january 13, 2015 care management news. today’s topics learning events maintenance of...
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January 13, 2015
Care Management News
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Today’s Topics
Learning events Maintenance of Certification How IHI views MNO care management activities Learning Community What’s new
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Training
Who Should Register? MNO PCPs and members of the practice team
Prerequisites: Knowledge of medical terminology and anatomy
Clock Hours: 10 (Note: 10 clock hours accounts only for time spent in the online or in-person course, proficiency exam and not study time. Study time will vary widely per individual.)
Course Length: To be completed within a 3-month period or less
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Training
Certificate of Completion: Yes Testing: A one-hour wrap up session followed by a
one hour competency exam is required Course Material: Workbooks and study guides
available after registration
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Why Attend
Identify conventions and guidelines used in coding Describe signs, symptoms and ill-defined
conditions Explain rule out versus probable, possible,
differential, suspected terms relating to diagnosis
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Why Attend
Explain CMS STAR ratings Illustrate how CMS STAR ratings are measured Identify the CMS STAR ratings data sources Demonstrate a strategy to improve STAR ratings Illustrate coding chronic illness conditions using
Medicare’s guidelines for correct coding Show the CMS Risk Adjustment Model and the
HCC Categories (Hierarchical Condition Categories)
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Why Attend
Show examples of appropriate documentation and coding
Describe common documentation inadequacies Illustrate how to correctly incorporate the Chronic
Care Management (CCM) codes Identify a successful patient-centered care plan
document Explain transition care management codes
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Cohort A: Instructor Led - Classroom
Wednesday, February 4 6:00pm-8:00pm Wednesday, February 11 6:00pm-8:00pm Wednesday, February 18 6:00pm-8:00pm Wednesday, February 25 6:00pm-8:00pm
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Cohort B: Instructor Led - Classroom
Thursday, March 5 6:00pm-8:00pm Thursday, March 12 6:00pm-8:00pm Thursday, March 19 6:00pm-8:00pm Thursday, March 26 6:00pm-8:00pm
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Cohort C: Instructor Led - Classroom
Monday, April 13 6:00pm-8:00pm Monday, April 20 6:00pm-8:00pm Monday, April 27 6:00pm-8:00pm Monday, May 4 6:00pm-8:00pm
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Full Day: Instructor Led - Classroom
Wednesday, February 4 8:30am-4:30pm Saturday, February 7 8:30am-4:30pm Wednesday, February 11 8:30am-4:30pm Wednesday, February 18 8:30am-4:30pm Saturday, March 7 8:30am-4:30pm Saturday, March 14 8:30am-4:30pm Saturday, April 18 8:30am-4:30pm Monday, April 20 8:30am-4:30pm
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Mandatory Wrap Up and Competency Exam
Thursday, April 16, 2015 9:00am-11:00am 6:00pm-8:00pm
Saturday, April 18, 2015 9:00am-11:00am 10:00am-12noon
Thursday, May 14, 2015 9:00am-11:00am 6:00pm-8:00pm
Saturday, May 16, 2015 9:00am-11:00am 10:00am-12noon
Tuesday, June 15, 2015 9:00am-11:00am 6:00pm-8:00pm
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Other Approaches
On demand On-demand interactive Self paced learning
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Why Attend Training
Contractual Agreement Documentation training Coding Preparation for ICD-10
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A Guide For Caring For the Elderly
Two day training for team members Certificate upon completion Membership in learning community First training in May
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Maintenance of Certification
Part IV module, ABMSF AF4Q Greater Detroit Area Health Council (GHAHC), was added to each Physician Portfolio
All MNO PCPs who successfully completed MLC III were awarded the CMEs for MOC – Part IV
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MOC - Part IV and MLC
A payment is required to complete the process. Within the Physician Portfolio, you will see a
Pending Payment link on the Modules Page under the modules listed in-progress. Click the "Pending Payment" link will permit you to make this payment online.
Until payment has been made credit will not be awarded.
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BCBSM, IHI and MNO
Target population• Medicare Advantage members with at least 6
chronic conditions who are attributed to a physician organization that is providing high intensity care model
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BCBSM, IHI and MNO
Target population’s core challenges• Psychosocial needs• Mental health needs that are unmet• Polypharmacy• Managing 6+ chronic conditions• Geo location• Lack of practice and PCP buy-in
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BCBSM, IHI and MNO
Integrated Care Team• Community-based multi-disciplinary care team with
heavy emphasis on psychosocial support• Integrated care team coordinates with dozens of
Primary Care Physicians in the community• PCPs sit outside the Integrated Care Team
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MNO Team
Nurse Practitioner• Oversees HICM including developing policies and
procedures• Provides medical interventions as needed• Makes home visits, including doing initial
assessment with social worker when needed
Geriatrician• Assess interdisciplinary team activities• Reviews cases• Advises team on assessments
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MNO Team
Registered Nurse• Assigned to Primary Care Provider to serve a panel
of patients• Does outreach to PCPs to recruit patients• Assists in patient recruitment• Provides home visits• Navigates care with patient/caregiver/family • Interacts with hospitalist, home care agency, DME• PCMH –N activities
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MNO Team
Psychologist (PhD)• Supervises the masters level behavioral health
providers • Oversees psychosocial assessments• Provides home visits when necessary
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Clinical Psychologist
Consults with the team around care plans as each patient is reviewed in the weekly huddle
Leads learning modules related to behavioral health factors (eg. depression, dementia, caregiver burden, chronic pain... and adds BH perspective to other modules)
Participates in the development of policies and procedures and clinical protocols from a BH perspective
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Behavioral Health Care Management
BH CM goes beyond assessment, care planning, and linking to community resources• Provides brief behavioral health, evidence-
based interventions shown to be helpful with geriatric patients• Facilitates self-management support of mental
health and physical health symptoms through motivational interviewing, patient education, and brief action planning
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Behavioral Health Care Management
Other kinds of interventions include• brief problem solving therapy• teaching relaxation techniques• supportive counseling to caregivers• brief cognitive-behavior therapy
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MNO Care Team
Social Workers • Perform initial assessment with nurse practitioner or
RN• Co-create care plans with patient and other care team
members• Link patients to community resources
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MNO Care Team
Dietitian and/or Certified Diabetes Educator• Co-create meal plans with patients/caregivers• Access community resources for patients and their
caregivers• Teach care team
Pharmacist• Provide medication education, management and
reconciliation• Meet with Primary Care Physicians• Teach care team
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MNO Care Team
Medical Assistants• Provide back-up support and complete paperwork
Health Coaches: Certified Exercise Specialists • Trained in wellness, health, and injury prevention as
well as health coaching• Design exercise programs in the home
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MNO Care Team
Primary Care Physicians• Provides primary care in various communities• Assesses care plans • Communicates with Integrated Care Team via
Protected Time
MNO Care Team coordinates with over 80 Primary Care Physicians
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MNO Care Team
Caregiver/Family members• Interact directly with the care team• Partner in creating and carrying out the care plan
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What Else…
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Central Training and Education Hub: Comprised of Nurse Practitioner, Registered Nurse, Pharmacist and PsychologistProvide trainingLead team in a 4 hour weekly metingAssess team competencyLead Quality Improvement activitiesDevelop and share PDSAs
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MNO Care Team Support
IT Support• Data capture• Maintain central electronic health record• Create templates• Repository
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MNO Care Team Support
Coding and Billing• Interacts with payer• Coders and Billers• Revenue Cycle Consultant• Run reports on documentation completion by the
team• Advise on ways that team can increase efficiency
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What We’ve Learned So Far
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Behavioral health is the key component of the care team
Relationship between Primary Care Physicians (PCPs) and patients is very significant
Collaborating with PCPs requires finding the key person in each PCP office
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What We’ve Learned So Far
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Learning how PCP and practice team prefer to communicate, and using technology to communicate in real time (secure text & email)
PCPs are very responsive to Integrated Care Team including making same-day appointments available to Integrated Care Team patients
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What’s New
SIM Grant Innovation Grant Clinical Team
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Open Discussion
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