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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