PRACTICE FLASH. Important Dates: SAVE THE DATES! MiPCT Regional Annual Summits

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1 PRACTICE FLASH Michigan Primary Care Transformation Volume 5 - Issue 3 - March 21, 2016 We can do this together - we can make care better...one patient at a time. SAVE THE DATES! MiPCT Regional Annual Summits The dates and venues for the 3 confirmed 2016 MiPCT Regional Annual Summits are: Summit West Grand Rapids, MI Tuesday, October 18, confirmed Frederik Meijer Gardens and Sculpture Park 8AM to Noon General Session open to all; Afternoon Care Management Focus Summit Southeast Ann Arbor, MI Wednesday, October 26, confirmed University of Michigan NCRC 8am to Noon General Session open to all; Afternoon Care Management Focus Summit North Thompsonville, MI Thursday, October 13, confirmed Crystal Mountain Resort & Conference Center 11 AM to Noon Project Leadership Briefing, Afternoon Care Management Focus Sign Up Now! Registration Opens for the 2016 MiPCT-Led Billing and Coding Collaborative (4 Practice Learning Credits) Again this year, the MiPCT will centrally host a Multipayer Billing and Coding Learning Collaborative (4 practice learning credits for successful completion) to continue our efforts to assist and support POs and practices in robust structures that support G- and CPT-code billing for embedded care management services. Expectations for 2016 practice team participants include: Front office staff, Care Manager and other interested PO or non-physician practice team members would need to participate in three to four MiPCT-led team webinars (with pre and post work). The timing of webinars would be spread throughout the year (e.g., March, May, July, December). (Note: Physicians are not required to participate in the team webinars.) Practice teams will be need to participate in the majority of the hosted webinars (e.g., in the instance of scheduling conflicts, up to one webinar can be reviewed retrospectively from the posted online material.) Physician participation in one Physician-focused webinar. Depending upon the preferences of the collaborative participants, an in person half day session may also be included. Important Dates: MiPCT CARE MANAGER TRAININGS: 3/23 MICMRC/MiPCT CM WEBINAR: EFFECTIVE (2PM) COMMUNICATION WITH PHYSICIANS. PRESENTER- MAUREEN MURPHY, RN, BSN, FNP-BC (2PM) REGISTER: 3/28-31 MiPCT/MICMRC CCM TRAINING COURSE 4/15 MICMRC/MiPCT CM PEDIATRIC WEBINAR: AUTISM SCREENING, FORMAL TESTING, AND TREATMENT: DETERMINING THE NEXT STEPS IN THE PLAN. PRESENTER-LAURISA CUMMINGS, LMSW, CHILDREN S MEDICAL GROUP OF SAGINAW BAY (10AM) REGISTER: 4/27 CE OPPORTUNITY: MICMRC/MiPCT CM WEBINAR: COGNITION 101. PRESENTER-LINDA J KEILMAN, DNP, GNP-BC, ASSISTANT PROFESSOR, MICHIGAN STATE UNIVERSITY(10AM) REGISTER: EVENTS: 3/22 PO SUSTAINABILITY WEBINAR (12:00 PM) 4/6 MIPCT OPERATIONS GROUP (10:30AM) 4/6 MIPCT ADT WORKGROUP (NOON) 4/13 WEBINAR: TOOLKIT FOR INTEGRATING SOCIAL DETERMINANTS OF HEALTH & BEHAVIORAL HEALTH (1:30PM) REGISTER: 4/14 STEWARDSHIP & PERFORMANCE COMMITTEE 10/ MIPCT REGIONAL ANNUAL SUMMIT NORTH (CONFIRMED) 10/ MIPCT REGIONAL ANNUAL SUMMIT WEST (CONFIRMED) 10/ MIPCT REGIONAL ANNUAL SUMMIT SE (CONFIRMED) DUE DATES: 4/30 PO Q REPORTS DUE

2 Expectations for 2016 PO representatives who wish to participate in the collaborative on behalf of their practices include: Participation as outlined above Demonstration (via submitted minutes or other documentation) evidence that the collaborative material was conveyed in a meaningful way to practices and is incorporated in workflow/practice. Submission of the names and addresses of practices involved Please register using the links in Steps 1, 2 and 3 below, if your practices (or your PO on behalf of practices) intend to participate in the 2016 Billing and Coding Collaborative. Step 1: Sign up to Participate in the 2016 MiPCT Billing & Coding Learning Collaborative as EITHER a PO or Practice Team using the appropriate link below: Link for Practices: Link for PO on Behalf of Practices: Step 2: RSVP to this link to let us know you re attending the 3/29/2016, 1:00PM webinar: Link to RSVP to 3/29 Webinar: Step 3: Pre-Register with WebEx to receive Webinar Login: REQUIRED - PRE-REGISTRATION PLEASE READ INSTRUCTIONS CAREFULLY The following webinar requires all individuals to register for participation. Please follow the link below and select one of the register options to complete the registration in full. Once you have registered, a confirmation with instructions for joining the meeting will be sent to you by messenger@webex.com. The subject line will state: Registration approved for Web seminar: MiPCT Billing & Coding Learning Collaborative Webinar. Please be sure to save the confirmation to access the webinar. If you have any questions, please contact the MiPCT mailbox at: mipctdemo@michigan.gov Topic: MiPCT Billing & Coding Learning Collaborative Webinar Date: Tuesday, March 29, 2016 Time: 1:00pm, Eastern Standard Time (New York, GMT-05:00) Duration: 1 hour Register for this Webex Using This Link: You re Invited to Join Now! MiPCT EHR User Groups MiPCT is facilitating the formation of 5 user groups based on shared EHRs/registries and we invite you to participate. The purpose of the groups is to identify and provide shared solutions to issues specific to each EHR. Participation by both POs and practices is welcome. The first meetings will be held as webinars, and will include identification of the issues each group would like to address (as well as potential solutions), a discussion of outside speakers and future meeting times. MiPCT has scheduled the first webinars for users of AllScripts Professional, Athena Health, Epic, NextGen and Wellcentive. MiPCT will facilitate the formation of user groups for all other EHRs and registries, but will be unable to attend the meetings. Following are the dates of all 5 upcoming EHR User Group Webinars for your reference: Wellcentive User Group Webinar: Monday April 18, 2016, 11AM to Noon NextGen EHR User Group Webinar: Monday, April 18, 2016, 4-5PM Athena Health EHR User Group Webinar: Tuesday, April 19, 2016, 1-2PM Epic EHR User Group Webinar: Monday, April 25, 2016, 11AM to Noon AllScripts Professional EHR User Group Webinar: Monday, April 25, 2016, 4-5PM If you are interested in joining the of these EHR User Groups, please Amanda First at afirst@med.umich.edu indicating: The EHR User Group you are interested in Name and Contact information for each person you would like to be included in the group s initial webinar meeting We will then include you in the webinar s Outlook notice, which includes the webinar login instructions.

3 Michigan Care Management Resource Center Approved Self-Management Support Training Programs Update For information about MiCMRC approved self-management programs, please see the document titled, Care Management Resource Center Approved Self-Management Support Training Programs, at: This document includes details for each MiCMRC-approved self-management program: location, objectives, modality, resources, course date/criteria to schedule, trainer qualifications, certification/ces, and cost. MiPCT Moderate, Complex and Hybrid Care Managers are required to complete a MiCMRC-approved self-management course. For questions please submit to: micmrc-requests@med.umich.edu MiPCT Care Managers - An Invitation to Earn Nursing and Social Work Continuing Education Contact Hours Educational Offering: MiCMRC/MiPCT Care Manager Webinar: Understanding the Complexities of Cognition The MiCMRC/MiPCT Educational Webinar: Understanding the Complexities of Cognition webinar focuses on the complexities of cognition. The expert presenter is: Linda J. Keilman, DNP, GNP-BC Assistant Professor Michigan State University. New this year! Nursing and Social Work continuing education contact hours for the Understanding the Complexities of Cognition webinar may be obtained by the following activities: Attend the LIVE webinar on April 27th, 2016 from 2:00-3:00 pm -OR- Listen to the recorded webinar which will be available early May. For details coming soon, check Details about the steps and requirements for completion will be coming soon via upcoming FLASH Newsletter and To Register for the Live webinar: Continuing Education: Understanding the Complexities of Cognition 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 Addressing Social Determinants of Health (SDOH) and Behavioral Health Integration (BHI) - the Role of the Practice Team 80% of health care outcomes depend on factors outside of clinical care delivery. (ROBERT WOOD JOHNSON COMMUNITY HEALTH RANKINGS) Mental health high-cost patients were younger, lived in poorer neighborhoods, and had different health care utilization patterns, compared to other high-cost patients, ie., those with complex chronic disease or cancer. (HEALTH AFFAIRS, JAN 2016) The simple question, Do you (ever) have difficulty making ends meet at the end of the month?, has a sensitivity of 98% and specificity of 60% in predicting poverty. (AAFP) As the advanced medical home begins to address these complex situations it requires: Practice teams which utilize registries which capture and address these at a population level Partnerships with our medical neighborhoods Processes within our practices to optimize treatment protocols and community linkages MiPCT has created a toolkit to support POs and practices to be successful in addressing SDOH and BHI.

4 The link is: Go to the Resources tab Select Social determinants of health and behavioral health A Practical Guide A Practice-focused webinar will be held on Toolkit for Integrating Social Determinants of Health and Behavioral Health : Wednesday, April 13, 2016 from 1:30pm 2:30pm. Click here to join: MiCMRC Care Manager Monthly Update - March 2016 Fisher (fishjody@umich.edu) know. If you have any questions about the Patient Advisory Council, please contact Diane Marriott (dbechel@umich. edu) or MiCMRC/MiPCT Complex Care Management Course - For MiPCT Care Managers 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). On February 24th, 2016 the Michigan Care Management Resource Center (MiCMRC) hosted a webinar titled, 2105 Summit Best Practice Award Presentations Presented by Alpine Internal Medicine and Pediatrics, Cereal City Pediatrics, Moazami Pediatrics, New Day Family Medicine, and CHC Fort Gratiot. Also, on March 9th, 2016 MiCMRC held a webinar titled, Depression in the Older Adult, presented by Linda J. Keilman, DNP, GNP-BC, Assistant Professor at the Michigan State University, College of Nursing. The MiCMRC/MiPCT Care Manager recorded webinars, PowerPoint presentations, as well as related articles and handouts are posted on the Michigan Care Management Resource Center website. To access the recorded webinars and associated information please visit: Please submit questions to micrmc-requests@med.umich.edu Practice PAC Recruitment Flyer Attached Attached is a flier that Care Managers or Physicians in MiPCT practices can give to MiPCT members or caregivers who would be good candidates for Patient Advisory Council participation. To make things even easier, at your request, we will send you a set of hardcopy fliers ready for you to hand out. If you want a set mailed to you, please let Jody Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period. The course consists of: DAY 1 - Live Webinar - introduction of MiCMRC/MiPCT CCM course DAY 2 - 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) DAYS 3 and 4 - In-person training Upcoming course dates and course registration close dates: March 28-31, Introductory Webinar March 28th, Total six hour self-study modules and post-tests, March 28-29, In-person training March 30-31, NOTE: Registration for this course will close as of March 24th, May 23-26, Introductory Webinar May 23, Total six hour self-study modules and post-tests, May 23-24, In-person training May 25-26, NOTE: Registration for this course will close as of May 26th, Continuing Education: Social Work This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: Number of Social Work CE Contact Hours approved: 16 Continuing Education: Nursing The activity listed above applies to the following

5 Michigan Board of Nursing (MBON) Rules for Relicensure: Nursing Workshop dealing with patient care issues (no formal contact hours or CEs). MiPCT Care Manager Webinars Upcoming 2016 MiCMRC/ MiPCT Care Manager Educational Webinars: MBON Rule 2(1). A maximum of 10 continuing education hours may be earned for participation in a workshop dealing with patient care issues offered by a health care organization or professional organization that falls outside the already accepted methods of approval that have already been adopted by the Board. Register for all MiCMRC/MiPCT CCM Courses Here: Date: March 23, 2016 (2PM) Title: Effective Communication with Physicians Presenter: Maureen Murphy, RN, BS, FNP-BC Date: April 15, 2016 (10AM) Title: Autism Screening, Formal Testing, and Treatment: Determining the Next Steps in the Plan Presenter: Laurisa Cummings, LMSW, Children s Medical Group of Saginaw Bay Please submit questions regarding the MiCMRC/ MiPCT CCM course to: micmrc-requests@med.umich.edu. Date: April 27, 2016 (2PM) Title: Cognition 101 Behind the Data by Dear MiPCT Partner: We have fielded many questions and investigated the possibility of using the MiPCT project clinical MiPCT project clinical data repository may be an option for As you know, sustainability is a focus of our efforts for the MiPCT project and we hope to be able to provide this option to you next year. We will keep you informed as we know more about those efforts. data repository as an option for Meaningful Use specialized registry reporting. A recent FAQ from CMS has clarified the exclusion rule, and therefore eliminated the immediate need for Specialized Registry attestation in 2016, but CMS FAQ What counts as an allowable exclusion. CMS FAQ What counts as a specialized registry. we wanted to make our partners aware that the

6 Presenter: Linda J Keilman, DNP, GNP-BC, Assistant Professor, Michigan State University To register for these webinars: Stories of Your Care Management Success Jennifer Train, St. John Providence Partners in Care Northpointe Pediatrics was looking to ensure adequate and appropriate follow up for newly diagnosed ADD/ADHD patients. This was due in part to HEDIS measures requiring that patients be seen within 30 days after index prescription start date and then again two more times in the following 270 day period. Initially there was difficulty establishing a way to identify those who were newly diagnosed. One idea that the office tried was to make a master list of patients with the diagnosis of ADD or ADHD then compare a new registry search on a monthly basis for new names. This proved time consuming and inaccurate. The office tried a few different ways to keep an accurate account of newly diagnosed patients but nothing proved very helpful or time effective. Initial trials were not successful. Subsequently, our physician had an idea, which we implemented: To help ensure that we were tracking and following up with our newly diagnosed ADD/ADHD patients, physician champion, Dr. Engel, created an internal ICD 10 code. Providers in the office would use this code along with the pertinent ICD 10 code for ADD/ADHD on the index prescription start date. This new code allowed the gaps in care coordinator along with the care manager to utilize the electronic registry to track patients who were newly diagnosed with ADD or ADHD. Once the list was generated it was easy to ensure adequate follow up was taking place. In addition the care manager and gaps in care coordinator now had the ability to check on those patients monthly who had been started on medication in the past nine months and ensure that they were being followed closely and met the HEDIS measure. medications and those not progressing well on their new medication regimen. As a result of this, our gaps in care coordinator created a spreadsheet of newly diagnosed patients designated by month. Those patients are then checked to ensure they have follow up appointments scheduled. If patients do not have a current appointment scheduled or have expressed concerns regarding medication, side effects, or other areas of concern she then forwards that information to the care management team or the provider for further follow up as needed. Dear Stakeholders: Note from the Editor: A Fond Farewell I have accepted a promotion in another department within the University of Michigan and this will be the last issue of the FLASH on which I will serve as editor. We are in the process of identifying my replacement now and expect to offer a seamless transition to you in terms of communications regarding the FLASH. It has been my sincere pleasure to have served the MiPCT since the beginning, and I will miss it very much. As a reminder, should you have any questions going forward, please send them to the mipctdemo@michigan.gov mailbox, where they will be promptly forwarded to the most appropriate person to address your question. Best Wishes for a Successful Future! Jody Fisher MiPCT FLASH Editor/Project Assistant/Event Planner NEXT ISSUE DATES: Next MiPCT P.O. FLASH Issue: April 4, 2016 The change the practice made has led to an increase in medication compliance as well as follow up needed for those patients with ADD/ADHD. In addition, we have been able to identify those patients who have been non-adherent due to side effects of medication, difficulty obtaining those Next MiPCT Practice FLASH Issue: April 18, 2016