Transcript Complex Care Manager

1
The Michigan Primary Care
Transformation (MiPCT) Project
Care Management:
MiPCT Tiers 3 and 4
2
What is Care Management?
The Center for Health Care Strategies definition:
“Programs [that] apply systems, science, incentives, and
information to improve medical practice and assist consumers
and their support system to become engaged in a
collaborative process designed to manage
medical/social/mental health conditions more effectively.
The goal of care management is to achieve an optimal level of
wellness and improve coordination of care while providing
cost effective, non-duplicative services.”
3
OK… WHAT is care management??
4
5
Care Management Models (example)
• Complex care managers (Tier 4)
▫ 1 per 5,000 MiPCT patients (active cases ~ 150)
▫ Target: patients with multiple co-morbidities and/or
high utilization
▫ Goal: coordinate care, maximize function
• Care managers (Tier 3)
▫ 1 per 5,000 MiPCT patients (work with ~ 10%)
▫ Target: patients with moderate complexity illness
▫ Goal: mitigate risk factors, optimize chronic
conditions, provide self-management support
Targeting the Efforts of
MiPCT Care Management
IV. Most
complex
(e.g., Homeless,
Schizophrenia)
<1% of population
Caseload 15-40
III. Complex
Complex illness
Multiple Chronic Disease
Other issues (cognitive, frail
elderly, social, financial)
II. Mild-moderate illness
Well-compensated multiple diseases
Single disease
I. Healthy Population
3-5% of population
Caseload 50-200
50% of population
Caseload~1000
7
Care Management: Basic Principles
• Care manager is a member of the PCMH team
• Close partnership with patient’s physician
▫ Help patients achieve health goals
▫ Coordinate care, provide follow up between visits
• Who can be an MiPCT care manager?
▫ Complex care manager: Registered Nurse, Social
Worker (MSW), Nurse Practitioner, Physician
Assistant
▫ Other team members can also provide care
management services: Pharmacist, Registered
Dietician, Certified Diabetes Educator, etc.
Goal #1: Avoid Bad Outcomes
Goal #2: Avoid Unnecessary Care
10
Models for MiPCT Care Managers
11
Role Comparison:
Moderate Risk Care Manager (MiPCT Tier 3),
Complex Care Manager (MiPCT Tier 4)
Moderate Risk Care Manager (MCM)
Complex Care Manager (CCM)
Patient
Population
Moderate risk patients identified by registry,
PCP referral for proactive and population
management.
High risk patients identified by PCP referral
and input, risk stratification, patient MiPCT
list.
Patient Caseload
Caseload 500 (approx. 90 - 100 active
patients); one MCM per 5,000 patients.
Caseload 150 (approx. 30 - 50 active patients);
one CCM per 5,000 patients.
Focus of Care
Management
Duration of Care
Management
Proactive, population management. Work with Targeted interventions to avoid hospitalization,
patients to optimize control of chronic
ER visits. Ensure standard of care, coordinate
conditions and prevent/minimize long term
care across settings, help patients understand
complications.
options.
Typically a series of 1 to 6 visits
Frequency of visits high at times, duration of
months
12
Functions of a Care Manager
•Partners with practice leadership team to integrate care management
•Assesses healthcare, educational, and psychosocial needs of
patient/family
•Provides self management support
•Provides patient/family education
•Implements evidence-based care
•Assists with transitions between settings
•Assists with advance directives
13
Additional Functions:
Complex Care Manager Role
• Conducts comprehensive patient assessments (Functional
status, fall risk, depression, etc.)
▫ initial and periodically, over time
• Creates/maintains individualized, longitudinal plan of care
• Implements evidence-based care based on chronic disease
protocols and guidelines
▫ intervene early during acute exacerbations
▫ analyze complex data sets
▫ monitor patient/family response
14
Hybrid Care Manager Model
Definition of hybrid model: one individual who fills both
Complex Care Manager (CCM) and Moderate Risk Care
Manager (MCM) role
▫ Use only for special circumstances
 Practices with significantly fewer that 5,000 MiPCT attributed patients
 Practice that serve primarily pediatric patients and have fewer complex patients
▫ Individual filling both roles must complete the MCM and
CCM training requirements
▫ Hybrid model will be evaluated during first year of
intervention; continued if successful
16
MiPCT Care Management Priorities
• Care managers work in close proximity to PCP team
▫ In PCP office as much as possible
▫ Work with PCP team to meet their needs
▫ Evidence supports this model as superior to vendor-based
• Ensure Complex Care Management coverage
▫ Manage high-complexity, high-cost patients
▫ Patients selected based on risk score plus PCP input
• Focus on evidence-based interventions
▫
▫
▫
▫
Medication reconciliation
Care transitions
In-person contact with patients whenever possible
Comprehensive care plan for complex patients
17
Funding for Care Management
18
MiPCT Care Management Funding
• Two sources of care management funding:
▫ Per Member Per Month (PMPM) payments
 Funding not directly tied to encounters
 Paid on a monthly basis
 $4.50 PMPM – Medicare patients
 $3.00 PMPM – Medicaid patients
▫ G codes and CPT codes
 Encounter-based payments for services
 Blue Cross Blue Shield of Michigan
 Blue Care Network
19
G Codes/CPT codes
• BCBSM/BCN replacement for T-codes
• Encounter-based reimbursement for care
management services provided by non-physicians
• Advantages over T-codes
▫ Patients will not receive a bill for services if not a
covered benefit under employer group plan
▫ Allow mechanism for POs/PHOs to bill for services
• Specific codes and reimbursement details are
available at www.mipctdemo.org (webinar #6)
BCBSM/BCN Billing Codes
CODE
SERVICE
G9001
Initial assessment
$112.67
G9002
Individual face-to-face visit (per
encounter)
$56.34
98961
Group visit (2-4 patients) 30 minutes
$14.08
98962
Group visit (5-8 patients) 30 minutes
$10.47
98966
Telephone discussion 5-10 minutes
$14.45
98967
Telephone discussion 11-20 minutes
$27.81
98968
Telephone discussion 21+ minutes
$41.17
*Net of Incentive amount, plus E/M uplift
20
FEE*
Self-Management Support
March 13th, 2012
Kevin Taylor MD, MS
Associate Medical Director MiPCT
The Impact of Improving Patients’
Self-Management
“Improving patient self-management of chronic diseases
would have a far greater impact on the health of the
population than any improvement in specific medical
treatments.”
World Health Organization, 2003
Conditions Needed for Patient SelfManagement
• Sufficient knowledge and skills
• Motivation
• Confidence in one’s own ability
to perform specific tasks
(“self-efficacy”)
• Adequate support and resources
to initiate and sustain behavioral changes
Self-Management Support
Institute of Medicine definition:
▫ “the systematic provision of education and
supportive interventions to increase patients’ skills
and confidence in managing their health problems,
including regular assessment of progress and
problems, goal setting, and problem-solving
support.”
IOM, Priority Areas for National Action: Transforming Health Care Quality 2003.
Self-Management Support
1. Series of techniques or tools that
encourage patients to choose
healthy behaviors
2. Collaborative Decision Making
(a fundamental shift in the
patient-caregiver relationship)
Techniques or Tools
• Engage Patients By Connecting
Them To Their Data
▫ Patient care notebook
▫ Graphic display of information
▫ Patient entry of data
 Blood Pressure, Blood sugar graphs
▫ CHF TeleScale
• Patient Visit Summaries
▫ Patient Instruction or Prescription Sheet
Collaborative Decision Making:
Setting Action Plans
Begin with your patient’s
interests
2. Believe that your patient is
motivated to live a long, healthy
life
3. Help your patient determine
exactly what they might want to
change
• Identify and respect
ambivalence
4. Develop a reasonable, detailed
action plan
1.
There is no improvement, Henry.
Are you sure you’ve given up
everything you enjoy?
Unachievable Action Plans
• Unclear
▫ “I’m supposed to start
exercising.”
• Unrealistic
▫ “My doctor told me to lose 10
lbs before the next visit.”
▫ “Taking care of my diabetes
means I’m supposed to eat
perfectly and never cheat.”
Achievable Action Plans
1.
2.
3.
Patients and the care team work
together to set general goals for
treatment that are important to the
patients.
With the help of the care team,
patients create a care plan or
specific action plan for their own
self-care.
Patients and the care team review
the plan periodically to ensure
that it is effective in reaching the
desired goals.
Maureen Bisognano
President and CEO Institute for Healthcare
Improvement
“What matters to you?”
33
The Family Health Center Teamlet Project
(San Francisco CA)
• Health workers participating in
clinician visits and meeting with
patients in post-visit sessions (15
to 45 minutes)
• Discuss issues related to chronic
disease self-management
• Initiate visit “Is there anything you
would like to talk about that you
did not have a chance to say in
your visit with the doctor?”
• Training:
▫ Basic information on chronic
conditions such as diabetes,
hypertension and elevated
cholesterol
▫ Asking patients to re-state what
they heard in the clinician visit
(Ask/Tell/Ask)
▫ Working with the patient to
understand why they are taking
their medications
▫ Assist patients to make action
plans and help them to achieve
their goals
Self-Management Support Video
• http://www.youtube.com/watch?v=Nb0Kikgien
g
35
Tools
• Video with Techniques for Effective Patient SelfManagement
▫ http://www.chcf.org/publications/2006/08/video-withtechniques-for-effective-patient-selfmanagement
42
MiPCT Care Manager Training
and Infrastructure
43
MiPCT Complex Care Manager
Train the Trainer Program
44
Current Statistics: Complex Care Manager
Train the Trainer Model
• 4 Master Trainers
• Adult CCM
▫ 13 Clinical Leads
• Pediatric Care Managers
▫ 3 Pediatric Clinical Leads
 2 open positions
▫ In development – Pediatric Curriculum and Care
Manager job description
▫ Physician Lead: Dr. Jane Turner (MSU)
45
Master Trainer Complex Care Manager Role
• Oversight of 3-4 Complex Care Manager (CCM) Clinical Leads
• Does not have a patient caseload
• Leadership role in providing CCM professional development
• mentoring, coaching and education
• Gathers data, populates and analyzes specified CCM activity reports for
region
• Collaborates with MiPCT leadership and MiPCT clinical subcommittee to
assess, study, and refine CCM training and interventions as needed
• Presents educational offerings for CCMs in small group setting as well as a
statewide audience
46
Complex Care Manager (CCM)
Clinical Lead Role
•Preceptor for CCMs in a defined region, has reduced patient caseload
•Leads small group discussions, facilitates networking, sharing best
practices
•Contributes to ongoing CCM curriculum development by assisting
Master Trainers with CCM education, workflow support, and resources
•Collaborates with CCM Master Trainer, MiPCT leadership, MiPCT
clinical subcommittee to assess CCM interventions
47
Adult CCM Master Trainers, Clinical Leads
Attend Geisinger Training
• First wave 2/6/12 – 2/24/12:
▫ 3 Master Trainers, 6 Clinical Leads
• Second wave 3/5 – 3/23:
▫ 1 Master Trainer, 5 Clinical Leads
• Both waves take place in Pennsylvania
48
MiPCT Adult Clinical Leads and Master Trainers
Adult CCM Geisinger
Training for Master
Trainer and Clinical
Lead
location
time line
1 week didactic, 2 weeks
embedded with case
Geisinger manager
PA
MI trainees 9: 2/6/12 -2/24/12
MI trainees 6: 3/5/12 -3/23 /12
Geisinger Preceptor &
Practice Assessment
MI
May 2012 – scheduling in progress
49
MiPCT Adult CCM Training - Michigan Roll out
To Be Held Regionally in Michigan:
• April 23, 2012 – New Hudson
• April 30, 2012 – Grand Rapids
• May 7, 2012 – Ann Arbor
• June 2012 and thereafter monthly or as needed
based on demand
Required training for Adult MiPCT Complex Care Managers (CCM) and Hybrid
Care Managers (HCMs)
50
Training plan:
Complex/Hybrid Care Managers
One-week Michigan MiPCT didactic training
▫ Three days - Complex Care Management Fundamentals,
based on Geisinger model
▫ Two days - MiPCT curriculum
• MiPCT approved self-management support training
• (see list on www.mipctdemo.org)
• On-going learning
▫ Precepting: with local Clinical Lead (CL)
▫ Case Study sessions: led by CL
▫ Webinars: continuing education on special topics
51
Training plan:
Moderate-Risk Care Managers
• MiPCT approved self-management support (SMS)
training (www.mipctdemo.org)
• Additional suggested topics as defined by MiPCT
clinical subcommittee (www.mipctdemo.org)
▫ Many MiPCT-approved SMS training programs also
include these additional topics
• Ongoing education through MiPCT-sponsored
webinars
51
Michigan Care Management Resource Center
• UMHS/BCBSM collaboration
• Goal is to help disseminate effective, evidence-based care
management models throughout Michigan
• Initial focus is MiPCT practices -available to all Michigan
PO/PHOs /practices
• Web-based resource for templates, tools, evidence-based
information
• Webinars, workshops and mentoring in care management
• Personalized care management consultation service
52
Getting Started
53
Getting Started- Orientation
suggestions for Care Managers
• Complete an MiPCT-approved self management training
program
• Complete Orientation - guided by PO/Practice
Leadership
▫ MiPCT Care Manager orientation outline
 Content developed by MiPCT Clinical Leads
▫ In progress - orientation checklist
 Development by Master Trainers
▫ Available by April 1
54
Getting Started- Orientation suggestions for
Care Managers
•Become familiar with role and responsibilities of health care
team members
•Navigating the Medical neighborhood
 Develop relationships: ex. Inpatient case managers,
Home Health Agencies, Behavioral health resources,
- Meet and establish relationship with team
•Review the Clinical Guidelines used by PO/Practice
•Identify/learn HIT used by Practice
▫ EMR
▫ Registry (required by the end of 2012)
▫ Care management documentation (note: may be a work-inprogress)
55
Case Presentation
56
Case Study
• 65 year old woman admitted to the hospital after a
syncopal episode while at church
▫ Other Diagnoses/conditions: History of breast cancer 25
years ago
▫ Admitted to the hospital - CM notified of admission and
followed her progress by viewing the hospital EMR
• Assessment
▫
▫
▫
▫
Skull and finger fracture
Cardiac echo revealed severe mitral regurgitation
Heart cath revealed no CAD, confirmed severe MR
ADLs - requires assistance
• Care giver support
▫ Lives with spouse
57
Case Study
• CCM follow up phone assessment resulted in:
▫Confirmation that the patient received O2 as ordered
at discharge
▫understood the use and correct liter flow
▫Medication reconciliation
▫identified the need for clarification and further
education
▫Review of the patients concerns
▫ revealed a lack of understanding for the post cath
groin wound care/pressure dressing
58
Case Study
• Home Health Care
▫ Complex Care Manager coordinated referral to HHC
▫ Concerns communicated
 Address groin dressing care needs and education for
the patient and spouse
 Reinforce education on medications
 Complete medication reconciliation with the CCM and
HHC RN
 Review the signs and symptoms of Heart Failure risks
 Health insurance covered HHC
59
Case Study
• CCM follow up
▫ Confirmed HHC visit occurred the same day
▫ Verified the patient had a follow up appointment
with the PCP and the Cardio-thoracic Surgeon
▫ The CCM will meet with the patient at the time of the
PCP visit
• What ongoing steps will the CCM take?
Questions and Discussion