the michigan primary care transformation (mipct) project
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The Michigan Primary Care Transformation (MiPCT) Project
2013 Annual SummitSharing Care Management Best Practice & Building the Care Manager Caseload
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MiPCT Care Manager Update Patient Panel SizeMary Ellen Benzik,MD
Hybrid59%
(248)
Mod-erate26%
(109)
Complex15% (63)
Care Manager RolesN=420
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Not what we had planned ---
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2013 PO Report – 1st & 2nd Quarter Care Manager ActivitiesThe Mean increases are statistically significant.
25th
Perce
ntile
50th
Perce
ntile
75th
Perce
ntile
90th
Perce
ntile
050
100150200250300350
Face-Face En-counters/ FTE qtr 1Face-Face En-counters/ FTE qtr 2Phone Encounters/ FTE qtr 1Phone Encounters/ FTE qtr 2Unique Patients/ FTE qtr 1Unique Patients/ FTE qtr 2
Care Manager Volume Quarter 2, 2013
EncountersUnique PatientsFace to
Face Phone
Total 15,250 32,709 22,237
Per CM FTE 63 112 82
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Care Management Breakdown-80/20 Rule
Complex
Well
Moderate
Simple Math
•1,000,000 patients •20% = 200,000 patients potentially for
care management •22,234 in one quarter •Potentially over 100,000 patient
encounters a year at the current pace
MiPCT Benchmark* for Care Manager Caseload
Care manager’s patient caseload – 2nd Quarter PO Data
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Care Manager Role
90th Percentile Qtr 2 face to face/FTE
90th Percentile QTR 2Phone encounters/FTE
Encounters per day = Benchmark*
Complex 84 260 6 encounters per day
Hybrid 160 321 8 encounters per day
Moderate
193 238 7 encounters per day
But this is NOT About NUMBERS
Care Manager Survey Results
•Care Managers reported working with an average of 8.4 physicians
•On average, 83% of these physicians referred patients
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Physician Interaction
Care Manager Survey Results
Daily Weekly Every 2 weeks
> Every 2 weeks
Never0%
20%
40%
60%
42%35%
6% 8%3%
How Often Care Managers Converse with PCP Regarding MiPCT-Eligible
Patients
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Care Manager Survey Results
•The physician(s) I work with support the concepts of the MiPCT care management team.
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Strongly
Disagree
Disagree
Neither Agree
nor Disagre
e
Agree Strongly Agree
Care Manager Survey Results
•Physicians are available on a daily basis to address questions related to management of MiPCT patients.
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Never Rarely
Sometimes
Frequently
Always
Care Manager Survey Results•Physicians understand and are actively
involved in population management
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Never Rarely
Sometimes
Frequently
Always
Does Anybody Achieve Target CaseLoads?
Yes!
How Do The Best Performing Practices Do It?• Front office staff screen member lists, confirm
current eligibility, identify gaps in care, etc.
• Office, PO and Nursing management support team-based care
• Backfilling occurs
• Physicians partner with the Care Manager and refer patients
• Team meets regularly as a team to discuss successes and opportunities for improvement
Today is about Solutions
Sharing Best Processes
Engaging your care team
Letting go of patients when appropriate
Henry Ford Medical Group (HFMG) MiPCT
HTN Initiative Juliann Testy RN, BSN
Henry Ford Health System
New Initiative for HFMG: Measure Up, Pressure Down Campaign
Sponsored by AMGF
CMs Participate in Blood Pressure Campaign80% BP Control Target by 2015
Case Managers and Diabetes Care Team Educators have BP related program goals as part of their Performance Management process- Disease management & RN BP re-check visit process
As self-management site champions, support staff with skill application following interactive self-management workshops for Medical Assistants and RNs
Developed collaborative protocols with Home Health Care: Telehealth Home Monitoring Process; calibration of BP cuffs
Pharm D’s share tips on medication reconciliation issue recognition
New “Gimme 5” CampaignHelps Manage MiPCT Population
Campaign targets final gap in diabetes care Uses Registry & Epic to link meaningful info
to ProvidersBumped against MiPCT Attribution for Team
Care ◦Site/Physician based by component◦Identifies active point person/program◦Eligibility status◦Identifies patients with poor BP Control and
more…
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“Gimme 5” Campaign: A Twist on Diabetes Population Management
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Group Work – Care Management Processes
Group Work Description Title of Work FlowA. Team Based Care – Care Manager Patient Engagement using HTN Registry
Henry Ford Health System – MIPCT Eligible HTN Registry
B. Building Care Manager Caseload – PO, Health System, Practice Support
McLaren Holt Family Practice: Building Care Management Integration Process
C. Team Based Care – Care Manager Daily Work Processes
McLaren Holt Family Practice: Team Based Care
D. Care Manager Processes – Case Closure
Lakeshore Health Network/Mercy Health Primary Care Network: Transitioning Care Management Patients
E. Team Based Care – Care Manager Daily Work Processes
Lakeshore Health Network/Mercy Health Primary Care Network Care Manager Warm Handoff
F. Team Based Care – Care Manager Daily Work Processes (includes case closure)
West Front Primary Care: Care Manager Work flow
Report Out
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