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

14

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