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Web view4/14/2014 · Health care professionals who may furnish TCM services; TCM services settings; Components included in TCM; Billing TCM

Feb 08, 2018





MiCMRC Care Manager Monthly Update

April, 2014

Complex and Hybrid Care Manager Training: Training was held April 7-10, 2014.

Updates to the MiPCT-Approved Self-Management Programs: The April 7th, 2014 edition of the MiPCT Monday FLASH provided information on the most up to date Self-Management Programs that are approved by MiPCT. The article can be found at

November and December 2013 G-Code Reports:

The November 2013 G-Code Reports were not re-created because no new G-Code claims were provided in the updated November paid claims data received.

New G-code Reports for December 2013 were made available on the Download PO Reports tab of the MiPCT Dashboards on April 2, 2014. These reports use March 2014 attribution for claims paid in December 2013. The reports are located in the file.

The January 2014 reports were posted in April. The reports use March 2014 attribution for claims paid in January 2014.

MDC Release 8.0: This release occurred on April 1, 2014 and included the following:

For measures that MDC calculates, the measurement year includes dates of service from 9/1/2012 through 8/31/2013 based on paid claims through 11/30/2013. This calculation allows for a three month claims run-out.

Priority Health PPO data is included.

Standard Cost values have been updated for new claims from the newest version of the Truven Health Analytics Commercial MarketScan data.

Added Inpatient utilization trend data to the MiPCT and PO Utilization Trends dashboards.

Added Inpatient utilization data to the PO Comparison Utilization dashboard.

Added new PO Inpatient Utilization Comparison Reports (one comparing all POs and one comparing all Practices within your PO).

Changed the titles of the Comparison Reports in the file to better reflect the reports included.

Updated documentation, including the Release Notes and User Guide is posted on the Support page of the MDC Website.

MDCs April 2014 MiPCT All-Payer Patient Lists: The Michigan Data Collaborative posted the April 2014 MiPCT All-Payer Patient Lists the week of April 28th, 2014. An email announcing the release was sent to Dashboard users. The MiPCT All-Payer Patient Lists are located on the Download PO Reports tab of the MDC MiPCT dashboards. The patient list .zip file includes a list of all MiPCT patients for the PO, formatted lists for each Practice within your PO, and a dropped patient list.

BCBSM PDCM Reimbursement Policy and Billing Guidelines: The BCBSM PDCM Reimbursement Policy and Billing Guideline-Commercial was recently updated. Also, the BCBSM Medicare Advantage Reimbursement Policy and Billing Guideline Medicare

Advantage was updated January 2014. These documents can be found at

Centers for Medicare & Medicaid Services (CMS) Transitional Care Services Fact Sheet:

The CMS Transitional Care Management (TCM) services Fact Sheet includes:

Health care professionals who may furnish TCM services;

TCM services settings;

Components included in TCM;

Billing TCM services;

Frequently Asked Questions; and


The CMS TCM Service Fact Sheet can be found at

MiPCT Clinical Focus Areas for 2014: The April 28th, 2014 edition of the Practice and PO FLASH presented information on the clinical focus areas for 2014. The clinical focus areas for the adult population include improving clinical indicators for individuals with diabetes, targeting the right (high-risk) patients, behavioral health and depression, and palliative care. The clinical focus areas for the pediatric population include targeting the right (high-risk) patients and behavioral health and depression. The complete article including the rationale and strategies for impacting these areas of focus can be found at

Care Manager Conference Calls: Care managers, identified by their PO to be eligible to participate, attended the Transition of Care (LMSW and Adult care managers) and Depression Revisited (Pediatric care managers) conference calls in April. Five conference calls were held (4/2/14 Adult CMs-South East region, 4/9/14 Adult CMs-North region, 4/11/14 Pediatric CMs, 4/16/14 Adult CMs-West region, and 4//18/14 LMSW CMs). The care manager conference calls provide an opportunity for discussion of application of concepts presented in webinars as well as sharing of best practices and networking.

Resources reviewed during the Transition of Care conference calls included the following: community resources document template, TOC roles template, LACE tool, post discharge tool, and TOC team process. The resources presented during the conference call are provided in the resource list below.

Pediatric webinar: A webinar/conference call was held April 21, 2014 titled Depression Revisited.

Adult webinars: One webinar was held April 23, 2014 titled Care Manger Survey Results.

Webinar recordings can be found on the private side of the Michigan Care Management Resources Center website at

April 2014 Resource List

Adult Webinar Conference Call Resource Links

Transition of Care Conference Call

Slide deck (Double click on the image to view the file)

Community Resources Document Template (Double click on the image to view the document)

TOC Roles Template (Double click on the image to view the document)

LACE Tool (Double click on the image to view the document)

Post Discharge Tool (Double click on the image to view the document)

TOC Team Process (Double click on the image to view the document)

Care Manager Survey Results

Slide deck (Double click on the image to view the document)

Pediatric Webinar Conference Call Resource Links

Depression Revisited (Resources are provided within the webinar slide deck provided below).


Call 3 26 14.pdf

The Michigan Primary Care Transformation (MiPCT) Project

Transition of Care Care Management Conference Call April, 2014


Identify MiPCT utilization evaluation metrics and TOC MiPCT data

What do patients/families identify as important to have a smooth transition from one setting to another

Identify TOC interventions success/barriers, tools, and resources to address


TOC - Why are we talking about this Now?

Voice of the patient Post hospitalization, what do patients and

caregivers identify as important?

MiPCT TOC data what does it tell us? For many MiPCT practices, TOC intervention

began 4/2012

What have we learned? MiPCT Care Managers lessons learned


MiPCT Patient Advisory Council

What is important to you as a patient/caregiver when preparing to go home after a hospitalization?


Patient/Caregiver questions when preparing to go home from the hospital

When should I follow up with my doctor(s)?

How do I take my medication?

When can I start weaning off my pain medication?

How do I arrange for care/treatment needed at home?

Who do I call at my doctors office during office hours, after office hours and on week ends to ask questions, address concerns? (to prevent going back to the ED.)

When should I expect to return to my normal routine?

Written information for quick reference. (community resource sheet with current phone numbers)

What does my insurance cover? MiPCT Patient Advisory Council


Question: What would have happened in Michigan without the

MiPCT demonstration? Conducted by: Research Triangle Institute (RTI)

Outcomes of MiPCT beneficiaries must improve at a greater rate than comparison beneficiaries


Centers for Medicare & Medicaid Services MiPCT Measures Cost Average PMPM Measured as Medicare


Quality Diabetes care: LDL-C screening HbA1c testing Retinal eye examination Medical attention for

nephropathy All 4 diabetes tests

Ischemic Vascular Disease: Total lipid panel test

Patient experience survey

Utilization All-cause hospitalizations ACSC hospitalizations (PQI) All-cause ED visits % ED visits that do not lead to

hospitalization Discharges from short-term

general, rehabilitation, and SNF with (billed) clinical follow-up within 14 days

Rate of 30-day unplanned readmissions (CMS definition developed by the Yale New Haven Health Services Corporation)

Quarterly Trend Comparison: Medicare PMPM Payments


Quarterly Trend Comparison: Hospital Admissions


MiPCT Transition of Care Intervention Care Manager conducts Transition of Care follow

up phone call within 24-48 hours post hospital discharge Then weekly x 4 phone visit

Address: Medication reconciliation Follow up - PCP appt., specialist appt., tests Social support Assessment barriers Red flags Care coordination Inform patient/caregiver Access to PCP office how to


Data were collected via Survey Monkey Dec.16, 2013- Jan 5, 2014

424 Care Managers were emailed invitations to participate

Data cleaning and analysis was performe