Important Dates:

Michigan Primary Care Transformation www. mipct.org Volume 5 Issue 9 September 12, 2016

MiPCT Webinars Webinar September 27, 2016 12:00 – 1:00 PM

Practice Level Care Management Code by Code Analysis PO Register Here

PRACTICE Register Here

Webinar November 15, 2016 12:00 – 1:00 PM

Care Management Billing and Cod-ing and the 2017 SIM PCMH MiPCT Partnership Note: Registration is not yet availa-ble

EVENTS September 20, 2016

2016 MiPCT PEDIATRIC CARE MAN-AGEMENT SUMMIT

October 13, 2016

2016 MiPCT REGIONAL ANNUAL SUMMIT-NORTH

October 18, 2016

2016 MiPCT REGIONAL ANNUAL SUMMIT-WEST

October 26, 2016

2016 MiPCT REGIONAL ANNUAL SUMMIT-SOUTHEAST

SIM PCMH/MiPCT Partnership Initiative

Application Period - Submission

Deadline September 30

As the MiPCT transitions to an ongoing program in partnership with the State Innovation Model (SIM), all current MiPCT practices in good standing are eligible to apply for the SIM PCMH Initiative for Medicaid PMPM funding in 2017. The State held a webinar last Thursday (the slides are included as an attachment to this edition's Flash as are the links to the applications and other material).

Please keep in mind that payment will flow to the submitter of the application. Thus if a PO submits for its MiPCT practices and any PCMH practices in the five SIM regions then the PO receives the funding and is responsible for compliance and reporting. Converse-ly, if a practice submits, they receive the funding , compliance, and reporting obligations.

The link for Physician Organizations applying on behalf of practices, click this link.

If you are a practice applying individually, please click this link.

SIM PCMHMiPCT Partnership Initiative Files.zip

REGISTRATION OPEN! 2016 MiPCT

Regional Annual Summits

Once again this year, the MiPCT Project will convene a Stakeholder Annual MiPCT Summit in three statewide re-gional locations.

Summit North – Thompsonville, MI Tuesday, October 13, 2016 Crystal Mountain Resort & Conference Center 12500 Crystal Mountain Drive Thompsonville, Michigan 49683 Register Here *Registration CLOSES 10/03/2016*

Summit West – Grand Rapids, MI Tuesday October 18, 2016 Frederik Meijer Gardens and Sculpture Park 1000 E Beltline Ave NE Grand Rapids, MI 49525 Register Here

*Registration CLOSES 10/07/2016*

Summit Southeast – Ann Arbor, MI Wednesday, October 26, 2016 University of Michigan North Campus Research Center (NCRC) 2800 Plymouth Road, Building 18 Ann Arbor, MI 48105 Register Here

*Registration CLOSES 10/17/2016*

Note: Registration for Summits may close earlier if capac-

ity limits are reached. Early registration STRONGLY

encouraged*

2

2016 Summit Pre-Work Webinars MiPCT 2016 Annual Summit Care Manager After-noon Session PREWORK Earn Nursing or Social Work Contact Hours for Com-pleting Summit PREWORK Recorded Webinars: We have partnered with the Centre for Collaboration, Motivation

and Innovation (CCMI) to design a series of five pre-work webinars to enrich your learning experience at the in-person Summit after-noon CM education session.

The presenter is Connie Davis, RN, MN, GMP, and Co-director of the CCMI. Connie is an internationally known trainer, educator, speaker and consultant on health care design and health behavior change.

Viewing the webinars prior to the live Summit CM afternoon ses-sion is highly recommended.

Each of the 5 webinars listed below and the Summit afternoon CM in-person session are standalone in terms of earning contact hours.

*Recorded webinars will be available August 29th 2016. Steps to complete the Summit CM Prework and receive nurs-ing or social work contact hours: 1. Access the link on the MiPCT Summit 2016 pre-work web page

https://mipct.org/ 2. View the entire online recorded webinar 3. Click the link below the webinar titled “Request CE Credit” Click

Here 4. Complete the brief form, include your e-mail address, click submit 5. This will generate an email message to you containing a link to com-

plete the CE request and required evaluation form 6. Follow instructions in the e-mail: Complete the evaluation and sub-

mit. This step generates an email to you containing the CE certifi-cate

New For 2016: Stepped Care for Self-Management Support

This Webinar addresses population segmentation, agenda setting,

social determinants of health, and patient shared decision making with complex patients.

“Stepped Care for Self-Management Support” is approved for 1.0 contact hours by the Michigan Nurses Association, an ap-prover of continuing nursing education by the Michigan Board of Nursing.

“Stepped Care for Self-Management support” is approved by the Michigan Social Work Education Collaborative. Course approval #: 080416-07

The next edition of the:

MiPCT Practice FLASH will be

distributed on September 26 , 2016

MiPCT PO FLASH will be distrib-

uted on October 10, 2016

INSIDE THIS ISSUE:

SIM PCMH/MiPCT Partnership Initiative

Application Period - Submission Deadline

w/attachments 1

PCMH Initiative Application Guide

PCMH Initiative Application Release

Webinar Slides

PCMH Initiative Beneficiary Inclusion-

Exclusion

PCMH Initiative Payment Model Excerpt

from Participation Agreement

PCMH Initiative Transformation Objective

Menu

PO and Practice Requirements Excerpt from

Participation Agreement

MiPCT Regional Summit Registration 1

Important Dates 1

2016 Summit Pre-Work Webinars 2

New for 2016 Stepped Care for

Self- Management 2

MiCMRC/MiPCT Complex Care

Management Course 4

Upcoming course dates and

course registration close dates 5

MiPCT Pediatric Summit 2016

MiPCT Pediatric Summit Pre-Work 6

Success Story Hybrid Care

Management and MiPCT Clinical Lead 7

Behind the Data 8

2016 MiPCT Summit Flyer 9

MiCMRC/MiPCT Recorded

Webinar Flyer 10

3

MiPCT care managers who did not have the opportunity to view 2015 MiPCT Summit pre-work webinars or would like a refresher, the following webinars are available. *Please note: if you received Nursing CE credit for the 2015 Summit pre-work webinars listed below in 2015, you will not be eligible to receive credit in 2016. Understanding Motivational Interviewing (MI): How the elements of Motivational Interviewing provide a context for BAP “Understanding Motivational Interviewing (MI): How the elements of Motivational Inter-

viewing provide a context for Brief Action Planning (BAP)” is approved for 1.5 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 081116-00

*If you received nursing continuing education contact hours in 2015 for this ed-ucational offering, you are not eligible to receive CE credit in 2016

Effective Communication with Patients (Ask-Tell-Ask): Identify ways to provide information consistent with the Spirit of MI “Effective Communication with Patients: Ask-Tell-Ask” is approved for 1.5 contact

hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaboration. Course approval #: 081116-01

*If you received nursing continuing education contact hours in 2015 for this ed-ucational offering, you are not eligible to receive CE credit in 2016

Understanding Brief Action Planning: Describe the components of BAP “Understanding Brief Action Planning” is approved for 1.5 contact hours by the Michi-

gan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaboration. Course #: 081116-02

*If you received nursing continuing education contact hours in 2015 for this ed-ucational offering, you are not eligible to receive CE credit in 2016

Applying Brief Action Planning in the Care Setting: Identify the application of BAP in work settings “Applying Brief Action Planning in the Care Setting” is approved for 1.5 contact hours

by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaboration. Course #: 081116-03

*If you received nursing continuing education contact hours in 2015 for this ed-ucational offering, you are not eligible to receive CE credit in 2016

4

Upcoming course dates and course registration close dates:

October 3-6 , 2016. Introductory Webinar October 3rd , 2016. Total six hour self-

study modules and post-tests October 3-6, 2016. In-person training October 5-6

2016.

NOTE: Registration for this course will close as of September 29th , 2016.

November 7-10 , 2016. Introductory Webinar November 7 , 2016. Total six hour

self-study modules and post-tests November 7-8 2016. In-person training Novem-

ber 9-10 2016.

NOTE: Registration for this course will close as of November 3 , 2016

Register for all MiCMRC/MiPCT CCM Courses Here:

http://micmrc.org/programs/micmrc-mipct-complex-care-management-course/registration

MiCMRC/MiPCT Complex Care Management Course

The 2016 MICMRC/MIPCT Complex Care Management (CCM) Course is provided in a blended

learning activity format. The MiCMRC/MiPCT CCM course is designed for new MiPCT Hybrid

Care Managers (HCMs) and Complex Care Managers (CCMs).

Completion of the MiCMRC/MiPCT CCM Course occurs over a 4 day period. The course consists

of:

Live Webinar on day 1 - introduction of MiCMRC/MiPCT CCM course

Self-study modules and post- tests which are completed prior to the in-person training (total

expected time to complete the self-study and post tests is six hours)

In person training days 3 and 4

5

MiPCT Pediatric Summit 2016

The MiPCT Pediatric Care Manager Summit this year will address the clinical focus areas of 1) so-cial determinants of health, specifically Adverse Childhood Experiences (ACEs) and Resiliency and 2) integration of behavioral health in primary care, including specific screening tools, as well as cul-tural diversity. We will offer presentations and panel discussions about how to address these themes when working with children, youth, and families. Parents of children/youth with special health care needs will join us to help keep us family-centered in all that we do. Small group discus-sions will give participants the opportunity to learn from each other and to build networking rela-tionships.

Date: September 20, 2016

Time: 8:30 am – 4 pm

Location: BCBSM Lyon Meadows Facility, 53200 Grand River Avenue New Hudson, MI 48165

To register for the MiPCT Pediatric Summit 2016, please Click Here

*Registration CLOSES Tuesday September 13th @ 4:30 PM*

Continuing Education:

“MiPCT Pediatric Care Management Summit” is approved for 5.5 contact hours by the Michigan Nurses Association, and approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collab-orative. Course approval #: 081616-00

6

MiPCT Pediatric Summit Pre-Work

MiPCT Pediatric Care Managers will also find that the pre-summit webinar on “Specific Screening

Tools for ACES and Behavioral Health” to be aligned with the summit, and is highly recom-

mended.

The MiCMRC/MiPCT Educational Webinar: “Specific Screening Tools for ACES and Behavioral

Health” will enable the learner to develop a deeper understanding of adverse childhood experiences

(ACES) and behavioral health issues that are commonly treated in the pediatric primary care practice.

The expert presenters are: Jane Turner, MD, Professor HP, Pediatrics and Human Development Mich-

igan State University and Laurisa Cummings, LMSW, MiPCT Pediatric Care Manager, Care Manage-

ment Supervisor, MiPCT Pediatric Clinical Lead, Children's Medical Group of Saginaw Bay.

Nursing and Social Work continuing education contact hours for the “Specific Screen-

ing Tools for ACES and Behavioral Health” webinar may be obtained by:

- Listening to the recorded webinar which will be available by end of August.

The CE request link is posted on http://micmrc.org/webinars/continuing-ed . Click this link to initiate

a request for CE Credits. This will generate an email message containing a link to complete the CE re-

quest and required evaluation form. Follow the CE instructions contained in the email. Once the re-

quired evaluation is submitted, an email will be sent containing the CE certificate.

CE credit for viewing the recorded webinar will be available until August 12, 2017. While the webinar

will still be available for viewing, please note that CE credit for the viewing the recorded webinar will

not be available after August 12, 2017.

Continuing Education:

"Specific Screening Tools for Adverse Childhood Experiences (ACES) and Behavioral Health" is ap-proved for 1.0 contact hours by the Michigan Nurses Association, an approver of continuing nursing education by the Michigan Board of Nursing.

This course is approved by the Michigan Social Work Continuing Education Collaborative. Course approval #: 063016-00

For more information regarding contact hours, or for other questions, please submit to micmrc-requests@med.umich.edu

7

Success Story

Lindsay Schohl, RN

Hybrid Care Management and MiPCT Clinical Lead

Lakes Family Medicine

Mercy Health Muskegon

Lindsay Schohl works with the providers at Lakes Family Medicine in Muskegon, Michigan. A

patient was referred to Lindsay for pain management by the primary care physician, and the pa-

tient's spouse who is also a current patient of Lindsay's. The patient had been struggling with

pain management; she had recurrent colon cancer that she was no longer pursuing treatment

for. She was told by oncology that the chemotherapy would not be curative, and her previous

experience with chemotherapy did not result in good quality of life. Prior to working with the

care manager she had not been receiving any follow up care by oncology and her pain was rated

at 8-10/10. She was not able to sleep well, not able to drive, and not able to leave her home with-

out excruciating pain.

The patient's pain management skills and knowledge were lacking for multiple reasons. She

was prescribed Norco by her PCP but hadn't been taking it. The patient was opiate naïve, and

had fears of addiction that resulted from a mother who had a Norco addiction in the past.

Lindsay began communicating with the patient, providing pain management education and op-

tions for resources for pain management. The patient was adamant about declining Hospice,

but she was receptive to a Palliative Care Referral for pain and symptom management. The Pal-

liative Care Program we chose together offered a physician led approach, a one on one consult

with a Palliative Care physician. Lindsay helped coordinate services for Palliative Care for this

patient along with coordinating with her oncologist. Lindsay provided medication education to

the patient along with addressing issues with breakthrough pain and how to handle that at home

on her own with the medications Palliative Care recommended.

Through a series of nursing interventions for pain management, care coordination, and re-

sources, the patient is doing much better. She was able to leave her home a few weekends ago to

go to a comedy show with her family, she is sleeping much better. She rates her pain at a 3/10

on average, and can verbalize how to stay on top of her pain before it gets away from her and she

can't get it back under control. She continues following up with the Palliative Care physician

monthly for pain and symptom management, and she continues follow up with her oncologist

for support as her disease progresses. The patient reports a much better quality of life now that

her pain is controlled, and thanks us for the care and support we have provided to her and her

family through this difficult time.

8

Behind the Data

By Michigan Data Collaborative

MDC’s Behind the Data section provides high-level information about the data for the MiPCT project in a Q & A for-

mat.

Q: What is the incentive period used to calculate the performance incentive scores?

A: MDC published release 18 of the MiPCT Dashboard on Thursday, September 8, 2016. The data from this release

will be used for the 48 month incentive measure calculations. The 48 month incentives are based on the measure-

ment year 1/01/2015 thorough 12/31/2015, although some clinical quality metrics include an additional look-back

period.

Viewing the data in release 18 will provide an early opportunity to review metrics and quantify incentive result ex-

pectations.metrics are found on both the Quality page and Utilization page of the Dashboard, and the underlying

data can be viewed by clicking the See Detail link on each page. Additional information and instructions about

viewing the data, see the MiPCT Dashboard User Guide (https://www.michigandatacollaborative.org/MDC/assets/

MiPCT_New_Dashboard_UG.pdf). Other helpful documentation can be found on the MDC Website Support page

(https://www.michigandatacollaborative.org/MDC/#/support).

New Measures Added in the 2015 MiPCT Performance Incentive Program

Childhood Immunizations/Combo 3

Adult ED Risk Adjusted Visits (per 1000 attributed patients)

Pediatric ED Risk Adjusted Visits (per 1000 attributed patients)

2014 Measures Retired in 2015

Part I: Primary Care Sensitive ED visit rates

Part IV: Notification of Hospital Admissions & Discharges

Part IV: Follow-Up Referrals to a Community-­-Based Program or Agency

Part IV: Self-Management Support Offered for Chronic Condition of Focus

For more details on the incentive metrics or methodology, please refer to the MIPCT 2015 Performance Incentive

documents located at https://mipct.org/resources/performance-incentives/ or contact MDC at MichiganDataCol-

laborative@med.umich.edu.

9