MICMT Complex Care Management Course Introduction 2018 by
MICMT Complex Care Management Course Introduction © 2018 by the Regents of the University of Michigan. For questions or permissions please contact micmrc-requests@med. umich. edu
Welcome! HOUSE KEEPING
Group Activity Introductions • • Your name Your discipline Your practice location How long have you been in your role
Question What’s Most important for You to learn today
Learning Objective • Describe Michigan Institute for Care management and Transformation goals and resources available for physician office team members
Competencies • I identify patients and populations appropriate for care management utilizing available clinical data and a risk score if available. • I collaborate/coordinate care with the PCP and member of the PCP practice team to improve the health of the population of patients attributed to the PCP, as measured by the outcomes measures of demonstration programs the practice participates in: CPC+, SIM, PDCM, Priority Health. • I apply the key steps of the evidence based Care Management 5 step process (referrals, screen, enroll, management, and case close) for patients on Care Management Services to assess, plan, and manage patients and caseload.
Competencies Cont. • I use transition of care patient follow-up information to assess and plan care management services • I am applying the key steps of the evidence based 5 step process for patients on Care Management services to assess, plan, and manage patient and case load • I incorporate identified SDOH needs into the patient’s plan of care and care interventions and conduct follow-up on needs, goals and outcomes. • I build and balance case load and services across the team to optimize care, billing codes and create sustainability of the care management program and services.
Michigan Institute for Care Management and Transformation (MICMT) • Who we are: – Partnership between University of Michigan and BCBSM Physician Group Incentive Program • Goal of MICMT: – To help expand the adoption of and access to multidisciplinary care teams providing care management to populations served by the physician community in order to improve care coordination and outcomes for patients with complex illness, emerging risk, and transitions of care
MICMT Team Members • Hai Mi Choe, Pharm. D – Executive Director • Marie Beisel, MSN, RN, CCM, CPHQ – Administrative Manager Senior Healthcare • Alicia Majcher, MHSA – Administrative Director of Care Management • Julie Geyer, BBA – Senior Project Manager • • • Scott Johnson, BBA, MSA, RN – Project Manager • Sarah Fraley, LMSW, ACSW – Project Manager • Betty Rakowski, BSN, RN, MA Ed – Curriculum Designer • Nicole Rockey, Pharm. D – Pharmacist • Cindy Stevens – Administrative Assistant Sr. • Julie Wolf – Administrative Assistant Sr. Sandy Becker, MA – Data Analyst Judy Avie, BSN, M. Ed. IT, RN – Program Manager
MICMT Care Manager Resources • Statewide Live and Recorded Webinars • One webinar per month • Care Management Connection Newsletter • e. Learning Modules • Care Management 101 • Care Management/ Team Based Success Stories • Best Practice Sharing • • Tools Quality Michigan Care Management Resource Center website www. micmrc. org
MICMT Complex Care Management In-Person Course Curriculum • • Care Management Delivery in the Primary Care Setting Team Based Care 5 Step Process Financial Aspects of a Care Manager’s Day Transitions of Care in the Primary Care Setting Comprehensive Assessment and Care Plan Social Determinants of Health
Successful completion of the MICMT CMC • Completion of self-study modules through MICMT website – Post test grade of 80% or better • Completion of 1 day, in person training – Post test grade of 80% or better TBD – Completion of CM course evaluation, (sent to your email address)
Care Management in the Primary Care Setting – The Michigan Landscape 2012 -12/31/2016 Michigan Primary Care Transformation demonstration (Mi. PCT) 1/1/2015 Centers for Medicare & Medicaid Services (CMS): Chronic Care Management Services 2015 and ongoing: Michigan Health plans have Care Management programs for practices who meet criteria 1/1/17: Michigan State Innovation Model and the Comprehensive Primary Care Plus models of care
Care Management Programs Michigan Care Management Programs for Practices who meet Criteria: – State Innovation Model (SIM) • http: //www. michigan. gov/mdhhs/0, 5885, 7 -339 -71551_2945_64491 ---, 00. html – Comprehensive Primary Care Plus (CPC+) • https: //innovation. cms. gov/initiatives/comprehensive-primary-care-plus – BCBSM Provider Delivered Care Management (PDCM) • http: //www. bcbsm. com/providers/value-partnerships/physician-group-incentive-prog/models-of-care. html – Priority Health Care Management • http: //www. priorityhealth. com/provider/manual/billing-and-payment/services/care-management-codes
Activity • Care Management Introduction Activity – Share your example from self-study:
Contact Us General Questions/Inquiries: micmrc-requests@med. umich. edu Mi. CMRC Complex Care Management Course Questions/Inquiries: micmrc-ccm-course@med. umich. edu
Mi. CMRC CCM Course Reference Guide • Mi. CMRC Recorded Webinars………………………. . 8 • Michigan Care Management Resource Center Website…………. 13
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