Care Management in the Patient Centered Medical Home. Self Study Module

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1 Care Management in the Patient Centered Medical Home Self Study Module

2 Objectives Describe the goals of care management Identify elements of successful care management Recognize the 5 step Care Management process

3 What is a Care Management Program? Care management programs 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. reference:

4 Goals of Care Management Enhance coordination of care Minimize fragmentation of care Improve patient s functional health status Eliminate duplication of services Reduce the need for unnecessary, costly medical services

5 Features of Successful Care Management Models Close collaboration between Care Manager and Primary Care Physician (PCP) High level of in-person contact between care manager and patient Close attention to transitions of care Handoffs are where many errors occur Need timely information on hospital/snf discharges Medication reconciliation is regularly performed Need access to patient record/ehr Assess adherence to medication regimens Target patients at high risk for hospitalization or ED use reference:

6 CASE STUDY MICHIGAN PRIMARY CARE TRANSFORMATION (MIPCT) BACKGROUND AND CARE MANAGEMENT INTERVENTION

7 CMS Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Centers for Medicare & Medicaid Services (CMS) is exploring the role of the PCMH in improving US health care Participating in state-based PCMH demonstrations CMS Demo Stipulations Must include Commercial, Medicaid, Medicare patients Must be budget neutral over 3 years of project Must improve cost, quality, and patient experience 8 states selected for participation, including Michigan Michigan start date: January 1,

8 The Vision for a Multi-Payer Model Use the CMS Multi-Payer Advanced Primary Care Practice demo as a catalyst to redesign MI primary care Multiple payers will fund a common clinical model Allows global primary care transformation efforts Support development of evidence-based care models Create a model that can be broadly disseminated Facilitate measurable, significant improvements in population health for our Michigan residents Bend the current (non-sustainable) cost curve Contribute to national models for primary care redesign Form a strong foundation for successful ACO models

9 MiPCT Focus Areas Include Care Management Self-Management Support Care Coordination Linkages to Community Services

10

11 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 # Patients % Patients Medicare 186, % Medicaid 214, % BCBSM 361, % BCN 275, % Priority Health 119, % Total 1,158, %

12 MiPCT Demonstration Timeline Original Demonstration Period 1/1/12 12/31/14 Demonstration Two Year CMS Extension 12/31/16 Post-Demo MiPCT GOAL: To sustain our gains (effective, efficient teambased care with embedded Care Managers) postdemonstration period

13 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

14 Care Management Care management is defined as a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocating for options and services to meet an individual s health needs through communication and available resources to promote quality cost effective outcomes. reference: Care Management Society of America definition of care management

15 Case Management Society of America Guiding Principles Care Management is a patient-centric, collaborative partnership approach Facilitate self-care Comprehensive, holistic approach Practice cultural competence Use of evidence-based care Promote optimal patient safety Promote integration of behavioral change science and principles Link with community resources Assist with navigating the health care system

16 Functions of a Care Manager Partners with primary care practice leadership to integrate care management into the practice Assesses healthcare, educational, and psychosocial needs of patient/family Provides self management support empower patient/family Provides patient family education teach back Implements evidence based care Close gaps in care; addresses prevention, chronic conditions Assists with transitions between settings Assists with advanced directives, End of life care Completes Comprehensive Assessment, Creates and maintains individualized plan of care follow up visits, longitudinal

17 Managing Populations: Stratified approach to patient care and care management IV. Most complex (e.g., Homeless, Schizophrenia) <1% of population Caseload III. Complex Complex illness Multiple Chronic Disease Other issues (cognitive, frail elderly, social, financial) 3-5% of population Caseload II. Mild-moderate illness Well-compensated multiple diseases Single disease 50% of population Caseload~1000 I. Healthy Population

18 Ramsay, Rebecca (2011). Implementing Effective Clinical Care Management; Building Care Management Capacity within a Transforming Primary Care System, Care Oregon (PowerPoint slides). Retrieved from shttp:// Rebecca (2011). Implementing Effective Clinical Care Management; Building Care Management Capacity within a Transforming Primary Care System, Care Oregon 20 Care Management Continuum:

19 Care Management Delivery Team Based Care Example of the Care Management Team in the Primary Care Office Care Manager RN, NP, PA, LMSW care manager who has responsibility for the care management of a patient in partnership with the patient s Primary Care Physician Other Health Care Professionals may include licensed practical nurse, certified diabetes educator, registered dietician, masters of science trained nutritionist, clinical pharmacist, behavioral health specialist, certified asthma educator, and others

20 Care Management Evidence Based Interventions Relationship-based Communication Transitions of Care across settings Behavior change Motivational Interviewing, Brief Action Planning Self-management Chronic Disease Management, Protocols, & Health Promotion

21 Care Management Process Five Steps: Referral Screening Enrollment Management Closure

22 Referral Physician input Transition of Care Gaps in Care uncontrolled chronic condition(s) Targeted chronic conditions

23 Screening Review the medical record Chronic conditions Psychosocial Utilization Emergency room visits Hospital admissions Underutilization Claims data Condition specific CHF COPD Children with complex needs CHF and COPD are currently at the top of list in terms reducing ED visits and inpatient hospitalizations.

24 Enrollment / Patient Engagement Obtain patient consent Complete initial comprehensive assessment Lessons Learned PCP in person introduction of the care manager to patient/caregiver Helpful tools include* Flyer physician may use to explain the care management program Care Manager phone script *Note access tools here:

25 Management - Interventions Establish an individualized care plan and identify goals Identify any critical care plan needs and initiate action Set short and long term goals Make sure patients/care givers are a part of the plan of care Reinforce patient self-care and self-management Establish on going follow up monitor /adjust care plan

26 Case Closure Examples to consider for case closure: Improved ability to self manage Transfer to hospice care Disenrollment - patient no longer interested in participating in care management An important step - Collaboration and Communication Discuss with PCP prior to closing case

27 Building & Managing a Patient Case Load Design Workflow and Processes to address: Admission Discharge Transfer alerts (ADTs) Referrals to the Care Manager Office team members are aware of criteria for patients who may benefit from care management Multidisciplinary team in the physician office Ability to view the care managers patient schedule Ability to view the individualized patient care plan identify, review and update patient goals Tracking and Monitoring - Data Reports Billing the care manager visits Quality metrics ex. Care manager activity process metrics

28 The Right Care Manager/Patient Ratio? The right care manager / patient ratios will evolve over time The ratios will vary based on your patient population and acuity Care Manager embedded in the practice A common ratio seen in complex care programs is one care manager per 200 commercial patients, or one care manager per highest-acuity patients Analyze the particular needs of your population by looking at top diagnoses Reference: California Quality Collaborative Complex Care Management Toolkit,

29 MiPCT Example - Moderate Risk Care Manager Complex Care Manager Moderate Risk Care Manager (MCM) Complex Care Manager (CCM) Patient Population Patient Caseload Focus of Care Management Duration of Care Management Moderate risk patients identified by registry, PCP referral for proactive and population management. Caseload 500 (approx active patients); one MCM per 5,000 patients. Proactive, population management. Work with patients to optimize control of chronic conditions and prevent/minimize long term complications. Typically a series of 1 to 6 visits High risk patients identified by PCP referral and input, risk stratification, Caseload 150 (approx active patients); one CCM per 5,000 patients. Targeted interventions to avoid hospitalization, ER visits. Ensure standard of care, coordinate care across settings, help patients understand options. Frequency of visits high at times, duration of months

30 Michigan Care Management Resource Center Website micmrc.org Care Management 101 Topics Webinars

31 Michigan Care Management Resource Center Website micmrc.org Care Management 101 is a web based self study opportunity a suggested road map of staged content for the new Care Manager may be utilized to create customized curriculum for selfstudy based on the CM's self-assessment Care managers may identify their areas of strengths and gaps Review CM 101 content to select recorded webinars, tools, resources Access Care Management 101:

32 Michigan Care Management Resource Center Website micmrc.org Topics for Care Managers Include: Advance Care Planning Palliative Care Pediatrics Medication Management Transitions of Care Patient Centered Medical Home & Team Based Care Chronic Conditions Quality and Population Health Management Elderly Population Behavioral Health

33 Thank You! Questions

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