Integrated Health Partners

• PHO located in Battle Creek, MI• Partnership between Calhoun County

Physicians Organization and Bronson Battle Creek Hospital

• 170 affiliated physicians, including 34 specialty areas

Care Management Model• 11 Practices • 4 Complex Care Managers - 1 CCM embedded in each practice with

exception of OMG-MIFM, Olivet and Tekonsha - 2 Hybrids• Moderate Care Managers employed by practice• 2 Hospitals in Calhoun County participating: Bronson Battle Creek Oaklawn Hospital

Oaklawn Medical Group: Marshall Internal and Family Medicine, Olivet Family Practice,

Tekonsha Family Practice

• Located in Marshall, Olivet, and Tekonsha• 7 physicians, 6 midlevel providers, including

certified diabetes educator• MIPCT population of 5138 patients • Trivia

OMG-MIFM, Tekonsha and Olivet Providers

Dr. Jose ValleMIPCT Physician Champion

Care Managers

Renee Leslie, RN, BS, CCMComplex Care Manager

Integrated Health Partners

Jane Ruhl, RN, BSNComplex Care Manager

Integrated Health Partners

Tami Starks, LPNModerate Care Manager

OMG-MIFM

Dee Pennington, LPNModerate Care Manager

OMG-MIFM

OMG-MIFM, Tekonsha and Olivet Statistics

• 21,268 patients in MIPCT• OMG-MIFM, Olivet Family Practice and

Tekonsha Family Practice have 5138 patients eligible for care management

• Largest practice participating in MIPCT in Calhoun County

• Level of patient engagement increased from 3.78% in April to 5.48% in July, 2013

It takes a village to raise a child, it takes teamwork for care management to be

successful in a practice

Moderate Care Managers target and engage patients using the following

tools

• Community Resource Sheet• Registry – Gaps in Care• Emergency Room Reports• BCBSM List

CommunityResource

Guide

IHP Registry Progress

Note

Insert registry sheet

Emergency Reports

• Insert emergency action plan

BCBSM List

Complex Care Managers Target and Engage Patients

• Inpatient admissions• Provider’s daily schedule• Referrals

Inpatient Admissions

Two hospitals in Calhoun County, Oaklawn Hospital in Marshall, MI and Bronson Battle Creek• Daily access inpatient admission information• Identify MIPCT PCP and patient

•MiPCT list starts with 81 columns•Our IT Analyst reduces this to 9 columns •Pertinent information is loaded into CTC

Criteria for Identifying a Patient for Care/Case Management

• 1. Unscheduled Inpatient admission*– Moderate: – 2 admissions in 90 days– Complex:– 2 admissions in 30 days

• 2. ED Visits:– Moderate:– 2 visits in 30 days– Complex:– 2> visits in 30 days

• 3. Poly-pharmacy 5> medications• 4. Diagnosis:

– Moderate:– more than 2 comorbidities– Complex:– complex medical diagnoses and psychological diagnosis*

Criteria for Identifying a Patient for Care/Case Management (continued)

• 5. Psycho-social/depression screen:– PHQ-2, PHQ-9– Moderate:– 5 or more symptoms, score 15-19*– Complex:– Score 20>*

• 6. Age:

– -over 85– -under 50 with readmission– -peds under age 2

• 7. More than 6 visits to PCP within 1 year* *criteria that in itself can trigger referral to care/case

management

Providers Daily Schedule

• Print providers daily schedule• Identify patients in MIPCT• Discuss with provider any identified needs

Referrals

• Providers• Office staff• Hospital case managers• Home Care• Community Agencies

Patient Story