Medical Home Monitor
Medical Home Monitor
August 18, 2008
Vol. I, No. 5

Medical Home Monitor Archives

Medical Home Q&A:
Transitioning a Practice to a Medical Home

Medical Home Monitor

Q: Which improvements better position a physician practice to become a medical home?

A: In my organization, we try to implement health IT and the efficiencies gained from that to improve care that may occur at home and to coordinate care. The difficulties with patient-centered medical homes (PCMH) are interoperability and communication from one physician to another who may not have the same standard or interoperability that we may have. From the standpoint of office redesign, it’s important that not only the idea of getting health IT into your office will improve the concept of a PCMH, but going through the process — mapping out how you deal with telephone calls and discharges, how you communicate with a patient and how your office communicates — is important as well. (Dr. John A. Michos, M.D., is the medical director of the Physicians Office Quality Improvement Support Center (PO QIOSC) at Virginia Health Quality Center.)

For more information on physician practice transformation, please visit:

Certain Conditions Warrant Co-Management of Medical Home

Approaches that recognize the appropriate division of care between PCPs and subspecialists, facilitate comanagement when needed, and reward the collaboration required to provide medical homes for patients should be investigated as models of care, according to a survey of North Carolina pediatricians and endocrinologists about care management and coordination for children with insulin-dependent diabetes. The study, published in the August issue of Pediatrics, the official journal of the American Academy of Pediatricians, concluded that an effective medical home model of care depends on establishing clear lines of responsibility between the PCP and subspecialist.

Of 201 pediatricians surveyed, 132 responded (65 percent), and among the 61 endocrinologists who treat children, 59 percent replied. Nearly all of the respondents agreed that PCPs should have responsibility for routine primary care (e.g., well-child checkups, treating minor illnesses or injuries, and immunizations). Likewise, large majorities favored endocrinologists as leads for diabetes-specific care (e.g., 94 percent for training in insulin pump use and 82 percent for training in glucometer use.)

For more details on the survey, please visit:

HealthSounds Podcast: Medical Home Builds Community

The solid relationships that patients build with ACCESS Plus providers and office staff, many of whom live in the neighborhood, keep them coming back in for care, explains Dr. Lonnie E. Fuller, medical director for the Pennsylvania Medicaid ACCESS Plus Primary Care Case Management and Disease Management (PCCM-DM) program, which provides medical homes for its population. "Road shows" put on by ACCESS Plus's regional advisory committee foster dialogue among consumers, providers and community organizations, and its DM and telephone triage line efforts are reducing unnecessary trips to the ER.

To listen to this complimentary HIN podcast, please visit:

Changes in Culture, Workflows Hallmarks of Award-winning Medical Home Initiative

The American Medical Group Association (AMGA) has awarded its 2008 Acclaim Award to Mercy Clinics, Inc. for its initiative, “The Medical Home: Adding Value to Our Gains, Managing Growth, Expanding Our Reach.” The program uses the six Institute of Medicine (IOM) aims — safe, effective, patient-centered, timely, efficient and equitable care — to improve the healthcare delivery system in primary care settings throughout the organization. Mercy Clinics’ long history of continuous quality improvement and high level of leadership involvement were instrumental in creating an environment in which changes in culture and workflows were successfully spread across various provider offices. The result was significant improvement in clinical care for patients with chronic illness and increased access to care.

AMGA’s Acclaim Award honors organizations that embrace the IOM’s aims for an ideal healthcare system and have demonstrated dramatic, measurable progress in moving their organizations toward one or more of the six aims.

For more information, please visit:

Patient Registries: Essential Tool for the Medical Home

Patient registries — clinical information systems used by physicians to identify and track patients with a defined disease or condition — put physician practices on the path to becoming a medical home. Besides creating realistic views of clinical practices, patient outcomes, safety and comparative effectiveness and supporting evidence development and decision-making, patient registries are associated with improved chronic care and simplified performance reporting.

To download this complimentary white paper, please visit:

Online Guide to Medical Home Pilots and Projects

The Online Guide to Medical Home Pilots and Projects, a new online service from the Healthcare Intelligence Network, will help you identify and connect with the numerous medical home pilots and projects being developed across the United States. This directory will be available on August 25, 2008. Get online access to a directory of medical home pilots and projects with key information such as sponsoring organizations, key executives, populations and geographic regions served, program launch date and links to additional online information on the program.

Reserve your link today at:

Please forward this news announcement to your colleagues who might find it useful.
Contact HIN:
Editor: Patricia Donovan,;
Sales & Marketing Coordinator: Deirdre McGuinness,;
Publisher: Melanie Matthews,

HIN's Medical Home Monitor Archives put at your fingertips complimentary video, podcasts, white papers and blog posts on the advancement of the PCMH — plus back issues of this e-newsletter and links to additional medical home resources. Please bookmark this site and check back often for new content:

For products and services available from the Healthcare Intelligence Network, contact us at (888) 446-3530 / (732) 528-4468, fax (732) 292-3073 or email us at
All contents of this message Copyright 2008