The Michigan Primary Care Transformation (MiPCT) Project - Webinar #3 Complex Care Manager Training...
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Transcript of The Michigan Primary Care Transformation (MiPCT) Project - Webinar #3 Complex Care Manager Training...
The Michigan Primary Care Transformation (MiPCT) Project - Webinar #3Complex Care Manager Training and Care Management Documentation Updates
MiPCT TeamDecember 9, 2011
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Agenda
• Introduction• Complex Care Management Training
Update• Care Management Documentation and
Reporting
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MiPCT Complex Care Manager Training
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CCM Train the Trainer Model• Proposed model for first group of CCMs
▫ 4 Master Trainers (3 open positions)▫ 16 CCM Clinical Leads ▫ Employed by the PO/Practice
Exception – One Master Trainer position filled by Marie Beisel MiCMRC Project Manager
• CCM Master Trainer and CCM Clinical Leads▫ Complete Complex Care Manager Fundamentals course with
Geisinger faculty (may require two waves of on-site training)▫ 3 weeks on site in PA
One week didactic Two weeks partnered with a Geisinger Care Manager
▫ Training in MI, mentoring by Geisinger faculty• CCM Master Trainer additionally completes curriculum
for train the trainer model
*Model is designed for year one MiPCT intervention phase
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MiPCT Leadership
Team
CCM Master Trainer
4 CCM Clinical Leads
CCM Master Trainer
4 CCM Clinical Leads
CCM Master Trainer
4 CCM Clinical Leads
CCM Master Trainer
4 CCM Clinical Leads
MiPCT Complex Care Manager Train the Trainer Program
Complex Care Manager Clinical Lead• Completes Complex Care Manager Fundamentals course at
Geisinger ▫ 3 weeks on site in PA▫ supplemental training in MI
• Preceptor for CCMs in a defined region, has reduced patient caseload
• Leads small group discussions, facilitates networking, sharing best practices
• Contributes to ongoing CCM curriculum development by assisting Master Trainers with CCM education, workflow support, and resources
• Collaborates with CCM Master Trainer, MiPCT leadership, MiPCT clinical subcommittee to assess CCM interventions
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Complex Care Manager Clinical Lead
Sample of key preferred qualifications• Current MI License: RN, NP, PA• 3 to 5 years experience
▫ some adult medicine ▫ setting: home health agency, primary care practice, skilled nursing
facility, hospital medical-surgical unit
• Preceptor experience - working with licensed clinical staff
• Demonstrated ability to create and support a learning environment that is characterized by mutual respect, constructive feedback, and conflict resolution
• Knowledge of chronic conditions and prevention ▫ evidence-based guidelines
• Excellent communication, interpersonal, teaching and facilitation skills
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Master Trainer Complex Care Manager Role• Completes Complex Care Manager Fundamentals course and a Train the
Trainer program with Geisinger faculty ▫ 3 weeks on site in PA ▫ also training in MI
• Oversight of four Complex Care Manager (CCM) Clinical Leads
• Does not have a patient caseload
• Leadership role in providing CCM professional development through mentoring, coaching and education
• Gathers data, populates and analyzes specified CCM activity reports for region
• Collaborates with MiPCT leadership and MiPCT clinical subcommittee to assess, study, and refine CCM training and interventions as needed
• Presents educational offerings for CCMs in small group setting as well as a statewide audience
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Complex Care Manager Master TrainerSample of key preferred qualifications
• Current MI License: RN, NP, PA
• 5 years experience ▫ some adult medicine ▫ setting: home health agency, primary care practice, skilled nursing facility, hospital
medical-surgical unit
• 2 years experience ▫ clinical manager - preferred▫ clinical program development, implementation, monitoring, evaluation - preferred
• Demonstrated ability to create and support a learning environment that is characterized by mutual respect, constructive feedback, and conflict resolution
• Excellent communication, interpersonal, teaching and facilitation skills
• Excellent teaching, presentation, and facilitation skills
• Demonstrated ability to effectively develop educational resources, tools, processes
Training Timeline
•CCM Master Trainers and Clinical Leads▫1-2 waves, likely February for first wave
•Subsequent training plans▫Michigan-based training waves▫Progress from Geisinger-led to combination
of taped webinars and Master-Trainer led sessions
▫Regionally based▫Having four Master Trainers will allow
more flexibility with timing and geography
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Next steps
• Additional details on CCM Master Trainer and clinical leads sent out by December 15▫ Position description details▫ MiPCT salary subsidization amount for each role▫ Definition of selection process
• PO/PHO responses requested by December 22▫ Letter of interest for CCM clinical lead position▫ Letter of interest for CCM Master Trainer position▫ Submit letter of interest to Marie Beisel at
• Positions for first Geisinger trip identified by January 15▫ Anticipated travel date is early February▫ Timing of second wave likely early March
• MiPCT team to finalize contract details with Geisinger by 12/31
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Care Management Documentation
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Current state
•No ideal single source solution for EHR documentation, registry functionality and care management support▫Integration costly, cumbersome▫Difficult to mimic manual processes with HIT
solutions▫Recognized problem across the country
•Care managers need tools to support workflow
•Supervisors need a way to track productivity
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Basic HIT Functions: Support Care Manager’s work • Create and maintain a list of active patients
• Generate a Patient Tickler List▫ patients scheduled for Care Manager (CM) follow up
visit▫ ideally includes past and future CM visits
• Document Patient Care management visits using a template▫ Common diagnoses▫ Common follow up
Self management goal setting▫ Transitions of care
• Create and maintain individualized patient care plan by Complex Care Managers
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Advanced HIT Functions: Support Care Manager’s work• Access to information
such as: view of patient includes: diagnoses, care giver, PCP, insurance, demographics, care manager and health team member visit schedule, assessments, referrals, patient goals, medications, lab results
• Protocols• Ability to generate Care
Manager activity reports
• Compatibility with care manager’s work flow
• Notification - patient’s appointment with PCP, ER visit, hospitalization
• Assessments ( Functionality, PH Q 9, . .) completed and tracked - longitudinal view
• Patient worksheet: history of goals, assessments, care manager encounters past and future
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MiPCT Required Care Manager Reports
• Care Manager Activity Reports▫ Number of Care Manager encounters at practice
location per Care Manager, by payer
• Frequency of reporting – TBD, likely quarterly
• Purpose of reports▫ Provide accountability to payers, demonstrate value ▫ Allow PO and MiPCT leadership to see where
practices are having difficulty with implementation/integration
Ways to accomplish varying levels of Care Management functions •EHR
▫customization▫built in care management feature (rare)
•Registry ▫customization▫built in care management feature (rare)
•Care Management Software▫not integrated▫integrated
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Options for Care Management Documentation and Reporting
•PO develops solution – works with practices
•Common MiPCT solution▫Not required, but option for those
interested▫Care management software options
reviewed by MiPCT team ▫Two possible options
Care Team Connect OHSU Care Management Plus
▫Cost to PO/PHO/practice negotiated by MiPCT
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Care Team Connect
•Currently in use or in negotiations with several MiPCT PO/PHOs
•Highly customizable▫Accept MiPCT data feeds ▫Risk stratification▫Specific protocols for clinical situations▫Connect multiple team members▫Can interface with registry/EHR at
additional cost•Will generate claims for G codes/CPT
codes•Will create MiPCT activity reports
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Care Management Plus
•Low cost, web-based product•Provides basic care management support
▫Active patient list▫Tickler lists▫Activity reporting
•Some customization possible▫Templates▫Interface with practice management
system, EHR
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What is the best solution for you?• PO/Practice will need to assess current HIT
capability for care managers• Can PO/practice report the required MiPCT
activity?• Will the HIT in the practice currently provide
the basic functions needed to support the care manager workflow?• If yes, can PO/Practice add support such as
customized documentation templates?• If no, how will PO/Practice address this?
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Next steps
•Assessment of MiPCT PO/PHO capabilities▫Best practice webinar?▫Common solutions for same EHRs?▫Have something that works? We’d like to
hear from you!•Demonstrations from software vendors
▫Care Team Connect, Care Management Plus▫If PO/PHO has care management software
product they would like MiPCT to assess, please contact Marie Beisel at [email protected]
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Questions and Discussion
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