Tools: Asthma
Navigator
Winning Category: Best Practice Pediatrics
Practice Name: Dr. Luna
• WHAT MADE A DIFFERENCE:
Asthma Patients
▫ Efficient at scheduling f/u appts before patient leaves
▫ Use of Wellcentive to check inpatient & ER admissions
▫ Good relationship with hospital which calls & makes f/u appt for pt
before being discharged
▫ With asthma flare ups, will always have patient come back for recheck in
2-3 days-1 week
Preventive Care
▫ Efficient at scheduling
▫ Multiple calls to reschedule for no shows
▫ Send letter if unable to reach
• HINTS FOR OTHER PRACTICES
▫ Staff has personal knowledge of families. They know which ones need
extra reminders, preferences, likes/dislikes etc.
Winning Category: Best Overall Pediatric Practice
Practice Names: Cereal City Pediatric and Moazami Pediatric
WHAT MADE A DIFFERENCE
• A Focus on Training
▫ The entire office (including front office) participated in in-service with an
asthma educator; in-services from an Asthma Allergy Center on injections
▫ Physicians conducted an in service with the nursing staff on identifying
respiratory distress. Now, the content of the in service has been included as
part of the new hire training process.
• Useful Standard Tools and Processes
▫ In 2012, a cough protocol/algorithm for the front desk and triage was created
to screen phone calls and prioritize appointments. The office also purchased
a spirometer and had the supplier conduct an in service on proper use.
▫ Annual well visits with an asthma action plan is required for all medication
refills and notes for medication usage at school for patients with asthma.
▫ Medication follow-up appointment is required for patients w/frequent refills.
▫ Asthma patients are tracked and flagged in PCC and Gaps in Care reports and
the office has a designated Asthma Champion.
Winning Category: Best Overall Pediatric Practice
Practice Names: Cereal City Pediatric and Moazami Pediatric
WHAT MADE A DIFFERENCE, cont.
▫ Priority calls are placed to patients with asthma when flu vaccine arrives,
along with other high risk patients before reminder calls for the healthy.
▫ Refills are monitored for compliance.
• Attention to Patient Education
▫ Patient Asthma Education folders are given to patients with a new asthma
diagnosis.
▫ Individual care management education sessions are conducted to teach
patients how to use a spacer, inhaler, or nebulizer.
HINTS FOR OTHER PRACTICES
▫ Take time for training and incorporate processes and useful tools as aids to
guide your work
▫ Watch for patterns (which patients are requesting frequent refills, are there
repeating situations that cause rework, etc.) and act on them
Most Improved – Pediatric
• Pediatric Consultants of Troy PC
• CHC Fort Gratiot
• Forest Hills Pediatric Associates PC
• Briarwood Center For Women
Children and Young Adults
• Pediatric Care of Lansing
Winning Category: Most Improved – Pediatric
Practice
Practice Name: Forest Hills Pediatrics
• WHAT MADE A DIFFERENCE (Process Change, etc.):
▫ Care Plan created with built in triggers for recall
▫ Phone calls within two days of all ED visits
▫ Recheck with educator after every asthma flare
• HINTS FOR OTHER PRACTICES
▫ Never assume patients remember what you told them
last time! Keep educating and empowering them to
manage their own medications.
Forest Hill – Care Plan Management
Winning Category: Most Improved-Pediatric Practice
Practice Name: CHC Fort Gratiot
• WHAT MADE A DIFFERENCE:
▫ Dedicated process and staff focus on closing gaps in care
 Office staff diligently follow up with parents by phone and via letters.
 Each visit (regardless of reason for visit) is used as an opportunity to close gaps
in care
▫ ED calls are made to patients who visit the ED to remind them of
extended access hours and arrange a follow-up visit, if appropriate
▫ Using data to identify opportunities for improvement
 Data analysis indicated that the most frequent driver of ED visits was
constipation. Discussion with parents found that they didn’t know what to do
when their child was in pain, or how to prevent constipation
 The practice offered a group visit that included how to prevent constipation
(e.g., with a high fiber diet that is appealing to kids), and offered information
on what do if constipation reoccurs
 Care Managers and physicians identified patients who could benefit
 The group visit was held at a convenient time for parents (from 5:30 to 7:30)
and was a hit!
 Now, group visits are conducted for asthma, nutrition, and ADHD
Winning Category: Most Improved-Pediatric Practice
Practice Name: CHC Fort Gratiot
• WHAT MADE A DIFFERENCE:
▫ The Care Managers are centrally located but huddle once a week to discuss cases
▫ One Care Manager is a social worker and has good relationships with community
mental health agencies and behavioral health resources
▫ Community resources are monitored and published on their website and in a
hardcopy binder. All employees are trained on community resources and there
are good relationships with local agencies. The practice helps the agencies by
documenting activity for funders so that they can provide it to their funders as
evidence of use
• HINTS FOR OTHER PRACTICES
▫ The whole team must know they play important roles and that others depend on
them
▫ Connect your offices with community resources
▫ Define and document processes. Create standard work and expectations.
▫ Use your data to find out what your issues are; Add a midlevel or increase your
after-hours schedule if needed.
Winning Category: Most Improved-Pediatric Practice
Practice Name: The Briarwood Center for Women,
Children and Young Adults
• WHAT MADE A DIFFERENCE:
▫ Support and direction from higher level leadership in Ambulatory
Care
▫ Establishment of a multidisciplinary Medical Home Committee
▫ Set clear goals and objectives
▫ Obtain and understand reports and data
▫ Create standard workflows
• HINTS FOR OTHER PRACTICES
▫
▫
▫
▫
▫
Invite the right people to the table
Don’t wait for others to provide you with the answers
Meet regularly, keep good notes and follow up
Share your project with as many people as you can
Celebrate improvements as you go
Workflow for Asthma GAP Report
Winning Category: Most Improved Pediatric Practice
Practice Name: Pediatric Care of Lansing
• WHAT MADE A DIFFERENCE (Process
Change, etc.):
▫ Educating patients on disease management
▫ Improving access to the PCMH through extended
hours
• HINTS FOR OTHER PRACTICES
▫ Use your Care Manager!
A Round of Applause for ALL Our 2015
Winners
….And Your Practice Could be
Recognized in 2016!
113
THANK YOU FOR ATTENDING THE SUMMIT!
• Please complete your online Summit Evaluation by November 12 at:
http://mipct.org/2015-summit-prework-webinars/2015-mipct-regional-annualsummit-evaluation-links/
(the link will also be emailed to attendees after the summit)
• Care Managers, remember to be in your designated rooms by 1pm to start
the afternoon session!
• All morning summit material is posted at mipctdemo.org
• If you haven’t visited the Tiger Team chart to identify your PO’s current
status, please do so!
• If you are not staying for the afternoon sessions, please drop your name
badges in the box at the exit of this room (or at the registration
table).
• Watch for a “Best of the Best” Compendium of the Best Practice Slides from
All Three MiPCT 2015 Summits!