2. Description of the program
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 (MiPCT, 2016). Michigan was one of the eight
states selected by CMS in November 2010 for participation in a multi-payer demonstration of
advanced primary care practices, also known as patient-centered medical homes (PCMH).
The Patient-Centered Medical Home (PCMH) model is an approach to providing comprehensive
primary care for children, youth and adults. The PCMH is a health care setting that facilitates
partnerships between individual patients, and their personal physicians, and when appropriate,
the patient's family American Academy of Family Physicians. (2008). The key principles of
PCMH model are personal physician; physician directed medical practice; whole person
orientation; Care is coordinated or integrated; Quality and Safety; Enhanced Access and
Payment.
MiPCT’s vision is to have Michigan as national leader in Primary Care Transformation. This
program started in 2012 as a demonstration project, and was extended until December 2016.
Michigan has the largest demonstration project in the country, reaching over 1.2 million
patients served by 1900 providers in 350 primary care practices.
Implementation of MiPCT at Mercy Health Physician Partners
Mercy Health Physician Partmers are among the primary care organizations that takes part in the
MiPCT. The MiPCT has been implemented in all Mercy Health Physician Partners offices in
3. Grand Rapids and all surround area. In interview with Jeanne Gorton, Care Manager at Mercy
Health Physician Partners located in Rockford, she shared with me that Mercy Health Physician
Partners (MHPP) have witnessed improvements in the coordination and quality of care provided
for their patients.
Population of interest
The population of interest for the MiPCT program are all beneficiaries of healthcare insurers as
Medicare, Medicaid, Blue Cross Blue Shield, Priority Health and others. But, Mercy Health
Physician Partners decided to focus on the coordinated and integrated care of chronic ill patients.
According to Jeanne Gorton, more than 50% of her MiPCT’s patiets have diabetes.
Chronic illness, its prevention, treatment and care is a global and national concern. Chronic
illness is becoming widely known not by what it is, but by what it is not […] Noncommunicable
diseases, also known as chronic diseases, are not passed from person to person. They are of long
duration and generally slow progression...These diseases are driven by the forces of aging, rapid
unplanned urbanization, and the globalization of unhealthy lifestyles (Guse, 2015). According to
Farmer, the cost and management of patients with multiple chronic conditions present unique
challenges to the health care system (Farmer, 2001).
At Mercy Health Physician Partners (MHPP), the care managers watch close patients with
chronic illnesses that are referred to them through the physicians or other providers. For every
patient, Care Managers meet with the primary care providers once a month to reassess the
patient. Care Managers also call to all possible chronic ill patients discharged from the hospital
4. and work directly with these patients to better assess and referral them to the best providers in
the network.
Program intended outcomes
The MiPCT has as its guiding principles: Make information widely available; Improve
population health and lower health care costs and improve the care experience, keeping the
patient at the center; Project goals and stakeholder alignment over self-interests; Common
metrics, incentives, payment systems, and community solutions whenever possible; and,
Transformation with accountability for dollars spent (MiPCT, 2016).
Through the MiPCT program, payers measure improvements of each patient, and based on this
data, Mercy Health Physician Partner is able to assess the transformation in the care of its
chronic ill population. According to Jeanne Gorton, MHPP has been satisfied with the results
obtained through the MiPCT program and expects it continues for more years to come.
Recommendations
The MiPCT program provides training and many resources to support Care Managers and
primary care providers as they continue to build on Patient Centered Medical Home capabilities.
The classes are coordinated by Michigan Care Management Resource Center (MiCMRC). At
Mercy Health Physician Partners, in the beginning of the MiPCT, all lead physicians and Care
Managers were trained. Thus, at least one lead physician in each office has received training
5. about the PCMH model and complex care management. Every year, the Care Managers are
required to obtain a minimum amount of education credits geared to care management and the
PCMH model.
The Patient Centered Medical Home (PCMH) model focus on improvements in population
health, patient experience and reduction of costs for patients and healthcare systems. Mercy
Health Physician Partners also have population health and people centered care within their core
values. Hence, my recommendation would be for an extension in the training provided about the
PCMH model, that would not just comprise of trained lead physician and care managers, but it
would also include all other primary care providers, physician assistants, specialists and nurses.
Another aspect of the MiPCT is a statewide Patient Advisory Council with real patients and
families as representatives, as a way to listen the voice of the patient. Thence, my second
recommendation for MHPP would be the application of patient surveys as a form to assess the
quality of care offered for these chronic ill patients. And as final recommendation, I would
suggest the establishment of a Patient Advisory Council within each primary care practice, where
patients and caregivers could actively participate in their care and in the transformation of
Patient-Centered care across the spectrum.
6. References:
MiPCT (2016, February 24) – Retrieved from http://mipct.org
American Academy of Family Physicians. (2008). Joint principles of the patient-centered
medical home. Delaware Medical Journal, 80(1), 21.
Garis, R., Farmer, K., & Arora, M. (2001). the incremental cost of diabetes in chronic illness co-
occurrences. Value in Health, 4(2), 58-59. doi:10.1046/j.1524-4733.2001.40201-30.x
Guse, L. (2015). chronic illness and chronic care. Perspectives, 38(2), 4.
