2018 sim pcmh initiative regional summit · mipct statistics: • over 1800 providers participated...

2018 SIM PCMH Initiative Regional Summit

THE KENSINGTON HOTEL3500 SOUTH STATE STREET

ANN ARBOR, MI

MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES

Seamless Partnerships for Effective Patient Care

Welcome - Overview


KATHERINE COMMEY, MPHSIM CARE DELIVERY LEADPOLICY, PLANNING, AND LEGISLATIVE SERVICES ADMINISTRATIONMICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES

DisclosuresThere is no conflict of interest for anyone with the ability to control content for this activity.

Participants who successfully attend the entire conference event and complete the online CE request process, including required evaluation with email address, will earn 4.5 contact hours.

This continuing nursing education activity was approved by the Ohio Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91) ONA # 21757

DisclosuresThe project described was supported by Grant Number CMS-1G1-14-001 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.

Requirements for Nursing, Social Work, and Commission for Case Manager Certification CE Contact Hours• Attend the entire Summit

• Sign in upon arrival• Complete the evaluation Access the evaluation on the MDHHS SIM PCMH Initiative Summit

registration web page or click here

Note: For a Certificate of a Completion use the above web link

https://www.michigan.gov/mdhhs/0,5885,7-339-71551_64491_86032_87364---,00.html

Instructions for Obtaining CE Credit or a Certificate of Completion

To receive Nursing, Social Work, or CCMC continuing education contact hours or a certificate of completion for “Michigan State Innovation Model (SIM) Patient Centered Medical Home (PCMH) Initiative Summit 2018”:

Access the Summit evaluation form and certificate request by clicking on this link to the MDHHS SIM Summit web page, scroll down the page to Summit Southeast-Ann Arbor, and click on “Ann Arbor Summit Evaluation".

• You will need to use your MiCMRC dashboard log in.

• If you do not have a MiCMRC dashboard, you will need to create a dashboard login on the micmrc.org website.• Please note that after creating your login, you will need to return to the MDHHS SIM Summit web page .

To request CE or a Certificate of Completion, complete the brief form and click submit Next, complete the evaluation and submit. This step generates an email to you containing the certificate If you do not receive the email with attached certificate in your Inbox, please check your Junk/Spam email You will also have the option to download your certificate directly from your dashboard

For technical assistance please e-mail: [email protected]

https://na01.safelinks.protection.outlook.com/?url=https://www.michigan.gov/mdhhs/0,5885,7-339-71551_64491_86032_87364---,00.html&data=02|01|[email protected]|f7d4134fece84b98c10a08d632c55f11|d5fb7087377742ad966a892ef47225d1|0|0|636752221641874562&sdata=wS1iNpAQFuDqKxNXq5VmiLdwDdPszSt4hCz8UmNruWw%3D&reserved=0https://na01.safelinks.protection.outlook.com/?url=http://micmrc.org/&data=02|01|[email protected]|f7d4134fece84b98c10a08d632c55f11|d5fb7087377742ad966a892ef47225d1|0|0|636752221641874562&sdata=tJq/U0jrjIJccrAbIxUPpmEw8YML6AaOsunEjwxYHas%3D&reserved=0https://na01.safelinks.protection.outlook.com/?url=https://www.michigan.gov/mdhhs/0,5885,7-339-71551_64491_86032_87364---,00.html&data=02|01|[email protected]|f7d4134fece84b98c10a08d632c55f11|d5fb7087377742ad966a892ef47225d1|0|0|636752221641884572&sdata=JiCdAEKZWJBSdvCrpfjMIisg3qWKS4TnOB1JAeTyQro%3D&reserved=0mailto:[email protected]

Agenda - Morning8:00 - 9:00 AM Registration and Continental Breakfast

Resource Table / Networking

9:00 - 9:30 AM Welcome: Michigan's SIM PCMH Initiative Regional Summit and Objectives

9:30 - 10:45 AM Plenary: Effective Patient Care Delivery: Patient Identification and Medical Behavioral and Social Need Support

10:45 - 11:00 AM BREAK

11:00 - 12:00 PM Concurrent Breakout SessionsA. Social Determinants of Health and Community Resources B. Medicaid Tracking Codes C. Behavioral Health

12:00 - 12:45 PM LUNCH: Boxed Lunches available, Informal Networking Opportunity

Agenda - Afternoon12:45 - 2:00 PM Concurrent Breakout Sessions

D. Practice Workflow for Target PopulationsE. Medicaid Tracking Codes (Repeat of Morning Session)F. Behavioral Health (Repeat of Morning Session)

2:00 - 2:15 PM BREAK

2:15 - 3:15 PM Plenary: Sustainability Post-SIM

3:15 - 3:30 PM Wrap-Up and Closing

What Does Sustainability Mean To You?Handout on your tablePlease complete by the end of the dayYour responses will be used to help inform future MDHHS priorities

Welcome - State of the State


KATHY STIFFLERACTING DIRECTOR MEDICAL SERVICES ADMINISTRATIONMICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES

Learning Objectives• Identify SIM Successes• Year 2 progress to date and opportunities• Year 3 looking ahead

Before SIM – There Was MiPCT

MiPCT Statistics: • Over 1800 providers participated• 346 PCMH practices were involved• Over 1,158,650 patients were attributed• MiPCT supported the hiring and training of over

500 care managers

Overall MiPCT demonstrated: • Better patient experience• Improved cost and utilization with high risk

patients• Improved adult quality indicators

The Michigan Primary Care Transformation demonstration was a 5 year multi-payer program sponsored by the Centers for Medicare and Medicaid Services (CMS). With the goal of supporting advanced primary care including care coordination, improved access, patient education, etc.

MiPCT offered many foundational elements to further advanced primary care delivery in Michigan.

SIM was designed to:• Provide Michiganders with improved access to healthcare and

increased connection with community resources• Create capacity for resource coordination and promote strategy

alignment across stakeholders• Enhance patient-centered outcomes• Promote more efficient and effective healthcare expenditures

SIM Components

Supported by:• Stakeholder engagement• Data sharing and interoperability• Consistent performance metrics

Care Delivery• Patient-centered medical homes• Advanced payment models

Population Health• Community health

innovation regions

Focused on:Clinical-community linkage

SIM Care Delivery Goals1. Champion models of care which engage patients using

comprehensive, whole person-oriented, coordinated, accessible and high-quality services centered on an individual’s health and social well-being.

2. Support and create clear accountability for quantifiable improvements in the process and quality of care, as well as health outcome performance measures.

3. Create opportunities for Michigan primary care providers to participate in increasingly higher level Alternative Payment Methodologies.

The PCMH InitiativeSIM PCMH Initiative Participants:

355 practices:

Capacity and experience with PCMH capabilities including comprehensive coordinated care, and screening for social need varied across participants

• 328 members of a Physician Organization• 18 Federally Qualified Health Center sites• 9 Single Practice sites

238 previous MiPCT participants

125+ CPC+ (track 1 & 2) participants

206 within a SIM Test Region150 outside of a SIM Test Region

PCMH Initiative: SuccessesClinical Community Linkages

• Significant effort in the development of Social Determinants of Health Screening processes and workflows

• Over 50% of participants implement a screening system that allows patients to self-administer the screening or for staff to administer the screening

• While Care Managers and Coordinators play a large role in the administration and review of completed screenings, many team members are involved in the whole process

• Over 250,000 screenings have been completed to date! • Areas of Greatest Reported Need:

• Healthcare (Behavioral Health)• Food Assistance• Transportation

• 68% of providers have reported using Social Determinants of Health Screening data to inform treatment/service delivery

• 94.3% practices strongly believe they have an important role in identifying/addressing their patient's social needs

Care Management and Coordination• Preliminary Reports indicate that in 2017 alone over

14,000 Medicaid Beneficiaries received at least one Care Management/Coordination service as a result of the SIM PCMH Initiative

• SIM patients were more likely than other Medicaid beneficiaries to receive multiple CM/CC services (illustrating provision of longitudinal relationships)

• Almost half of the SIM patients with a CM/CC claim had a face to face visit

• SIM patients are more likely to receive a CM/CC service following an inpatient hospitalization

Note: only 2017 data has been analyzed at this time and MDHHS acknowledges that the data is likely an underrepresentation of the overall services provided within the SIM PCMH Initiative due to claims optimization processes that occurred in late 2017 and early 2018.

PCMH Initiative: Opportunities• Provider/Patient Attribution

• Support Policies and processes to ensure appropriate patient attribution to providers

• Care Management and Coordination• Support processes to ensure appropriate and timely adjudication of care management and

coordination claims • Support opportunities to explore how the provision of similar services to the same beneficiaries can

be coordinated across Medicaid Health Plans, Providers, Community Partners, etc.

• Social Determinants of Health • Define and Standardize Social Determinants of Health Priority data and sharing amongst appropriate

partners

PCMH Initiative: Looking to the FutureMDHHS Values:

• The Patient Centered Medical Home • Comprehensive Whole Person-Centered Care • Access to resources to address health and social service needs • Care Managers and Coordinators

•Future Challenges: • Impending Election• Ever Changing Healthcare

Landscape

•Future Opportunities: • SIM Plan for Improving Population

Health • Proposal for Change

Effective Patient Care Delivery: Patient Identification and Medical, Behavioral and Social Need Support

How Implementation Science Can Help͠


KATHRYN HARMES, MD, MHSACLINICAL ASSISTANT PROFESSOR, ASSOCIATE CHAIR OF POPULATION MEDICINEDEPARTMENT OF FAMILY MEDICINEUNIVERSITY OF MICHIGAN MEDICAL SCHOOL

Learning ObjectiveDescribe effective patient care delivery addressing Patient Identification, Medical, Behavioral and/or Social Determinants of Health Support.

AgendaExplain Implementation Science and describe benefit for practice transformation efforts.

Explain specific examples in which implementation science can improve care.

Describe the importance of Social Determinants of Health and challenges to addressing them in the primary care setting.

National Trends in Primary Care Transformation

2002 Chronic

Care Model

2001 Institute of

Medicine Report

2004 Future of Family Medicine Report

2007 Joint Principles of

PCMH

Patient Centered Medical Home

American Academy of Family Physicians, et al., 2007

Joint Principles include:• Personal physician• Physician-directed medical practice• Whole person orientation• Coordinated/integrated care throughout the system

and community• Quality and safety Robust patient-family-physician relationship Evidence-Based Medicine, clinical support tools,

continuous QI, shared decision making, IT use,accreditation

• Enhanced access• Payors recognize value of PCMH

February 2016PCPCC Annual Evidence Report

Patient Centered Primary Care Collaborative, retrieved from https://www.pcpcc.org/results-evidence

https://www.pcpcc.org/results-evidence

How do we move from Evidence to Practice?

Lessons Learned from the Study of Primary Care Transformation

• Strong foundation needed for successful redesign

• Process of transformation can be a long and difficult journey

• Approaches to transformation vary• Visionary leadership and supportive culture

ease the way for change

• Contextual factors are inextricably linked to outcome

McNellis et al., 2013

Challenges• Primary Care practices are diverse • One-size-fits-all approach to transformation will not work• Complexity and breadth of care • Many specialty guidelines to incorporate• Limited resources• Limited time and capacity in frontline medicine

Future Directions• Increased aging population and associated burden of chronic illness• Health Equity and Social Determinants of Health• Precision Medicine

How long does it take for an evidence-based intervention to become routine practice?

17 years!

Practice Transformation Evidence - Based

Intervention

Implementation Strategy

Improved Outcomes

Grandes G. et al., 2018

Implementation Science• What factors determine successful uptake of innovation in primary

care settings?

• Shifts focus from “what” (evidence-based intervention) to “how” (adoption of recommendation into routine practice).

3 Reasons for Failure

•Incongruence between context of testing and practice

•Process of implementation not meeting the needs of stakeholders

•Instability – staff, funding, other unforeseen variables

Blakemore A. et al. 2018

3 Requirements of Implementation Science Framework

•Integrate multi-stakeholder perspectives

•Provide pragmatic guidance on planning implementation process

•Consider interaction between implementation and context

Implementation Strategies

•How well does an intervention work?•What implementation strategies are effective?

•How broadly is the intervention implemented to achieve desired effects?

•Any unintended consequences?•What is the cost?•What is the potential for generalizability and sustainability?

Holtrop et al., 2018

Implementation ScienceDissemination Research

• The systematic study of processes and factors that lead to widespread use of an evidence-based intervention by the target population.

Implementation Research

• Seeks to understand the processes and factors that are associated with successful integration of evidence-based interventions within a particular setting.

The Ingredients for Better Care

Evidence-based intervention

Implementation Science

Uptake in community

clinical practice

Implementation Science• Typically mixed-methods research identifies factors that affect uptake

on multiple levelsPatient, provider, clinic, organization, community, policy

• Studies strategy for process of implementatione.g. consensus building meetings among key staff to determine workflows

• Training for clinicians and staff on how to use and document results• Audit and feedback on initial success• Adaptions based on feedback

This sounds familiar…..

How is Implementation Science different from QI?• Quality Improvement processes are local.

• Implementation Science frameworks are generalizable.

MANY Implementation Models in Health Research and Practice( retrieved from, http://dissemination-implementation.org/viewAll_di.aspx)

MANY Implementation Models in Health Research and Practice, cont.

Behavior change wheel

Implement Sci. 2013; 8: 46.

Examples of Implementation Studies

Keep in Mind….

Implementation studies are typically qualitative or mixed-methods.

Gather information and use a conceptual framework to identify “themes”.

Focused more on understanding the process, rather than the outcome.

Jargon:

“Learning collaborative”

“Stakeholders”

“Sense-Making”

Strategies for addressing challenges of PCMH implementation

Study of strategies to overcome implementation barriers• 20 “exemplary” clinics in Oregon Patient-Centered

Primary Care Home (PCPCH) implementation• Used modified Success Case Method• Semi-structured interviews and focus groups• 10 themes regarding clinical strategy

Gelmon et al., 2018


Successful practices shifted patterns of care usage

• Expanding access through teams, schedules, andstaffing

• Preventing unnecessary emergency departmentvisits through patient outreach and emergencydepartment information exchange

• Ensuring care with outside providers throughimproved communication and referral tracking

Gelmon et al., 2018


Fidelity to the PCPCH model• Prioritization of select standards and metrics• Implementing patient-centered practices including

bilingual/bicultural staff, cultural competencytraining, and new population demographic metrics

• Developing new continuous improvement capacitythrough committees, training, and clinic”champions”

Refining care processes• Incorporating screenings, preventive services, and

chronic disease management• Standardization of workflows• Customizing electronic health records for

communication and reporting• Integration of mental health

Gelmon et al., 2018

Understanding effective care management implementation in primary care

• Care Management in primary care offices requiresredesign of clinical workflow and innovation instaff responsibilities.

• Macrocognition Framework – study of thinking asit occurs in the performance of complex, real-world tasks.

• Cognitive Task Analysis – tool used to understandimplementation in terms of decision making,knowledge, and communication.

Holtrop, et al., 2015


Mixed-methods study, using semi-structured interviews and observations at baseline and 9 months

• 10 practices, 74 interviews and 5 observations

• RE-AIM elements as evaluation framework

Reach # patients enrolled/FTE CM

Effectiveness Improvement in clinical values

Adoption Providers referring to CM

Implementation Knowledge, use, meaning andvalue, enthusiasm

Maintenance Patient follow-up completion rates

Holtrop, et al., 2015


• Care Management patients improved on% A1C < 8 and weight loss

Using the Theoretical Domains Framework (TDF) to understand adherence to multiple evidence-based indicators in primary care

• UK study of implementation of evidence-based guidelines

• TDF – framework developed to identify determinants of professional behavior changeKnowledge Skills Social professional role and identityBeliefs about capabilitiesBeliefs about consequencesMotivation and goalsMemory, attention, and decision processesEnvironmental context and resources Social influenceEmotionBehavioral regulation

Lawton et al., 2016

Indicators Evaluated• Risky prescribing practices• Treatment targets in DM2• Blood pressure targets in Hypertension• Anticoagulation in Atrial Fibrillation

60 interviews• 30 General Practitioners • 15 Nurses• 15 Practice Managers

Lawton et al., 2016



5 meta-themes representing influences on implementation of evidence-based practice

• Perceived nature of job and norms of practice• Internal and external sources of support• Communication pathway and interaction• Meeting the needs of patients• Perceptions of value of indicators

Lawton et al, 2016

Understanding Implementation of Complex Interventions in Primary Care Teams

• Part of a larger study of improving care for obesity in Canada• 29 participants from 12 clinics in a large, urban primary care

network 7 Mental health care workers 7 Registered dietician 15 RN or NP

• Intervention: 6 months of bi-weekly lectures on topics identified by participants, facilitated learning collaborative sessions to share best practices, identified clinic challenges, created practice improvement goals.

• Interactive Systems Framework Knowledge synthesis and translation Innovation support through capacity building Innovation delivery

Luig et al., 2018

Understanding Implementation of Complex Interventions in Primary Care Teams

3 Novel Themes•Collective Sense-MakingNeed to promote time and space for team

relationships and communicationNeed to foster effective team development

•Dynamic evaluation and implementation process evaluationPractice change did not unfold in linear fashion Flexibility allowed intervention to be meaningful and

applicable to providers

•Consistent engagement with stakeholdersPresentations were tailored to stakeholdersPerception of addressing organizational need led to

sustainable practice changes

Luig et al., 2018

The Dahlgren-Whitehead Rainbow

Lancet, 1991

The Ten SDoH Domains of the SIM PCMH Initiative

6. Family Care7. Education8. Transportation9. Personal and

Environmental Safety10. General

1. Healthcare2. Food3. Employment and

Income 4. Housing and Shelter5. Utilities

Social Determinants of Health

Race/ethnicity

Education

Financial resource strain

Stress

Depression

Physical activity

Tobacco use and exposure

Alcohol use

Social connections and social isolation

Exposure to violence: Intimate partner violence

Neighborhood and community compositional characteristics

National Academies Press, 2015

Addressing Social Determinants of Health

Gather Information(Community or patient-

reported data)

SIM SDoH Screening

Integrate into Clinic Workflows

(POC, panel management)

Care Management and Coordination

Intervention(Referral, coordination, patient

engagement)

Clinical Community Linkages

How can Implementation Science help with integration of SDoH screening?

Identify Barriers •FFS Payment Structure•Culture focused on treatment vs prevention•Limited technologies

Identify Facilitators•Comprehensive Payment Structure (CPC,ACO, etc.)

•Primary Care Delivery Transformation(PCMH Initiative Model)

•Technological facilitators (EHR)

How can we use SDoH data effectively to improve health?

• Implementation strategies can help interventions into practice and scale to diverse settings

• Develop tools, optimize for settings and populations

• Workforce feasibility studies• Evaluate impact on patient and provider

experience, health outcomes, health care costs, and utilization

• Examine potential unintended consequencese.g. Referrals to community agencies

What is the role of the health system in identifying and addressing patient social and economic needs?

Evaluating Accountable Health Communities demonstration project

Accountable Health Communities – 2016 CMMI Initiative • Developed to respond to disconnect between growing interest in

addressing SDoH and gaps in effectiveness evidence $157 million over 5 years 44 states, over 3 million patients

• 5 core social needs Screening and Intervention Housing Food Security Transportation Intimate Partner Violence Utilities

• Metrics Total Cost of Care Health Care Utilization Provider and Beneficiary Experience

Does addressing SDoH in the context of health care settings impact individual or population health?

Gottlieb, et al., 2017

Evaluating Accountable Health Communities demonstration project

• Barriers to measuringPathway to evaluation involves many steps,

each with confounding factors5-year funding window may be too short to

see outcomes

• Countermeasures Incorporate mediating factors sensitive to

changes in social condition which may lead to better health outcomesPatient satisfactionConnectedness to practiceOperational processes• Referral• Connection to resourcesProvider burnoutWorkforce retention

Clinician experiences with screening for social needs in primary care

• Purpose – to understand PCP experience with SDoH screening and how information is used in routine practice

• Mixed-methods• Studied learning collaboratives, social needs surveys,

clinician diaries• 17 PCPs from 12 practices in Northern Virginia

encompassing one health system with shared EMR• Clinicians reported that SDoH screening changed care

in 22% of encounters• In 52.5% of encounters, SDoH survey helped them

know their patients better• 70.77% of patients screened positive, 3.3% asked for

help

Tong et al., 2018


Themes

• The act of assessing social needs is difficult and resource intensive.Less beneficial for well-known patientsPatients may be hesitant to share needsPatients who need help do not come in for visits Information is overwhelming to physicians

• Few resources exist to help patients with social needsProviders lack agency to addressNot aware of community resourcesPractices lack adequate support to address


Themes

• Screening did seem to change clinician-patient interactions May increase clinician awareness May or may not change practice In some cases, can cause harm

• More evidence needed about how to help address needs and their impact on health Some questioned if the health care system is

the right place to address needs. Does addressing needs improve outcomes?

How Does the SIM PCMH Initiative Help Us to Improve Care for Our Patients?

• Provides Funding to Enable Change Efforts for Medicaid Patients PMPM One-Time Capacity and Clinical-Community

Linkages (CCL) Social Determinant Funding Opportunities

• Reinforces Key PCMH Tenets Requirements for expanded access, same-day

visits, etc. Emphasizes Clinical-Community Linkage (CCL)

development Use cases for electronic capture and flow of key

information

• Defines the goal but allows flexibility in how best to reach the goal

Conclusion • Recognize that the “how” is as important as the “what”

• Prioritize time• Communicate and collaborate

ReferencesAmerican Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians , & American Osteopathic Association. (2007). Joint principles of the patient-centered medical home. Retrieved from http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf

Blakemore A, Neale AV, Lupo P, & Seehusen D. (2018 May-June). Advancing the science of implementation in primary health care. J Am Board Fam Med, ..31(3) 307-311. doi: 10.3122/jabfm.2018.03.180091. PubMed PMID: 2974321

Dale SB, Ghosh A, Peikes DN, Day TJ, Yoon FB, Taylor EF,……Brown R. (2016, April). Two-year costs and quality in the comprehensive primary care initiative. N Engl J Med, 374(24) 2345-56. doi: 10.1056/NEJMsa1414953. Epub 2016 Apr 13. PubMed PMID: 27074035

DeVoe JE, Bazemore AW, Cottrell EK, Likumahuwa-Ackman S, Grandmont J, & Spach N, Gold R.(2016, March). Perspectives in primary care: A conceptual framework and path for integrating social determinants of health Into primary care practice. Ann Fam Med, 14(2) 104-8. doi: 10.1370/afm.1903. PubMed PMID: 26951584; PubMed Central PMCID: PMC4781512.

Gelmon S, Bouranis N, Sandberg B, & Petchel S.(2018, May-June). Strategies for addressing the challenges of patient-centered medical home implementation: Lessons from Oregon. J Am Board Fam Med, 31(3) 334-341. doi: 10.3122/jabfm.2018.03.170265. PubMed PMID: 29743217

Gottlieb L, Colvin JD, Fleegler E, Hessler D, Garg A, & Adler N. Evaluating the accountable health communities demonstration project. J Gen Intern Med, 32(3) 345-349. doi: 10.1007/s11606-016-3920-y. Epub 2016 Nov 14. PubMed PMID: 27844261; PubMed Central PMCID: PMC5331008

Gottlieb L, Cottrell EK, Park B, Clark KD, Gold R, & Fichtenberg C. (2018, May-June). Advancing social prescribing with implementation science. J Am Board Fam Med, 31(3) 315-321. doi: 10.3122/jabfm.2018.03.170249. PubMed PMID: 29743213.

Grandes G, Pinnock H, Bazemore A, Meissner P; & StaRI Group. (2018, May-June). Improving the quality of primary care by optimizing implementation research reporting. J Am Board. Fam Med,31(3) 484-487. doi: 10.3122/jabfm.2018.03.170195. PubMed PMID: 29743231

http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf

ReferencesHaggerty J, Chin MH, Katz A, Young K, Foley J, Groulx A, ….., Uchendo U. (2018, May-June) Proactive strategies to address health equity and disparities: Recommendations from a bi-national symposium. J Am Board Fam Med, 31(3) 479-483. doi: 10.3122/jabfm.2018.03.170299. PubMed PMID: 29743230.

Holtrop JS, Potworowski G, Fitzpatrick L, Kowalk A, & Green LA. (2015, August). Understanding effective care management implementation in primary care: a macrocognition perspective analysis. Implement Sci, 10:122. doi: 10.1186/s13012-015-0316-z. PubMed PMID: 26292670; PubMed Central PMCID: PMC4545994.

Holtrop JS, Rabin BA, & Glasgow RE. Dissemination and implementation science in primary care research and practice: Contributions and opportunities. (2018, May-June). J Am Board Fam Med, 31(3) 466-478. doi: 10.3122/jabfm.2018.03.170259. PubMed PMID: 29743229.

Lawton R, Heyhoe J, Louch G, Ingleson E, Glidewell L, Willis TA ……., Foy R. (2016, August). ASPIRE programme. Using the theoretical domains framework (TDF) to understand adherence to multiple evidence-based indicators in primary care: a qualitative study. Implement Sci, 8;11:113. doi: 10.1186/s13012-016-0479-2. PubMed PMID: 27502590; PubMed Central PMCID: PMC4977705.

Luig T, Asselin J, Sharma AM, & Campbell-Scherer DL. (2018, May-June). Understanding implementation of complex interventions in primary care teams. J Am Board Fam Med, 31(3) 431-444. doi: 10.3122/jabfm.2018.03.170273. PubMed PMID: 29743226.

McNellis RJ, Genevro JL, & Meyers DS. (2011, April). Lessons learned from the study of primary care transformation. Ann Fam Med,11 Suppl 1:S1-5. doi: 10.1370/afm.1548. PubMed PMID: 23690378; PubMed Central PMCID: PMC3707240

Michie S, Van Stralen, MM, & West R. (2011, April). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci, 23;6:42. doi: 10.1186/1748-5908-6-42. Review. PubMed PMID: 21513547; PubMed Central PMCID: PMC3096582.

Committee on the Recommended Social and Behavioral Domains and Measures for Electronic Health Records, Board on Population He alth and Public Health Practice, & Institute of Medicine. (2015, January). Capturing social and behavioral domains and measures in electronic health records: Phase 2. Washington (DC): National Academies Press (US); PubMed PMID: 25590118

Tong ST, Liaw WR, Kashiri PL, Pecsok J, Rozman J, Bazemore, AW, & Krist AH. (2018, May-June). Clinician experiences with screening for social needs in primary care. J Am Board Fam Med, (3) 351-363. doi: 10.3122/jabfm.2018.03.170419. PubMed PMID: 29743219.

Questions?

10:45 - 11:00 AM

BREAK

Concurrent Breakout Sessions11:00 - 12:00

Social Determinants of Health and Community

ResourcesMaryam Tout, LLMSW

Yellow Dot

Grand Ballroom 1 & 2Breakout Room

Medicaid Tracking CodesTheresa Landfair

Red Dot

Conservatory Breakout Room

Behavioral HealthLaurisa Cummings, LMSW

Green Dot

Westminster 1 & 2Breakout Room

Note: The colored dot on the left side of your name badge indicates the morning breakout session that you will be participating in.

Social Determinants of Health and Community Resources


MARYAM TOUT, LLMSWINTEGRATED HEALTH ASSOCIATES (IHA)SOCIAL WORK

Learning ObjectivesOutline successful strategies for SDoH screening, engaging patients and family, and follow up of the linkages with community resources

Summarize key steps for SDoH screening, assessing the high priority needs of your practices patient population and building the Clinical-Community Linkages

What would you like to learn from this presentation?

Let’s make this helpful to you!

SDoH Overview• ACE Study• Non-medical health management Income, immigration status, education, housing, race andgender, etc.

• Avoidable health disparities across groups

Patient reaches out to resources and touches

base with SW for support and as other

needs arise

Patient

SW meets with patient to assess

and problem solve

SW

MD briefly explores identified

needs and provides warm

hand-off

MD

MA assists patients complete

the screening*

MA

Receptionist provides screening tool to identified

patients

Reception

SDoH Screening Process

*MAs also act as a safety net, providing SDoH screening to patients they identify as being in need

Screening for SDoH• Psychosocial risk factors Discomfort around sensitive questions

• Opportunity for education• Common challenges

Engaging Patients and Families

• Cultural competency• Meeting them where they are• Empowerment• Know your resources• Follow-Up

Community Resources• Building connectionsDeveloping partnerships

• Involved linkingSituational adjustments

• Ensuring follow up

ReferencesAdler, N. E., Glymour, M. M., & Fielding, J. (2016). Addressing social determinants of health and health inequalities. Jama, 316(6), 1641-1642.

Andermann, A. (2016). Taking action on the social determinants of health in clinical practice: A framework for health professionals. CMAJ: Canadian Medical Association Journal, 188(17-18), E474-E483.

Theiss, J., & Regenstein, M. (2017). Facing the need: screening practices for the social determinants of health. Journal of Law, Medicine & Ethics, 45(3), 431-441.

Questions?

Thoughts?

Thanks very much!(734) [email protected]

Medicaid Tracking Codes


THERESA LANDFAIRPROGRAM SPECIALISTMEDICAL SERVICES ADMINISTRATIONMICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES

Learning Objective•Articulate the importance of identifying appropriate patients for caremanagement and coordination.

•Discuss the lifecycle of patient identification/patient servicing/inter-team coordination/tracking code submission/building the case forsustainability.

•Explain resources available to assist practices (including coordinationwith Medicaid Health Plans)

Care Management Tracking Codes • The PCMH Initiative requires all participating practices to track Care

Management and Coordination Service provision using a designated set ofHealthcare Common Procedure Coding System (HCPCS) and the AmericanMedical Association's Current Procedural Terminology (CPT) codes.

Code Quick Description

G9001 Comprehensive Assessment

G9002 In-person Encounter

98966, 98967, 98968 Telephone Services

99495, 99496 Care Transition

G9007 Team Conference

G9008 Physician Coordinated Care Oversight Services

98961, 98962 Group Education and Training

S0257 End of Life Counseling

New codes added for 2018: Could bill these codes

as of 1/1/2018

General Service Documentation RequirementsAll Services rendered should be documented in electronic Care Management and Coordination Documentations Tools (either a stand alone product or component of EHR), with information accessible to all care team members at the point of care.

Documentation should, at a minimum, include the following: • Date of Contact*• Duration of Contact• Method of Contact• Name(s) of Care Team Member(s) Involved in Service• Nature of the discussion and pertinent details regarding updates on patient’s

condition, needs, progress related to care plan with goals and target dates

* Date of service reported should be the date the care management and coordination service took place. In some cases, aservice may take place over the course of more than one day, in such an event the date of service reported should be the date the service was completed

Why do we use the Tracking Codes1. Submission of the Care Management and Coordination service claims supports

one of the SIM PCMH Initiative Care Management and Coordination Metrics:

2. Regular claims submission supports more than the SIM PCMH Initiative!◦ Shows the value of a Patient Centered Medical Home to Medicaid

beneficiaries◦ Shows the value of provider delivered care management and coordination

to Medicaid beneficiaries

Any patient who has had a claim with one of the applicable codes during the reporting period

Eligible Population

General Conditions for Tracking Code UseFor SIM PCMH Initiative Care Management and Coordination services to be tracked within the Initiative, the following applies: oThe patient must be within the SIM PCMH Initiative Eligible Population. oServices must ordered by a Primary Care Provider within the approved practice; a note

indicating these services were ordered must be in the medical record.oServices performed must be based on patient need oService is performed by the appropriate qualified, non-physician health care professional

employed or contracted with the approved practice or PO oBilled to participating Medicaid Managed Care Organizations in accordance with Medicaid billing

guidelines oThere is no cost share (copay, coinsurance or deductible) for Care Management and

Coordination services.

From Service Provision to Report Capture

Participant provides CMCC

service

Claim submitted to appropriate

Medicaid Health Plan (MHP)

MHP Adjudicates claim and submits

to MDHHS

MDHHS reviews, processes, and

“clears” the claim

Cleared claims are loaded into the

MDHHS Data Warehouse

Michigan Data Collaborative

(MDC) pulls claims from the MDHHS Data Warehouse

MDC generates monthly Care Coordination

Reports using the cleared claims and

the eligible population for

that month

Eligible Patient PopulationA Medicaid beneficiary must have full Medicaid coverage and be served through a Medicaid managed care organization (Medicaid Health Plan) to be attributed to a participating practice and provider within the SIM PCMH Initiative:

A patient’s eligibility can be verified on both the PCMH Patient Lists produced by the Michigan Data Collaborative on a monthly basis, or by checking the Community Health Automated Medicaid Processing System (CHAMPS).

Included Benefit Plans:

BMP Benefits Monitoring Program

MA-HMP-MC Healthy Michigan Plan – Managed Care

MA-MC Medicaid – Managed Care

TCMF Targeted Care Management Flint

Ensuring Patient Eligibility in CHAMPS

Claims ReportingCURRENT STATUS UPDATE

Patient List v. Patient PanelSome Participants have reported differences in their patient panel (who they see/treat) and who is on their PCMH Patient List (on the MDC Dashboard).

Important to keep in mind:

1. The PCMH Initiative population is dependent on Medicaid enrollment, eligiblebenefit plan, and Medicaid Health Plan assignment.

2. Monthly Patient Lists are dependent on patient eligibility and enrollment at thebeginning of the month, and sometimes there is retroactive enrollment thattakes place, but not reflected on the patient list.

If you believe the above does not explain the differences you are seeing: First, contact the health plan when discrepancies are noticed to ensure corrections are made immediately.

Claims not reflected on the Reports Some Participants have reported differences in the services they are rendering and what is reflected on the Care Coordination Reports generated and posted on the PCMH Portal by Michigan Data Collaborative:


1. Reports are driven by timely claims adjudication and processing

2. Claims are only included if the service was provided to a patient on the PCMH Patient List

If, after confirming the above, a claim is not appearing on the Care Coordination Report, check CHAMPS!

If after 60 days past the date of your clean claim adjudication you are unable to see your claim in CHAMPS, contact your health plan representative.

When to Contact the InitiativeParticipants of the PCMH Initiative are encouraged to work with their Medicaid Health Plan representatives to resolve issues related to patient assignment and claims adjudication, however, if issues arise regarding your patient lists or tracking claims are not resolved in a timely fashion, contact the SIM PCMH Initiative and state staff will contact the practice and health plan.

[email protected]

mailto:[email protected]

Care Navigator Documentation

Krista L. Yezback, MSN, APRN, FNP-BCComplex Care Navigator Nurse PractitionerMichigan Medicine Canton Health Center

Care Navigator Templates

Template Example:

• Set up in “SOAP” note format• “Auto-populated” into our Documentation • Use EMR tools to improve efficiency • Associate Diagnoses to drop LOS Billing

Codes on Date of Service• Document Plan of Care & next Follow up• Close Encounter to drop “Charge”

Care Navigator Medication Reconciliation

Care Navigator Plan of Care

Care Navigator Best Practice Advisory (BPA)

Care Navigator Level of Service

Care Navigator Follow-up

Addressing Behavioral Health Needs In The Primary Care SettingLAURISA CUMMINGS, LMSWCHILDREN’S MEDICAL GROUP OF SAGINAW BAY


Learning Objectives• Explain effective mental health management through the care team,

including integration of behavioral health into primary care• Identify best practice and lessons learned when advancing care

management services and implementing behavioral health screeninginto primary care

• Discuss behavioral health screening and follow up, matchingresources to address practice population needs

Agenda•Learners will be able to discuss behavioral health conditions commonly treated in primary care practices

•Learners will be able to identify screening tools in which to screen for particular behavioral health conditions

•Learners will be able to use evidence-based tools for improved assessment and management of behavioral health issues

•Learners will be able to identify referral processes to address behavioral health needs

•Learners will be able to identify additional billing opportunities for care managers who hold a LMSW

Rationale to Address Mental Health Needs in Primary Care• 56% of American adults with a mental illness did not receive treatment (Mental Health

America 2017)

• 1.7 million youth with major depressive episodes did not receive treatment (MentalHealth America, 2017)

• One half of all chronic mental illness begins by the age of 14; three-quarters by the ageof 24 (National Institute of Mental Health, 2017)

• 90% of those who die by suicide have an underlying mental illness; suicide is the 10thleading cause of death in the U.S. (National Institute of Mental Health, 2017)

Michigan Statistics•Michigan ranked 23 of all states having lower prevalence of mental health and substance use issues

•Michigan ranked 19 of all states having lower prevalence of mental illness and higher rates ofaccess to care for adults

•Michigan ranked 17 of all states having lower prevalence of mental illness and higher rates ofaccess to care for youth

•Michigan ranked 16 of all states providing access to insurance and mental health treatment foradults and youth

•Michigan ranked 22 of all states providing mental health workforce availability with a ratio of 460:1(includes psychiatrists, psychologists, LSMWs, counselors, LMFT, and NPs)

(National Institute of Mental Health, 2017)

Why Addressing Behavioral Health Needs In Primary Care Settings Is So Important• Increased compliance• Lessen stigma of mental health needs• Increase self management of chronic mental health needs• Improved coordination of care• Decreased morbidity• Preventative services• Integration of physical and emotional care

Behavioral Health Integration: Resources For Primary Care Use• American Academy of Pediatrics (https://www.aap.org)

• SAMHSA-HRSA for Integrated Health Solutions (CIHS) (https://integration.samhsa.gov)

• National Alliance on Mental Health (https://nami.org)

• World Health Organization (https://who.int)

https://www.aap.org/https://integration.samhsa.gov/https://nami.org/https://who.int/

Behavioral Health Integration: Two Example ModelsMental Health Tool Kit, American Academy of Pediatrics

www.aap.org

Mental Health Initiatives, Primary Care Tools

A Global Perspective, World Health Organization

www.who.int/en/

Mental Health, Policies and Services

http://www.aap.org/http://www.who.int/en/

Where To Begin: Advancing Care Management, Adding Behavioral Health ServicesSocial Determinants of Health

Domains of Social Determinants of Health:

Healthcare, food, employment & income, housing and shelter, utilities, family care, education,

transportation, personal and environmental safety, and general

ACES Screening

Pair of ACEs:

Screening for adverse childhood experiences (ACEs)

Addressing adverse community environments (ACEs)

(http://go.gwu.edu/BCR)

http://go.gwu.edu/BCR

Social Determinants of Health•Healthcare In the past month, did poor health keep you from doing your usual activities, like work, school or

a hobby? In the past year, was there a time when you needed to see a doctor but could not because it

cost too much?

•Food In the past year, did you ever eat less than you needed to because there was not enough food?

• Employment & Income Is it hard to find work or another source of income to meet your basic needs?

• Housing & Shelter Are you worried that in the next few months, you may not have housing?

•Utilities In the past year, have you had a hard time paying your utility company bills?

Social Determinants of Health, Cont’d•Family Care Do you need help finding or paying for care for loved ones? For example, child care or day care for an older

adult.

•Education Do you want help with school or job training, like finishing a GED, going to college, or learning a trade?

•Transportation Do you ever have trouble getting to school, work, or the store because you don’t have a way to get there?

•Personal and Environmental Safety Do you ever feel unsafe in your home or neighborhood?

•General If you answered yes, would you like to receive assistance with any of these needs? Yes No

Are any of your needs urgent? Yes No

Pair of ACEs

Screening Tools Used For Behavioral Health In Primary Care SettingsPHQ-9 Initial Depression Screening Tool

KADS-Depression Screening Tool

MDQ-Bipolar Screening Tool

SCARED-Anxiety Screening Tool

Suicide Lethality Screening Tool

MCHAT -R Screening Tool for Autism

AQ-10 Child Screening Tool for Autism (Age 4-11)

AQ-10 Adolescent Screening Tool for Autism (Age 12-15)

Screening Tools Used For Behavioral Health In Primary Care Settings, Cont’dGAD-7 Anxiety Screening Tool for Adults

Edinburgh Postnatal Depression Scale

AUDIT-Alcohol Use Disorders Identification Test

CAGE AID- Screens for drug and alcohol use

Columbia-Suicide Severity Rating Scale (C-SSRS)

Life Event Checklist-Screens for potentially traumatic events during lifetime

ACEs-Adverse Childhood Experiences

Commonly Identified Behavioral Health Needs In The Primary Care Setting

• ADHD/ADD and AutismBoth pediatric and adultEvaluation and treatment options

• General Behavioral Concerns

• Social Pragmatic Communication Disorder

Commonly Identified Behavioral Health Needs In The Primary Care Setting, Cont’d• Mental Health DepressionAnxiety SuicidalityBipolarNeed for acute hospitalization

• Delays In Development Referral and treatment options

• Fatigue, Stress from Chronic Conditions

Meeting The Patient’s Needs: Behavior Health and Care ManagementCare Management and Coordination• Medication Management PCP vs. Psychiatry written, oversight

• Transportation Needs Community support and coordination

• Appointment Coordination• Collaborative Communication Internal AND externalTeam Huddles, coordination and communication with specialists

• Additional Services and NeedsReferrals, coordination, and collaboration

Meeting The Patient’s Needs: Behavior Health and Care Management, Cont’dBehavioral Health Needs

• Psychiatry NeedsReferral, medication management and oversight

• Counseling Needs Internal referral vs. external referral

• Additional Services and NeedReferrals, coordination, and collaboration

Patient Referrals: Differentiating Care Management and Behavioral Health• Care Management ReferralsCompleted by care manager, billing G Codes, Phone Codes, and S Code

• Chronic Disease Management• Patient Education• Self Management

• Behavioral Health ReferralsCompleted by mental health specialist credentialed with health insurance

provider, billing behavioral health codes• Individual, family, group, and crisis behavioral health needs• May be referred internally or to external providers

Care Management Coordination of Behavioral Health Needs

Services completed by any trained care manager:

(1) G9001 Assessment and (2) G9002 Face to Face Visits:• Completed by approved, trained care manager

G9001 – Comprehensive Assessment and Care Plan*Education: Assessment-G9001• Include patient and care giver assessment, discussion and collaboration: Beliefs about diagnosis Basic education about diagnosis Dispel myths Provide hope Collaborate with Psychiatrist, PCP

*For details see the SIM Care Management and Coordination Tracking Quick Reference Guide

https://www.michigan.gov/documents/mdhhs/2018_SIM_PCMH_Initiative_Participation_Guide_604730_7.pdf

Care Management Coordination of Behavioral Health Needs, Cont’dPrevention-G9002 Face to Face Visit•SIM face to face criteria must be met Triggers Identify and highlight strengths Identify barriers and ways to overcome barriers Collaborate with Psychiatrist, PCPModify care plan

Management and Rescue-G9002 Face to Face Visit•SIM face to face criteria must be met Daily treatment Develop rescue, crisis plan Collaborate with Psychiatrist, PCPModify care plan

Beyond Care ManagementCare management may not be enough•Chronic disease management leads to fatigue, which leads to mood, behavioral concerns

•Services may be limited due to care manager’s licensure

Other services that may be necessary•Behavioral health counseling

•Medication management

•Specialist for further evaluation and treatment

Behavioral Health Services:Internal and External External behavioral health services

•Psychiatrist, Psychologist, Neuro Psychologist, Physician Assistant, Nurse Practitioner

•Counseling services

•Inpatient, outpatient behavioral health services

Internal behavioral health services



LMSW Behavioral Health Billing OpportunitiesBehavioral Health Codes

• Becoming CredentialedCoordinate and credential through participating health insurance providersWill be necessary to gain an understanding of contract rules, accepting

providers, limitations, billing procedures• Billing ProceduresDevelop procedures and policiesDevelop confident understanding of billing practicesCollaborate with other practicing professionals

• NASW• SIM BCBSM collaborative efforts

Behavioral Health Treatment-InternalLMSW Specific Treatment Methods• Motivational Interviewing• Cognitive Behavioral Therapy• Dialectical Behavior Therapy• Trauma Focused Cognitive Behavior Therapy• Applied Behavioral Therapy• Forensic Interviewing

SIM/Behavioral Health Coding Algorithm

Please refer to hand out

Behavioral Health Coding 101 –Commercial Codes

Behavioral Health Coding 101 –Commercial CodesAssessment-1+ visits, Annual, Significant changes 90791

Face to face visit per minutes 16 -37 90832

38-52 90834

53+ 90837

60-89 90837,99354

Each 30+ minutes 90837, 99354, 99355 (#)

Group Therapy 2+ Non-family group 90853

Crisis Visit Per Minutes 30-74 90839 Each 30+ minutes 90840

Behavioral Health Coding 101, Cont’dFamily therapy (27-59 minutes) with patient 90846

Family therapy (27-59 minutes) without patient 90847

Family therapy of 2+ family members 90849

60-89 minutes 99354

60-89 minutes, each 30+ minutes 99354, 99355

Report not for court purposes 90889

Interactive complexity present 90785*

*Interactive Complexity can be added to all behavioral health visits

Behavioral Health Coding 101, Cont’dReferral and Intake Process

Benefits, Coding and Billing• Very important to determine benefits of patient BEFORE visits begin• Submit prior authorizations as required BEFORE visits begin• Select appropriate coding and bill accurately with each visit

Diagnosis• Select most specific and appropriate diagnosis with each visit

ReferencesBlock, R.W. (2015, February). Recognizing the importance of the social determinants of health. Pediatrics 135 (2), 526-d527.

Garg, A., Toy, S., Tripodis, Y., Silverstein, M., & Freeman E. (2015, February). Addressing social determinants of health at well child care visits: A cluster RCT. Pediatrics,135(2), 296-304.

Gottlieb, L., Hessler, D., Long, D., Amaya, A., & Adler, N. (2014, December). A randomized trial on screening for social determinants of health: The iScreen study. Pediatrics, 134(6), 1611-1618.

Garner, A., Shonkoff, J.P., Siegel, B.S., Dobbins, M.I., Earls, M.F., Garner, A.,…Wood, D.L. (2012, January). Early childhood adversity, toxic stress, and the role of the pediatrician: Translating developmental science Into lifelong health. Pediatrics 129(1)224-231.

James, S.E., Herman, J.L., Rankin, S., Keisling, M., Mottet, L., Anafi, M. (2015). The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality. 1-302.

References, Cont’dMental Health America. (2017) Retrieved from http://www.mentalhealthamerica.net/issues/2017-state-mental-health-america-prevalence-data

National Institute of Mental Health. (2017) Retrieved from https://www.nimh.nih.gov/index.shtml

Nguyen, T., Hellebuck, M., Halpern, M., Fritze., D. (2017). The State of Mental Health in America 2018. Mental Health America, Inc. 1-63.

Pratt, Laura A. and Brody, Debra J. (2008). Depression in the United States Household Population, 2005-2006. NCHS Data Brief. No 7 1-8.

Shonkoff JP, Garner A. (2012, January) The lifelong effects of early childhood adversity and toxic stress. Pediatrics 129(1), 232-246.

http://www.mentalhealthamerica.net/issues/2017-state-mental-health-america-prevalence-datahttps://www.nimh.nih.gov/index.shtml

12:00 - 12:45 PM

LUNCH

Concurrent Breakout Sessions12:45 – 2:00

Practice Workflow for Target Populations

Jessica Kehoe, MAMisha Strauss Moore, PhD

Blue Dot

Grand Ballroom 1 & 2Breakout Room

Medicaid Tracking CodesTheresa Landfair

Red Dot

Conservatory Breakout Room

Behavioral HealthLaurisa Cummings, LMSW

Green Dot

Westminster 1 & 2Breakout Room

Note: The colored dot on the right side of your name badge indicates the morning breakout session that you will be participating in.

Practice Workflow for Target Populations


JESSICA KEHOE, MA, QUALITY AND COMPLIANCE MANAGER, PACKARD HEALTH

MISHA STRAUSS MOORE, PHD, CO-FOUNDER AND EXECUTIVE ADMINISTRATORGREEN TREE PEDIATRICS

SIM at Packard HealthJESSICA KEHOE, MA

QUALITY AND COMPLIANCE MANAGER


Learning ObjectiveDescribe work flow for a specific patient population, using standing orders, standard activity guides, and/or protocols for 2 or more team members

Overview of Packard Health• Family medical practice, Federally Qualified Health Center (FQHC) in Ann Arbor• Primary care for the whole family, behavioral health services, women’s health,

prenatal care, chronic disease management, addiction treatment services (including MAT), nutrition, insurance enrollment assistance, food/medication/transportation assistance, language services

• 31,000 primary care patient visits projected this year + 3,160 BH visits so far (up until June)

• SIM CHIR Hublet

Packard’s Population by Payer (unduplicated)Uninsured

7.17%

Medicaid34.90%

Medicare15.44%

Private42.50%

Care Management Team

• Rebecca Fleming MPH, RN (Lead Nurse)• Karen Koeppe, MS, RDN, CDE (Nutritionist, Diabetes Educator)• Kristen Chandler, MSW (BH Care Manager)• Katharine Marquez, BSW (Patient Advocate)• Huron Valley Physician Association (HVPA)

Care Management Flow for SIM Patients

Check SIM list

Needs assessment

Create planProvide CM Services

Document in MICareConnect

and Athena (plus G code for

tracking)

Top 3 Issues

(1) Alcohol/substance abuse and general behavioral health issues (2) Chronic pain issues- majority having multiple chronic co-morbidities (diabetes, hypertension, etc.) (3) Uncontrolled diabetes

Common Care Management Services ProvidedConnecting with community organizations for social support

Accompanying to specialist visits

Medication Reconciliation

Arranging social activities

Follow up and needs assessments every 3 months

•Separate from care management- Recent change added Social NeedsAssessment to Athena tablespace so results are in pullable fields

What’s our goal?

Meet patients' medical and psychosocial needs in order to decrease ED use and improve health outcomes.

[email protected]

Introducing Care Management into a Primary Care Clinic


MISHA STRAUSS MOORE, PHDCO-FOUNDER AND EXECUTIVE ADMINISTRATORGREEN TREE PEDIATRICS

About Green Tree Pediatrics• 2 Locations• 4 Pediatricians• 3 Nurse Practitioners• Staffed by RN’s, Nutritionists, and Social Worker• Designated PCMH with BCBSM / PGIP since 2011• Athenahealth since 2012; fully electronic since 2005• Privately Owned Practice• Philosophy: Patient Centered and Focused

Why PCMH is a Critical Part of Our Operating Model

• Primary Care does not have many procedures and so revenue is typically generated through volume.

• We have been committed to an alternate vision since our founding in 2005

Technology Workflow Billing Practices

The principles of PCMH figure critically into our operating model.

“To provide the highestlevel of care in a warmwelcoming environment, creating a community among our patients.”

Connect back toMission andValues

-Green Tree Pediatrics MissionStatement

Key Steps in Successfully Implementing ChangeYou need the right people on the bus! Accepting change can be like going through

the 5 Stages of Grief:

Process is everything!

You cannot succeed in aCultural vacuum!

Denial: “If I didn’t see the email, it doesn’treally apply to me”

Anger: “Do they have any idea howoverworked I am already and now theywant me to do one more thing!”

Bargaining: “Don’t we really already dothis?”

Depression: “Is it Friday yet?”

Acceptance: “You know, I can see how thiscould really make us better.”

PCMH on Steroids

• Social Determinants of Health• Telemedicine• Care Management

• Relying on resources/expertise• Breaking down the perspectives: clinical; billing reporting• Trial and Error• Orientation• Logistics• Supportive Leadership• Communication tools

Ingredients for Successful Implementation

Sharing our Success Stories

Care Management

Questions?

Medicaid Tracking Codes


THERESA LANDFAIRPROGRAM SPECIALISTMEDICAL SERVICES ADMINISTRATIONMICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES

Learning Objective•Articulate the importance of identifying appropriate patients for caremanagement and coordination.

•Discuss the lifecycle of patient identification/patient servicing/inter-team coordination/tracking code submission/building the case forsustainability.

•Explain resources available to assist practices (including coordinationwith Medicaid Health Plans)

Care Management Tracking Codes • The PCMH Initiative requires all participating practices to track Care

Management and Coordination Service provision using a designated set ofHealthcare Common Procedure Coding System (HCPCS) and the AmericanMedical Association's Current Procedural Terminology (CPT) codes.

Code Quick Description

G9001 Comprehensive Assessment

G9002 In-person Encounter

98966, 98967, 98968 Telephone Services

99495, 99496 Care Transition

G9007 Team Conference

G9008 Physician Coordinated Care Oversight Services

98961, 98962 Group Education and Training

S0257 End of Life Counseling

New codes added for 2018: Could bill these codes

as of 1/1/2018

General Service Documentation RequirementsAll Services rendered should be documented in electronic Care Management and Coordination Documentations Tools (either a stand alone product or component of EHR), with information accessible to all care team members at the point of care.

Documentation should, at a minimum, include the following: • Date of Contact*• Duration of Contact • Method of Contact• Name(s) of Care Team Member(s) Involved in Service• Nature of the discussion and pertinent details regarding updates on patient’s condition, needs,

progress related to care plan with goals and target dates

* Date of service reported should be the date the care management and coordination service took place. In some cases, a service may take place over the course of more than one day, in such an event the date of service reported should be the date the service was completed

Why do we use the Tracking Codes1. Submission of the Care Management and Coordination service claims supports

one of the SIM PCMH Initiative Care Management and Coordination Metrics:

2. Regular claims submission supports more than the SIM PCMH Initiative!◦ Shows the value of a Patient Centered Medical Home to Medicaid

beneficiaries◦ Shows the value of provider delivered care management and coordination

to Medicaid beneficiaries

Any patient who has had a claim with one of the applicable codes during the reporting period

Eligible Population

General Conditions for Tracking Code UseFor SIM PCMH Initiative Care Management and Coordination services to be tracked within the Initiative, the following applies: oThe patient must be within the SIM PCMH Initiative Eligible Population. oServices must ordered by a Primary Care Provider within the approved practice; a note

indicating these services were ordered must be in the medical record.oServices performed must be based on patient need oService is performed by the appropriate qualified, non-physician health care professional

employed or contracted with the approved practice or PO oBilled to participating Medicaid Managed Care Organizations in accordance with Medicaid billing

guidelines oThere is no cost share (copay, coinsurance or deductible) for Care Management and

Coordination services.

From Service Provision to Report Capture

Participant provides CMCC

service

Claim submitted to appropriate

Medicaid Health Plan (MHP)

MHP Adjudicates claim and submits

to MDHHS

MDHHS reviews, processes, and

“clears” the claim

Cleared claims are loaded into the

MDHHS Data Warehouse

Michigan Data Collaborative

(MDC) pulls claims from the MDHHS Data Warehouse

MDC generates monthly Care Coordination

Reports using the cleared claims and

the eligible population for

that month

Eligible Patient PopulationA Medicaid beneficiary must have full Medicaid coverage and be served through a Medicaid managed care organization (Medicaid Health Plan) to be attributed to a participating practice and provider within the SIM PCMH Initiative:

A patient’s eligibility can be verified on both the PCMH Patient Lists produced by the Michigan Data Collaborative on a monthly basis, or by checking the Community Health Automated Medicaid Processing System (CHAMPS).

Included Benefit Plans:

BMP Benefits Monitoring Program

MA-HMP-MC Healthy Michigan Plan – Managed Care

MA-MC Medicaid – Managed Care

TCMF Targeted Care Management Flint

Ensuring Patient Eligibility in CHAMPS

Claims ReportingCURRENT STATUS UPDATE

Patient List v. Patient PanelSome Participants have reported differences in their patient panel (who they see/treat) and who is on their PCMH Patient List (on the MDC Dashboard).


1. The PCMH Initiative population is dependent on Medicaid enrollment, eligible benefit plan, and Medicaid Health Plan assignment.

2. Monthly Patient Lists are dependent on patient eligibility and enrollment at the beginning of the month, and sometimes there is retroactive enrollment that takes place, but not reflected on the patient list.

If you believe the above does not explain the differences you are seeing: First, contact the health plan when discrepancies are noticed to ensure corrections are made immediately.

Claims not reflected on the Reports Some Participants have reported differences in the services they are rendering and what is reflected on the Care Coordination Reports generated and posted on the PCMH Portal by Michigan Data Collaborative:


1. Reports are driven by timely claims adjudication and processing

2. Claims are only included if the service was provided to a patient on the PCMHPatient List

If, after confirming the above, a claim is not appearing on the Care Coordination Report, check CHAMPS!

If after 60 days past the date of your clean claim adjudication you are unable to see your claim in CHAMPS, contact your health plan representative.

When to Contact the InitiativeParticipants of the PCMH Initiative are encouraged to work with their Medicaid Health Plan representatives to resolve issues related to patient assignment and claims adjudication, however, if issues arise regarding your patient lists or tracking claims are not resolved in a timely fashion, contact the SIM PCMH Initiative and state staff will contact the practice and health plan.

[email protected]

mailto:[email protected]

Care Navigator Documentation

Krista L. Yezback, MSN, APRN, FNP-BCComplex Care Navigator Nurse PractitionerMichigan Medicine Canton Health Center

Care Navigator Templates

Template Example:

• Set up in “SOAP” note format• “Auto-populated” into our Documentation• Use EMR tools to improve efficiency• Associate Diagnoses to drop LOS Billing

Codes on Date of Service• Document Plan of Care & next Follow up• Close Encounter to drop “Charge”

Care Navigator Medication Reconciliation

Care Navigator Plan of Care

Care Navigator Best Practice Advisory (BPA)

Care Navigator Level of Service

Care Navigator Follow-up

Addressing Behavioral Health Needs In The Primary Care SettingLAURISA CUMMINGS, LMSWCHILDREN’S MEDICAL GROUP OF SAGINAW BAY


Learning Objectives•Explain effective mental health management through thecare team, including integration of behavioral health intoprimary care

• Identify best practice and lessons learned when advancingcare management services and implementing behavioralhealth screening into primary care

•Discuss behavioral health screening and follow up, matchingresources to address practice population needs

Agenda•Learners will be able to discuss behavioral health conditions commonly treated in primary carepractices

•Learners will be able to identify screening tools in which to screen for particular behavioral healthconditions

•Learners will be able to use evidence-based tools for improved assessment and management ofbehavioral health issues

•Learners will be able to identify referral processes to address behavioral health needs

•Learners will be able to identify additional billing opportunities for care managers who hold aLMSW

Rationale to Address Mental Health Needs in Primary Care• 56% of American adults with a mental illness did not receive treatment (Mental Health

America 2017)

• 1.7 million youth with major depressive episodes did not receive treatment (MentalHealth America, 2017)

• One half of all chronic mental illness begins by the age of 14; three-quarters by the ageof 24 (National Institute of Mental Health, 2017)

• 90% of those who die by suicide have an underlying mental illness; suicide is the 10thleading cause of death in the U.S. (National Institute of Mental Health, 2017)

Michigan Statistics•Michigan ranked 23 of all states having lower prevalence of mental health and substance use issues

•Michigan ranked 19 of all states having lower prevalence of mental illness and higher rates of access to care for adults

•Michigan ranked 17 of all states having lower prevalence of mental illness and higher rates of access to care for youth

•Michigan ranked 16 of all states providing access to insurance and mental health treatment for adults and youth

•Michigan ranked 22 of all states providing mental health workforce availability with a ratio of 460:1 (includes psychiatrists, psychologists, LSMWs, counselors, LMFT, and NPs)

(National Institute of Mental Health, 2017)

Why Addressing Behavioral Health Needs In Primary Care Settings Is So Important• Increased compliance• Lessen stigma of mental health needs• Increase self management of chronic mental health needs• Improved coordination of care• Decreased morbidity• Preventative services• Integration of physical and emotional care

Behavioral Health Integration: Resources For Primary Care Use• American Academy of Pediatrics (https://www.aap.org)

• SAMHSA-HRSA for Integrated Health Solutions (CIHS)(https://integration.samhsa.gov)

• National Alliance on Mental Health (https://nami.org)

• World Health Organization (https://who.int)

https://www.aap.org/https://integration.samhsa.gov/https://nami.org/https://who.int/

Behavioral Health Integration: Two Example ModelsMental Health Tool Kit, American Academy of Pediatrics

www.aap.org

Mental Health Initiatives, Primary Care Tools

A Global Perspective, World Health Organization

www.who.int/en/

Mental Health, Policies and Services

http://www.aap.org/http://www.who.int/en/

Where To Begin: Advancing Care Management, Adding Behavioral Health ServicesSocial Determinants of Health

Domains of Social Determinants of Health:

Healthcare, food, employment & income, housing and shelter, utilities, family care, education,

transportation, personal and environmental safety, and general

ACES Screening

Pair of ACEs:

Screening for adverse childhood experiences (ACEs)

Addressing adverse community environments (ACEs)

(http://go.gwu.edu/BCR)

http://go.gwu.edu/BCR

Social Determinants of Health•Healthcare In the past month, did poor health keep you from doing your usual activities, like work, school or

a hobby? In the past year, was there a time when you needed to see a doctor but could not because it

cost too much?

•Food In the past year, did you ever eat less than you needed to because there was not enough food?

• Employment & Income Is it hard to find work or another source of income to meet your basic needs?

• Housing & Shelter Are you worried that in the next few months, you may not have housing?

•Utilities In the past year, have you had a hard time paying your utility company bills?

Social Determinants of Health, Cont’d•Family Care Do you need help finding or paying for care for loved ones? For example, child care or day care for an older

adult.

•Education Do you want help with school or job training, like finishing a GED, going to college, or learning a trade?

•Transportation Do you ever have trouble getting to school, work, or the store because you don’t have a way to get there?

•Personal and Environmental Safety Do you ever feel unsafe in your home or neighborhood?

•General If you answered yes, would you like to receive assistance with any of these needs? Yes No

Are any of your needs urgent? Yes No

Pair of ACEs

Screening Tools Used For Behavioral Health In Primary Care SettingsPHQ-9 Initial Depression Screening Tool

KADS-Depression Screening Tool

MDQ-Bipolar Screening Tool

SCARED-Anxiety Screening Tool

Suicide Lethality Screening Tool

MCHAT -R Screening Tool for Autism

AQ-10 Child Screening Tool for Autism (Age 4-11)

AQ-10 Adolescent Screening Tool for Autism (Age 12-15)

Screening Tools Used For Behavioral Health In Primary Care Settings, Cont’dGAD-7 Anxiety Screening Tool for Adults

Edinburgh Postnatal Depression Scale

AUDIT-Alcohol Use Disorders Identification Test

CAGE AID- Screens for drug and alcohol use

Columbia-Suicide Severity Rating Scale (C-SSRS)

Life Event Checklist-Screens for potentially traumatic events during lifetime

ACEs-Adverse Childhood Experiences

Commonly Identified Behavioral Health Needs In The Primary Care Setting• ADHD/ADD and AutismBoth pediatric and adultEvaluation and treatment options

• General Behavioral Concerns• Social Pragmatic Communication Disorder

Commonly Identified Behavioral Health Needs In The Primary Care Setting, Cont’d• Mental HealthDepressionAnxiety SuicidalityBipolarNeed for acute hospitalization

• Delays In DevelopmentReferral and treatment options

• Fatigue, Stress from Chronic Conditions

Meeting The Patient’s Needs: Behavior Health and Care ManagementCare Management and Coordination• Medication Management PCP vs. Psychiatry written, oversight

• Transportation Needs Community support and coordination

• Appointment Coordination• Collaborative Communication Internal AND externalTeam Huddles, coordination and communication with specialists

• Additional Services and NeedsReferrals, coordination, and collaboration

Meeting The Patient’s Needs: Behavior Health and Care Management, Cont’dBehavioral Health Needs

• Psychiatry NeedsReferral, medication management and oversight

• Counseling NeedsInternal referral vs. external referral

• Additional Services and NeedReferrals, coordination, and collaboration

Patient Referrals: Differentiating Care Management and Behavioral Health• Care Management ReferralsCompleted by care manager, billing G Codes, Phone Codes, and S Code

• Chronic Disease Management• Patient Education• Self Management

• Behavioral Health ReferralsCompleted by mental health specialist credentialed with health insurance

provider, billing behavioral health codes• Individual, family, group, and crisis behavioral health needs• May be referred internally or to external providers

Care Management Coordination of Behavioral Health Needs

Services completed by any trained care manager:

(1) G9001 Assessment and (2) G9002 Face to Face Visits:• Completed by approved, trained care manager

G9001 – Comprehensive Assessment and Care Plan*Education: Assessment-G9001• Include patient and care giver assessment, discussion and collaboration: Beliefs about diagnosis Basic education about diagnosis Dispel myths Provide hope Collaborate with Psychiatrist, PCP

*For details see the SIM Care Management and Coordination Tracking Quick Reference Guide

https://www.michigan.gov/documents/mdhhs/2018_SIM_PCMH_Initiative_Participation_Guide_604730_7.pdf

Care Management Coordination of Behavioral Health Needs, Cont’dPrevention-G9002 Face to Face Visit•SIM face to face criteria must be met Triggers Identify and highlight strengths Identify barriers and ways to overcome barriers Collaborate with Psychiatrist, PCPModify care plan

Management and Rescue-G9002 Face to Face Visit•SIM face to face criteria must be met Daily treatment Develop rescue, crisis plan Collaborate with Psychiatrist, PCPModify care plan

Beyond Care ManagementCare management may not be enough•Chronic disease management leads to fatigue, which leads to mood, behavioral concerns

•Services may be limited due to care manager’s licensure

Other services that may be necessary•Behavioral health counseling

•Medication management

•Specialist for further evaluation and treatment

Behavioral Health Services:Internal and External External behavioral health services


•Counseling services•Inpatient, outpatient behavioral health services

Internal behavioral health services



LMSW Behavioral Health Billing OpportunitiesBehavioral Health Codes

• Becoming CredentialedCoordinate and credential through participating health insurance providersWill be necessary to gain an understanding of contract rules, accepting

providers, limitations, billing procedures• Billing ProceduresDevelop procedures and policiesDevelop confident understanding of billing practicesCollaborate with other practicing professionals

• NASW• SIM BCBSM collaborative efforts

Behavioral Health Treatment-InternalLMSW Specific Treatment Methods•Motivational Interviewing•Cognitive Behavioral Therapy•Dialectical Behavior Therapy•Trauma Focused Cognitive Behavior Therapy•Applied Behavioral Therapy•Forensic Interviewing

SIM/Behavioral Health Coding Algorithm

Please refer to hand out

Behavioral Health Coding 101 –Commercial Codes

Behavioral Health Coding 101 –Commercial CodesAssessment-1+ visits, Annual, Significant changes 90791

Face to face visit per minutes 16-37 90832

38-52 90834

53+ 90837

60-89 90837,99354

Each 30+ minutes 90837, 99354, 99355 (#)

Group Therapy 2+ Non-family group 90853

Crisis Visit Per Minutes 30-74 90839 Each 30+ minutes 90840

Behavioral Health Coding 101, Cont’dFamily therapy (27-59 minutes) with patient 90846

Family therapy (27-59 minutes) without patient 90847

Family therapy of 2+ family members 90849

60-89 minutes 99354

60-89 minutes, each 30+ minutes 99354, 99355

Report not for court purposes 90889

Interactive complexity present 90785*

*Interactive Complexity can be added to all behavioral health visits

Behavioral Health Coding 101, Cont’dReferral and Intake Process

Benefits, Coding and Billing• Very important to determine benefits of patient BEFORE visits begin• Submit prior authorizations as required BEFORE visits begin• Select appropriate coding and bill accurately with each visit

Diagnosis• Select most specific and appropriate diagnosis with each visit

ReferencesBlock, R.W. (2015, February). Recognizing the importance of the social determinants of health. Pediatrics 135 (2), 526-d527.

Garg, A., Toy, S., Tripodis, Y., Silverstein, M., & Freeman E. (2015, February). Addressing social determinants of health at well child care visits: A cluster RCT. Pediatrics,135(2), 296-304.

Gottlieb, L., Hessler, D., Long, D., Amaya, A., & Adler, N. (2014, December). A randomized trial on screening for social determinants of health: The iScreen study. Pediatrics, 134(6), 1611-1618.

Garner, A., Shonkoff, J.P., Siegel, B.S., Dobbins, M.I., Earls, M.F., Garner, A.,…Wood, D.L. (2012, January). Early childhood adversity, toxic stress, and the role of the pediatrician: Translating developmental science Into lifelong health. Pediatrics 129(1)224-231.

James, S.E., Herman, J.L., Rankin, S., Keisling, M., Mottet, L., Anafi, M. (2015). The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality. 1-302.

References, Cont’dMental Health America. (2017) Retrieved from http://www.mentalhealthamerica.net/issues/2017-state-mental-health-america-prevalence-data

National Institute of Mental Health. (2017) Retrieved from https://www.nimh.nih.gov/index.shtml

Nguyen, T., Hellebuck, M., Halpern, M., Fritze., D. (2017). The State of Mental Health in America 2018. Mental Health America, Inc. 1-63.

Pratt, Laura A. and Brody, Debra J. (2008). Depression in the United States Household Population, 2005-2006. NCHS Data Brief. No 7 1-8.

Shonkoff JP, Garner A. (2012, January) The lifelong effects of early childhood adversity and toxic stress. Pediatrics 129(1), 232-246.

http://www.mentalhealthamerica.net/issues/2017-state-mental-health-america-prevalence-datahttps://www.nimh.nih.gov/index.shtml

2:00 - 2:15 PM

BREAK

Plenary: Sustainability Post-SIM

MICHIGAN DEPARTMENT OF HEALTH AND HU

2018 sim pcmh initiative regional summit · mipct statistics: • over 1800 providers participated...

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