Transcript The Michigan Primary Care Transformation

The Michigan Primary Care
Transformation (MiPCT) Project
WELCOME TO THE
2016 MiPCT SUMMIT!
Ann Arbor
The Michigan Primary Care
Transformation (MiPCT) Project
MiPCT Welcome and Overview
8:30-8:35 AM
Sue Moran
The Michigan Primary Care
Transformation (MiPCT) Project
MiPCT Evaluation Findings
8:35-9:00 AM
Clare Tanner
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• Conducted by: Michigan Public Health Institute
• Presented by: Clare Tanner
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MiPCT Scale
Care Manager Embedment
Care Management Caseload
Access & Registry Use
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MiPCT Scale
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 Care Managers Over Time
600
500
400
300
200
100
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2012
2013
RN
MSW
2014
NP & PA
2015
Others
2016
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Physician Referrals
(% Reporting frequently/always)
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CM and Physician Communications
(% Reporting daily – several times/week)
Summer
2013
Winter
2013
Summer
2014
Winter
2014
Summer
2015
Winter
2016
Summer
2016
10
Practice Understanding of Care
Management
(% Agree/strongly agree team members know who would benefit)
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Practice Team Supports Concepts
of Care Management
(Agree/strongly agree)
Patient Rating of Care Managers
Seemed to be on the same page as doctor
Increased your understanding of your conditions
Helped you understand how to prevent problems
Gave you confidence to take care of your health
Supported you in making lifestyle changes
Helped you understand what treatments are available
Worked with you to set goals, plan, and reach goals
Helped you get other needed medical services
Encouraged you to get services in the community
Performance on Practice
MiPCT
Requirements
Other PCMH
Non-PCMH
Patient Registry Score
Extended Access Score
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Patient Experience
Provider Experience
Cost
Utilization
Quality of Care
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Impact
Patient Experience
• 3,898 patients
surveyed Jan/Feb
2015
Domain
Access
Communication
Coordination
Self-Management
Mental Health
Provider Rating
MiPCT vs.
PCMH
MiPCT vs.
NonPCMH
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Impact
Provider & Staff Experience
• Providers & staff
surveyed in 2012
(n=2,156) and 2014
(n=1,027)
Provider/staff change 20122014
Chaos
Burnout
No change
Intent to Leave
No change
Satisfaction
No change
Stress
Communication
Facilitative Leadership
Teamwork
Culture of Learning
No change
Work Environment
No change
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• Results are preliminary
• High risk patients
 Medicare cost (conducted by RTI)
 All-payer cost and utilization
• Quality
 Diabetes
 Adult preventive care
 Childhood well care
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Average Changes in Medicare
Expenditures (RTI, PMPM)
Outcome
Total Medicare
Acute-care
Post-acute-care
ER
Outpatient
Specialty physician
Primary care
physician
Home health
Other non-facility
Laboratory
Imaging
Other facility
v. PCMH
v. non-PCMH
-43.37*
-22.84*
-13.03*
-0.93
5.26
-10.05*
-20.68
-12.45
-9.08
0.25
10.63*
-7.21*
2.12
-2.70
0.35
-0.55
-2.62*
-0.05
-0.74
1.94
0.08
-2.68*
-0.69
0.19
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Cost Impact on Medicare
Special Populations
Population
v. PCMH
v. non-PCMH
-118.93*
-133.37*
Behavioral health conditions (N=36,472)
-40.07
-54.26
Beneficiaries with disabilities (N=70,679)
-23.81
10.35
Dually eligible (N=42,345)
-61.97*
-30.69
Rural beneficiaries (N=17,898)
-14.01
8.29
Non-white beneficiaries (N=37,080)
-20.85
83.86
Multiple chronic conditions (N=63,881)
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Multi-Payer Trends
• Three groups
▫ MiPCT
▫ CG1= PCMH
(non-MiPCT)
▫ CG2= non-PCMH
• 95% confidence
intervals
• Not adjusted for
secular trends
• Comparison groups
weighted to match
MiPCT
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Age and gender
Concurrent risk score
Payer
PCPs employed by hospital
Region
Urban area
Median income of zip code
Practice type (FQHC, RHC)
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Two Questions
• How does MiPCT compare at any given point
in time?
• Does MiPCT improve relative to comparison
groups?
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High Risk Adults: Standard Cost
(PMPM)
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High Risk Adults: Utilization
ED Visits/1000
Hospitalizations/1000
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Pediatric ED Visits with Asthma
Per 1000 Patients with Asthma
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Diabetes Measures
HbA1c Testing (%)
Eye Exam(%)
Nephropathy (%)
Diabetes: All Three (%)
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Adult Preventive Care
Breast Cancer Screening (%)
Chlamydia Screening (%)
Cervical Cancer Screening (%)
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Well Child Care
Childhood Immunizations (%)
3-6 yr. Well Child Visits (%)
Adolescent Immunizations (%)
Adolescent Well Care (%)
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Summary
• Preliminary signs indicate:
Better patient experience
Improved cost and utilization with high risk patients
Improved adult quality indicators
• Analyses underway:
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Payer-by-payer analyses
Cost and utilization performance in the general
population
Childhood quality indicators
Statistical modeling to control for secular trends
What will we learn about best practices?
The Michigan Primary Care
Transformation (MiPCT) Project
MiPCT Payer Leadership Panel:
Working Together in Partnership
9:00-9:50 AM
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MiPCT Payer Leadership Panel:
Working Together in Partnership
• Diane Marriott, Moderator
• Tom Simmer, MD, Sr. VP and Chief Medical Officer,
Blue Cross Blue Shield of Michigan
• Kathy Stiffler MiPCT Co-Director; Bureau of Medicaid
Care Management and Quality Assurance, Medical
Services Administration, MDHHS
• Greg Gadbois, MD, Medical Director, Priority Health
How Payments Will Be Made in 2017
• Medicare participation:
• CPC+ (CMS will give selection priority to current MiPCT
practices)
• Utilization of CMS Care Management and Behavioral
Integrated Health codes
• Custom Model (but approval unlikely before 2018)
• Medicaid participation:
• SIM PCHM/MiPCT Partnership
• Both CPC+ and non-CPC+ practices are eligible
• Commercial participation (BCBSM, Priority):
• Continuation of G/CPT submission for both CPC+ and non-CPC+
practices
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Challenges for Population Management
Poorly aligned payment model. Must support population management
infrastructure and sustain a more pro-active and effective model of care.
Lack of population focus. Identify population served (panel), perform
routine outreach and point of care intervention, performance measurement
and improvement.
Fragmented healthcare delivery. Information shared across settings of
care to achieve an integrated care process.
Weak primary care foundation. Patient Centered Medical Homes with
proactive, data-driven care process and care teams coordinate care across
settings.
Lack of focus on process excellence. Organized Systems of Care
support value stream management within and across settings of care.
Passive role of the patient in healthcare. Informed, activated patients
adopt healthy lifestyle and self manage medical conditions guided and
supported by a healthcare team.
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“It’s got to come out of course, but that
doesn’t address the deeper problem.”
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SIM PCMH Initiative Practice
Application Status
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•
The primary and secondary contacts at each applying
organization received notification on 10/21/16
regarding the outcome of their application
•
Any questions should be directed to:
[email protected]
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Morning Break
9:50 -10:00
The Michigan Primary Care
Transformation (MiPCT) Project
MiPCT and Population Health
Innovation in Michigan
- The SIM & Beyond
Meghan Vanderstelt
Policy Director, Policy Division
Policy, Planning, and Legislative Services
Michigan Department of Health and Human Services
10:00-10:45 AM
State Innovation
Model
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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State Innovation
Model
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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State Innovation Model
A Vision of Empowerment
A person-centered health system that is coordinating care
across medical settings, as well as with community
organizations to address social determinants of health, to
improve health outcomes; and pursue community-centered
solutions to upstream factors of poor health outcomes.
Rationale
• Clinical care accounts for 10%-20% of health outcomes
• Social and environmental factors account for 50%-60% of health
outcomes
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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Vision Components (Strategic Framework)
• Patient-Centered Medical Home (PCMH)
• Advanced Payment Models (APM)
• HIT/HIE (Technology)
• Community Health Innovation Region
• Stakeholder Engagement, Measurement, Evaluation
and Improvement
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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Patient-Centered Medical Home (PCMH)
• Build on existing practice-based care management
efforts
• Improve information sharing
• Incentivize performance improvements on quality
and cost
Community Health Innovation Regions (CHIR)
• Build on existing community coalition efforts
• Improve community governance
• Invest in healthcare payor and provider
partnerships with community organizations
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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Alternative Payment Models (APM)
• Align with Federal and Medicare policies and strategies
• Allow for market-based innovation in payment and
clinical integration
• Maximize provider opportunities for Medicare
incentives
Health Information Exchange (HIE)
• Leverage a statewide foundation of HIT infrastructure and
HIE use cases to enable critical information sharing that
support care coordination
• Explore other use cases to enable information sharing
across payor, clinical and community partners
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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Stakeholder Commission and Committees
• Organize an efficient, yet effective, set of stakeholder
groups (including implementers)
• Discuss and analyze past, present and future implications
and evaluation of SIM policy and strategy tests
• Make recommendations for continuation, modifications
and elimination of tests
Measurement, Evaluation and Improvement
• Support the overall solution by ensuring measures and
evaluation strategies are attentive to existing information
technology capacity.
• Lead data-driven model improvement discussions
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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Care Delivery
Transformation
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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Michigan Has Impressive Care Delivery Assets
Primary Care
Transformation
Experience
Learnings from
Accountable Care
Significant Health
Coverage Gains
Health IT
Infrastructure
Capable Provider
Networks
Care Management
and Coordination
Competency
Credibility with
Federal Partners
Working Models
for Community
Connections
Dedicated
Leadership
Respected
Learning
Institutions and
Programs
Expanded Care
Teams
Committed Payer
Partnership
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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Michigan SIM Care Delivery Focus
Support Scale for
What’s Working
• Support the care delivery
foundation in Michigan
•
including team-based care,
advanced access, care
management, self-care
support
and core HIT Practices
Test
Promising
functions
Encourage the “Next
Step” for
Advancement
Develop more effective care
transitions, informed referrals,
integrative treatment, risk
stratification, HIT enabled
Where
Opportunities
quality improvement
and
Exist information exchange
• Encourage a community-centered health focus, fully linking clinical
practice with community resources and population health
interventions
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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Applying Care Delivery Focus to the PCMH Initiative
Support Scale for What’s Working
Encourage the “Next Step” for Advancement
Test Promising Practices Where Opportunities Exist
PCMH Accreditation/Recognition as a
Foundation
Team-Based Care Practices
Clinical-Community Linkages
Advanced Access
Integrative Treatment Planning
Referral Decision Supports
Electronic Health Record and Registry Base
Technology
Provider Collaboration and Integration
Patient Engagement, Health Literacy and Social
Determinants Perspectives
Structured Quality Improvement
Robust Care Management and Coordination
Patient-Reported Outcomes
Patient Education and Self-Care
Caregiver Engagement
Transitions of Care
Managing Total Cost of Care
Health Information Exchange Use Cases
Patient Experience Perspectives
Population Health Strategies
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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Where We’re Headed… and How We Get There
• The world around us continues to present opportunities for growth
and improvement that take many forms
• But, our shared aims in improving the health of Michigan residents
don’t change as the landscape does, the way we work together and
the resources we use to accomplish those aims evolve
CPC+
MiPCT
PCMH
Initiative
PCMH Initiative (custom
option)
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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2017 PCMH Initiative
• MDHHS completed an application process for the 2017 PCMH
Initiative in September
• The Department received applications encompassing over 480
practice units and over 2,400 primary care providers
• Applications included 31 physician organizations submissions on behalf of
multiple practices in addition to numerous practice units applying
independently
• MDHHS will notified physician organizations and practices of
selection decisions on Friday October 21st
• Shortly following the notifications and subsequent legal documents, MDHHS
will distribute a participant guide to all selected physician organizations and
practices
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
49
2017 PCMH Initiative By The Numbers
• Applications Received
•
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486 practices units applied for the PCMH Initiative
2,444individual providers were represented in those practice unit applications
31 applications were received from a physician organizations (on behalf of multiple practice units)
51 applications were received from individual practice units
• Selection Process Results
• 130 unduplicated practices were excluded from participation based on the selection criteria
applied and minimum required number of beneficiaries (100)
• 331 unduplicated practices are recommended for participation in the 2017 PCMH Initiative (2,034
individual primary care providers)
• 25 unduplicated practices are provisionally recommended for participation (76 individual primary
care providers)
• Counting both accepted and provisionally accepted practices, a total of 356 practice units, 2,110
providers and 346,522 Medicaid beneficiaries are recommended for participation in the 2017
PCMH Initiative
• 238 of the 356 practice units accepted and provisionally accepted (approximately 67%) are current
MiPCT participants
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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2017 PCMH Initiative Regional Composition
REGION
Jackson
Washtenaw/Livingston
Muskegon
Genesee
Northern
PRACTICES
PROVIDERS
11
48
26
63
24
50
342
137
135
172
172
184
356
836
1275
2111
(Antrim, Emmet, Wexford, Kalkaska, Leelanau,
Missaukee, Benzie, Charlevoix, Manistee, Grand
Traverse)
TOTAL SIM Region
TOTAL Non-SIM Region
TOTAL
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
51
Custom Option
• Following a considerable amount of stakeholder engagement earlier
this year, MDHHS took a brief pause in custom option demonstration
development in light of Michigan’s selection as a CPC+ region
• Since both CPC+ and the PCMH Initiative have completed application
processes and partnership between the two programs is underway,
custom option efforts can and will resume
• MDHHS intends to leverage the Care Delivery and Payment
Committee (including its sub-committees) announced earlier this
month as a critical forum and stakeholder leadership opportunity for
the custom option development process going forward
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
52
Population Health
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
5
3
Community Health Innovation Region—multi-stakeholder
groups addressing community health improvement
What?
How?
Engage communities in health system transformation
•
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Broker partnerships between healthcare institutions and
community organizations
Align healthcare and community organization interests and
goals
Integrate health systems and social services through
community organizing
Focus partnerships, leadership discussions, and cooperative
operations on addressing the social determinants of health
Develop a structure and process for assessing and
improving community health on an ongoing basis
•
•
•
Community-based governance inclusive of payers, providers,
and community organizations
Linking delivery of clinical and community services
Sharing data to assess and improve community health
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Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
Accountable System of Care Role in CHIR
• Support development of clinical-community
linkage initiative, for example:
• Refining target population(s)
• Develop tools and processes
• Develop reports and communication protocols
• Provide input into centralized intake and data storage
• Support development of plan for analyzing
clinical-community linkage information.
• Support development of plan for
incorporating analysis into community
decision-making.
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Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
Payment Reform
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
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6
Health Care Payment Learning & Action Network Framework
Providerfacing
Medicare
Incentives
available for
Categories 3
and 4 APMs.
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
57
SIM Vision for Payment Reform
Collaboratively develop and implement broad-based pursuit of
advanced alternative payment models (APMs) that align with providerfacing Medicare incentives, while allowing for market-based innovation
between payers and providers.
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
58
Broad Advanced Alternative Payment Model (APM) Approach
• Accountable Systems of Care  Broader Adoption of APMs
Accountable Systems of Care Pilots
Broad APM Adoption
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•
•
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•
•
•
Regulated construct
Resource intensive
Limited scale
Limits provider ability to receive Medicare
incentives
Market-driven approach to broader scale
Leverages existing and future clinical integration
State plays a policy and strategy role
Maximizes provider opportunity for participating in Medicare
incentives
• ASCs in SIM Regions will be eligible for SIM grant funding
• ASC support will be focused on work related to the priorities and goals of
the Community Health Innovation Region
• Developing clinical-community linkages will be a required activity
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
59
Modified SIM Payment Approach
Broad APMs
Initiative Year 1
Initiative Year 2
Initiative Year 3
2017
2018
2019
Collect Michigan’s APM
baseline and establish
goals
Progressively increase percentage of payment in APMs
• Broad adoption of APMs will be allowable statewide
• APM adoption in Medicaid will be administered through the
Medicaid managed care organization contract
• APM adoption by other payers will be encouraged through
collaborative discussion and partnership
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
60
Health Information
Technology and
Statewide Use Cases
Supporting SIM
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
6
1
Network of Networks:
PIHPs (10)
Federal
Health
Plan QOs
Other Data Sharing
Organizations
MSSS
MiHIN
Statewide
Shared Services
Consumer QOs (more
coming)
Immunizations
MDHHS Data Hub
MyHealthPortal
MyHealthButton
HIE
MI Disease Surveillance
Stat
System
Qualified Organizations
(QOs)
e
Lab
s
Data
Warehouse
Chronic
Disease
s
Medicaid
Virtual QOs
Pharmacies
(more coming)
Providers &
Health Systems
MI
Syndromic
Surveillance
System
Single point of
entry/exit for state
Sponsored Organizations
Copyright 2015-2016 Michigan Health Information Network Shared Services
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
6
2
HIT and HIE Objectives in the SIM Operational Plan
• Performance Metrics and Reporting
• Provide data aggregation and reporting capabilities needed to support SIM performance reporting and
evaluation to CMS, and provider performance feedback
• Care Coordination Technology
• SIM will facilitate access to information which supports care coordination activities within the model
test
• Population Health Technology
• SIM will explore Population Health technology solutions that will enable community
data sharing and track cross-care delivery approaches
• Relationship Attribution Management Platform
• Enable a consistent shared process for communicating and tracking affiliations and linkages among SIM
stakeholders.
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
63
Medicaid Health Plan Onboarding
• Medicaid Payer Qualified Organization Day:
• Legal and Technical process for the following SIM use cases:
• Statewide Active Care Relationship Service
• Statewide Health Provider Directory
• Statewide Admission, Discharge, and Transfer Service
• Send payments associated with PCMH Initiative
• Submit Provider Incentive Program Plan
• Year 2 contract requirement
• Timeline and cost
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
64
State Innovation Model
Year 1 (Planning & Design) Highlights
• Filed no-cost extension for year 1 with CMS
• Selected 5 SIM Regions (Washtenaw/Livingston, Northwest
Lower MI, Genesee, Muskegon, and Jackson)
• Modified strategy based on CMS announcements (CPC+,
MACRA, Custom Option guidance, and Medicaid managed
care regulations)
• Launched SIM Implementation Summit
Year 2 (Implementation) Goals
•
•
•
•
Launch local CHIR planning and design
Launch and expand HIE use cases
Launch PCMH application and initiative in alignment with CPC+
Launch stakeholder committees and evaluation RFP
Putting people first, with the goal of helping all Michiganders lead
healthier and more productive lives, no matter their stage in life.
65
The Michigan Primary Care
Transformation (MiPCT) Project
Best Practice Awards and
Recognitions
10:45-11:55 AM
Celebrating Success in
MiPCT Practices!
The 2016 Winning Practices!
Most Improved Diabetes Practice
Winners
1.
2.
3.
4.
5.
Cherry Street Health Center
SMG St. Johns
SMG Holt
Dhiraj Bedi, DO
HFMC - Harbortown
Most Improved Diabetes Practice
Henry Ford Harbortown Medical Center
1. No Missed Opportunities
•
•
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Consistent Use of “Health Maintenance” section of EMR
Culture changed to address health maintenance at every visit
Prior to discharge, the patient is escorted to the lab
2. Health-Care Team Approach
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Standing agenda item on monthly staff meetings
Utilized provider and non-provider staff to help improve
process
Ongoing education to both the providers and support staff
Consistent posting of scores on huddle boards
3. Outreach
•
Panel Manager outreach targeting specific quality measures
Samples of Communication Tools
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Most Improved Adult and Family
Practice Winners
1. E. Ann Arbor Med-Peds
2. SMG Okemos
3. Domino's Farms Fam Med
4. HFMC – Plymouth
5. David L. Cooley, DO
Winning Category: Most Improved
Practice Name: East Ann Arbor Adult Medicine and Pediatrics
• WHAT MADE A DIFFERENCE?
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▫
▫
▫
Continue to educate patients and providers on the role of Care Navigators in patient care
Work with social workers, dieticians, and Complex Care Management to ensure patient needs
are met across the continuum of care
Adjusted the process steps for greater efficiency and improved patient experience for Health
Maintenance Exams
Active use of Panel Manager:



▫
▫
Flags chronic conditions in patient charts prior to appointments
Notes services that patients are due for, for example, foot exams, lead screening to ensure completion
during appointments
Medical Assistants play a significant role to assure Best Practice Alerts are ordered/pended for their
providers, foot exams completed, etc.
Chronic Care Team meetings two times per month for 15 minutes
Focus on gaps in care and develop protocols for providers (MAs, RNs, etc.) on care team to
address gaps
Tool to Share
• Team coordination has been essential to success
at E. Ann Arbor Med-Peds, and allowed for improved
communication with providers in the clinic.
▫ Coordination among:
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

Care Navigators
Physicians
Panel Manager
Nurses
Social Workers
MAs
Family Medicine
at Domino’s Farms
Pam Szymanski, RN – Complex Care Nurse Navigator
Joanna Rew – Panel Manager
APPOINTMENT AVAILABILITY
 SAME DAY URGENT APPOINTMENTS
 TEAM BASED PHYSICIAN SETUP
 SATURDAY WALK IN CLINIC
 ON CALL PHYSICIAN AFTER HOURS
PATIENT OUTREACH
 CHECK FOR SCHEDULED APPOINTMENTS WITH PHYSICIAN AND
ADD REMINDER IN APPOINTMENT NOTE OF ANY NEEDED BPA
 OUTREACH TO PATIENTS WITH CARE GAPS
 PHONE TO SCHEDULE APPOINTMENT AS NEEDED FOR DIABETES
FOLLOW UP OR ANNUAL PHYSICAL
 SEND OUT REMINDER LETTERS FOR PATIENTS WHO WILL BE DUE
WITHIN THE NEXT SEVERAL MONTHS
PRE-VISIT PLANNING
 MA REVIEWS SCHEDULE AND PENDS BEST PRACTICE ORDERS FOR PHYSICIAN
REVIEW
 PHYSICIAN REVIEWS PENDED BPA’S AND PLACES ANY ADDITIONAL ORDERS
 MA CALLS PATIENT ONE TO TWO MONTHS PRIOR TO SCHEDULED ANNUAL
PHYSICAL APPOINTMENT.
 PATIENT TO COMPLETE LABS PRIOR TO VISIT
 AT VISIT RESULTS ARE REVIEWED WITH PHYSICIAN
DISCHARGE FOLLOW-UP
 RN FOLLOW UP HOSPITAL DISCHARGES WITHIN 24- 48 HOURS UNIVERSITY OF
MICHIGAN AND OUTSIDE HOSPITALS (OSH)
 RN FOLLOW UP ER VISITS WITHIN 24-48 HOURS PHONE CALL IF FOLLOW UP IN
PCP OFFICE IS NEEDED
 RN WILL CALL IF ER VISIT COULD HAVE BEEN AVOIDED WITH AN OFFICE VISIT
OR PHONE CALL
MICHART ELECTRONIC MEDICAL
RECORD
 ALL HOSPITAL DISCHARGES AND ER DISCHARGES ARE FOUND IN A DAILY
REPORT WITHIN MICHART
 CARE GAP REPORTS USED FOR PANEL MANAGEMENT ARE GENERATED BY
MICHART
GAP MANAGEMENT - DIABETES
 PANEL MANAGER REVIEW OF MONTHLY GAP REPORT
 EYE EXAM
 A1C
 LDL-C
 MONITOR NEPHROPATHY
TEAMWORK
 MIPCT LIST
 PHYSICIAN/MA PAIRING
 MONTHLY ALL STAFF AND TEAM MEETINGS
Henry Ford Medical Center - Plymouth
• What Made a Difference:
▫ Standardization
 Appointment code streamlining (adult/pediatric;
regular/extended)
 Honoring the 30% open access requirement
• Strong Physician Champions who support practice teams
 Primary Care Operations Group Meetings with physicians and
operations directors across primary care sites, Chief Medical
Officer, and the VP of Primary Care
 Physician meetings to review quality scores and data
Henry Ford Medical Center - Plymouth
• What Made a Difference (cont.):
▫ Robust use of Epic EHR
 Roll out of Epic in 2012 improved data reliability
 System also increased the number of data analysts to provide
teams with statistics on how we rate on our quality scores
and how we compare to other health systems. Results are
discussed monthly at Primary Care Operations Group meetings
and at site specific physician monthly meetings.
▫ Connecting to community resources
 Practice takes the time to connect patients with community
services when needed and appropriate
 Not afraid to make the hard calls ( e.g., use of Adult
Protective Services) to benefit patients
Winning Category: Most Improved - Adult and Family Practice
Practice Name: David L. Cooley, DO
•
WHAT MADE A DIFFERENCE
▫
▫
▫
▫
▫
▫
David L. Cooley, DO is a small, one physician office located in Dearborn Heights.
The physician, nurse practitioner and entire staff promote a “Team” approach to
care delivery.
The physician views and values everyone’s contribution to patient care activities.
The entire team is included in all program/practice meetings.
The practice calls patients within two days of all ED and inpatient visits.
Extended office hours are offered to evenings each week. Early morning
appointments are also available.
The practice completed a full two year’s activity with their EMR. The EMR
technology was fully embraced by the entire practice.
Most Improved Pediatric Practice
Winners
1. Pediatric Consultants of Troy PC
2. Child and Adult Medicine of Grand
Blanc, P.C.
3. Brighton Peds
4. Wendy B. Lawton, M.D., P.L.C.
5. Forest Hills Pediatric Associates PC
5. (Tie) Briarwood Center For Women
Children and Young Adults
Winning Category: Most Improved Pediatrics and
Pediatrics Best Overall
Practice Name: Pediatric Consultants of Troy PC
•
WHAT MADE A DIFFERENCE (What do you do in your clinical practice regarding workflow; your strategy for patient engagement and
outreach; in staffing and team coordination, etc.) to get such great results? For example here are examples from past winners – just
change the bullets to tell YOUR practice’s story:
▫
We call patients within two days of all ED visits, and study the time and day of the weeks of patterns of ED visits for patterns to better help us
understand extended hour care needs
▫
Priority calls are placed to patients with asthma when flu vaccine arrives, along with other high risk patients before reminder calls for the healthy.
▫
We require a check-in with the practice educator after a patient comes in for an asthma flare (at the same time as the visit if possible)
▫
We start each day with a morning all-team huddle for the first fifteen minutes to identify who is complex, who might benefit from care
management, etc.)
▫
We have a FT staff member who enters data, identifies gaps in care for team, patients who have not been in with chronic illness, etc.
▫
Physicians meet together for an hour each week on co-managed patients, updates and practice needs
▫
Created a new policy to re-check blood pressures, added a reminder on the cuffs; placed colored magnets on the door if BP needed to be rechecked
▫
Performed time studies from check-in to check-out to determine how much time was needed to fulfill Health Maintenance items and to adjust the
process steps for greater efficiency and improved patient experience
▫
Our 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.
▫
Our Care Manager and Physician have an end of day meetings to discuss status and progress/challenges cases following Care Management
visits.
▫
Watching for and acting on patterns (which patients are requesting frequent refills, repeating situations that cause rework, etc.)
▫
We developed a cough protocol/algorithm for the front desk and triage criteria 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: Most Improved
Practice Name: Brighton Pediatrics
Asthma Action Plan Initiative
• Asthma Registry
 The Asthma Registry is run monthly to identify patients that need Asthma Action Plans.
 The registry information is reviewed by the providers to identify persistent asthmatics and
determine if the problem list needs to be updated and/or appointments need to be
scheduled.
• Huddles
▫
Biweekly huddles were started to identify quality improvement areas. Through this huddle our
team identify areas to improve care.
• Training
•
Teaching support on how to use spacers was offered to Medial Assistants, Nurses, and
additional interested staff.
• Office Visits
 As patients were seen Medical Assistants helped reviewing medications to identify patients
with persistent asthma. Physicians then updated the asthma action plan and reviewed the
information with the parents.
Winning Category: Most Improved
Practice Name: Briarwood Center For Women Children and Young Adults
•
WHAT MADE A DIFFERENCE (What do you do in your clinical practice regarding workflow; your strategy for patient engagement and
outreach; in staffing and team coordination, etc.) to get such great results? For example here are examples from past winners – just
change the bullets to tell YOUR practice’s story:
▫
We call patients within two days of all ED visits, and study the time and day of the weeks of patterns of ED visits for patterns to better help us
understand extended hour care needs
▫
Priority calls are placed to patients with asthma when flu vaccine arrives, along with other high risk patients before reminder calls for the healthy.
▫
We require a check-in with the practice educator after a patient comes in for an asthma flare (at the same time as the visit if possible)
▫
We start each day with a morning all-team huddle for the first fifteen minutes to identify who is complex, who might benefit from care
management, etc.)
▫
We have a FT staff member who enters data, identifies gaps in care for team, patients who have not been in with chronic illness, etc.
▫
Physicians meet together for an hour each week on co-managed patients, updates and practice needs
▫
Created a new policy to re-check blood pressures, added a reminder on the cuffs; placed colored magnets on the door if BP needed to be rechecked
▫
Performed time studies from check-in to check-out to determine how much time was needed to fulfill Health Maintenance items and to adjust the
process steps for greater efficiency and improved patient experience
▫
Our 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.
▫
Our Care Manager and Physician have an end of day meetings to discuss status and progress/challenges cases following Care Management
visits.
▫
Watching for and acting on patterns (which patients are requesting frequent refills, repeating situations that cause rework, etc.)
▫
We developed a cough protocol/algorithm for the front desk and triage criteria 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
Tool to Share
Asthma Medications Tool to identify patients with persistent asthma
Diabetes
Best Practice Overall Winners
1. Metro Health Hudsonville
2. Greater Michigan Internal
Medicine
3. Jane Castillo, MD
4. Lifetime Family Care, PLLC /A
Division of Michigan Healthcare
Professionals PC
5. Washtenaw Medicine of Saline
Winning Category: Best Overall - Diabetes Practice
Practice Name: Greater Michigan Internal Medicine
•
WHAT MADE A DIFFERENCE
▫
▫
▫
▫
▫
▫
▫
Greater Michigan Internal Medicine is a small, one physician office, with a
“Family Atmosphere”.
The entire team focuses on addressing gaps in care.
Diabetic patients are scheduled for appointments every 3-4 months.
If a patient misses an appointment, the office team calls the patient repeatedly
to educate the patient about the importance of regular follow-up and to
reschedule the appointment.
Medical Assistants play a significant role to assure Best Practice Alerts are
ordered/pended for their providers, foot exams completed, etc.
Diabetic medications are not refilled unless the patients follow-up for their
appointments.
The physician follows-up with all lab tests, writes notes to patients regarding
their results, progress and offers words of encouragement when improvement is
necessary.
Winning Category: Diabetes Overall
Practice Name: Jane Castillo, MD
WHAT MADE A DIFFERENCE
• Daily Huddles (Dr. Castillo/CM/Staff)
▫ Include MiPCT care management candidates
▫ Dedicated staff member manages registry to focus on obtaining test results
and closing 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
• 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
Winning Category:
Diabetes Best Overall
Lifetime Family Care
What Made the Difference?

Communication! Communication! Communication!

Physician Champion: The Leader

Learning Collaborative

Monthly staff meeting
Daily huddles (First 15 minutes of the day with entire
staff to discuss workflow, ADT, and workflow)

Impromptu meetings

Administrative meetings

Clinical management meetings

93
What Made the Difference?

Patient-focused Practice
• Patient survey results reviewed monthly and
changes made accordingly
• Monthly staff training on building patient and
practice team relationship
• Emphasize efforts to help patients feel valued

Care Management
• Care Team
• Pharmacist added value
94
What Made the Difference?

Maximize use of technology
• Wellcentive (Active Data Entry, Care Summaries,
Alerts, etc)
• EHR (Shortcuts, Reminders, CDS and Reports)
• Emphasize efforts to help patients feel valued

PatientPing
• ADT
95
Hints for Other Practices

Involve EVERYONE in all practice processes

Work as a TEAM

Develop policies as a TEAM

Enforce policies and don’t let them just exist on
paper
96
Team Huddle Template
97
Memo of Understanding
98
Memo of Understanding
99
Make Team Work Fun!
100
Winning Category: Diabetes Practice Award
Practice Name: Washtenaw Medicine Saline
• WHAT MADE A DIFFERENCE:
▫ Washtenaw Medicine of Saline incorporated far more rigorous panel management
processes this year to support population health and evidence-based care
medicine.
▫ The biggest change was truly incorporating a registry into our process (Health
Focus).
▫ Medical Assistants play a significant role – every patient has a ‘Point of Care’
sheet printed.

The Point of Care sheet identifies which measures are pending, completed, and open. This prompts our
team to support patients to engage and close gaps in care.
Tool to Share
(Process map, Protocol, Description
of Standard Work , Patient/Practice MOU, etc.)
• Chronic Conditions
& Screenings are
also tracked (but
don’t show up in the
screen shot)
• Labs are updated via
a feed.
• HVPA staff have
committed that any
info submitted to
this registry will
make it to the
payers.
Adult and Family Medicine
Best Practice Overall Winners
1. SMG DeWitt
2. 4069 Lake Internal Medicine
3. SMG Mason
4. Metro Health Rockford
5. Hamtramck Urgent Care/DBA
Oakland Medical Group
Best Pediatric Practice
Overall Winners
1.
2.
3.
4.
5.
Joseph B. Luna, M.D., P.C.
Moazami Pediatrics
Wendy B. Lawton, M.D., P.L.C.
Pediatric Consultants of Troy PC
Cereal City Pediatrics PC
105
Winning Category: Best Pediatric Overall
Practice Names: Moazami Pediatrics and Cereal
City Pediatrics PC
WHAT MADE A DIFFERENCE
•
Well Child Care and Immunizations
▫
▫
▫
▫
▫
▫
Birthday cards to patients for the upcoming month with a reminder to schedule a
complete well check
Working gaps in care reports
 Postcards to parents whose children have gaps
 Monthly reports of those without visits in the last year w/ phone outreach
If they are coming in for a sick appointment or recheck appointment, we prep the
chart if the child or a sibling is due for a WCC.
Appointments can be scheduled one year in advance; immunizations given in
series are scheduled so the family leaves with those dates in hand.
MCIR checks on all upcoming well child visits gaps ; MCIR reports run to identify
patients with needs with MCIR sheet and educational materials sent to those
families, prompting scheduling immunizations.
Priority calls are placed to patients with asthma when flu vaccine arrives, along
with other high risk patients before reminder calls are conducted for the healthy
population.
106
Winning Category: Best Pediatric Overall
Practice Names: Moazami Pediatrics and Cereal
City Pediatrics PC, cont.
WHAT MADE A DIFFERENCE – ASTHMA
•
•
•
•
•
•
•
•
•
Integrating in-services in ongoing training –e.g., all-team (including front office) training with
asthma educator; nursing session on identifying respiratory distress.
Asking staff about areas they feel unsure about and providing training (e.g. allergy injections,
etc.).
Hiring asthma expert from an allergy specialist practice brought a new focus on training and
education to the office; designating an Asthma Champion.
Using cough protocol/algorithm for the front desk and triage to screen calls and prioritize
appointments.
Purchasing a spirometer and had the supplier conduct an in-service on proper use.
Taking asthma action plans seriously
▫
Asthma medication refills require that annual well visits with an asthma action plan is completed; provide
notes for medication usage at school.
▫
Medication follow-up appointment required if patients are requesting frequent refills.
▫
Asthma patients are tracked and flagged in PCC and Gaps in Care Reports.
Developing care plans for monitoring of medication compliance and refills.
Patient asthma education folders are given to patients with a new asthma diagnosis.
Scheduling CM education sessions to teach patients how to use spacers, inhalers, and
nebulizers.
A Round of Applause for ALL Our 2016
Winners
….And Your Practice Could be
Recognized in 2017!
108
Clinical Lead Recognitions
109
THANK YOU FOR ATTENDING THE SUMMIT!
• A meeting evaluation link will be emailed to attendees
after the summit; Please complete your online Summit
Evaluation by November 11, 2016
• Boxed lunches are available at the back of the room.
Care Managers, remember to be in your designated
rooms by 1pm to start the afternoon session!
• All morning summit materials will be posted to the
mipctdemo.org website (under the Summit dropdown)