P.O. FLASH. Important Dates: MiPCT Pediatric Care Manager Summit Fall 2015 Don t Forget to Register!

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1 P.O. FLASH Michigan Primary Care Transformation Volume 4 - Issue 14 - August We can do this together - we can make care better...one patient at a time. MiPCT Pediatric Care Manager Summit Fall 2015 Don t Forget to Register! The MiPCT Pediatric Care Manager Conference will address the clinical focus areas of 1) social determinants of health, 2) integration of behavioral health in primary care and 3) palliative care. We will have 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 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. Register for the 9/22/15 MiPCT Pediatric Care Manager Summit! Date: Tuesday, September 22, 2015 Location: University of Michigan NCRC Bldg. 18, Ann Arbor Time: 9am 4pm REGISTER HERE: **Please note registration will close MiPCT Pediatric Care Managers will also find that the CM Summit 2015 pre-work of 4 recorded webinars will align with the MiPCT Pediatric CM 2015 Summit, and is highly recommended. Please see 2015 MiPCT Annual Summit page: **NEW** Pre-Conference Webinar hosted by Dr. Jane Turner! Join Dr. Turner in: Preparation for MiPCT Pediatric Summit Important Dates: DUE DATES: 9/9 REGISTRATION CLOSES* for MiPCT regional annual summit - west (event is 9/16; Reg. closes 9/9)* 10/13 REGistration closes* for MiPCT regional annual summit - north (event is 10/20; reg. closes 10/13)* 10/22 REGISTRATION CLOSES* for MiPCT regional annual summit - SE (event is 10/29; reg. closes 10/22)* * Registration may close earlier if capacity limits are reached. Early registration STRONGLY encouraged. MiPCT care manager TRAININGS: 8/17 MiPCT August CCM Training begins (aug ) 8/21 MiPCT webinar: Preparation for MiPCT Pediatric Summit presented by Jane Turner, MD Professor HP, Pediatrics and Human Development, Michigan State University Assistant Medical Director, Office of Medical Affairs, and Chief Medical Consultant, Children s Special Health Care Services, Michigan Department of Health and Human Services (10-11 AM) 8/26 MiPCT Webinar: Let s Talk Care Planning presented by Scott Johnson, RN, Michigan care management resource center, and ginger gamble, research associate, mphi (2-3PM) 9/8 MiPCT september CCM Training begins (sep. 8-10) 9/23 MiPCT Webinar: Participating in Wave 2 of the MiPCT/Patient Ping ADT PARTNERSHIP (9am) 9/23 Mipct webinar: high-risk medications in older adults presented by kimberly moon, pharmd, manager, clinical pharmacy stars team bcbsm (2-3pm) 10/13 mipct webinar: billing & coding collaborative (1pm) MiPCT events: 8/ MiPCT Pediatric CONFERENCE - (Ann Arbor) at um-ncrc, (full day) 9/16 MiPCT REGIONAL ANNUAL SUMMIT - WEST (Grand Rapids) at Frederik Meijer Gardens (8 AM) 10/20 MiPCT REGIONAL ANNUAL SUMMIT - north (thompsonville) at crystal mountain resort (11 AM) 10/29 MiPCT REGIONAL ANNUAL SUMMIT - southeast (ann arbor) at um - ncrc, bldg. 18 dining hall (8 AM) 11/17 MiPCT po quarterly webinar (Noon -1:30PM)

2 Date: Friday, August 21, 2015 Time: Duration: 1 hour 10:00am, Eastern Standard Time Please also view attached palliative care articles for discussion: Pediatric Palliative Care and Hospice Care Commitments, Guidelines, and Recommendations Integration of Palliative Care into the Care of Children with Serious Illness. Submit questions to MiCMRC at: Announcing the MiPCT/ PatientPing Partnership for MiPCT Admission, Discharge, Transfer (ADT) Notifications: An Opportunity for PO Participation MiPCT has transitioned from Crimson to PatientPing as a vendor partner for MiPCT patient ADT notifications to our primary care practices. PatientPing offers several advantages, including notifications on admissions and discharges at hospitals as well as post-acute care facilities across Michigan. PatientPing also allows POs to craft guidelines that are pushed by PatientPing to the admitting facilities so the facilities know who to contact about a MiPCT patient who has experienced a transition. Additionally, PpatientPing is working on integrating notifications directly into EHRs, as well as transmitting medication reconciliation information. Please keep in mind that this service is available for MiPCT patients at project cost to the PO or practice, to the extent that project funding allows. POs who participated in our collaboration with Crimson will be transitioned and onboarded to PatientPing first in Wave One. To the extent that project funding allows, we will also provide an opportunity for additional POs to participate so that their practices may also receive MiPCT patient ADT notifications as Wave Two participants. If you have participated in the ADT partnership in the past, your PO ADT leads will receive a meeting invitation to the Wave One webinar. For the remaining POs, there will also be a webinar on September 23 from 9-10am about the opportunity to be a part of Wave Two. In the interim, attached is brief overview of the structure of the MiPCT PatientPing partnership. Summit Care Manager Educational Activities Consist of NEW Prework Component, along with In-Person Session Summit 2015 Care Manager (CM) session consists of two parts, both of which offer nursing contact hours: 1. Completion of Prework consists of viewing 4 recorded webinars, with an opportunity to earn up to 6.0 Nursing Contact Hours 2. The in-person Summit afternoon care manager education session, with an opportunity to earn 3.0 Nursing Contact Hours, (see Expert Presenters Announced for Your Summit Afternoon CM Education Session following this article for more information.) Summit Care Manager Session Prework: This year, we have partnered with the Centre for Collaboration, Motivation and Innovation (CCMI) to design a series of four prework webinars to enrich your learning experience at the in-person Summit afternoon CM education session. The Summit prework consists of foundational content, offered in four, 1.5 hour pre-recorded webinars, available online, and eligible for earning nursing contact hours. Our presenter is Connie Davis, RN, MN, GMP, co-director of the CCMI. Connie Davis is an internationally known trainer, educator, speaker and consultant on health care design and health behavior change. Please view the 4 recorded webinars prior to the live Summit event. The links to the webinars will be available

3 August 1, 2015 to December 31, The recorded webinars will be posted on the website on the 2015 Summit Prework Webinars page located under the 2015 MiPCT Annual Summits tab: The webinars are available now; please access the prerecorded webinars at your convenience. Topics for the 4 CM Session Prework webinars: Please note the webinars are best if viewed sequentially. Viewing the webinars prior to the live Summit CM afternoon session is highly recommended. Webinar 1: 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. Webinar 2: 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. Webinar 3: 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. Webinar 4: 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. Steps to complete the Summit CM Prework and receive nursing contact hours: 1. View the online recorded webinar 2. Complete the webinar web-based evaluation and within the evaluation, include your address. 3. Upon completion and submission of the evaluation tool, your CE certificate will be sent to your address 4. Links to the prework webinars and instructions for completion are located on: NOTE: We recommend that you view the webinars sequentially prior to the Summit in-person event. If you find you are unable to view them prior to the Summit, the webinars will be available online through December 31, Each of the 4 webinars and the Summit afternoon care manager in-person session are standalone, in terms of earning contact hours. Expert Presenters Announced for Your Summit Afternoon Care Manager Education Session The Topic for the 2015 in-person Summit CM education session is: Brief Action Planning (BAP), Patient Engagement and Agenda-Setting. The Summit afternoon CM Session focuses on practical self-management support skills: BAP, patient engagement and agenda-setting. Build your self-management skills and learn new techniques for patient engagement that you can apply in your daily practice! Learning Objectives include: Discuss the BAP and its evidence base Demonstrate early proficiency in skills of BAP Explain the benefits of agenda setting Demonstrate early proficiency in skills of agendasetting Demonstrate Ask-Tell-Ask Learn how to effectively engage patients in their care

4 MiPCT Summit 2015 Care Manager 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. The 2015 Summit afternoon session Expert Presenters are from The Centre for Collaboration, Motivation and Innovation: September 16th Grand Rapids Presenters: Mike Hindmarsh, MA, Healthcare improvement consultant and faculty with the Centre for Collaboration, Motivation and Innovation. Cory Sevin, RN, MSN, NP; Director with the Institute for Healthcare Improvement and faculty with the Centre for Collaboration, Motivation and Innovation, Kriss Haren MA, MS, supervising clinical counselor and faculty with the Centre for Collaboration, Innovation and Motivation. October 20th Thompsonville Presenter: Kathy Reims MD, Assistant Clinical Professor Department of Family Medicine, School of Medicine, University of Colorado Health Sciences Center, codirects the Centre for Collaboration, Motivation and Innovation (CCMI). Summit North - Thompsonville, MI Tuesday, October 20, 2015 Crystal Mountain Resort & Conference Center Noon Project Leadership Briefing, followed by afternoon care management training REGISTRATION CLOSES 10/13/2015* Summit Southeast - Ann Arbor, MI Thursday, October 29, 2015 University of Michigan NCRC 8AM to Noon General Session open to all; afternoon care management training REGISTRATION CLOSES 10/22/2015* * Registration may close earlier if capacity limits are reached. Early registration STRONGLY encouraged. MiPCT Regional Annual Summit Flyer Attached for your Distribution Attached to this issue of the FLASH, please find the 2015 MiPCT Regional Annual Summit flyer. Please distribute and post to get the word out! October 29th Ann Arbor Presenters: Kathy Reims Cory Sevin, and Kriss Haren REGISTRATION OPEN! MiPCT Regional Annual Summits As previously announced, the dates and venues for the 2015 MiPCT Regional Annual Summits are: Statewide MiPCT Patient Advisory Council Member Nominations The statewide MiPCT Patient Advisory Council (PAC) is an advising resource to the Steering Committee, subcommittees and other MiPCT groups (PO Advisory Council, etc.). Our goal is to ensure that the patient voice is incorporated in MiPCT implementation and operations. We are recruiting additional nominations for this state-wide advisory group, which meets quarterly via conference call. Members should be: Summit West - Grand Rapids, MI Wednesday, September 16, 2015 Frederik Meijer Gardens and Sculpture Park 8AM to Noon General Session open to all; afternoon care management training REGISTRATION CLOSES 9/9/2015* a. MiPCT patients (especially patients who have experience with care managers) b. Able to use their own experience constructively c. Able to see beyond their own experience d. Able to listen to and hear differing opinions Member nominations are now being accepted at:

5 Following is a list of upcoming PAC Conference Calls: September 25, 2015, 1-2 PM December 18, 2015, 1-2 PM New Enhancements Added to the MiPCT Dashboard Report Writer! On August 6th, several updates were added to the Report Writer tool on the MiPCT Dashboard to improve functionality and usability. They include: The Report Writer sections automatically display all options (You no longer have to expand each section.) Total selection boxes were added for several measure groups. These display the totals for all components in the group combined. Overall rate selection boxes were added for several measure groups. These display the combined rate for all components of a measure group. Note: This month s Behind the Data feature in the PO FLASH references the Report Writer and how you can use this tool to target areas for improvement. For additional information and details, see the following documents, which are located on the Support page ( of the MDC Website: August 2015 Report Writer Enhancement Release Notes ( Details about the August 2015 Report Writer enhancement, including any known issues. Report Writer User Guide ( - Instructions about reating your own unique reports using the Report Writer tool. If you have any questions, or if you would like to provide feedback or suggestions, please contact MDC at MichiganDataCollaborative@med.umich.edu. MiPCT Complex Care Management Course The 2015 MIPCT Complex Care Management (CCM) Course is provided in a blended learning activity format. The MiPCT CCM course is designed for new MiPCT Hybrid Care Managers (HCMs) and Complex Care Managers (CCMs). Completion of the MiPCT CCM Course occurs over a 4 day period. The course consists of: Live Webinar on day 1 - introduction of 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 Register for upcoming MiPCT CCM course dates at the following site: Upcoming Course Dates and Course Registration Close Dates: September 8-10, 2015 Introductory Webinar September 8, Total six hour self-study modules and post-tests, September 8, In-person Training September 9-10, NOTE: Registration for this course will close as of September 1, 2015, 4 p.m. October 5-8, 2015 Introductory Webinar October 5, Total six hour self-study modules and post-tests, October 5-6, In-Person Training October 7-8, NOTE: Registration for this course will close as of October 1, 2015, 4 p.m. Please submit questions regarding the MiPCT CCM course to: micmrc-requests@med.umich.edu.

6 Stories of Your Care Management Success by her primary care provider was several months ago. The MiPCT list was reviewed for her eligibility. Laurie Smith, LMSW, HCM, Everingham Clinic, Medical Network One Health Solutions, BCBSM - Medicare Advantage While screening the BCBSM (Blue Cross Blue Shield of Michigan) gaps in care list, it was determined that Sue had an elevated HbA1C of 8.6, was overdue for her annual health maintenance exam, and the last time she was seen Sue was a 77 y/o at the time she was screened for care management. Her chronic conditions included Type 2 diabetes, hyperlipidemia, hypertension and ischemic heart disease. During the outreach call to the patient, Sue admitted to not taking her diabetes medication because it caused bloating. Sue agreed to meet with the care manager face-to-face Behind the Data by MDC s Behind the Data section provides high-level information about the data for the MiPCT project in a Q & A format. Q: On the Dashboard, the Quality Graph shows that most of my PO s diabetes measure rates are below the MiPCT benchmarks. From the tables below the graph, I can see that the Commercial payers had the lowest rates. What other information can I access to help me target areas for improvement? A: From the Report Writer, you can easily run a report that lists all your Practices and their associated diabetes measure rates for only the commercial population. To do so, complete the following steps: 1. Click the PO Reports tab, and then select Report Writer. 2. In the Display Data for box, confirm that your PO is selected. 3. In the Select Report Detail Level box, select Practice. 4. In the Quality section, under the Chronic Conditions heading, select Commercial. 5. Verify that all of the diabetes measures are selected. 6. Select to display the report on the page or in an Excel spreadsheet. The resulting report lists all of the Practices in your PO with their associated rates, limited to the diabetes measures and the commercial population. From here you can determine actions to help improve your diabetes metrics. For more detailed information about the Report Writer, see the Report Writer User Guide at ( If you have any questions, or if you would like to provide feedback or suggestions, please contact MDC at MichiganDataCollaborative@med.umich.edu

7 during the initial call. During the first face-to-face visit Sue stated she was not testing her blood sugar because she did not have glucometer strips. Sue agreed to enroll in care management. Improvement of Sue s HbA1C was established as the long term goal. Sue and the care manager began to work on a plan to achieve this goal through Sue s self-management of her condition. The patient learned about her diabetes medication. This included how to take her diabetes medication with meals, which then alleviated the bloating. During her follow-up with the primary care provider (PCP) her health maintenance exam was completed and the care manager, along with the medical assistants helped Sue obtain new prescriptions for her glucometer supplies. care manager. NEXT ISSUE DATES: Next MiPCT P.O. FLASH Issue: September 14, 2015 Next MiPCT Practice FLASH Issue: August 31, 2015 The care manager met with Sue over several weeks. Their visits focused on helping Sue gain an understanding about her diabetes medication, meal planning and her chronic conditions. This included teaching Sue about her diabetes, hypertension, and hyperlipidemia and how lifestyle changes such as exercise and diet could positively impact her health. Through coaching calls, Sue also revealed that she often falls asleep before taking her bedtime dose of her diabetes medication. When the PCP was consulted about lack of adherence to her medication, the PCP changed the administration time to the morning instead of bedtime. Additional topics of discussion were symptoms of hypoglycemia, avoiding constipation and increasing physical activity. While engaged in care management, Sue experienced a stroke and an amputation of a toe. During her hospitalization the care manager coordinated her care, which included scheduling appointments with specialists. Sue reported that despite her hospitalization, her blood sugars were the best they have ever been as evidenced by her improved HgA1C of 7.3. Soon after the hospitalization the care manager transferred this case to a high intensity care manager (HICM) who now follows the case through in-home visits. The goals set through HICM include increasing balance and lower limb strength through physical therapy. The goals of improving her daily nutrition and diet were carried over to the HICM