1. Michigan
Primary Care Transformation
Demonstration Project
May 15, 2013
Webinar

2. Congratulations:
URAC Accreditation!
 Hampton Medical Center
• Bruce Johnson, DO: Board Certified in Internal
Medicine and Geriatrics; American Medical
Directors Association as a Certified Medical Director
of Long Term Care Facilities
• Susan Tam, DO: Board Certified in Family Medicine
• Christie Schunemann, NP: Board Certified Family
Nurse Practitioner
• Cyndi Jones
• Janet Johnson, Office Manager
• Dawn Carroll, RN, Hybrid Care Manager
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3. Sequestration
 President Obama signed an order that imposes
across‐the‐board Federal spending reductions (also
known as sequestration) for Federal payments
effective as of April 2013.
 Congress did not take action to avert this, monthly
payments to practices and POs are reduced by 2%
beginning April 1, 2013 and this will continue until
there is resolution about the Federal budget and
Federal deficit.
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4. Metrics Year Three
 Committee review of proposed
Year Three Metrics
 Metrics submitted to Clinical
Sub‐committee
 All proposed process and
clinical outcome metrics
approved by Steering
Committee
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5. Pay for Performance Year End 2012
 Not available
 Fund release date is
unknown
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6. Sharing Activities: Teams
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7. Spotlighting Practices
 May 30
 Detroit Branch Federal Reserve Bank
 8:30am‐12 noon
 National speaker
 Volunteers?
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8. Physician Engagement
 PCP involvement with care managers
 PCP involvement with care team
 Number of patients referred by PCP
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9. Team Learning Events
 June 6, 2013 (9am‐3pm)
 June 8, 2013 (9am‐3pm)
 June 13, 2013 (4pm‐8pm) Teams participating in
Learning Collaborative
 Compulsory attendance of practice team members
 Required component of MiPCT practices
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10. Best Practices for Care
Coordination/Management
 Implement self management, coaching and
support with patient/family
 Implement effective medication management plan
 Manage care setting transitions
• Having a timely, comprehensive response to care
setting transitions (esp. from hospitals and skilled
nursing facilities)

11. Care Manager Training
 Complex to be online after testing is complete
 Moderate various opportunities
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12. Reflection
Don’t talk, just act.
Don’t say, just do.
Don’t promise, just prove.
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13. June: 20 Days Ultimate Challenge
 20 new Blue Cross patients enrolled
 10 new Blue Care Network patients enrolled
 20 new Medicare/Medicaid patients enrolled
 ~ 50 new patients
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14. Refresher:
What is Care Coordination?
 “A person‐centered, assessment based,
interdisciplinary approach to integrating health
care and social support services in a cost‐
effective manner in which an individual’s needs
and preferences are assessed, a
comprehensive care plan is developed, and
services are managed and monitored by an
evidence‐based process which typically
involves a designated lead care coordinator.”

15. Refresher:
What is the Problem?
 Most health care dollars are spent on a small percentage of
beneficiaries
 Those with complex chronic conditions
 Causes of high utilization and costs:
 Deviations from evidence‐based care
 Poor communication among primary providers, specialists,
health and community providers, patients, and families
 Failure to catch problems early
 Failure to address psychosocial issues
 Lack of coordinated, longitudinal management
 Ineffective transitional management

16. What is Effective Care Coordination?
 Intervention with rigorous evidence that:
• Improves outcomes
• Reduces total health care expenditures for
participating beneficiaries
• Improved satisfaction or clinical indicators not
sufficient
• Net savings require reduced hospitalizations

17. Promising Interventions
 New care coordination and care management
interventions being used by care managers
• Transitional care interventions
• Care Transitions Intervention (Coleman)
• Transitional Care Model (Naylor)
• Enhanced Discharge Planning Program – RUSH (Perry)

18. Promising Interventions
 Other promising care coordination and care
management interventions are emerging
• Comprehensive Care Management ‐ Medicare/ Duals
• Guided Care (Boult)
• GRACE (Counsell)
• Care Management Plus (Dorr)
• MCCD: Best Practice Sites (Brown)

19. Promising Interventions
 However, promising care coordination and care
management interventions are emerging
 Comprehensive Care Management – Medicaid/
Duals
 Integrated Care Management (Douglas)
 Community Based Chronic Care Management
(Lessler)
 Hospital to Home (Raven)
 Health Care Management Program (Reconnu &
Herndon)

20. What Distinguishes Successful
Models?
MODEL SYNTHESIS LITERATURE REVIEW
Targeting • Patients with select chronic conditions including
co-occurring serious mental health diagnoses and
substance abuse
• Those who were hospitalized in previous year or
at time of enrollment
• Program targeting to identify the
population who can most benefit
from a given intervention
Intervention • Conduct comprehensive in-home initial
assessment
• Develop a mutually agreed upon “action plan”
with goal
• Frequent face-to-face contact (home, office) with
patients (~1/month)
• Baseline and ongoing
assessment of health and social
needs
• Multidisciplinary approach to
allow providers to address a
spectrum of health and social
service needs
• Flexible provision of services and
service intensity
Primary care
provider
• Strong rapport with primary care
provider/specialist/hospital/family/caregiver
• Face-to-face contact through co-location, regular
hospital rounds, contact with hospitalist
•Assign all of a physician’s patients to the same
care manager when possible
• Enhanced communication among
providers, frequently including the
primary care physician

21. What Distinguishes Successful Models?
MODEL SYNTHESIS LITERATURE REVIEW
Patient
Education
• Providing a strong, evidence based
patient education/coaching
intervention for managing health,
symptoms, medications
• Evidence‐based protocols to assess
health and social condition and develop
care plan
Training • Initial comprehensive training of Care
Managers and Care Teams
• Performance feedback to Care
Managers and Care Teams
• At least 15 percent of articles included
for review report specialized training for
service providers as intervention
component
Community link • Coordinate communication among
physicians, health/community
providers and patient/family
• Connection to existing community
health and supportive services

22. Best Practices for Care
Coordination/Management
 Follow evidence based practices/guidelines for
care management
 Address psychosocial issues
• Staff with experts in social supports and community
resources for patients with those needs
 Being a communications facilitator
• Care managers actively facilitate communications
among providers and between the patient and the
providers

23. Open Discussion
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