integrated health partners
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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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
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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
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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
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OMG-MIFM, Tekonsha and Olivet Providers
Dr. Jose ValleMIPCT Physician Champion
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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
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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
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It takes a village to raise a child, it takes teamwork for care management to be
successful in a practice
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Moderate Care Managers target and engage patients using the following
tools
• Community Resource Sheet• Registry – Gaps in Care• Emergency Room Reports• BCBSM List
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CommunityResource
Guide
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IHP Registry Progress
Note
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Insert registry sheet
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Emergency Reports
• Insert emergency action plan
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BCBSM List
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Complex Care Managers Target and Engage Patients
• Inpatient admissions• Provider’s daily schedule• Referrals
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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
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•MiPCT list starts with 81 columns•Our IT Analyst reduces this to 9 columns •Pertinent information is loaded into CTC
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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*
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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
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Providers Daily Schedule
• Print providers daily schedule• Identify patients in MIPCT• Discuss with provider any identified needs
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Referrals
• Providers• Office staff• Hospital case managers• Home Care• Community Agencies
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Patient Story