Transcript 1330-1500-mipct-care-manager-update-panel-size-v-2-3

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The Michigan Primary Care
Transformation (MiPCT) Project
2013 Annual Summit
Sharing Care Management Best
Practice & Building the Care
Manager Caseload
MiPCT Care Manager Update
Patient Panel Size
Mary Ellen Benzik,MD
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Not what we had planned --Care Manager Roles
N=420
Complex
15% (63)
Moderate
26% (109)
Hybrid
59% (248)
2013 PO Report – 1st & 2nd Quarter
Care Manager Activities
The Mean increases are statistically
significant.
350
300
250
200
150
100
50
0
25th
50th
75th
90th
Percentile Percentile Percentile Percentile
Face-Face Encounters/
FTE qtr 1
Face-Face Encounters/
FTE qtr 2
Phone Encounters/ FTE
qtr 1
Phone Encounters/ FTE
qtr 2
Unique Patients/ FTE
qtr 1
Unique Patients/ FTE
qtr 2
4
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Care Manager Volume
Quarter 2, 2013
Encounters
Face to
Face
Phone
Unique
Patients
Total
15,250
32,709
22,237
Per CM
FTE
63
112
82
Care Management Breakdown80/20 Rule
Complex
Moderate
Well
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
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MiPCT Benchmark* for Care Manager
Caseload
Care manager’s patient caseload – 2nd Quarter PO
Data
Care
Manager
Role
90th Percentile Qtr 2
face to face/FTE
90th Percentile QTR 2
Phone
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
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Care Manager Survey Results
Physician Interaction
• Care Managers reported working with an
average of 8.4 physicians
• On average, 83% of these physicians referred
patients
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Care Manager Survey Results
How Often Care Managers Converse with
PCP Regarding MiPCT-Eligible Patients
60%
40%
42%
35%
20%
6%
8%
Every 2
weeks
> Every 2
weeks
3%
0%
Daily
Weekly
Never
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Care Manager Survey Results
• The physician(s) I work with support the
concepts of the MiPCT care management team.
Strongly Disagree
Disagree
Neither
Agree
nor
Disagree
Agree
Strongly
Agree
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Care Manager Survey Results
• Physicians are available on a daily basis to
address questions related to management of
MiPCT patients.
Never
Rarely Sometimes Frequently Always
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Care Manager Survey Results
• Physicians understand and are actively involved
in population management
Never
Rarely Sometimes Frequently Always
Does Anybody Achieve Target
CaseLoads?
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 Campaign
80% 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” Campaign
Helps Manage MiPCT Population
Campaign targets final gap in diabetes care
 Uses Registry & Epic to link meaningful info
to Providers
 Bumped 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
Description
A. Team Based Care – Care Manager
Patient Engagement using HTN Registry
B. Building Care Manager Caseload –
PO, Health System, Practice Support
C. Team Based Care – Care Manager
Daily Work Processes
D.
Care Manager Processes – Case
Closure
E.
Team Based Care – Care Manager
Daily Work Processes
F.
Team Based Care – Care Manager
Daily Work Processes (includes case
closure)
Title of Work Flow
Henry Ford Health System – MIPCT
Eligible HTN Registry
McLaren Holt Family Practice: Building
Care Management Integration Process
McLaren Holt Family Practice: Team
Based Care
Lakeshore Health Network/Mercy Health
Primary Care Network: Transitioning
Care Management Patients
Lakeshore Health Network/Mercy Health
Primary Care Network Care Manager
Warm Handoff
West Front Primary Care: Care Manager
Work flow
Report Out