Michigan Primary Care Transformation (MiPCT) Implementation Guide

I. Background

a. MiPCT Orientation

The Michigan Primary Care Transformation Project (MiPCT) is a demonstration project testing the value of the patient centered medical home (PCMH) model. This model expands access to primary care while improving care coordination. This model has been increasingly important given the rise in multiple chronic diseases and the dramatic increase in health care costs. The traditional model of health care delivery, with 15-minute in-person appointments and disconnected primary care physicians and specialists, is not working for patients or their doctors.

MiPCT addresses the shortcomings in the current system by providing funding to primary care physicians to hire care managers and implement all payor all patient registries to track and follow up with patients, especially those with multiple chronic diseases. In addition, MiPCT pays physicians to expand office hours and offer same day appointments. Finally, MiPCT rewards physicians for improving their patients’ health and avoiding unnecessary emergency department visits and hospitalizations.

MiPCT was developed in November 2010 after Michigan was selected by the Center for Medicare and Medicaid Services (CMS) as one of eight states to participate in the CMS Multi-Payer Advanced Primary Care Practice Demonstration. Michigan has the largest demonstration project in the country, reaching approximately 1.2 million patients served by 1,600 providers in almost 500 practices. All of the insurance companies and physician organizations in Michigan have been invited to participate.

Focus areas include:

Care Management Self-Management Support Care Coordination Linkages to Community Services

MiPCT and the Michigan Care Management Resource Center (MiCMRC) will provide assistance and support to physicians and their practices by providing training for care managers, facilitating care management integration into practices and hosting team-based learning activities. For questions regarding the MiCMRC please contact Marie Beisel at mbeisel@umich.edu .

1

b. What is Care Management?

Definition: (Center for Healthcare Strategies, 2007) “Activities that assist patients and their support systems to manage medical and psychosocial problems with the aim of improving care health and reducing the need for expensive medical services.”

Goals of Care Management:

1. Improve patient’s functional health status2. Enhance coordination of care3. Eliminate duplication of services4. Reduce the need for unnecessary, costly medical services

Primary Care: Moderate Risk Care Management, Complex Care Management and Panel Management

Facilitated by MiPCT team and Care Management Resource Center, POs/PHOs and practices will develop processes to provide coordinated, patient centered care. The care management interventions are focused on patients with mild to moderate chronic disease and patients that have high complexity, high cost, and/or high utilizers of the health care system. Additionally, panel management supports systematic processes to follow up with patients to ensure evidence based preventive services, and tests are ordered and completed (see figure 1).

Ramsay, Rebecca (2011). Implementing Effective Clinical Care Management; Building Care Management Capacity within a Transforming Primary Care System, Care Oregon (PowerPoint slides). Retrieved from http://qhmedicalhome.org/safety-net/evidencebasedcare.cfm#Guide

2

Moderate Risk Care Management

POs/PHOs and/or practices, with assistance from MiPCT and the Care Management Resource Center, will develop processes and train personnel to help patients with mild-moderate illness manage their chronic conditions, and help patients at risk for developing chronic conditions minimize these risks.

Role of MiPCT Moderate Risk Care managers:

a. Use registry for population identification and proactive patient management b. Provide care based on evidence-based practice guidelines c. Use collaborative practice models that include the primary care physician and other care team providers d. Provide patient self-management support (may also involve other team members) e. Work with patients to optimize control of their chronic conditions and prevent long-term complications f. Assist in transitions between settings g. Provide patient education with teach back to ensure understanding

Complex Care Management

POs/PHOs and/or practices, with assistance from MiPCT and the Care Management Resource Center, will develop processes and train personnel to provide coordinated, non-duplicative care for high-complexity and or/high-utilizing patients.

Role of Complex Care Managers:

a. Use high-risk patient list, augmented by PCP input, for population identification and proactive patient management

b. Create a comprehensive, proactive plan of care c. Provide care based on evidence-based practice guidelines d. Use collaborative practice models that include primary care physician and other care team

providers e. Provide patient self-management support f. Work with patients to optimize control of their chronic conditions, improve functional status,

and prevent/minimize long-term complications g. Provide patient education with teach back to ensure understandingh. Coordinate care with specialists, hospitals and other community resources i. Assist with advance directives, palliative care, hospice and other end-of-life care coordination

Please refer to Appendix A for a comparison of MCM and CCM roles.

Panel Management

Role of the Patient Care Coordinator

The role of the Patient Care Coordinator will vary depending on needs of the practice and the defined roles of members of the health care team. Often this role involves follow up and communication with

3

patients to ensure patients receive appropriate tests and preventive services as ordered by the primary care physician. Note that this role is not required for MiPCT participating practices, but may serve to enhance the team’s success with population management and care coordination.

The following are examples of activities that may be completed by a Patient Care Coordinator:

a. Utilize a registry patient list to identify patients with overdue tests/preventive servicesb. Generate registry patient lists for health care team membersc. Conduct outreach activities, such as patient reminder phone call regarding tests/preventive services due.d. Contribute to self-management support for patientse. Notify health care team members of patients that may benefit from care management f. Assist patients with scheduling appointments including coordination of tests and office visits

c. Components of Successful Care Management

As you begin to consider how your PO/PHO and practices will develop or build on current capacity in the area of care management, it is important to review components that are known to contribute to successful care management programs. Based on review of the literature, there are six key components for successful care management programs:

Targeting: The care manager should have access to patient health records and methods for identifying patients at risk for hospitalizations and/or complications from their chronic conditions. For complex care management, this includes access to information about patients who are at risk for high healthcare costs. This allows the care manager to work from a list of patients and ideally consult with the patient’s primary care physician to identify patients that will benefit from care management services.

In-person encounters: Evidence widely supports that the care manager is most effective when there is a significant amount of in person, face to face contact with patients. Other methods of interacting with patients between the face to face visits such as phone calls, e-mails can be utilized. However, the evidence is clear that regular in-person contact results in better outcomes.

Access to timely information on hospital admissions and emergency room visits: Access to hospital admission and emergency room visits, allows the care manager to intervene shortly after these events occur. The care manager can act immediately, by providing transition care interventions. The transition care interventions are aimed at addressing problems, coordinating care and follow up to prevent readmissions.

Close interactions between care managers and primary care practitioners: The care manager should work in close proximity with the primary care physician and be considered an integral part of the patient care team. Care management is optimized when services are provided in collaboration with the primary care physician. An integrated patient centered care plan is key and allows the care manager to offer support with services that meet the goals of the plan.

4

Services provided: Care management interventions focus on the interplay of multiple medical issues rather than a single disease state, and emphasize proper use and reconciliation of medications. Social support, access, and coordination of care are also important.

Care Management staff: The care managers need to complete training on how to perform all aspects of care management services. It is critical that care managers have appropriate training and education. Training in motivational interviewing and patient centered goal setting and tracking is particularly important.

II. Care Management Model and Staffing

a. How Many Moderate Risk Care Managers (MCMs) and Complex Care Managers (CCMs) do you need to hire?

The first steps involve reviewing the number of MiPCT patients attributed to your practice and the funding needed to support the salary of a CCM and MCM. Based on ratios used by successful care management programs, MiPCT is recommending the following care manager - patient caseload ratios:

Patient Caseload per

year

Moderate Risk Care Manager:Caseload 500 (approx. 90 - 100 active

patients); one MCM per 5,000 patients

Complex Care Manager:Caseload 150 (approx. 30 - 50 active

patients); one CCM per 5,000 patients

A “Funding Summary Spread Sheet” “which includes information specific for your practice has been sent to your PO/PHO/IPA. The spreadsheet includes practice level funding estimates for care management, MiPCT beneficiary counts, and number of care managers supported by MiPCT care coordination funding.

b. How many care managers will be covered by MiPCT Funding Sources?

There are two sources of care management funding: PMPM payments – “up-front” funding G codes and CPT codes – payment for services provided

Depends on appropriate staffing Funding model based on $3 PMPM equivalent in payments How much activity is needed to equate to $3 PMPM??

Assumptions:Hire one care manager for 2,500 patientsAverage G-code reimbursement is $60-$65 (fee schedule TDB)

Activity level: One full time care manager would need to bill 6-7 encounters per

work day (48 week year) to equate to $3 PMPM – very feasible

c. Selecting a Care Management Model

5

Successful care management programs to date have some common key elements: 1) The care manager(s) are located in close proximity to the PCP and 2) The care manager(s) are considered an integral part of the health care team. Care managers working remotely, in isolation of the team have not been shown to be as effective. Care Management Models and Staffing

Care Management models and staffing may be thought of in two dimensions.

Care management model – refers to the operational, logistic set up for care management. The care management model defines how care management is “set up” for practices.

Care management staffing – refers to “who does the work”. This has important implications and the patient population for each practice should be closely considered when making decisions about licensure of candidates to fill the CCM and MCM roles (see Appendix B and C: CCM and MCM Job descriptions).

B. Types of Care Management Models

There are several types of care management models:

Travel team – Consists of MCM and CCMs that are responsible for a patient caseload at multiple practices. A PO/PHO/IPA that has a cluster of practices within a reasonable geographic proximity may benefit from a Care Management travel team. For example if there are 5 practices and across all 5 practices there is a sum of 10,000 MiPCT attributed beneficiaries, the travel team could consist of 2 CCMs and 2 MCMs. Other team members, such as pharmacists, social workers, and dieticians can also serve as valuable members of the health care travel team.

Integrated – Consists of MCMs and CCMs that are located on site at the practice. This model works best when the practice has approximately > 5,000 MiPCT beneficiary volume that allows separate individuals to fill the MCM and CCM roles. In smaller practices, it is also possible to have a single MCM or CCM located on-site full time, while the other care managers and team members are part of a travel team.

Hybrid – With this model, the role of the CCM and MCM is filled by one individual. This model should be considered only for special circumstances as follows: Practices with significantly fewer than 5,000 MiPCT attributed patients or practices that serve primarily pediatric patients and/or have fewer complex patients. For practices with less than 1,000 MiPCT attributed patients, the hybrid model may take on these functions:

The care manager resides full-time in the practice, but does care management as a portion of his/her overall responsibilities (for example, devoting 1-2 days per week for care management )

The care manager works with multiple practices and spends 1-2 days (for example) per week in each of 2-3 practices.

Central – With this model, the care manager is located off-site and supports multiple practices. The role of the CCM and MCM may be filled by one individual or may be separate individuals. The offsite care

6

manager may partner with the on-site Patient Care Coordinator at the practice site. In order to be most effective, the care manager should see patients at the practice location for at least 50% of his/her FTE.

Care Management Models: Table 1

Care Management Model Travel team Integrated Hybrid Central

Model Characteristics:

Location of care manager CCM, MCM has a set schedule and conducts patient visits at multiple practices

CCM and MCM are onsite at the practice 100%

Care manager is onsite at the practice 100%

CCM and MCM are located off site and see patients at practice location 50% of FTE

MCM and CCM roles filled by same individual or separate individuals

Separate Separate Same May be separate or same

Availability of care managers – ease of scheduling patients to have face to face and phone visits with care managers

Set schedule for face to face visits (care manager is not on site every day)

Fluid, available 100% of schedule

Fluid, available 100% of schedule

Set schedule for face to face visits (care manager is not on site every day)

Documentation of care management encounters

Potential: care manager may need to learn several registries, EHRs

Care manager utilizes the EHR, registry used at practice

Care manager utilizes the EHR, registry used at practice

Potential: care manager may need to learn several registries, EHRs

Communication with primary care team members

Via EHR, secure email, scheduled formal meetings, ad hoc when on site

Huddles, team meetings, via EHR, ad hoc

Huddles, team meetings, via EHR, ad hoc

Via EHR, secure email, scheduled formal meetings, ad hoc when on site

Model pros and consCommunication/relationships with primary care team members

Con:Not on site daily, need to develop processes for health care team and patient communication

Comment: Requires more coordination with PO

Pro: Promotes optimal communication with PCP, heath care team andrelationship building with patients and health care team

Pro: Promotes optimal communication with PCP, heath care team andrelationship building with patients and health care team

Con:Not on site daily, need to develop processes for health care team and patient communication.

Comment: Requires more coordination with PO.

7

Efficiency - availability Pro:Practices that do not have a large volume of MiPCT attributed patients are able to have MCM and CCM on scheduled dates

Pro:Excellent availability of care managers since they are 100% on site.

Con: Patient that moves from complex to moderate may prefer to keep working with their CCM

Pro: Excellent availability of care managers since they are 100% on site.

Patient may move from complex to moderate and this model allows patient to keep the same care manager

Pro:May add efficiency for practices with very small number of MiPCT attributed beneficiaries

For practices with close to 2,500 attributed MiPCT patients, may also provide efficient use of resources

Efficiency – Access; scheduling phone and or face to face care manager visits

Con: Complexity of scheduling, limited face to face access for patients

Pro: Access is good. Role of MCM and CCM are separate. Able to use scheduling template, and access is good for patients

Pro: Access is good.

Con: Hybrid care manager may have moderate risk patients scheduled and has a crisis with complex patient. At times will be challenged to juggle both populations.

Con: Complexity of scheduling, limited face to face access for patients

Care Manager billing Need to establish criteria and mechanism for billing so patient visits will be billed to the provider of the service

Comment: Set up requires PO involvement

Pro: Billing by care manager will use similar process as other providers, but will use G codes

Pro: Billing by care manager will use similar process as other providers, but will use G codes

Need to establish criteria and mechanism for billing so patient visits will be billed to the provider of the service

Comment: Set up requires PO involvement

Care Manager work station space

Needs a flex work station at the practice (workstation may be used by others on dates care manager is

Needs a permanent workstation at the practice

Needs a permanent workstation at the practice

Needs a flex work station at the practice (workstation may be used by others on dates care manager is not working at the practice), also needs a

8

not working at the practice)

centrally-based workstation

Selecting a Care Management Model that fits your PO/PHO/Practices

Which care management model is a best fit for your PO/PHO/Practices?

Things to consider:

Identify patient population needs for each practice (ex. Practice has very low population of patients with multiple chronic conditions)

Map the geographic location of the practices (are the practices located in close vicinity to each other or far apart?)

Identify the total number of FTEs funded for CCM and the MCM roles for the PO Identify and sort allocated FTEs of CCM and MCM for each practice at your PO

(complete worksheet: Appendix D: Care Management Staffing for PO Practices) If you have care management in place, consider how the program will expand to build

on the current capacity Review the pros and cons of each model (see table 1: Care management model ) Based on the per practice CCM FTE and MCM FTE, patient population, and geography of

practice locations – at a high level identify the possible Care Management models (see table 2)

Narrow the selection of models to a “few potential models” and review with the physician champion at each practice to gain understanding of provider preferences

Gain consensus to select a model that is a best fit

B. Steps to Identify the Care Management Model that is a fit for your PO/PHO/Practice

Several factors must be considered to facilitate selection of a Care Management Model. The following steps will help identify the care management model(s) which have potential to be a good match for your situation:

Step 1. For my PO/PHO, how many total Moderate Risk Care Managers and Complex Care Managers can be funded via MiPCT? (This is based on MiPCT attributed beneficiaries - refer to funding table)

___ Total MCMs ___ Total CCMs

Step 2. For each practice in your PO/PHO:

a. Determine how many CCM and MCMs are possible. The number of MCM and CCM FTEs for each practice is based on the funding allocated for the MiPCT attributed beneficiaries. (Refer to MiPCT funding table for your PO). Note that there may be a need to adjust these numbers up or down by practice depending on the variable patient complexity at each site. If performing this type of adjustment, please keep in mind that the total number of care managers should approximate that listed in the Funding Spreadsheet.

9

b. Identify and sort allocated CCM and MCM FTEs, using Appendix D: Worksheet: “Care Management Staffing for PO/PHO Practices”. By completing this work sheet you will have a summary of CCM and MCM FTEs associated for each practice in your PO, sorted by FTE. It may also be helpful to include an assessment of practice population complexity (Low, Med, or High) to help with decision-making regarding CCMs and MCMs needed.

c. Review and answer questions below (see table 2). This table will help you address patient population needs, CCM and MCM FTE available for each practice, and practice location considerations.

Table 2:

Question/determine practice situation Potential Models to consider based on patient population, FTE and practice locations

Practices with < 0.5 MCM FTE and < 0.5 CCM FTE Practices are geographically clustered:Travel team - if several practices have <0.5 MCM FTE and <0.5 CCM FTE you may be able to form a Travel team to cover several practices

Practices are not geographically clustered:a) Hybrid model - part time employeeb) Central model - if several practices have significantly <0.5 MCM FTE and <0.5 CCM FTEc) Central model Phase 1 - start with a CCM

Practices with 0.5 MCM FTE and 0.5 CCM FTE Practices are geographically clustered:Hybrid or Travel team model

Practices are not geographically clustered:Hybrid model

Practices with > 0.5 MCM FTE and > 0.5 CCM FTE Model depends on the MCM and CCM FTE allocation and patient population:

a) Integrated model - if close to a 1.0 CCM FTE and 1.0 MCM FTE and patient population has significant number of high risk patientsb) Hybrid model - ex. if 0.6 CCM FTE and 0.6 MCM FTE and/or pediatric population with small number of high risk patients (i.e. hire a 1.0 FTE individual that performs both the CCM and MCM role)

Practices with 1.0 MCM FTE and 1.0 CCM FTE Model depends on patient population:a) Integrated model - patient population has significant number of high risk patientsb) Hybrid model – pediatric population and/or small number of high risk patients

Practices with 1.5 MCM FTE and 1.5 CCM FTE a) Hybrid- consider needs of patient population

10

b) Integrated model plus Travel Team- 1.0 MCM FTE and 1.0 CCM Integrated plus use travel team for the remaining 0.5 MCM FTE and 0.5 CCM FTE

Practices with > 1.5 MCM FTE and > 1.5 CCM FTE a) Hybrid- consider needs of patient populationb) Integrated model plus Travel Team - 1.0 or more MCM FTE and 1.0 or more CCM Integrated, plus use travel team for the remaining FTEs

Step 3: Review the pros and cons of the potential Care Management models you have identified. Consider the likelihood of each model and how it would work for your PO/practice. If you determine a model will not work, identify the reason and consider if there are any options /problem solving that may be possible and would result in successful implementation of the model.

Step 4: Share the outcome of your work: Meet with stakeholders and physicians at the practices to discuss each step and the outcome of your work. Ask stakeholder and physicians for feedback regarding strengths and risks of each potential model.

Step 5: Gain consensus – select the care management model.

d. Hiring Care Managers

Complex Care Manager (CCM)

CCM - key responsibilities:

Partners with practice leadership team to integrate care management into practice Completes comprehensive patient assessments – ex. functionality, depression

initial and periodically, over time Provides self-management support

focus is on building capacity of patient/family for self-care Provides patient/family education

with teach back, sustains over time Implements evidence-based care, chronic disease protocols and guidelines

intervenes early during acute exacerbations analyzes complex data sets monitors patient/family response

Creates/maintains individualized plan of care Coordination of care

assists to integrate care when patients need services from other providers, institutions, and/or agencies.

11

Transitions of care, including medication management and reconciliation Assists with advance directives, palliative care, hospice and other end of life

coordination

CCM – key qualifications:

Registered Nurse, Masters of Social Work, Nurse Practitioner, or Physician Assistant license. Minimum of 3 years experience in adult and/or pediatric medicine (as applicable to the practice) Experience is in the following settings: home health agency, primary care practice, skilled

nursing facility, hospital medical – surgical unit Ability to manage complex chronic conditions

Utilize evidence-based guidelines Critical thinking skills Excellent assessment and triage skills Ability to analyze complex data sets Ability to implement evidence-based interventions and protocols for

chronic conditions Excellent communication and facilitation skills

See Appendix B: CCM job description

Moderate Risk Care Manager (MCM)

MCM - key responsibilities:

Partners with practice leadership team to integrate care management into practice Assesses healthcare, educational, and psychosocial needs of patient/family Provides self-management support with focus 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

MCM - key qualifications of the MCM:

Registered Nurse, Masters of Social Work, Nurse Practitioner, Physician Assistant, Licensed Practical Nurse, Registered Dietician, Pharmacist license,

Minimum of 2 years experience in adult and/or pediatric medicine (as applicable to the practice)

Experience is in the following settings: home health agency, primary care practice, skilled nursing facility, hospital medical – surgical unit

Knowledge of chronic conditions

12

Excellent assessment, triage skills Excellent communication and facilitation skills

See Appendix C: MCM job description

Selecting a CCM and MCM A candidate’s years of experience, specialty area, appropriate licensure and background are factors to consider. However, the characteristics of the candidate are also very important. During the interview process assess the candidate for characteristics listed below.

Essential characteristics/skills for Care Manager

Strong communication skills Motivated, self-directed“People” skills Engagement of patients and providers

Critical thinking skills Psychosocial aspects of chronic conditionsPatient engagement and activation skills Basic computer skillsNegotiating and conflict resolution skills

Littlewood, D., Sciandra, J. (2010). The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination. New Jersey, Healthcare Intelligence Network.

III. Operations

a. Training for the Complex Care Manager

Training for the CCMs will be provided by MiPCT team and Care Management Resource Center. The CCM is required to complete this training, which is evidence based and utilizes standardized tools and interventions. If a PO/PHO/practice currently has a complex care training program in place, the MiPCT team will review the program to assess consistency with MiPCT training objectives. If you wish to have an existing program assessed, please contact Marie Beisel for consultation at mbeisel@umich.edu .

MiPCT is progressing toward a decision to partner with Geisinger for CCM training. Geisinger, MiPCT, and the Care Management Resource Center will implement a train the trainer model. In addition to the complex care training, the CCM is also required to complete Self-Management Support training. The Self-Management Support training for the CCMs will be included in their curriculum and this training will be arranged by the MiPCT team. Additional details on this CCM training will be available soon.

b. Training for the Moderate Risk Care Manager

Moderate Risk Care Manager Core Curriculum includes:

1. Self-Management Support Training: Self-management support training is a mandatory requirement for MCMs and non-licensed personnel who are assisting MCMs with self-management support. POs/PHOs and/or practices will select and complete a self-management training program which will

13

also meet PGIP 11.8 criteria. A summary of approved self-management training programs is posted on the MiPCT website: www.mipctdemo.org. For assistance with selection of self-management training programs, or to request the addition of a program to the approved list, please contact Marie Beisel at mbeisel@umich.edu .

2. General training topics: The MiPCT team has identified general training topics for the MCM role. Although training in an approved program for self-management support is the only mandatory MiPCT requirement for MCMs, additional training topics are considered important for building the MCM’s knowledge base and skills. However, there is an appreciation for individualized needs of the practice. POs/PHOs and/or practices may add and/or refine these topics as they consider and arrange for training based on individualized needs.

3. MiPCT training: The MiPCT team will provide ongoing training during the demonstration project to support the educational needs of the MCM. The training may include webinars, networking conference calls and informal site visits.

4. For details of MCM general training topics and MiPCT training, please refer to Appendix E: Moderate-Risk Care Manager Training.

Moderate Risk Care Managers: Who arranges/provides training?

MCM Training topic Shared by MiPCT and PO/PHO/IPA/practice

MiPCTteam

PO/PHO/IPA, Practice

Self-management support training – required, arranged by the PO/PHO/IPA, practice

x

General, suggested topics x

- subset of the general topics

x

MiPCT training topics - required

x

c. Integration of Care Managers into the practice setting

14

Once the Care Managers are hired they will need to orient to the practice and complete training specific to their role. This is an opportunity for the practice to have multidisciplinary meetings to identify current state roles of assistive clinical staff. You may find that the assistive clinical staff roles need modifications in order to optimize the team’s efficiency with delivering patient care.

Early in the orientation, it is helpful to have the Care Manager shadow team members. Ongoing, the practice should determine strategies for the Care Manager and team members to communicate. This may include huddles at specific times of the day, team meetings, regularly scheduled staff meetings, and identification of days of the week to touch base with team members. The goal is to have the Care Manager become an integral member of the team.

d. Team Roles

Appendix F provides an illustration of how the roles of care team members can be redesigned to accommodate new duties and responsibilities. Each team member plays a valuable role and should operate at a level that fully utilizes their skills and training. Care managers should work in close partnership with all team members to provide coordinated, non-duplicative patient care. Making this type of coordinated, team-based care run smoothly is not always easy, but it is one of the most important components of successful care management interventions. During the first year of the MiPCT demonstration, we will provide tools and educational sessions to help you define the roles of all team members, including care managers. We will also provide you with the opportunity to share your success stories and “best practices” on the CMRC web site and in other venues.

e. Identification of Patients for Care Management

Moderate Risk Care Manager:

The focus of the Moderate Risk Care Manager is to work with patients to optimize control of chronic conditions and prevent/minimize long term complications. Moderate risk patients may have a newly diagnosed chronic condition, be at a state of readiness to take an active role in managing their chronic condition and/or have a chronic condition that is poorly controlled. Moderate Risk patients are identified by registries and PCP referral to the MCM. Additionally, as members of the health care team interact with patients, team members may also identify potential patients that may benefit from working with the Moderate Risk Care Manager.

Registry reports may include the following fields: patient demographics, PCP, chronic condition diagnosis, pertinent test date and normal/abnormal results, next PCP visit date. The MCM actively reviews the registry reports and identifies patients that have poorly controlled chronic condition and /or follow up appointment with PCP is needed. The MCM reviews the “potential patients for care management” with PCP input to determine which patients will optimally benefit from care management. MCM consultation with the PCP is important: a) initially to identify and plan the care

15

management support and b) also ongoing to deliver a team approach to self-management support, patient education, and treatment plan.

Complex Care Manager:

The focus of the Complex Care Manager is to work with patients with high complexity and/or high utilization of medical care. CCMs will use high risk patient lists, augmented by PCP input, for population identification and patient management. An extensive review of the literature reveals that there is no single best method that emerges as superior for identification of patients that will benefit from intensive care management. Methods used by successful models generally involve some type of initial stratification (based on claims and/or clinical data) augmented by input from the primary care provider and other members of the health care team. Patients may also be identified for complex care management at hospital discharge, underscoring the importance of providing care during transitions.

For MiPCT beneficiaries, the Michigan Data Collaborative (MDC) will be providing bi-monthly lists of high-risk patients. These lists will be determined based on a prospective Diagnostic Cost Grouping (DCG) risk score derived from historical claims data. The list will also include additional information that may be helpful such as the number of hospitalizations and emergency department visits a patient has had over a given period. Any claims-based risk stratifier has inherent limitations, and PO/PHOs and their practices are encouraged to use additional information that is available (PCP/team input, registry information, pharmacy utilization data, etc.) to augment this high-risk list.

16

Appendix A

Michigan Primary Care Transformation Role Comparison: Moderate Risk Care Manager, Complex Care Manager

Moderate Risk Care Manager (MCM) Complex Care Manager (CCM)

Patient Population Moderate risk patients identified by registry, PCP referral for proactive and population management.

High risk patients identified by PCP referral and input, risk stratification, patient MiPCT list.

Patient Caseload Caseload 500 (approx. 90 - 100 active patients); one MCM per 5,000 patients.

Caseload 150 (approx. 30 - 50 active patients); one CCM per 5,000 patients.

Focus of Care ManagementProactive, population management. Work with

patients to optimize control of chronic conditions and prevent/minimize long term complications.

Targeted interventions to avoid hospitalization, ER visits. Ensure standard of care, coordinate care across settings, help patients understand

options.

1 Major Responsibilities

Assess healthcare, educational, and psychosocial needs of the patient/family. With PCP, assess need to refer to other care team members (CCM, etc.) if

indicated.

Conduct comprehensive patient assessment, initial and periodically over time (such as

depression, functionality, health risk assessment, etc.).

1

2 Provide self-management support - focus is typically on lifestyle and behavior change.

Provide self-management support - focus on building capacity of patient/family for self-care. 2

3 Provide patient/family education with teach back. Provide patient/family education with teach back, sustain over time. 3

4

Implement evidence-based care, chronic disease protocols and guidelines.

Implement evidence- based care, chronic disease protocols and guidelines; such as medication

titration, fluid status monitoring.4

5

Create/maintain individualized plan of care. Implement systems of care that facilitate close

monitoring. Intervene early during acute exacerbations.

5

6 Analyze complex data sets, monitor closely patient/family response to care. 6

7 Assist with transitions between settings. Includes medication reconciliation.

Coordinate care with specialists, hospitals and other community resources. Assist with transitions between settings. Includes

medication reconciliation.

7

17

Appendix B

DEPARTMENT OF HUMAN RESOURCES

JOB DESCRIPTION

TITLE: Complex Care Manager

FLSA: Exempt

DEPARTMENT:

LOCATION:

JOB SUMMARY:

Provides care management and care coordination for adult and pediatric patients with complex illness, in the primary care setting, under minimal supervision. In partnership with the primary care practice leadership team, the Complex Care Manager leads care management within the team through process improvement, workflow redesign, providing assistance with training, and delegating to other members of the team. Serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.

Manages a caseload of approximately 150 complex patients; of which 30 to 50 patients are actively followed by complex care manager. Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options. Infrequent, but possibility of home visits.

MAJOR DUTIES AND RESPONSIBILITIES:

1. Identifies the targeted high risk population within practice site(s) per PCP referral, risk

stratification, and patient lists. Includes patients with repeated social and/or health crises.

2. Assesses over time the health care, educational, and psychosocial needs of the patient/family.

Uses standardized assessment tools such as depression screening, functionality, and health risk

assessment.

3. Collaborates with PCP, patient, and members of the health care team, including continuum of

care settings and community. Responsible for developing a comprehensive individualized plan

of care and targeted interventions. Continually monitors patient/family response to plan of

care, and revises the care plan as indicated.

18

4. Provides patient self-management support with a focus on empowering the patient/family to

build capacity for self- care.

5. Implements systems of care that facilitate close monitoring of high-risk patients to prevent

and/or intervene early during acute exacerbations.

6. Implements clinical interventions and protocols based on risk stratification and evidence-based

clinical guidelines.

7. Coordinates patient care through ongoing collaboration with PCP, patient/family, community,

and other members of the health care team. Fosters a team approach and includes

patient/family as active members of the team. Takes the lead in ensuring the continuity of care

which extends beyond the practice boundaries. Serves as liaison to acute care hospitals,

specialists, and post-acute care services.

8. Provides follow-up with patient/family when patient transitions from one setting to another.

Completes timely post-hospital follow-up: Medication reconciliation, PCP or specialist follow-

up appointment, assess symptoms, teach warning signs, review discharge instructions,

coordination of care, and problem solve barriers.

9. Demonstrates excellent written, verbal, and listening communication skills, positive relationship

building skills, and critical analysis skills.

10. Maintains required documentation for all care management activities.

11. Works with practice and PO/PHO leadership to continuously evaluate process, identify

problems, and propose/develop process improvement strategies to enhance care management

and Patient Centered Medical Home delivery of care model.

12. Reviews the current literature regarding effective engagement and communication strategies,

care management strategies, and behavior change strategies and incorporates into clinical

practice.

SKILLS AND ABILITIES:

1. Demonstrates customer focused interpersonal skills to interact in an effective manner with

practitioners, the interdisciplinary health care team, community agencies, patients, and families

with diverse opinions, values, and religious and cultural ideals.

2. Demonstrates ability to work autonomously and be directly accountable for practice.

3. Demonstrates ability to influence and negotiate individual and group decision-making.

19

4. Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing

environment.

5. Demonstrates leadership qualities including time management, verbal and written

communication skills, listening skills, problem solving, critical thinking, analysis skills and

decision-making, priority setting, work delegation, and work organization.

6. Demonstrates ability to develop positive, longitudinal relationships and set appropriate

boundaries with patients/families.

Required Qualifications:

Current Michigan Registered Nurse, Nurse Practitioner, Physician Assistant or Master of Social

Work License

Three years of experience with adult medicine and pediatric patients in primary

care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical

setting, within the past five years

Knowledge of chronic conditions, evidence based guidelines, prevention, wellness, health risk

assessment, and patient education

Critical thinking skills and ability to analyze complex data sets. Ability to manage complex

clinical issues utilizing assessment skills and protocols

Excellent assessment and triage skills. Ability to implement evidence base interventions and

protocols for chronic conditions

Demonstrates excellent communication--both verbal and written

Excellent interpersonal and facilitation skills

Ability to affect change, work as a productive and effective team member, and adapt to

changing needs/priorities

Time management, priority setting, work delegation and work organization.

General computer knowledge and capability to use computer

Preferred Qualifications:

Bachelor’s degree or higher, in clinical field

Care management experience

Experience as participant in continuous quality improvement

Completion of self-management support training

Appendix C

20

DEPARTMENT OF HUMAN RESOURCES

JOB DESCRIPTION

TITLE: Moderate Risk Care Manager

FLSA: Exempt

DEPARTMENT:

LOCATION:

JOB SUMMARY:

Provides care management and care coordination for adult and pediatric patients with mild to moderate illness, under minimal supervision. In partnership with primary care practice leadership team, the Moderate Risk Care Manager leads population management within the team through process improvement workflow redesign, providing assistance with training, and delegating to other members of the team. Collaborates with members of the health care team to empower patients to manage their chronic conditions. Assists patients, who are at risk for developing chronic conditions, to minimize these risks. Serves in an expanded health care role to collaborate with PCP and patients to ensure the delivery of quality, efficient, patient centered, and cost-effective healthcare services. Assesses, plans, implements, monitors, and evaluates delivery of individualized patient care with the goal of optimizing the patient’s health status. Provides self-management support and patient education.

Works primarily with moderate risk patients to optimize control of chronic conditions and prevent/minimize long term complications. Manages a caseload of approximately 500 patients; of which 90-100 are actively supported at a time.

MAJOR DUTIES AND RESPONSIBILITIES:

1. Identifies the targeted population within practice site(s), per PCP referral and registry reports.

2. Assesses the healthcare, educational, and psychosocial needs of the patient/family.

3. Collaborates with PCP, patient, and members of the health care team, to assess patient, develop

and implement an agreed upon plan.

4. Provides self-management support and empowers the patient to achieve optimal health and

independence

5. Implements evidence-based care, chronic disease protocols and guidelines. Utilizes registry to

identify patients with chronic conditions, and a gap in clinical care. Utilizes patient list to ensure

overdue tests/labs are completed, monitors individual patient progress and population

management.

6. Coordinates patient care by linking patients to resources; including community resources.

21

7. Provides follow up with patient/family when patient transitions from one setting to another.

Completes post hospital discharge calls: Medication reconciliation, PCP or specialist follow up

appointment, assesses symptoms, teaches warning signs, coordinates care, reviews discharge

instructions, and problem-solves barriers.

8. Demonstrates excellent written, verbal, and listening communication skills, positive relationship

building skills, and critical analysis skills.

9. Participates in continuous quality improvement to enhance care management in the office

setting.

10. Maintains required documentation for all care management activities.

11. Works with practice and PO/PHO leadership to continuously evaluate processes, identify

problems, and propose/develop process improvement strategies to enhance the Patient

Centered Medical Home.

12. Reviews the current literature regarding effective engagement and communication strategies,

care management strategies, and behavior change strategies and incorporates into clinical

practice.

SKILLS AND ABILITIES:

1. Demonstrates customer focused interpersonal skills to interact in an effective manner with

practitioners, the interdisciplinary health care team, community agencies, patients, and families

with diverse opinions, values, and religious and cultural ideals.

2. Understands chronic disease management strategies and is able to implement appropriate protocols and guidelines.

3. Demonstrates ability to work autonomously and be directly accountable for practice.

4. Demonstrates ability to influence and negotiate individual and group decision-making.

5. Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing

environment.

6. Demonstrates leadership qualities including time management, verbal and written

communication skills, listening skills, problem solving and decision-making, priority setting, work

delegation and work organization.

Required Qualifications:

Current Michigan Registered Nurse, Nurse Practitioner, Physician Assistant, Licensed Practical Nurse, Master of Social Work, Registered Dietician, or Pharmacist License

22

Two years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical, within the past five years

Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education

Excellent assessment and triage skills Demonstrates excellent communication-both verbal and written Excellent interpersonal and facilitation skills Ability to affect change, work as a productive and effective team member, to be flexible, and

adapt to needs/priorities Time management, priority setting, work delegation and work organization General computer knowledge and capability to use computers

Preferred Qualifications:

Bachelor’s degree or higher, in clinical field Care management experience

Experience as participant in continuous quality improvementCompletion of self-management support training

Appendix D

23

Worksheet: Care Management Staffing for PO/PHO PracticesTotal Care

Manager FTE(arrange lowest

to highest)

Moderate-Risk Care Manager

FTE

Complex Care

Manager FTE

Practice Name Practice Population

Complexity (Low, Med, High)

24

Appendix E

MiPCT Moderate-Risk Care Manager Training

The MiPCT team has identified a core curriculum for Moderate Risk Care Managers (MCMs). The training for MCMs is a shared responsibility between the MiPCT team, POs/PHOs and/or practices.

POs/PHOs and /or practices will develop processes and arrange training for personnel to help patients with mild-moderate illness manage their chronic conditions, and help patients at risk for developing chronic conditions minimize these risks.

Moderate Risk Care Manager Core Curriculum includes:

1. Self-Management Support Training: Self-management support training is a mandatory requirement for MCMs and non-licensed personnel who are assisting MCMs with self-management support. POs/PHOs and/or practices will select and complete a self-management training program which meets PGIP 11.8 criteria and include the components listed in Section A, item 3 below. A summary of approved self-management training programs will be posted on the MiPCT website: www.mipctdemo.org. For assistance with selection of self-management training programs, or to request the addition of a program to the approved list, please contact Marie Beisel at mbeisel@umich.edu.

2. General training topics: The MiPCT team has identified general training topics for the MCM role. Although training in an approved program for self-management support is the only MiPCT requirement for MCMs, additional training topics are considered important for building the MCM’s knowledge base and skills. However, there is an appreciation for individualized needs of the practice. POs/PHOs and/or practices may add and/or refine these topics as they consider and arrange for training based on individualized needs. See section A below.

3. MiPCT training: The MiPCT team will provide ongoing training during the demonstration project to support the educational needs of the MCM. The training may include webinars, networking conference calls and informal site visits. See Section B below.

Section A: Training arranged by PO/PHO and /or practice

Suggested General training topics for Moderate Risk Care Manager

The MiPCT Clinical Steering Committee has identified suggested MCM training topics related to care management. These are general MCM training topics for POs/PHOs and/ or practices to consider when assessing/developing a training program or when assessing an existing regional/national program:

1. Chronic Care Model2. PCMH overview, addressing key areas (MiPCT and Care Management Resource Center will provide

training and tools. POs/PHOs/IPAs practices will individualize, develop processes, and implement). Coordination of care including Transitions of Care Medication reconciliation

3. Self-management support

25

Introduction to technique(s) Setting self-management goals Interactive practice sessions Overcoming resistance and barriers Ongoing follow-up (reinforce techniques, problem solve)

4. Identifying psychosocial needs and coordinating with community resources and practice team members (include criteria to identify and refer a patient for complex care management). Psychosocial Issues and Barriers

o Transportationo Financialo Food and sheltero Domestic violenceo Substance abuse, alcohol abuseo Family roles, caregiver supporto Palliative careo Cognitive decline, dementia

5. Developing competence in managing chronic diseases including DM, Asthma, CAD, HF, COPD, HTN, Depression Following Evidence based care/ Clinical guidelines

o Protocolso Understanding quality measures

Identifying “Red Flags” – signs &/or symptoms of significant change in clinical condition requiring intervention (if no intervention, likely to lead to negative decline)

6. Basic care manager concepts and tools Developing Standardization in Care Management: documentation templates, patient education

materials, patient assessment, education pathway, using registry reports Improving quality and efficiency –introduction to tools, techniques to manage work flow

efficiently Documentation Coding

7. Role of the Moderate Risk Care Manager Identification of patients Integration into team based care Specific responsibilities of care manager, complex care manager Documentation basics (criteria for billing, templates) Use of HIT/care management software Teach back technique, visit summary Data and measurement

Section B: Training to be provided by MiPCT team and Care Management Resource Center

MiPCT training topics (finalized list and schedule to be determined)

Orientation to PCMH model and statewide initiative

26

Participation in Michigan Care Management Consortium to disseminate knowledge, foster shared learning and recognition of best practices

MiPCT team member roles

Integration into PCMH designated practices

Care management documentation options

o Templates

o Care management software

G-code billing

Care management documentation, measurement, and reporting

Working with MiPCT data reports

Addressing key areas: Transition care, coordination of care, medication reconciliation, health literacy, cultural competency, advance directives

Develop additional training sessions/webinars to reinforce specific MiPCT goals and objectives, and address gaps in general training

27

Appendix F

The Vision for Transforming the Roles of Clinical Staff (Examples)

TYPICAL PRIMARY CARE OFFICE IN THE MEDICAL HOME

PRIMARY CARE PHYSICIAN

SPENDS MOST OF TIME TREATING ACUTE CONDITIONS

LITTLE STANDARDIZATION ACROSS PATIENTS

SPENDS TIME AFTER HOURS FOLLOWING UP ON TESTS AND APPOINTMENTS WITH PATIENTS

PROACTIVELY PROVIDES STANDARDIZED CHRONIC, PREVENTIVE CARE

MANAGES AND LEADS MULTI-LEVEL CARE TEAM

COORDINATES CARE WITH SPECIALISTS AND HOSPITALS

PARTICIPATES IN TEAM HUDDLES

REGISTERED NURSE

MAY NOT ROUTINELY BE PART OF CARE TEAM

TRIAGES INCOMING PATIENT CALLS

SPENDS MOST OF TIME ON ACUTE PATIENT ISSUES

LITTLE TIME DEVOTED TO PROACTIVE PATIENT MGMT

HAS PROTECTED TIME TO FOCUS ON DELIVERING CARE MANAGEMENT FOR PATIENTS WITH CHRONIC CONDITIONS (SEE DESCRIPTION BELOW)

PARTICIPATES IN TEAM HUDDLES

MEDICAL ASSISTANT

ROOMS PATIENTS, TAKES VITAL SIGNS, ASSESS REASON FOR VISIT

HAS DOWN TIME BETWEEN VISITS

THOROUGHLY SCREENS PATIENT NEEDS AND REVIEWS CHART, LABS, SELF-MANAGEMENT GOALS IN PRE-VISIT CHART REVIEW

PERFORMS PRE-PHYSICIAN SERVICES (FOOT SCREENING), RECORD IN CHART

PARTICIPATES IN TEAM HUDDLES

FRONT DESK STAFF

TRIAGES INCOMING PATIENT CALLS

PROVIDES REMINDER CALLS TO PATIENTS BEFORE APPOINTMENTS

LIAISES WITH CLINIC NURSE BEFORE APPOINTMENT TO CHECK FOR OUTSTANDING PATIENT NEEDS

IDENTIFIES SERVICES DUE THROUGH REGISTRY AND DISCUSSES PRE-VISIT TESTS WITH PATIENTS

MODERATE-RISK CARE MANAGER

MAY NOT ROUTINELY BE PART OF CARE TEAM

ENCOURAGES/PROMOTES SELF- MGMT OF CHRONIC CONDITIONS

CONDUCTS ONE-ON-ONE AND GROUP PATIENT EDUCATION

MANAGES CHRONIC CONDITIONS THROUGH PHYSICIAN LED PROTOCOLS

PERFORMS TRANSITION CARE WITH MEDICATION RECONCILIATION

OVERSEES AND FACILITATES COORDINATION OF CARE

PARTICIPATES IN TEAM HUDDLES

COMPLEX CARE MANAGER

MAY NOT ROUTINELY BE PART OF CARE TEAM

WORKS WITH PCP AND TEAM TO IDENTIFY PATIENTS FOR INTENSIVE CARE MANAGEMENT/COORDINATION

DEVELOPS COMPREHENSIVE CARE PLAN AND REVIEW WITH PATIENT/FAMILY

MANAGE CARE TRANSITIONS RECONCILE MEDICATIONS ACTS AS LIAISON FOR PRIMARY AND

SPECIALTY CARE TEAM MEMBERS PARTICIPATES IN TEAM HUDDLES

28

Appendix F

The Vision for Transforming the Roles of Clinical Staff (Examples - continued)

TYPICAL PRIMARY CARE OFFICE IN THE MEDICAL HOME

PATIENT CARE COORDINATOR

MAY NOT ROUTINELY BE PART OF CARE TEAM

REVIEWS REGISTRY AND IDENTIFIES GAPS IN CHRONIC AND PREVENTIVE CARE

NOTIFIES PATIENT OF CARE GAPS AND COMPLETE LAB/TEST REQUISITIONS

ASSISTS CARE MANAGERS WITH COORDINATING REFERRALS AND TESTS

DOCUMENTS SERVICES IN REGISTRY PRODUCES POPULATION REPORTS

SOCIAL WORKER

MAY NOT ROUTINELY BE PART OF CARE TEAM

LIAISON WITH COMMUNITY RESOURCES FOR PATIENT HOUSING, FOOD, TRANSPORATION NEEDS

FACILITATE REFERRALS FOR CHRONIC SUBSTANCE ABUSE, MENTAL HEALTH SERVICES, CARE MANAGEMENT

PSYCHOSOCIAL SPRITIAL ASSESSMENT AND SHORT TERM COUNSELING FOR ADJUSTMENT TO ILLNESS, GRIEF AND LOSS, FAMILY ISSUES

PHARMACIST

MAY NOT ROUTINELY BE PART OF CARE TEAM

FACE TO FACE AND TELEPHONIC MANAGEMENT TO INTENSIFY AND OPTIMIZE MEDICATION REGIMENS

ASSESS BARRIERS TO MEDICATION ADHERENCE

EDUCATE ON INSULIN THERAPY AND HOME GLUCOSE MONITORING

IDENTIFY FORMULARY ALTERNATIVES

REGISTERED DIETICIAN

MAY NOT ROUTINELY BE PART OF CARE TEAM

PERFORM NUTRITION ASSESSMENTS WORK WITH PATIENTS TO DEVELOP

AND IMPLEMENT A NUTRITIONAL PLAN TO TARGET CHRONIC CONDITIONS

IDENTIFY BARRIERS TO DIET ADHERENCE

NURSE PRACTITIONER/PHYSICIAN ASSISTANT

MAY NOT ROUTINELY BE PART OF CARE TEAM

ACTIVELY OWNS PATIENT MANAGEMENT

LEVERAGED FOR SAME-DAY AND AFTER-HOURS ACCESS

SEES PATIENTS WITH MINIMAL SUPERVISION

LICENSED PRACTICAL NURSE

MAY NOT ROUTINELY BE PART OF CARE TEAM

TELEPHONE MANAGEMENT: FOLLOW UP ON ITEMS DELEGATED BY PCP OR RN

MANAGE PRESCRIPTION REFILLS PERFORM TESTS AND PROCEDURES

(IVS, STRAIGHT CATH, SUTURE REMOVAL)

ASSIST WITH TRANSITION CARE AND CARE COORDINATION

29