This document summarizes a webinar for primary care physicians and practice teams from Medical Network One. It recognizes physicians who received Patient-Centered Medical Home designations from BCBSM. It outlines ongoing activities like care teams, collaborative projects, and enterprise-wide initiatives to support practices. These include the CMS MiPCT demonstration project, diabetes and behavioral health programs, care manager training, and organized systems of care. Attendees are asked for input on communication, collaboration, and future initiatives.

1. MEDICAL NETWORK ONE
PRIMARY CARE PHYSICIAN
AND PRACTICE TEAM WEBINAR
JUNE 20, 2012

2. Welcome and Acknowledgements
 Online Introductions
 Current PCP membership

3. Welcome and Acknowledgements
 Dedicated PCMH Implementation Team
 BCBSM PCMH Designations
 Behavior Health recruitment
 Provider and Health Plan Outreach
 Organized Systems of Care
 Specialist Contracts

4. Congratulations:
2012 BCBSM PCMH Designations
• Everett Campbell • James Miller, DO
• Douglas Hames, MD • Tedd March, DO
• Elzbieta Rozmiej, MD • Solon L. Alimario, MD
• Pam Cox, MD • Anthony Clarke, MD
• Al Juocys, DO • Alfred Newton, MD
• Shalija Rastogi, MD • Roy Elrod, MD
• Elena Stephan, MD • Katrice Herndon, MD
• Namir Stephan, MD • Nichole Massie, MD
• Rick Poston, DO • Lennox Pike, MD
• Michelle Pavlik, DO • Ralph E. Williams II, MD

5. Congratulations:
2012 BCBSM PCMH Designations
• Richard Fici, DO • James Miller, DO
• Polly Schmidt, DO • Ia Y. Kue, MD
• Kevin Klein, DO • Bruce Johnson, DO
• Thomas Mianecki, DO • Susan Tam, DO
• Karl Emerick, DO • Abdul Kabir, MD
• David Ginnenbaugh, MD • John Pradko, MD
• Thomas Horrigan, MD • Curtis LaJoie, DO
• Ashraf Barry, MD • Taras Lisovsky, DO
• Anna Fraymovich, MD • John Floreno, DO
• Antoun Oska, MD • Robert Moretzky, DO

6. Congratulations:
2012 BCBSM PCMH Designations
• David Everingham, DO • Stephanie Lucas, MD
• Craig Everingham, DO • Logan Oney, MD
• Gregory Henk, DO • Maan Askar, MD
• Vesna Evkoska, DO • Steven Zalla, DO
• Ricardo Cabrera, MD • James Kohlenberg, MD
• Fayes Shukairy, MD • WSU FP
• Jeetender Matharu, MD • WSU IM-5B
• Ronald Williamson, MD • WSU IM-4C
• Stephen Bell, DO
• Samar El-Achkar, MD

7. Goals and Purpose of Webinars Restated
 Provide information about ongoing company
endeavors both internal and external
 Describe to your colleagues and practice teams
what we do and what we are striving for
 Identify 3rd quarter goals
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8. Goals and Purpose of This Webinar
 Present an overview of the following:
• CMS Demonstration Project (MiPCT)
• Diabetes Cell Phone Project
• Behavior Health Initiative
• Organized System of Care Activities
• Care Manager and Population Manager Training
 Draw comments and input regarding:
• Communication efforts
• Collaborative efforts
• Initiatives
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9. Current Activities – Care Teams
 Adult
 Adolescent/Pediatric
 R-Team (Pediatric Healthy Lifestyle)
 Behavior Health
 DSME
 Worksite Wellness Programs
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10. Collaborative Activities
 Mackinac Learning Collaborative III
 Preparation for MLC IV
 Practice Coaching
 LEAN Coaching
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11. Enterprise Wide Activities
 Dedicated PCMH Implementation “A” Team
 Organized Systems of Care
 Specialist Agreements
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12. Enterprise Wide Activities
 IMPACT Model co-training with WSUPG Team
 Monthly Specialist Focus Group Meetings
 Quarterly Cluster Meetings
 Complex Care Manager Training
 Moderate Care Manager training
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13. Internal Activities
 Medical Management
 Physician Recruitment, Contracting and Retention
 Quality Improvement
 IT revamping
 AADE audit
 Staff training and education
 HAP Contract
 OMNICARE Contract
 Blue Complete Contract
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14. Current Activities - Ongoing
 MiPCT
 CDSMP - PATH
 Diabetes Crossover
 Matter of Balance
 Mindful Eating
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15. Clinical Activities
 Patient Registry
 ePrescribing
 Generic Use Rate
 QI Activities to Improve Quality Scores
 MUSIC: WSUPG Committee Member
 Cardiology: WSUPG Committee Member
 Transitions of Care
 Organized Systems of Care
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16. MiPCT: CMS Demonstration Project
 PCMH designated practices for 2 years
 Practice transformation payments
 Participating health plans contribute $3.00 PMPM
to the incentive program pool
 Performance incentive metrics in place
 PO scores will be ranked from high to low and
placed into payment deciles, ranging from 82% to
118% of the mean payment
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17. MiPCT: MNO
 Clinical leadership support
 Care Manager Support
 Implementation of tools and care processes that
enable the primary care practices to achieve
practice transformation
 Analytical support with generation of reports to
measure transformation progress
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18. MiPCT: MNO and PCP
 RN, MSW, PA-C and APRN care managers within
primary care practice settings
• Geisinger
• University of Massachusetts
• PTI
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19. MiPCT: MNO and PCP
 Develop processes that enable primary care
practice teams to engage patients and their
caregivers and/or families, as appropriate, in their
own care through:
Care management
Self-management support
Navigation and coordination of care
Effective transitions of care
Linkage with community resources
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20. MiPCT: PCP
 Develop processes that enable collaborative team
care
 Enhance access to quality care through:
Same day appointments
After hours care
Electronic access to care: email, e-visits
Patient portal
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21. MiPCT: Deliverables
 Year One: Develop primary care practice
infrastructure including enhanced access, all
patient registry system and embedding care
managers within the primary care practices
 Year Two: Optimize care management, improve
quality metrics and avoid high cost care
 Year Three: Achieve the “Triple Aim” of improved
quality of care, improved patient and primary
healthcare team experience of care and reduced
/stabilized costs of care
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22. MNO Engagement
 Travel Team
• Behavior health
• RN
• Dietitians
• Exercise specialists
 Medical Management
 Care Management
 Quality Improvement
 IT
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23. Our Enterprise… It’s Up To You Now
 What do we need to move forward effectively?
 What evidence do we have to prove that our work
is making a difference?
 What evidence do we have to prove that our work
made a difference?
 Have we shared the results of our work beyond
our organization?
 How can we share the results of our work beyond
our organization?
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24. Vision… Revision Required
 To be recognized and respected as the premier
independent healthcare organization in Michigan
that offers community-based inter-professional
patient-centered/family-centered quality care.
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25. Ask Yourself This Question…
 I know what action steps our organization is taking
next as a result of today’s meeting.
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