The “Michigan Primary Care Transformation” (MiPCT) demonstration project is a statewide health care change effort that addresses the federal Centers for Medicare & Medicaid Services’ (CMS) three-part aim of improved population health, better experience of care, and lower costs.
MiPCT is one of CMS’ Multi-Payer Advanced Primary Care Practice demonstration projects; six payers, 36 physician organizations, and 350 practices participate. More than 400 care managers in primary care practices serve more than 1.1 million Michigan residents, providing self-management support, medication management, care coordination, patient education, and transitional care.
Patient-centered medical home models hold great promise. As one of the largest demonstration projects in the U.S., Michigan’s outcomes are of great importance.
MPHI collects monitoring data and is conducting a robust evaluation, including analyzing claims and encounter data, and surveying care managers, providers, practice staff, physician organization leadership, and patients. The Michigan Department of Health and Human Services and the University of Michigan provide leadership and daily management.
MPHI, in partnership with the Michigan Department of Health and Human Services (MDHHS) and local community agencies, received a $14 million, three-year grant award from the federal Centers for Medicare & Medicaid Services in 2012 to implement the “Michigan Pathways to Better Health” (Pathways) initiative.
With the goal to improve client outcomes and lower costs of care, the Pathways program addresses social service needs and links clients to primary care and preventive health services. Community HUBs (referral/tracking centers) and Lead Agencies coordinate resources and deploy community health workers (CHW), who assist adult Medicaid and/or Medicare beneficiaries with two or more chronic conditions by using evidence-based pathways (protocols).
In Michigan, CHWs have been working in three high-need counties – Ingham, Muskegon, and Saginaw – where they assist clients with health care, housing, food, and transportation needs. In each county, several agencies work together to implement the model.
In 2014, MPHI and MDHHS collaborated on sub-projects to develop new pathways and provide client-education resources for tobacco cessation, hypertension, diabetes, and prevention of falls. The Pathways initiative collects and shares client data with MDHHS to better understand the client population and improve services.
As of December 1, 2015, Pathways had 8,197 cumulative clients. The initiative is currently in a No-Cost Extension year, with some reduction in the numbers of new clients and CHWs. Over the 3½ years of implementation, more than 80 CHWs have been trained and deployed.
The MiPathways data system (created by MPHI) continues to collect data entered by CHWs as they provide services to clients and document their activities. The extensive data accumulated permits analyses of client outcomes, utilization of Pathways, and the relationships among client data and Medicare and Medicaid data. The database constitutes a resource for the Centers for Medicare & Medicaid Services, MPHI, and MDHHS for future research into the reduction of health care utilization and costs.
The project described was supported by Grant Number 1C1CMS331025 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
The Patient-Centered Outcomes Research Institute’s (PCORI) “Pipeline to Proposal” (P2P) program provides resources to build a community of patients, caregivers, clinicians, and researchers with the expertise and passion to participate in patient-centered outcomes research. Capacity-building awards are provided to individuals and organizations who want to conduct research but are not yet ready to apply for funding from traditional sources.
PCORI is an independent, non-profit organization that was authorized by Congress in 2010. Its mission is to fund research that will provide patients, their caregivers, and clinicians with the evidence-based information needed to make better-informed healthcare decisions. PCORI is committed to continually seeking input from a broad range of stakeholders to guide its work.
These awards are a progressive, three-tiered funding approach that move forward incrementally as partnerships and research capacity is developed. Throughout the tiers, the involvement of patients, families, and caregivers is a critical component to the success of the project. In Tier I, awardees develop partnerships and a process for involving patients in the development of comparative effectiveness research (CER) ideas. In Tier II, awardees maintain and expand the partnerships and further develop CER ideas into CER questions; these questions are then developed into a full research proposal in Tier III.
MPHI serves as the Midwest Pipeline Award Program Office, providing operational, programmatic, and fiscal agent services to awardees in 12 states (currently with awardees in Illinois, Iowa, Kansas, Minnesota, Missouri, and Ohio). Technical assistance is provided to assist with development of community engagement strategies, creation of infrastructure, strategic planning, and capacity building for conducting patient-centered research. Technical assistance tailored to the needs of each awardee is provided via monthly conference calls and is supported by telephone, emails, and a SharePoint site. Webinars provided to all project partners enhance awardees’ progress. Most recently, MPHI produced a training webinar on the development of patient-centered research outcomes. Fiscally, MPHI contracts with awardees, manages payments, and monitors spending to ensure funds are being spent in accordance with PCORI guidelines.
MPHI’s first cohort of awardees began in spring 2015 and they are now preparing for Tier II (slated to begin May 2016). MPHI’s second cohort of Tier I awardees will begin in August 2016. A wide range of health concerns (such as diabetes, mental health, and multiple sclerosis) and populations (rural, youth, and newcomer) are included in the current cohort of projects.
The Athens Photography Project (APP), Inc. is a non-profit art program that promotes mental health recovery by providing opportunities for members living with mental illness to express themselves creatively through photography. APP and their partners at Ohio University are learning more about mental health recovery by building a patient-engaged community aiming to develop long-term solutions in mental health care and drive meaningful research into rural mental health care.
APP’s director, Nate Thomson, has a very close relationship with mental health patients through his involvement in the art program. As a result, he and his partners are working to build a patient-centered partnership during Tier I. Recently, the partnership coined a title and slogan for their project to reflect the region and consumer-centered focus on mental health, “The Front Porch Project ̶ our lives are the evidence of what works in rural mental health recovery.” The purpose is “to empower mental health consumers within rural Appalachia to participate in the ever-evolving conversation about what clinical treatment, recovery support options, and self-directed approaches are beneficial in mental health recovery.”
MPHI will continue to work with APP and the Front Porch Project, providing guidance and technical assistance throughout Tier I and the remaining tiers. MPHI is honored to provide assistance in this effort to conduct research on innovative methods for supporting the needs of mental health consumers.