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Jackie Prokop Program Policy Division
Medical Services Administration
July 24, 2017
MI Care Team Model Design
Funding was made available under the 2015 State Appropriation
The MI Care Team model builds on the philosophies of the IMPACT
and Nuka Care Models.
Interdisciplinary team of providers who will operate in a highly behavioral
health integrated primary care setting.
Emphasis on personalized care plan
Focusing outreach efforts on high need/high utilizers.
Intensive role of the CHW and addressing the social determinants of health
High Level Annual Review
First mailing campaign to eligible beneficiaries completed: ~ 110,000 letters
Distributed beneficiary informational (marketing) materials
www.michigan.gov/MICareTeam
Established MI Care Team peer-to-peer networks (MPCA)
Billing/Finance; Health Home Coordinator; RN Care Manager; CHW
Engaged key partners including Medicaid Health Plans
Multiple surveys of MI Care Team staff for process evaluation (IHPI)
First provider-level access to CareConnect360
Admission-Discharge-Transfer (ADT) messages added.
First provider-level access to Symmetry
Triaged the growing pains that come with a new program
Enrollment Analysis – Technology
On a monthly basis, the distribution of MI Care Team eligible beneficiaries is ran from the Waiver Support Application (WSA), which is the tool used for enrollment, by the sum of inpatient (IP) and emergency department (ED) visits.
Using the mean and standard deviation of this distribution, z-scores are calculated for each beneficiary’s IP/ED visit value.
Z-scores tell us how many standard deviations a given value is from the mean. Any z-score over 3 or under -3 standard deviations from the mean is an outlier. An outlier equates to a super utilizer in the context of the MI Care
Team.
Participating health centers have enrolled 9.14% of total eligible outliers. 29 outliers (27 or more IP/ED visits) enrolled; 1 pending
Total of 8 beneficiaries enrolled with a combined IP/ED visits at 50 or more (ranging from 61-224) within the last 18 months.
24.87% of those enrolled/pending have above average (>5) IP/ED visits
75.13% of those enrolled/pending have below average (<5) IP/ED visits
Bottom-line:
Enrolling more average/low utilizers than high utilizers
Outreach activities need to continue
Enrollment should be prioritized among the higher-need beneficiaries
Enrollment Analysis
First program to require the use of ICD-10 z-codes to track the factors influencing health status being addressed during the monthly contact.
11,000 of 30,000 encounters have a z-code diagnosis
1755 (15%) had a z-code diagnosis related to housing and economic circumstances.
1133 (9.4%) of these were specific to homelessness/inadequate housing.
1688 (14%) z-code diagnosis problems related to lifestyle (tobacco, exercise, diet & eating habits, etc.).
1307 (11%) z-code diagnosis life management difficulties.
209 (2%) z-code diagnosis related to employment or unemployment.
Social Determinants
MPCA and MI Care Team
Role:
MPCA coordinates a comprehensive MI Care Team Learning
Community that includes training, technical assistance and
peer network supports in partnership with the Medicaid
Services Administration.
Goals: Successful implementation of MI Primary Care Health Home
through systematic support, proactive training, technical assistance
Launch of MI Care Team infrastructure and Peer Learning Networks
Peer Learning Network is utilized by participating health centers to problem solve.
All staff involved with implementation will be knowledgeable of expectations, processes, and model of care (care coordination and care management)
Increase strategic partnerships to build efficiency in MI Care Team
Successful implementation of MI Primary Care Health Home through systematic support, proactive training, technical assistance, and MPCA staff optimization
Year 1MiCT Learning Community Trainings: ◦ MI Care Team Orientation and Kickoff (2/29/2016)
◦ MI Care Team Wavier Support Application (6/21/2016)
◦ Care Connect 360 (6/21/2017)
◦ MI Care Team Enrollment (9/15/2017)
◦ MI Care Team/ Care Connect 360 (10/17/2016)
◦ MI Care Team RN Care Manager Network (11/03/2016)
◦ Quarterly Health Homes Coordinator Training (12/07/2017)
◦ MI Care Team Workshop (2/27/2017-2/28/2017)
◦ MI Care Team Workshop (3/7/2017-3/8/2017)
◦ MI Care Team Nurse Care Manger Care Coordination Training (4/17/2017)
◦ MI Care Team Nurse Care Manager Care Coordination Follow-up (7/5/2017)
◦ MI Care Team CHW Health Literacy Training (6/26/2017)
◦ MI Care Team Coordinators Luncheon (7/24/2017)
Objective of the Learning Community Trainings:
Through MI Care Team community trainings, MPCA strives
to provide:
Learning opportunities for MI Care Team staff to enhance
their care coordination and management skills
Adequate trainings in order to foster interdependent
teams
Foster whole-person and team-based care
Support through need based trainings
MiCT Networks To ensure continued communication with each MiCT Health
site, MPCA has structured the following networks with agreed meeting times:
◦ MI Care Team Coordinators
MI Care Team Coordinators meet on a bi-weekly basis (Thursday’s 10:00am-11:00am)
◦ MI Care Team Billing and Finance MI Care Team Billing and Finance meet on a bi-weekly basis
(Friday’s 10:00am-11:00am)
◦ MI Care Team Community Health Worker MI Care Team Community Health Workers meet on quarterly basis
As of March 2017, MiCT CHW’s meet on monthly basis (Fourth Monday of each month)
◦ MI Care Team Nurse Care Managers MI Care Team Nurse Care Managers meet on a quarterly basis, as
requested by MICT Nurse Care Managers
Objectives for Peer to Peer Networks
Through MI Care Team peer to peer networks, MPCA strives to provide:
Channels of communication among each participating health center to promote network support
Opportunity to cultivate best practices
Opportunity to collaborate and problem solve among MPCA, MDHHS, and participating MI Care Team health centers
Online platforms for additional community learning trainings
Questions?
For more information, please contact:
Jessica Bautista
Program Consultant-MI Care Team/ Health Homes
517-827-0872
Sara Coates
Associate Director of Integrated Health
517-827-0875
MI Care Team Evaluation
Renu Tipirneni, MD MSc
Evaluation Team
Principal Investigator
Overall Evaluation Approach
• Compare each MI Care Team enrollee’s health care utilization and
costs to his or her own health care utilization and costs prior to
enrollment
• Compare health care utilization and costs of enrollees to a group
of similar individuals not enrolled in MI Care Team who are
receiving care at non-participating FQHCs
Cost and Utilization Analyses
• We will analyze claims data from the MDHHS Data Warehouse to report the following evaluation outcomes:
•
– Health care utilization: • Emergency department (ED) visits and hospital admissions
• Skilled nursing facility (SNF) admissions
• Outpatient care, including physical and behavioral health visits
– Costs over the entire demonstration period calculated in total and per-member-per-month (PMPM)
– Cost efficiency/sub-group analyses will also be conducted to examine variation in health care utilization and costs across a range of key enrollee and health center characteristics
Implementation Survey
• We are using a unique implementation survey completed by
Health Homes Coordinators to inform the evaluation and the
ongoing deployment of the program through the health center
learning community
• Initial surveys were launched in September 2016 and March 2017
Implementation Survey
• Results presented here are from the second implementation
survey conducted March 2, 2017-March 20, 2017.
• Responses are from the 10 health centers participating in the MI
Care Team demonstration.
Health Action Plan
• Half of respondents noted that it takes 16-30 minutes, on average,
to complete the health action plan with a patient, and two health
centers reported that it took longer than 30 minutes.
• Completion of the Health Action Plan may take less time than it did
earlier in the demonstration period.
• In the first survey, half of respondents noted that it takes 31-60 minutes, on
average, to complete the Health Action Plan with a patient. The other five
health centers spent less 30 minutes or less, on average, completing the
Health Action Plan.
MI Care Team Communication
• Common ways MI Care Team members communicate with one another:
– Pre-session huddles (9)
– Notes or notices sent as alert in the record, email, or other written communication (8)
– Routine access to the documentation of other team members in medical record (7)
– Informal conversations (6)
• Nine out of 10 health centers huddle, and two-thirds of these (6) do so 5 times per week.
• Most (8) health centers reported that their MI Care Team has become more efficient with information sharing since MI Care Team.
• In open-ended responses, health centers noted that utilizing EHRs, regular team meetings/huddles, tracking system/ database, & better communication between team members helped their MI Care Team become more efficient in sharing information.
Referrals to Community Resources
• Common types of social services/organizations that MI Care Team members work with to provide resources to and referrals for patients:
– Food assistance (10)
– Housing assistance (10)
– Transportation assistance (10)
– Resources for seniors/people with disabilities (8)
– Community centers/other public spaces for community activities/exercise (7)
– Intimate partner violence/domestic violence/child abuse resources (7)
– Job or vocational training programs (6)
– GED or other community education assistance programs (6)
– Childcare assistance (5)
– Resources for non-English speakers (e.g., translation assistance, ESL classes) (5)
• Commonly reported resources that remain difficult for MI Care Team patients to access include: housing assistance (5) and transportation assistance (5)
Communication with Local Hospitals or Emergency
Rooms
• MI Care Team members report communicating with local hospitals
and emergency rooms most often in the following ways:
– Messaging via the electronic health record (EHR) about
admission/discharge/transfer (6)
– Messaging via fax about admission/discharge/transfer (6)
Level of Behavioral Health Integration
Level of Behavioral Health Integration
• The majority of MI Care Team organizations report that they are a Level 4 or Level 5 on the integration scale (Co-located or Integrated).
• More than half of MI Care Team organizations (6) report moving up at least one level in behavioral health integration compared to before MI Care Team implementation.
• Some health centers reported variation in level of integration across delivery sites participating in MI Care Team.
Level of Behavioral Health Integration Over Time
Number of Health Centers
Before MI Care Team Sept/Oct 2016 March 2017
Level 1 0 0 0
Level 2 1 0 0
Level 3 5 2 1
Level 4 2 7 4
Level 5 0 0 4
Level 6 1 1 1
Total 9 10 10
Reported Barriers to Achieving Greater Behavioral
Health Integration
• Provider buy-in, time, shared providers/ scheduling conflicts,
challenges of being able to have real-time access to ER
information
Experience with Waiver Support Application (WSA)
• Some report using it regularly/daily
• Others described challenges with accuracy and noted infrequent
use
CareConnect 360
• Experience with CareConnect360: – Used by many but not all of those who completed the survey
– Used to view demographics, diagnosis, recorded patient use of the ER
• Barriers to using CareConnect360: – Some reported technical challenges with the information they are able to
access
– Not updated in real time
– Remaining questions about how to use it
Patient Satisfaction
• Many people reported that their MI Care Team patients are very
satisfied
• Some noted that patients do not understand the benefits of the
program or are not comfortable with the monthly contacts
Reported Challenges to Care Model Implementation
• Too few staff to address all patient needs
• Provider buy-in; providers not given enough time for MI Care Team patients
• Underutilizing CHWs
• Trying to minimize patient burden while providing assistance and support to patients and maintaining monthly contact/follow-ups is challenging, especially as number of patients enrolled in MI Care Team increases
Impact of Demonstration on Patient Health & Health
Care Utilization
• Reported decreases in A1C, reductions in smoking, increases in
exercise, patients calling providers before going to the ER
• Providing new resources to help patients overcome barriers
• Learning more about and addressing patients’ needs around health literacy, behavioral health, social determinants, social support, and community resources, especially through CHWs
• Frequent contact has enabled trust with patients
• Frequent contact allows for more follow through with providers/referrals
Questions?
• Contact information:
– Renu Tipirneni – [email protected]
– Erica Solway – [email protected]
Heather Beauxis
Enabling Services Manager
All four of our primary health center locations are participating:
Atlanta
Hillman
Onaway
Rogers City
Enrollment
330 Beneficiaries Enrolled
45% of eligible population
Per health center:
Providers
Medical Support Staff (LPN, MA)
RN Care Manager(s)
CHW
Behavioral Health Consultant (LMSW)
Over 4 health centers:
Psychologist
Health Homes Coordinator
MI Care Team Advisory Committee; weekly meetings ◦ Health Homes Coordinator ◦ Clinical Supervisors ◦ Clinical Director ◦ Reimbursement Director ◦ Quality Improvement Director
Committee provides weekly updates to: • CEO • CFO • CMO • Medical Director
Roll out at departmental meetings ◦ MI Care Team procedure manual
◦ How to bill laminated card
◦ Initial Visit Check List laminated card
Schedule appointment for following month
MI Care Team- Initial Visit Checklist
Consent Forms
Self-management goals, encouragement
Comprehensive Care Management, Initial Code
Health Literacy
Social Determinants
How to Bill for MI Care Team
Initial Visit (Must be with provider)
Comprehensive Care Management, Initial S0280
Follow up appointments (Any member of the care team)
Comprehensive Care Management, Ongoing Care S0281
o Use diagnosis code from “MI Care Team Dx for S0281”
list anytime S0281 is used. Choose at least one or as
many as apply.
Must touch on 2 aspects of Health Action Plan
What is MI Care Team?-Role Play
Eliminate Barriers
Monitor Program
Real Time Follow-Up
Continued Efforts
CFO presentation on the future of reimbursement; MI Care Team is preparing us
Regular communication
Share data ◦ Teams enrollment %
◦ Missed Opportunities
Regular Communication Case studies training; prioritize patients
number one concern Share success stories related to care
coordination Add to rooming procedure Missed opportunities report
Work with Practice Management software vendor to complete necessary system setup.
Communicate requirements to Billing Agent.
Test, test, test!
Submit claims frequently to ensure encounters are received timely.
Internal Process ◦ Verify encounters submitted (weekly)
◦ Verify Payments received through CHAMPS
◦ Work with State of MI and MPCA on discrepancies
Strong internal processes = LOW recoupment rates!
• Display marketing materials
• “Normalize” the program • Send TBCHS letter to those
not scheduled to come in
• Practice change – all staff are MI Care Team staff • Behavioral Health and CHW join morning huddle • CHW and Care Manager huddle regularly • Move CHW to care team work area
