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 26, 2016 SIM PCMH/MiPCT Partnership Initiative Application Period - Submission Deadline September 30 Important Dates: MiPCT Webinars Webinar September 27, :00 1:00 PM Practice Level Care Management Code by Code Analysis Note: Registration is not yet available 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 Included as attachments 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, as will the responsibilities for all reporting and compliance. 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. Many POs have already reached out to practices to discuss this and how they can best support practices to ensure that a seamless transition from 2016 to 2017 for SIM PCMH Initiative Medicaid funding. The link for Physician Organizations applying on behalf of practices, click this link. If you are a practice applying individually, please click this link. Note: Link to attachments is also located in the index table on page 2. 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. Webinar November 15, :00 1:00 PM EVENTS October 13, 2016 October 18, 2016 October 26, 2016 Care Management Billing and Coding and the 2017 SIM PCMH MiPCT Partnership Note: Registration is not yet available 2016 MiPCT REGIONAL ANNUAL SUMMIT-NORTH 2016 MiPCT REGIONAL ANNUAL SUMMIT-WEST 2016 MiPCT REGIONAL ANNUAL SUMMIT-SOUTHEAST 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 MiPCT 2016 Regional Summits - Afternoon Care Manager Sessions INSIDE THIS ISSUE: SIM PCMH/MiPCT Partnership Initiative Application 1 Attachments below Registration for 2016 MiPCT Regional Annual Summits 1 Important Dates 1 MiPCT 2016 Regional Summits - Afternoon Care Manager Sessions Summit Pre- Work Webinars 3 MiCMRC/MiPCT Complex Care Management Course 5 New 2016 Medication Reconciliation HEDIS Measure 5 Michigan Care Management Resource Center Approved Self- Management Support Training Programs Update 8 Cornerstone Family Practice Learns It Takes a Trusting Relationship with the Patient and the Family To Achieve Quality Care 8 BEHIND THE DATA: By Michigan Data Collaborative 9 MiPCT SUMMIT FLYER 10 SIM PCMH/MiPCT Partnership Initiative Application Attachments from Page 1 PCMH Initiative Application Guide PCMH Initiative Application Release Webinar Slides PCMH Initiative Medicaid Beneficiary Inclusion-Exclusion (1) PCMH Initiative Medicaid Beneficiary Inclusion-Exclusion PCMH Initiative Payment Model Excerpt from Participation Agreement PCMH Initiative Payment Model Excerpt from Participation Agreement PCMH Initiative Practice Transformation Objective Menu (2) PCMH Initiative Practice Transformation Objective Menu PO and Practice Requirements Excerpt from Participation Agreement PO and Practice Requirements Excerpt from Participation Agreement The next edition of the: MiPCT PO FLASH will be distributed on October 10, 2016 MiPCT Practice FLASH will be distributed on October 24, The 2016 in-person Summit Care Manager session: Social Determinants of Health, Agenda Setting, and Population Management when Delivering Self-Management Support focuses on the complex and/or high risk disengaged patient. Learn how to identify the right patients for care management. Build upon your population management skills and learn new techniques for working with complex and/or high risk disengaged patients that you can apply in your daily practice! The Summit 2016 MiPCT Care Management session consists of two parts: Attend a Summit Afternoon in-person session. Learning Objectives: Summit Care Management afternoon session (in person) Describe the impact of health disparities in patient care Describe the critical Social Determinants of Health when supporting patients Describe techniques for agenda setting with the the complex/high-risk disengaged patient Describe tools to facilitate shared decision making and patient empowerment Discuss the importance of population segmentation for delivering self -management support Learn how to apply population segmentation to a care manager s caseload Expert Presenters from The Centre for Collaboration, Motivation and Innovation: Kathy Reims, MD; Cory Sevin, RN, MSN, NP; Connie Davis, RN, MN, GNP; and Kelly Reilly, RN, MS, CDE Summit Locations and dates: Thompsonville, MI October 13, 2016 Grand Rapids, MI October 18, 2016 Ann Arbor, MI October 26, 2016 For additional Care Management Summit in person session details please see the 2016 MiPCT Summit Flyer below Registration: Register for the MiPCT Summit at Early registration is STRONGLY encouraged. 2

3 Continuing Education In Person MiPCT Care Manager Session "MiPCT Summit 2016 Care Management Session" is approved for 3.0 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 #: *Summit Pre-work recorded webinars designed for MiPCT Care Mangers are available. Nursing and Social work continuing education contact hours are available for the Summit Pre-work webinars Summit Pre-Work Webinars MiPCT 2016 Annual Summit Care Manager Afternoon Session PREWORK Earn Nursing or Social Work Contact Hours for Completing Summit PRE- WORK 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 are now available* 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 3 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 #:

4 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

5 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 self-study 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 th, Total six hour selfstudy modules and post-tests November 7-8 th,, In-person training November NOTE: Registration for this course will close as of November 3rd, Register for all MiCMRC/MiPCT CCM Courses Here: Please submit questions regarding the MiCMRC/MiPCT CCM course to: micmrc-requests@med.umich.edu. New 2016 Medication Reconciliation HEDIS Measure An inconsistency on the drug list is found in two-thirds of discharge summaries 1, which contributes to nearly one in five Medicare patients being readmitted to the hospital within 30 days. 2 One approach to resolving this is to reconcile medication lists with the patient shortly after discharge, which is why the National Committee for Quality Assurance Healthcare Effectiveness Data and Information set includes a quality improvement measure 3 aimed at ensuring that all patients receive a medication reconciliation within 30 days of any discharge. To satisfy the measure, the medication reconciliation must be recorded in the outpatient medical record. Medication reconciliation can be defined as a comparison of a patient s current medications against what they were taking in a previous setting of care, to identify any discrepancies or medication-related issues 4. Here are tips for performing a high-quality medication reconciliation, and improving transitions of care: Ask the patient to bring discharge instructions, medication bottles and lists, including nonprescription products (over-the-counter, vitamins, supplements) 5

6 Review medication bottles, and match them to the discharge instructions, including any new prescriptions Address all potentially clinically significant drug therapy problems, such as therapy duplication or drug interactions, with the prescriber(s) After reconciling medications, create a new list of all medications the patient should be on. Go through the new list with the patient, and make sure there is one copy for the patient and another copy in the patient s medical record. Talk to your patients about the importance of maintaining an accurate and up-to-date record of all active medications. Medications can often change between settings and the list of medications can be inaccurate or outdated. Encourage your patients to keep a copy of the updated medication list and bring it to all appointments. A comprehensive list of medications should include all prescription medications, herbal supplements, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives and intravenous solutions. Explain to your patients that this reconciliation is done to avoid medication errors as they relate such matters as duplications, omissions, dose, timing and adverse drug interactions. Establish a process asking patients to bring their medication bottles, including all over-the-counter preparations, to every health care encounter. A computer order entry system should be used when possible. It reduces errors and confusion caused by illegible handwriting. The updated hospital medication list and discharge instructions are printed for education and review with the patient before he or she leaves the hospital. Request the medication list to better assist in your review and update of the chart during post-discharge medication reconciliation. Always include medication reconciliation in your post-discharge visit note, whether you see your patient during an outpatient visit or you review medications over the phone with your patient. New Medicare star ratings measure: Medication reconciliation post-discharge About the measure The measure assesses patients age 18 and older who were discharged from an acute or non-acute inpatient stay between Jan. 1 and Dec. 1 of the measurement year. It looks at patients whose medications were reconciled from the date of discharge through 30 days after discharge (31 days total). Medical record documentation requirements Health care providers must meet certain criteria when documenting evidence of medication reconciliation in Medicare patients medical records for the reconciliation to count toward this measure. Documentation in the medical record must include evidence of medication reconciliation and the date it was performed. Any of the following meets documentation criteria: A note from the provider that current and discharge medications were reconciled The current medication list with a notation that references the discharge medications (for example, no changes in medication since discharge, same medications at discharge, discontinue all discharge medications) Current medication list with a notation that the discharge medications were reviewed Documentation of a current medication list, a discharge medication list and notation that both lists were reviewed on the same date of service Notation that no medications were prescribed or ordered upon discharge Only documentation in the outpatient chart meets the intent of the measure; an outpatient visit isn t required. Medication reconciliation can also be done by phone. 6

7 How to receive BCBSM reimbursement for medication reconciliation post-discharge When Medicare Advantage PPO members are discharged after a hospital stay, schedule a postdischarge office visit as soon as possible and perform medication reconciliation during the visit. The outpatient medical record must state that the current and discharge medications were reconciled. Bill $10 for *1111F with the post-discharge office visit claim within 30 days of the discharge. Medication reconciliation should be performed after every inpatient discharge. CPT 2 code *1111F states, Discharge medications reconciled with the current medication list in outpatient medical record. In addition to the office visit, Blue Cross will reimburse providers an additional $10 for billing 1111F within 30 days of a patient s discharge. Description Discharge medications reconciled with the current medication list in the outpatient medical record Transitional care management services: Communication (direct contact, telephone or electronic) with the patient or caregiver within two business days of discharge. Medical decision-making of at least moderate complexity during the service period. Face-to-face visit within 14 calendar days of discharge. Transitional care management services: Communication (direct contact, telephone or electronic) with the patient or caregiver within two business days of discharge. Medical decision-making of at least high complexity during the service period. Face-to-face visit within seven calendar days of discharge. Codes *1111F *99495 *99496 Reimbursement for codes or include medication reconciliation and therefore 1111F should not be billed with transitional of care codes. There is no member cost share for 1111F. On 7/11/16 or after, if a provider has conducted medication reconciliation post-discharge within 30 days but did not bill 1111F, a claim for 1111F can be submitted (alone.) Make sure the date of service was within 30 days of the hospital discharge to home. Providers who have billed 1111F after 7/11/16, but with a charge of $0.01 instead of $10, providers may rebill with a $10 charge. 1. Perren et al. Omitted and unjustified medications in the discharge summary. Qual Saf Health Care 2009;18: Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360: NCQA. Measure #46 (NQF 0097): Medication Reconciliation Post-Discharge National Quality Strategy Domain: Communication and Care Coordination. Available at: Accessed August 28, Gleason KM, Brake H, Agramonte V, Perfetti C. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. AHRQ Publication No 11(12) Rockville, MD: Agency for Healthcare Research and Quality. Revised August

8 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 MiCMRCapproved self-management course. For questions please submit to: micmrcrequests@med.umich.edu Cornerstone Family Practice Learns that it Takes a Trusting Relationship with the Patient and the Family Situation: Cornerstone Family Practice was selected as a Best Practice site based on high HE- DIS scores in measures. The practice achieved this by finding ways to establish a trusting relationship with patients and families and the care team. This was done through development of shared tools. Cornerstone Family Practice s tag line is Your Foundation for Good Health. Strategy: Cindy Denk, PA and Care Manager in the practice states that patients and their families are actively engaged in improving their health and receiving quality care (HEDIS measures) over many touch points in the practice. The practice started with creating the Welcome Patient Information Brochure. This introduction to the practice lays the foundation for a trusting partnership between Cornerstone Family Practice and the patient/family. The brochure provides patients and families with key information regarding what is a medical home, scope of their practice, practice responsibilities, patient responsibilities, communication methods, open access and preferred urgent care facilities. To take this a step further the practice provides each patient, each visit with a Patient Visit Information form to fill out and utilize during their visit to help document their needs, describe chronic condition control and work on an action plan to improve their health. From the front office to the back patient room clinical area, all staff members are aware of and working with the patient on goals and closing gaps in care. They use standard chart preparation, chart flags, standing orders and a referral coordinator who works to schedule tests and appointments with the patient and family. In addition the practice has developed specific responsibilities for the MAs to create standard work and reminders. The practice uses monthly staff meetings as the opportunity to review data and reasons for missed gaps in care. The meeting is centered on how the team may improve their process and care for the patient. Cindy states We achieved these results because everyone including the patient is actively involved and on the same page in improving care both in the office and in the medical neighborhood. 8

9 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. Incentive 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. For additional information and instructions about viewing the data, see the MiPCT Dashboard User Guide ( Other helpful documentation can be found on the MDC Website Support page ( support). 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. 9

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