SIM PCMH/MiPCT Partnership Initiative Application Period - Submission Deadline September 30

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1 Michigan Primary Care Transformation www. mipct.org Volume 5 Issue 9 September 12, 2016 SIM PCMH/MiPCT Partnership Initiative Application Period - Submission Deadline September 30 As the MiPCT transitions to an ongoing program in partnership with the State Innovation Model (SIM), all current MiPCT practices in good standing are eligible to apply for the SIM PCMH Initiative for Medicaid PMPM funding in The State held a webinar last Thursday (the slides are included as an attachment to this edition's Flash as are the links to the applications and other material). Please keep in mind that payment will flow to the submitter of the application. Thus if a PO submits for its MiPCT practices and any PCMH practices in the five SIM regions then the PO receives the funding and is responsible for compliance and reporting. Conversely, if a practice submits, they receive the funding, compliance, and reporting obligations. The link for Physician Organizations applying on behalf of practices, click this link. If you are a practice applying individually, please click this link. Important Dates: MiPCT Webinars Webinar September 27, :00 1:00 PM Webinar November 15, :00 1:00 PM EVENTS September 20, 2016 October 13, 2016 October 18, 2016 October 26, 2016 Practice Level Care Management Code by Code Analysis PO Register Here PRACTICE Register Here Care Management Billing and Coding and the 2017 SIM PCMH MiPCT Partnership Note: Registration is not yet available 2016 MiPCT PEDIATRIC CARE MAN- AGEMENT SUMMIT 2016 MiPCT REGIONAL ANNUAL SUMMIT-NORTH 2016 MiPCT REGIONAL ANNUAL SUMMIT-WEST 2016 MiPCT REGIONAL ANNUAL SUMMIT-SOUTHEAST SIM PCMHMiPCT Partnership Initiative Files.zip REGISTRATION OPEN! 2016 MiPCT Regional Annual Summits Once again this year, the MiPCT Project will convene a Stakeholder Annual MiPCT Summit in three statewide regional locations. Summit North Thompsonville, MI Tuesday, October 13, 2016 Crystal Mountain Resort & Conference Center Crystal Mountain Drive Thompsonville, Michigan Register Here *Registration CLOSES 10/03/2016* Summit West Grand Rapids, MI Tuesday October 18, 2016 Frederik Meijer Gardens and Sculpture Park 1000 E Beltline Ave NE Grand Rapids, MI Register Here *Registration CLOSES 10/07/2016* Summit Southeast Ann Arbor, MI Wednesday, October 26, 2016 University of Michigan North Campus Research Center (NCRC) 2800 Plymouth Road, Building 18 Ann Arbor, MI Register Here *Registration CLOSES 10/17/2016* Note: Registration for Summits may close earlier if capacity limits are reached. Early registration STRONGLY encouraged*

2 2016 Summit Pre-Work Webinars MiPCT 2016 Annual Summit Care Manager Afternoon Session PREWORK INSIDE THIS ISSUE: The next edition of the: SIM PCMH/MiPCT Partnership Initiative Application Period - Submission Deadline w/attachments 1 PCMH Initiative Application Guide PCMH Initiative Application Release Webinar Slides PCMH Initiative Beneficiary Inclusion- Exclusion PCMH Initiative Payment Model Excerpt from Participation Agreement PCMH Initiative Transformation Objective Menu PO and Practice Requirements Excerpt from Participation Agreement MiPCT Regional Summit Registration 1 Important Dates Summit Pre-Work Webinars 2 New for 2016 Stepped Care for Self- Management 2 MiCMRC/MiPCT Complex Care Management Course 4 Upcoming course dates and course registration close dates 5 MiPCT Pediatric Summit 2016 MiPCT Pediatric Summit Pre-Work 6 Success Story Hybrid Care Management and MiPCT Clinical Lead 7 Behind the Data MiPCT Summit Flyer 9 MiCMRC/MiPCT Recorded Webinar Flyer 10 MiPCT Practice FLASH will be distributed on September 26, 2016 MiPCT PO FLASH will be distributed on October 10, 2016 Earn Nursing or Social Work Contact Hours for Completing Summit PREWORK Recorded Webinars: We have partnered with the Centre for Collaboration, Motivation and Innovation (CCMI) to design a series of five pre-work webinars to enrich your learning experience at the in-person Summit afternoon CM education session. The presenter is Connie Davis, RN, MN, GMP, and Co-director of the CCMI. Connie is an internationally known trainer, educator, speaker and consultant on health care design and health behavior change. Viewing the webinars prior to the live Summit CM afternoon session is highly recommended. Each of the 5 webinars listed below and the Summit afternoon CM in-person session are standalone in terms of earning contact hours. *Recorded webinars will be available August 29 th Steps to complete the Summit CM Prework and receive nursing or social work contact hours: 1. Access the link on the MiPCT Summit 2016 pre-work web page 2. View the entire online recorded webinar 3. Click the link below the webinar titled Request CE Credit Click Here 4. Complete the brief form, include your address, click submit 5. This will generate an message to you containing a link to complete the CE request and required evaluation form 6. Follow instructions in the Complete the evaluation and submit. This step generates an to you containing the CE certificate New For 2016: Stepped Care for Self-Management Support This Webinar addresses population segmentation, agenda setting, social determinants of health, and patient shared decision making with complex patients. Stepped Care for Self-Management Support is approved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing. Stepped Care for Self-Management support is approved by the Michigan Social Work Education Collaborative. Course approval #:

3 MiPCT care managers who did not have the opportunity to view 2015 MiPCT Summit pre-work webinars or would like a refresher, the following webinars are available. *Please note: if you received Nursing CE credit for the 2015 Summit prework webinars listed below in 2015, you will not be eligible to receive credit in Understanding Motivational Interviewing (MI): How the elements of Motivational Interviewing provide a context for BAP Understanding Motivational Interviewing (MI): How the elements of Motivational Interviewing provide a context for Brief Action Planning (BAP) is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing. This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: *If you received nursing continuing education contact hours in 2015 for this educational offering, you are not eligible to receive CE credit in 2016 Effective Communication with Patients (Ask-Tell-Ask): Identify ways to provide information consistent with the Spirit of MI Effective Communication with Patients: Ask-Tell-Ask is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing. This course is approved by the Michigan Social Work Continuing Education Collaboration. Course approval #: *If you received nursing continuing education contact hours in 2015 for this educational offering, you are not eligible to receive CE credit in 2016 Understanding Brief Action Planning: Describe the components of BAP Understanding Brief Action Planning is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing. This course is approved by the Michigan Social Work Continuing Education Collaboration. Course #: *If you received nursing continuing education contact hours in 2015 for this educational offering, you are not eligible to receive CE credit in 2016 Applying Brief Action Planning in the Care Setting: Identify the application of BAP in work settings Applying Brief Action Planning in the Care Setting is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing. This course is approved by the Michigan Social Work Continuing Education Collaboration. Course #: *If you received nursing continuing education contact hours in 2015 for this educational offering, you are not eligible to receive CE credit in

4 MiCMRC/MiPCT Complex Care Management Course The 2016 MICMRC/MIPCT Complex Care Management (CCM) Course is provided in a blended learning activity format. The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs). Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period. The course consists of: Live Webinar on day 1 - introduction of MiCMRC/MiPCT CCM course Self-study modules and post- tests which are completed prior to the in-person training (total expected time to complete the self-study and post tests is six hours) In person training days 3 and 4 Upcoming course dates and course registration close dates: October 3-6, Introductory Webinar October 3 rd, Total six hour selfstudy modules and post-tests October 3-6, In-person training October NOTE: Registration for this course will close as of September 29 th, November 7-10, Introductory Webinar November 7, Total six hour self-study modules and post-tests November In-person training November NOTE: Registration for this course will close as of November 3, 2016 Register for all MiCMRC/MiPCT CCM Courses Here: 4

5 MiPCT Pediatric Summit 2016 The MiPCT Pediatric Care Manager Summit this year will address the clinical focus areas of 1) social determinants of health, specifically Adverse Childhood Experiences (ACEs) and Resiliency and 2) integration of behavioral health in primary care, including specific screening tools, as well as cultural diversity. We will offer presentations and panel discussions about how to address these themes when working with children, youth, and families. Parents of children/youth with special health care needs will join us to help keep us family-centered in all that we do. Small group discussions will give participants the opportunity to learn from each other and to build networking relationships. Date: September 20, 2016 Time: 8:30 am 4 pm Location: BCBSM Lyon Meadows Facility, Grand River Avenue New Hudson, MI To register for the MiPCT Pediatric Summit 2016, please Click Here *Registration CLOSES Tuesday September 4:30 PM* Continuing Education: MiPCT Pediatric Care Management Summit is approved for 5.5 contact hours by the Michigan Nurses Association, and approver of continuing nursing education by the Michigan Board of Nursing. This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #:

6 MiPCT Pediatric Summit Pre-Work MiPCT Pediatric Care Managers will also find that the pre-summit webinar on Specific Screening Tools for ACES and Behavioral Health to be aligned with the summit, and is highly recommended. The MiCMRC/MiPCT Educational Webinar: Specific Screening Tools for ACES and Behavioral Health will enable the learner to develop a deeper understanding of adverse childhood experiences (ACES) and behavioral health issues that are commonly treated in the pediatric primary care practice. The expert presenters are: Jane Turner, MD, Professor HP, Pediatrics and Human Development Michigan State University and Laurisa Cummings, LMSW, MiPCT Pediatric Care Manager, Care Management Supervisor, MiPCT Pediatric Clinical Lead, Children's Medical Group of Saginaw Bay. Nursing and Social Work continuing education contact hours for the Specific Screening Tools for ACES and Behavioral Health webinar may be obtained by: - Listening to the recorded webinar which will be available by end of August. The CE request link is posted on Click this link to initiate a request for CE Credits. This will generate an message containing a link to complete the CE request and required evaluation form. Follow the CE instructions contained in the . Once the required evaluation is submitted, an will be sent containing the CE certificate. CE credit for viewing the recorded webinar will be available until August 12, While the webinar will still be available for viewing, please note that CE credit for the viewing the recorded webinar will not be available after August 12, Continuing Education: "Specific Screening Tools for Adverse Childhood Experiences (ACES) and Behavioral Health" is approved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing. This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: For more information regarding contact hours, or for other questions, please submit to micmrc-requests@med.umich.edu 6

7 Success Story Lindsay Schohl, RN Hybrid Care Management and MiPCT Clinical Lead Lakes Family Medicine Mercy Health Muskegon Lindsay Schohl works with the providers at Lakes Family Medicine in Muskegon, Michigan. A patient was referred to Lindsay for pain management by the primary care physician, and the patient's spouse who is also a current patient of Lindsay's. The patient had been struggling with pain management; she had recurrent colon cancer that she was no longer pursuing treatment for. She was told by oncology that the chemotherapy would not be curative, and her previous experience with chemotherapy did not result in good quality of life. Prior to working with the care manager she had not been receiving any follow up care by oncology and her pain was rated at 8-10/10. She was not able to sleep well, not able to drive, and not able to leave her home without excruciating pain. The patient's pain management skills and knowledge were lacking for multiple reasons. She was prescribed Norco by her PCP but hadn't been taking it. The patient was opiate naïve, and had fears of addiction that resulted from a mother who had a Norco addiction in the past. Lindsay began communicating with the patient, providing pain management education and options for resources for pain management. The patient was adamant about declining Hospice, but she was receptive to a Palliative Care Referral for pain and symptom management. The Palliative Care Program we chose together offered a physician led approach, a one on one consult with a Palliative Care physician. Lindsay helped coordinate services for Palliative Care for this patient along with coordinating with her oncologist. Lindsay provided medication education to the patient along with addressing issues with breakthrough pain and how to handle that at home on her own with the medications Palliative Care recommended. Through a series of nursing interventions for pain management, care coordination, and resources, the patient is doing much better. She was able to leave her home a few weekends ago to go to a comedy show with her family, she is sleeping much better. She rates her pain at a 3/10 on average, and can verbalize how to stay on top of her pain before it gets away from her and she can't get it back under control. She continues following up with the Palliative Care physician monthly for pain and symptom management, and she continues follow up with her oncologist for support as her disease progresses. The patient reports a much better quality of life now that her pain is controlled, and thanks us for the care and support we have provided to her and her family through this difficult time. 7

8 Behind the Data By Michigan Data Collaborative MDC s Behind the Data section provides high-level information about the data for the MiPCT project in a Q & A format. Q: What is the incentive period used to calculate the performance incentive scores? A: MDC published release 18 of the MiPCT Dashboard on Thursday, September 8, The data from this release will be used for the 48 month incentive measure calculations. The 48 month incentives are based on the measurement year 1/01/2015 thorough 12/31/2015, although some clinical quality metrics include an additional look-back period. Viewing the data in release 18 will provide an early opportunity to review metrics and quantify incentive result expectations.metrics are found on both the Quality page and Utilization page of the Dashboard, and the underlying data can be viewed by clicking the See Detail link on each page. Additional information and instructions about viewing the data, see the MiPCT Dashboard User Guide ( MiPCT_New_Dashboard_UG.pdf). Other helpful documentation can be found on the MDC Website Support page ( New Measures Added in the 2015 MiPCT Performance Incentive Program Childhood Immunizations/Combo 3 Adult ED Risk Adjusted Visits (per 1000 attributed patients) Pediatric ED Risk Adjusted Visits (per 1000 attributed patients) 2014 Measures Retired in 2015 Part I: Primary Care Sensitive ED visit rates Part IV: Notification of Hospital Admissions & Discharges Part IV: Follow-Up Referrals to a Community- -Based Program or Agency Part IV: Self-Management Support Offered for Chronic Condition of Focus For more details on the incentive metrics or methodology, please refer to the MIPCT 2015 Performance Incentive documents located at or contact MDC at MichiganDataCollaborative@med.umich.edu. 8

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