The Michigan Primary Care Transformation (MiPCT) Project: An Overview. Medicaid Health Plan- MiPCT Coordination Meeting

Transcription

1 The Michigan Primary Care Transformation (MiPCT) Project: An Overview Medicaid Health Plan- MiPCT Coordination Meeting April 14, 2016

2 2 Welcome and Goals for the Day

3 3 Welcome! Our Goals for the Day Create relationships between key experts at plans and MiPCT POs and practices To discuss how best to work together for value for the benefit of our patients/members that avoids duplication and confusion To develop ideas and models that will help to make partnerships more effective To provide resources necessary to ensure success (today and into the future)

4 4

5 5 Ground Rules We are here for a common purpose Focus on partnerships and collaboration It isn t either/or, it is both When in doubt, think about the effect on the patient/member

6 6 An Opportunity for Synergy: The New Medicaid Health Plan Contract The new five year Medicaid Managed Care Plan Contract includes a requirement for health plans to establish standardized work processes (including a single point of contact) between health plan care management staff and MiPCT care managers to promote coordination of services and to avoid duplication of services.

7 Laying the Cornerstones 7

8 8 Foundations and Cornerstones There are some elements that are unique to each plan and to each practice But there are key areas we can identify and work towards The spirit is collaborative and constructive

9 9 Michigan Primary Care Transformation Overview

10 MiPCT Origin and Partners 10

11 11 MiPCT Participants 350 practices 37 POs 1,953 PCPs 303 are NPs and PAs 1.2 million patients Medicare (16%) Medicaid managed care plans (19%) BCBSM (35%) BCN (20%) Priority Health (11%)

12 12 MiPCT Practice Expectations: Maintain PGIP or NCQA Patient Centered Medical Home (PCMH) designation Are affiliated with a participating PO/PHO/IPA Maintain key PCMH capabilities (e.g., extended access; 30% same-day scheduling; registry, etc.) Provide care management services to patients (ratio of two trained Care Managers per 5,000 MiPCT patients)

13 13 MiPCT Practice Expectations, cont. Conduct regular medical home to review population health performance and discuss care plans for those with the greatest health challenges Coordinate timely transitions of care Maintain an all patient registry to identify gaps in care

14 14 MiPCT Timeline Original Demonstration Period Two Year Demonstration Extension MiPCT as SIM PCMH Pillar GOAL: To sustain our gains (effective, efficient teambased care with embedded Care Managers) and the way we deliver care

15 15 MiPCT Timely Transition Care Partnership: Admission Discharge Transfer Electronic Alerting Patient arrives at admission site Admitting provider sees MiPCT PO care guideline MiPCT PO or practice receives Ping PatientPing collects facility and post acute care (PAC) admissions on MiPCT patients MiPCT PO provides customized care guidelines with contact points at PO or practice MiPCT PO or practice receives actionable, realtime Pings

16 16 MiPCT Clinical Model: Optimizing Patient Engagement, Improving Population Health

17 17 Patient Centered Medical Home Agency for Healthcare Research and Quality (AHRQ) defines medical home not simply as a place but as a model of the organization of primary that delivers the core functions of primary health care. The medical home encompasses five functions of and attributes: Comprehensive Care Patient centered Coordinated Care Quality and safety

18 18 18 Managing Populations: Stratified approach to patient care and care management IV. Most complex (e.g., Homeless, Schizophrenia) III. Complex Complex illness Multiple Chronic Disease Other issues (cognitive, frail elderly, social, financial) <1% of population Caseload % of population Caseload II. Mild-moderate illness Well-compensated multiple diseases Single disease 50% of population Caseload~1000 I. Healthy Population

19 Michigan Primary Care Transformation Project Advancing Population Management PCMH Services PCMH Infrastructure Complex Care Management Functional Tier 4 Care Management Functional Tier 3 Transition Care Functional Tier 2 Navigating the Medical Neighborhood Functional Tier 1 All Tier services plus: Home care team Comprehensive care plan Palliative and end-of life care All Tier 1-2 services plus: Planned visits to optimize chronic conditions Self-management support Patient education Advance directives All Tier 1 services plus: Notification of admit/discharge PCP and/or specialist follow-up Medication reconciliation Optimize relationships with specialists and hospitals Coordinate referrals and tests Link to community resources Health IT - Registry / EHR registry functionality * - Care management documentation * - E-prescribing (optional) - Patient portal (advanced/optional) - Community portal/hie (adv/optional) - Home monitoring (advanced/optional) Patient Access - 24/7 access to decision-maker * - 30% open access slots * - Extended hours * - Group visits (advanced/optional) - Electronic visits (advanced/optional) Infrastructure Support - PO/PHO and practice determine optimal balance of shared support - Patient risk assessment - Population stratification - Clinical metrics reporting Prepared Proactive Healthcare Team Engaging, Informing and Activating Patients P O P U L A T I O N M A N A G E M E N T *denotes requirement by end of year 1

20 20 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 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

21 21 Care Management Resources For 2012 launch, partnered with Geisinger for Care Management training Developed a MiPCT Train the Trainer program How to identify patients for care management Tools for care management deliver that draw from best practices How to integrate within your practice Over 500 MiPCT care managers trained! National and local evidence-based models Also allow credit for existing PO/PHO training models

22 22 MiPCT Required Care Manager Training Care Managers who care for high risk, complex patients: MiCMRC/MiPCT Complex Care Management course MiCMRC approved self-management support training program Care Managers who care for moderate risk patients MiCMRC approved self-management support training program

23 23 Michigan Care Management Resource Center Standardized, evidence based MiCMRC/MiPCT Complex care management course offered monthly Web-based resource for templates, tools, evidence-based information, care manager job descriptions, etc. micmrc.org Webinars, workshops and mentoring in care management Goal is to help disseminate effective, evidence-based care management models throughout Michigan

24 24 MiPCT Care Manager Infrastructure

25 25 Care Management Continuum 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 (PowerPoint

26 26 Functions of a MiPCT Care Manager Partners with practice leadership team to integrate care management Assesses healthcare, educational, and psychosocial needs of patient/family develops individualized plan of care Provides self management support focus is typically on lifestyle and behavior change Provides patient/family education with teach back Implements evidence-based care chronic disease protocols and guidelines Assists with transitions between settings includes medication reconciliation Assists with advance directives

27 27 Role Comparison: Moderate Risk Care Manager (MiPCT Tier 3), Complex Care Manager (MiPCT Tier 4) 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, patient MiPCT list. 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

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29 29 Dedicated MiPCT page Multiple topics related to care management Resources, tools, webinars - registration for future events, and access to recorded webinars Share your Success Story web based template MiCMRC/MiPCT Care Manager Webinars; Opportunity to Earn Nursing & Social Work Continuing Education Contact Hours

30 Questions 30

31 31 Michigan Medicaid Health Plans Overview - Survey Results March 2016

32 32 Data were collected via Qualtrics March 8 March 30, 2016 Survey was completed by Michigan Medicaid Health Plans Medical Directors, Health Services Directors, Managers of Care Management Medicaid Completed the survey N=6 Thank you to those who completed the survey!

33 33 Health Plan Survey: What criteria is used to identify patients for Medicaid Health Plan Care Management? Predictive modeling algorithm Care management programs for the most vulnerable population in the top percentile of our membership High cost, complex care needs multiple diagnoses high-risk maternity, chronic medical conditions, catastrophic conditions high utilization - inpatient extended length of stay Referrals from members and providers

34 34 Health Plan Survey: Standardized Work Processes for Specific Patient Populations? Chronic diseases Prenatal Transplants Mental health coordination

35 35 Health Plan Survey: Communication and Coordination Do You Coordinate with MiPCT Care Managers currently? Majority of responses Yes Do you receive MiPCT practice lists on a monthly basis? Majority of responses No

36 36 Health Plan Survey: Communication Between MiPCT CM and Plan CM Is there a process in place for Health Plan CM and MiPCT CM to follow up? Majority of responses - Yes For those who responded yes: Is there a written protocol? Majority of responses No Is there a process in place for the Health Plan CM and MiPCT CM to communicate regarding a case closure? Majority of responses - No

37 37 Health Plan Survey: Describe the Standardized processes between Health Plan CM and MiPCT CM Coordination of care Share information with practice Care Managers through care conferences Share resources

38 38 Health Plan Survey: Please describe examples of successful joint Medicaid Health Plan/MiPCT coordination Worked with a Clinic with mutual patients and collaborated with MiPCT Care Managers We attend IHP Care Collaborative which includes MiPCT Care Managers occurs quarterly

39 39 MiPCT Physician Organizations Overview - Survey Results March 2016

40 40 Data were collected via Qualtrics March 8 March 30, 2016 Survey was completed by MiPCT participants: PO Leaders, Care Managers Completed the survey N=49 Thank you to those who completed the survey!

41 41 PO Survey: Communication and Coordination Do You Coordinate with Medicaid Health Plan Care Managers currently? Majority of responses No Do the Health Plans provide you access to a system to electronically exchange patient information for the purpose of Care Coordination and Management? Majority of responses - No Do Medicaid Health Plans provide you with Health Plan Care Manager contact information? Majority of responses - No *Important Note: For all of the above, examples do exist where this is occurring

42 42 PO Survey: For those that Coordinate with the Medicaid Health Plans, describe the Standardized Work Processes in place Patient file is sent from the plan with risk scoring and notes on which CM has been involved with the patient and whether the care is opened or closed Payer lists are reviewed. If a patient is being managed by the Health Plan CM the MiPCT CM will attempt to contact plan CM to coordinate care or phone call when necessary Monthly care reviews and quarterly meetings

43 43 PO Survey: Communication between MiPCT CM and Plan CM Is there a formal process for following up and closing a case for patients enrolled in care management by a Medicaid Health Plan CM? Majority responded -No For those who responded yes: Is there a written protocol? All responded - Yes

44 44 Please describe examples of successful joint Medicaid Health Plan CM and MiPCT CM Coordination Care reviews and joint meetings to discuss patients Participation in workgroups to review mutual gain activities Point person to serve as liaison for ADT access Identify patient health plan benefits, identify Specialists not available In Network Collaboration to bring services to patient in their home

45 45 Summary of Survey Findings Access to contact information for the Care Managers, both Health Plan and MiPCT For the most part, surveys reveal this is not in place Coordination and communication between Health Plan CMs and MiPCT CMs Not occurring consistently Formalized processes Examples exist Opportunity to identify coordination between the Health Plan CMs and MiPCT CMs What is mutually helpful? What does better look like for patients?

46 Questions 46

47 47 An Example of Effective Plan-MiPCT Practice Partnership: Priority Health

48 Priority Health/MiPCT Collaborative Barb Dusenberry, BSN, RN Manager, Care Management, Medicaid April 14, 2016

49 Priority Health exists to improve the health and lives of the members we serve!

50 We have earned an EXCELLENT rating from the National Committee for Quality Assurance (NCQA) every year since 1998! Top ranked Medicaid Health Plan in the State of Michigan (2016 Medicaid Health Plan Consumer Guide) Medicaid Population: 107,752 members Serve members in 20 counties Regions 4 and 8

51 The Priority Health Approach

52 The Triple Aim Better member experience Improve health of our members Lower cost of care

53 Priority Health Clinical Medicaid Team Director/Manager/Supervisor Care Managers RNs MSWs HHC CHWs HMC Outreach Staff

54 PH Clinical Management Team Behavioral Health team Prior Authorization Team Pharmacy Staff In House Transportation Team All dedicated staff within each team for the Medicaid members.

55 Our Approach Within Spectrum Health System Access to EPIC/Cerner Identification of System Care Managers working with member Exchange of clinical information

56 Magic Screen

57 Our Approach Outside Spectrum Health System Collaboration with clinic/office CM Flexibility of Priority Health CM Case Conferences

58 Questions

59 Contact Information Barb Dusenberry, BSN, RN Manager of Case and Disease Management. 250 East Eighth Street Holland, MI Priorityhealth.com

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61 61 Table Exercise/Group work Purpose: Discuss and develop a future state description of coordination between Medicaid Health Plans and MiPCT Care Managers 10:15-11:30-Table discussion and development of future state Select a recorder for your table Discuss questions on the table exercise sheet Using words and bullet points, list the key steps on the large post -it pads at your table; Put a star or asterisk on the critical steps (the things that are have to have, not nice to have

62 62 Table Exercise/Group work, cont. Use the large post-it pads to draw out the process using pictures or flowcharts; Put a star or asterisk on the critical steps Agree on who will do the report out for your table at the 11:30 round robin results sharing session Pick up a boxed lunch! We ll then invite each table to share their results at the round robin session (table by table)!