Resource Library

2019 Best Practice Awards Submission for Care Management Workflow

After the conclusion of the Michigan Primary Care Transformation program, Clinton County Medical Center saw an opportunity to restructure its office staff, including care managers, into physician-led teams to offer care management to all patients who could benefit from it. Through the changes in workflow over an 18-month period, CCMC was able to substantially increase engagement in both Provider Delivered Care Management (PDCM) claims and overall longitudinal care management.

2019 Best Practice Awards Submission for Care Management Workflow

A Health Navigator was embedded in the Skilled Nursing Facility with the highest admission and readmission rate to assist patients with discharge and coordinate with PCP. Working in conjunction with the MSW, nurse, and attending physician, barriers to discharge were also identified and community resources engaged as appropriate. The Health Navigator coordinated at time of discharge assisting with follow-up appointments and communication to PCP office.

2019 Best Practice Awards Submission for Care Management Workflow

The care management program was developed at the PO level and was modified and tailored to each practice to meet its patient population needs. A documented workflow process helped practices streamline care at patient level. Ongoing education, training and coaching is required for sustained improvement and engagement.  The workflow assisted practices to improve HEDIS quality scores and a decreased inpatient admission rate.

2019 Best Practice Awards Submission for Care Management Workflow

Ambulatory Care Managers began reporting through a centralized reporting structure to an AMC supervisor. Under the new structure, the orientation process was also revised and standardized to customize and track progress. Through improved training and standard orientation, this has led to an increase in billing codes dropped, number of patients in chronic care management, and ACM understanding of care management upon completion of orientation.

2019 Best Practice Awards Submission for Care Management Workflow

Through the implementation of the centralized care management model, an experienced RN care manager was hired to run the program with an initial focus on transitional care management following inpatient discharges and ED visits, and expanding to providing more longitudinal care management and adding additional centralized care managers.

2019 Best Practice Awards Submission for Behavioral Health Interventions

The process includes identifying patients and screening for Adverse Childhood Experiences. Based on the screening score, education is provided and appropriate referrals are made. For high-risk patients, coordination with the school takes place on a regular basis. Providers perform a medication review to determine if medications are appropriate. Educational materials are provided to families.

2019 Best Practice Awards Winner for Behavioral Health Interventions

The goal was to implement behavioral health integration services in a family practice setting. Patients could see a behavioral health provider for support with both medical and behavioral health diagnosis. A Diabetes Distress Screening was implemented to be completed in behavioral health integration visits with diabetic patients. Behavioral health integration education was provided to clinical and front office staff to embed workflows into daily practice. Behavioral health providers began attending morning huddle to help identify patients who could benefit from integration services.

2019 Best Practice Awards Submission for Behavioral Health Interventions

With the use of MiHIN Admission, Discharge, and Transfer data and internal discharge notifications, patients discharged from ED or inpatient with risk of suicide were identified. Behavioral Health Specialists use the list of identified patients to conduct transition of care phone calls. This new process aligns with the Spectrum Health system-wide initiative of Behavioral Health integration and Zero Suicide. The new process also utilizes standard Behavioral Health TOC assessment.

2019 Best Practice Awards Submission for Behavioral Health Interventions

A centralized behavioral health counselor was made available for unlimited referrals to 21 primary care practices. There were over 720 referrals, over 330 unique individuals documented/counseled, and over 1,600 patient encounters completed within 2.5 years. A directory of behavioral and mental health service agencies was maintained to directly assist with coordinating patient referrals and connections to resources. Behavioral Health was provided to PO-specific members free of charge or cost-sharing.

2019 Best Practice Awards Winner for Behavioral Health Interventions

HVPA developed a unique adaptation of the AIMS collaborative care model in order to support independent offices with psychiatric resources. This included contracting with local hospital systems to lease psychiatrist time; contracting with community psychiatrist to lease time to be used in the collaborative model; and placing Behavioral Health Care Managers into offices to provide brief intervention or clinical evaluation of patients to better meet the mental health needs of patients in the primary care setting.