Oakland Southfield Physicians

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Care Management Program

Oakland Southfield Physicians (OSP) is pleased to support the local and national trend of advancing primary care practice by including care management services.   The care manager serves as a collaborative member of the practice-based clinical care team and works in concert with the patient's primary care physicians to support patient health improvement and wellness.  

Care managers promote patient-centered care through activities such as:

  • Care coordination support
  • Transitional care assistance
  • Linkage with community resources
  • Optimize diagnosis code capture and close gaps in care
  • Self-management and patient education
  • Patient risk assessment and support

Comprehensive Practice Support

OSP is pleased to announce we are an approved training organization recognized through the Michigan Institute for Care Management & Transformation.  In addition, OSP offers our eligible primary care offices access to an interdisciplinary care management team comprised of registered nurses, pharmacists, masters in social work, and dieticians; all trained in moderate and complex care management models.

To learn more about OSP's care management support click here to email or call 248.357.4048.

Care Management Programs

OSP understands that care management programs can serve a variety of patient populations and are customized to the practice and the unique needs of the patients that it serves; from children to older adults, new diagnoses to transitions of care, health improvement or end-of-life.  Therefore, OSP is proud to support our practices in several unique and innovative care management programs.

The Provider Delivered Care Management (PDCM) program is rooted in the Patient Centered Medical Home program. It is a care management program delivered in the physician’s office, provided by trained care managers in conjunction with the physician and clinical team. The goal of PDCM is to provide patient education, care coordination, and other support services either face-to-face or telephonically by care managers working collaboratively with the patient and the patient’s physician. The program is designed to help patients with health care issues address medical, behavioral, and psychosocial needs, to ensure the patient is successful in meeting their health goals.

The High Intensity Care Management (HICM) program is designed to help the most complex BCBSM Medicare Advantage PPO patients manage their multiple health conditions, coordinate their health care, and achieve optimal health. Services include a comprehensive array of patient education, care management, and other support services delivered face-to-face, often in the patient's home, and over the telephone by a trained team of ancillary health care professionals who work collaboratively with the patient, the patient's family, and the patient's primary physician.

The Collaborative Care Model (CoCM) integrates behavioral health with primary care to ensure effective treatment in the primary care setting. The Collaborative Care Model is highly evidence-based and has been shown to be the best approach to treating depression and anxiety. The model uses an enhanced care team to provide a population-based, treat-to-target approach to care. Through shared care planning, the team makes proactive changes in treatment to ensure no patients fall through the cracks.

OSP's Early Care Management Experience

The Michigan Primary Care Transformation (MiPCT) project was a five-year, multi-payer collaborative to strengthen and expand the delivery of patient-centered medical care throughout Michigan. The project was designed to provide practice-based care management support to continue the growth of patient-centered and evidence-based health care services in an effort to determine the value of the patient centered-medical home (PCMH) approach compared to traditional care.

The Enhanced Care Program (ECP) was a selective healthcare pilot program sponsored by Ford Motor Company and the UAWTrust and, in collaboration with the UAW, which sought to support and redefine primary care delivery in Southeastern Michigan.  The concept of the ECP was to create an ambulatory intensive care coordination and management experience.  In this program, ambulatory patients received longitudinal, holistic and comprehensive care through a nurse care manager, under the leadership of the patient's primary care physician.  Click here to see the results of this foundational care management pilot.

Michigan Pharmacists Transforming Care and Quality (MPTCQ) was a statewide consortium led by the University of Michigan Health System (UMHS). OSP is one of ten physician organizations from across Michigan selected to participate in MPTCQ. Objectives were to adopt and modify clinical infrastructure and process elements of the integrated pharmacist practice model, as well as improve patient care and outcomes through pharmacist integration in primary care practices. By incorporating pharmacists in direct patient care, we demonstrated performance improvement on several quality and process related measures including, but not limited to HEDIS and STARS.

The State Innovation Model (SIM) Patient Centered Medical Home (PCMH) Initiative was Michigan’s three-year State Innovation Model grant from the Centers for Medicaid and Medicare Services (CMS) testing both delivery and payment system changes.  In the SIM model, embedded care managers functioned as integral, fully-involved members of every participating care team to further enhance the cost-effective, high quality care provided.   Care managers partnered with physician-led care teams to enhance patient experience and quality outcomes by supporting coordination of care within the medical system and to improve disease management and utilization.  SIM also included a focus on the social determinants of health and enhancing partnerships within community agencies. Oakland Southfield Physicians (OSP) was pleased to sponsor practices selected to participate in this program. 

Comprehensive Primary Care Plus (CPC+)  was a national advanced primary care medical home model that aimed to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation. CPC+ included two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States (U.S.).  OSP was proud to be part of the nearly 2,893 primary care practices participating in Comprehensive Primary Care Plus.

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