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Care Management
While care management is typically thought of as an effective healthcare approach for patients, independent physicians and their practices can also realize benefits from integrating care managers into the healthcare team. The benefits for care management range from improved cost to higher quality outcomes, the positive results of care management are observed in many areas.

Care management allows for a cohesive and collaborative approach to patient care. The primary care provider, specialists, and the patient and/or patient’s family and caregivers work together to coordinate care to result in the best possible outcomes for the patient. With a focus on quality of life and self-management strategies for disease management, care management particularly benefits those patients with chronic of complex conditions, who move along the health care continuum.

The Department of Health and Human Services (HHS) states that “by 2030, 25 percent of the U.S. population will be 60 and older, and 19 percent of the population will be 65 years of age and older. At least 90 percent of those 65 and older now have one or more chronic conditions.” Further, HHS explains that if the health-related needs of this population are not met appropriately, through enhanced clinical and community coordination, that “may increase the risk of developing chronic conditions, reduce an individual’s ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization.”

Care management delivers benefits to this demographic and those patients with chronic conditions by:
• Decreasing treatment costs
• Lowering the rate of hospitalizations
• Eliminating unnecessary and redundant testing
• Managing medications to prevent adverse interactions and/or readmissions
• Involving the patient’s family and community to boost emotional well-being and ensure the patient has the necessary resources to manage his/her health
• Ensuring the primary care physician maintains a complete picture of the patient’s overall health and no services fall through the cracks
• Enabling the provider to properly manage all care, improving outcomes for the patient

The bottom line for patients and providers is that care management, by enabling the primary care physician to provide more efficient and coordinated healthcare, improves outcomes, and reduces costs for all involved.

Erica Ross, Clinical Services Manager


Patient Centered Medical Home
Welcome to the Blue Cross Blue Shield of Michigan Patient Centered Medical Home (BCBSM PCMH) monthly newsletter update! Each month we will bring together all relevant PCMH news and updates for our participating provider community. This month we will discuss the requirements for new capability 9.13.

9.13 Systematic approach in place to screen patients for reducing the risk of falling and for monitoring physical activity

PCP and Specialist Guidelines:

  1. Screening tool should include yearly assessment sheet regarding fall risk
    • Examples of acceptable tools may include John Hopkins Fall Assessment Tool or Fall Risk Assessment, STRATIFY or Morse Fall Scale
    • Practice must have a scripted discussion with the patient about fall risk
  2. Approach for fall risk should include education related to fall prevention or treating problems with balance and walking
    • Discuss balance problems, falls, difficulty walking and other fall risks
    • Suggest cane or walker use
    • Check blood pressure with patient standing, sitting, and reclining
    • Suggest exercise, physical or occupational therapy
    • Suggest vision/hearing test
    • Perform bone density screening, especially for high-risk members
  3. Approach for monitoring physical activity should include yearly discussion regarding the patient’s current activity
    • Discuss how to start, increase, or maintain activity
    • Refer patients with limited mobility or walking/balance issues to physical therapy to learn safe and effective exercise

Kathryn Correll-Rice, Manager of Quality Improvement Strategy

MEDICAL MANAGEMENT UPDATES
HELLO, JUST A REMINDER TO ALL THE PRACTICES – March 2022

  1. Global and outpatient referrals go through Medical Network One’s POD’s system (www.mednetone.net). If you need assistance uploading a referral, send a fax to 248-475-5777 or a secure email to cpourcho@mednetone.net.
  2. Office managers can add new members to access PODS. Have the office manager log into the site and select “Request a New Account”. Our referral specialist checks the site daily and will set up new accounts as requested.
  3. All MRI’s and CT Scans go through AIM now (1-800-728-8008).
  4. All PT/OT/ST (physical/occupational/speech therapy) go through EVICORE (1-877-531-9139). Chiropractor referrals are only good until the end of the year. Initial referral is good for 30 visits and then unlimited after that.
  5. Patients with BCN Advantage DO NOT need a global referral to see a specialist. They only need a referral for the procedure that they are having done (e.g. colonoscopy/EEG).
  6. Diagnosis codes need to be specific. Please do not submit Z00.00 for any specialist. For example: Knee Pain Unspecified (need specific knee). – If we receive unspecified diagnoses, we will contact you for a different diagnosis.
  7. Any practice that cannot get on to PODS and needs a referral completed can print this referral form, fill it out, and fax it to 248-475-5777.

If you have any questions, please contact us, we are here for you. Stay Safe!!!
Christina Pourcho, Referral Specialist
Phone: 248-475-4759
Fax: 248-475-5777
Email cpourcho@mednetone.net (SECURE EMAIL ONLY)


Quality Improvement
Welcome to the quality improvement portion of the newsletter. We will be going over important updates to quality measures and changes that may occur throughout the year.

This month we will be going over when new payer reports will be available for different payers in the state for measurement year 2022. As many of you are aware, most of the payer portals that accept supplemental data for measurement year 2021 quality gaps are already closed, with the last ones closing February 28th, 2022. Due to this, the transition to measurement 2022 gaps in their systems take a little time to process on their end. Most of the new 2022 gap-in-care data will be available at the end of March through the end of April. However, we were able to pull measurement year 2021 gaps prior to the tools being closed done. So, if you would like to start outreach for cancer screenings, retinal eye exams, etc., we do have a list of patients you could work off, based on who didn’t have a given service by the end of 2021. If you would like to get this list, feel free to reach out to your population health coach or you can always reach out to Kathryn Correll-Rice or Andrew Kurecka.

Andrew Kurecka, Director of Innovation, Research, and Improvement


Human Resources
Workplace leaders should follow eight key tenets to discourage harassment and bullying.

  1. Model respect and civility. Don’t shut an employee down with a caustic comment during a meeting, for example, but if someone says something that is unclear, ask for clarification.
  2. Refrain from harassing employees and other unacceptable conduct. Emphasize the importance of respect and civility. If an employee’s dignity is taken away, he or she is more likely to sue.
  3. Instill a culture of reporting complaints to HR. Make clear to supervisors and directors that they need to report claims of harassment to HR, as well as retaliation complaints, wage and hour claims, and allegations of waste and abuse. Once a complaint is reported, the company can determine if something went wrong and address the issue if necessary.
  4. Respond proactively to harassing and unacceptable conduct even in the absence of a complaint. Tell your employees about their responsibilities as bystanders. When someone says something unacceptable, a leader should speak up. So if someone tells a co-worker during a meeting “You look sexy today,” any manager present should call out the employee for saying something unacceptable and counter to the organization’s culture.
  5. Work with HR to remedy unacceptable conduct. HR does not have exclusive ownership of respectful and civil behavior. Leaders need to work with HR and keep in mind that there’s no “rock-star defense” for unacceptable conduct by their star performers. If an offending employee objects to discipline by saying, “But I bring a lot of money into the organization,” note that there can’t be exceptions to the rules.
  6. Refrain from engaging in retaliatory conduct. Employers should prohibit retaliatory conduct. Moreover, employers need to create cultures where employees aren’t afraid to speak up out of fear of such cultural retaliation.
  7. Refrain from interfering in investigations. Sometimes leaders try telling witnesses what to say during investigations. Obstructing an employer investigation is a separate wrong apart from retaliation and one that must be avoided if there is to be a culture of respect.
  8. Promote inclusion. Promoting inclusion means more than fostering a civil and respectful environment so people can reach their full potential. It also means ensuring employees aren’t succumbing to implicit bias.

Robert Pejas, Director of Human Resources