MiPCT Launch Tier 1 and Tier 2

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MiPCT Launch Tier 1 and Tier 2

• Mary Ellen Benzik,MD
• Associate Medical Director
• MiPCT

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I wear many hats Family Physician Medical
Director of Integrated Health
Partners Active participant in the BCBSM PDCM
Associate Medical Director MiPCT
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Significance of a Demonstration Project

• When successful may lead to direct redesign of
  CMS/Medicare funding without congressional
  confirmation
• Awesome opportunity to impact the future of
  primary care in the country
• Ability to improve the quality of care for our
  patients
• Do what we have always wanted to do

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Critical Areas

• Self-management support
• Community resources
• Care transitions
• Care coordination

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Requires System Change Not Superman
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(No Transcript)
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Care Management MiPCT Framework
Person side
Population side
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Population health one person at a time
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Care Management Conceptual Framework
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Care Management Conceptual Framework
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SWOT sheet
Navigating the medical Neighborhood Strength Weakness Opportunity Threat
Relationship with MD/hosp
Coordination Referrals
Coordination tests
Link to community Resources
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Navigating the Medical Neighborhood

• Optimize relationships with specialists and
  hospitals
• Coordinate referrals and tests
• Link to community resources

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The Care Coordination Model
http//www.improvingchroniccare.org
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PCMH in the Neighborhood

• Accountability
• Know who your patients are (registry)
• Track referrals and test results
• http//www.improvingchroniccare.org/downloads/3_re
  ferral_tracking_guide.pdf
• Patient Support
• Identification of patient medical, logistic,
  insurance needs
• Motivational interviewing
• Transition of care
• Identification of barriers

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Connecting to the Neighborhood

• Relationships and Agreements
• Community Agencies
• Hospitals / Emergency rooms
• Specialist
• http//pcmh.ahrq.gov/portal/server.pt/community/pc
  mh__home/1483/PCMH_Tools2020Resources_v2
• http//www.pcmh.ahrq.gov/portal/server.pt/communit
  y/pcmh__home/1483
• Connectivity
• http//www.improvingchroniccare.org/index.php?pCo
  nnectivitys415
• Case examples of three area solutions

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Its all about relationships
More than just a handshake
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Concept of Compacts
Establishes specific agreements and expectations
related to Transitions of Care Access
Collaborative Care Management Patient
Communications Great definitions Templates for
all of these four areas
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SWOT analysis
Table conversation Report out
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Care Management Conceptual Framework
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SWOT sheet
Transitions of care Strength Weakness Opportunity Threat
Notification of
Admissions
Discharges
Emergency room
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SWOT sheet
Transitions of care Strength Weakness Opportunity Threat
PCP Follow up
Specialist Follow up
Medication Reconciliation
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Transitions of Care
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Transitions of Care

• Notifications of admissions, discharges , ER
  visits

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Transition of care

• The Post-Hospital Follow-Up Visit A Physician
  Checklist to Reduce Readmissions
• Eric A. Coleman, MD
• Read more http//www.chcf.org/publications/2010/
  10/the-post-hospital-follow-up-visit-a-physician-c
  hecklistixzz1omLp27nz

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Transition of care Check list for post
hospital follow up

• Prior to visit
• Review discharge summary
• Clarify outstanding questions with send physician
  
• Reminder call to patient or family care giver
• Stress the importance of the visit and address
  any barriers
• Remind to bring medication list, medications both
  otc and rxd
• Provide instructions on seeking after hours care
  both emergent and nonemergent
• Coordinate care with home health or care managers
  if necessary

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Transition of care Check list for post
hospital follow up

• During the Visit
• Ask the patient to explain
• His/her goal for the visit
• What factors they believed led to admission/er
  visit
• What medications they are taking and on what
  schedule
• Perform medication reconciliation with attention
  to pre-hospital regiment
• Determine the need to
• Adjust meds
• Follow up on any outstanding tests
• Do monitoring or testing
• Discuss advanced directives
• Discuss future treatments (POLST)

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Transition of care Check list for post
hospital follow up

• During the visit (continued)
• Collaborate with patient on self management
  support perform teach back
• Explain warning signs and how to respond have
  patient teach back
• Provide instruction on how to seek after hours
  care both emergent and nonemergent

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Transition of care Check list for post
hospital follow up

• At the Conclusion of the Visit
• Print reconciled and dated medication list and
  provide a copy to the patient, family care giver,
  home health nurse, and case manager (if
  applicable)
• Communicate changes in the care plan to family
  care givers, health care nurses, and care
  managers
• Consider skill home health care and other
  supportive services
• Ensure the next appt is made as appropriate

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Medication Reconciliation
Insanity doing the same thing over and over
again and expecting different results.Albert
Einstein
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Tools for medication reconciliation
More than you can count - in all different sizes
and colors!!
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Which is the Correct List

• The one the patient states they are taking

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The Correct List

• In home assessment
• Asking how do you take your medications
• Not do you take X in Y way
• Bag review
• ..

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So why cant we get it right??
Guhad A, Farris KB, Batra P,   Benzik ME.
  Community health partners perceptions of
problems with medication reconciliation.
Ongoing research. 
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Engaging Patient
Educating patients on issue related to safety and
medication Community partners to work with
patients on medication Personal Health Record
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How-to Guide Improving Transitions from the
Hospital to the Clinical Office Practice to
Reduce Avoidable Rehospitalizations
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SWOT analysis
Table conversation Report out
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Challenges for Care Management
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Thanks Mary Ellen Benzik, MD mebstork_at_aol.com C
ell 269-580-7738 Office 269- 245- 3850