Medical Home Monitor
Medical Home Monitor
September 15, 2008
Vol. I, No. 6

Medical Home Monitor Archives

Medical Home Q&A:
Reducing Inappropriate ER Use with Medical Homes

Medical Home Monitor

Q: How can healthcare professionals drive home the differences between urgent care and emergent care facilities to patients and when to use each?

A: The first and most important thing is that healthcare professionals — and more specifically PCPs — should strive to create a medical home for their patients. That’s probably the single most important strategy toward reducing inappropriate ER use. When a member or a patient is established in a high quality relationship with a PCP and practice, then they are more likely to seek care and/or advice for an urgent medical problem. Physicians, their staff or their practice literature can make clear to patients how to seek care or medical advice during times when the practice is not available or open to see patients — specifically in the evenings, on weekends and holidays...Practices that have expanded hours or adequate coverage arrangements so that they can see patients for urgent medical problems in the evening and weekends will enable their patients to seek care that is timely, appropriate and less expensive than going to the ER. (James Glauber, M.D., is medical director for Neighborhood Health Plan of Massachusetts.)

For more information on the role of the patient-centered medical home (PCMH) in reducing non-urgent ER use, please visit:

Large Physician Groups Score Low On Key Medical Home Measures

Even large physician practices lack the essential elements to create a medical home for patients to receive care, according to a new study published in the journal Health Affairs. Between March 2006 and March 2007, researchers surveyed all practices with more than 20 physicians across the United States that treat patients with asthma, diabetes, CHF and depression. They looked at four key aspects of the medical home model: whether physicians work closely with other healthcare providers in patient care “teams”; how well care is coordinated and integrated; whether care is delivered in ways that maximize quality and safety; and whether patients can reach physicians in nontraditional ways, such as by e-mail. Researchers also looked at physicians’ use of EMRs, disease registries, patient reminders and performance feedback as well as their distribution of educational materials to patient.

Groups with more than 140 physicians and those owned by a hospital or HMO scored highest on critical measures of the medical home model. Researchers also found that certain components of the medical home appear to be more prevalent than others. For example, 41 percent said that they use EMRs, and just over half share information electronically with hospitals and specialists, but fewer than one-third rely on primary care teams to deliver care. Almost two-thirds distribute guidelines about proper care for chronic diseases. However, only 10 percent scored high on incorporating feedback from patients to improve their practices.

For more details on this study, please visit:

HealthSounds Podcast: Cementing Payor-Provider Investments in the Medical Home

While there is a great deal of interest among public payors in medical home funding models, their funding needs pose several challenges, explains Lesley Reeder, quality improvement specialist for the Colorado Department of Health Care Policy and Financing. In this interview, Reeder shares the secrets to a successful payor-provider partnership and discusses some of the code-dependent strategies used by Colorado to reimburse physicians for preventive care services dispensed from the medical home.

To listen to this complimentary HIN podcast, please visit:

Johns Hopkins to Use Guided Care Model to Assist Practices in Medicare Medical Home Demo

Drawing upon its Guided Care model, the Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public Health will use a $1.7 million grant from the John A. Hartford Foundation to develop and provide primary care practices with online courses for physicians and nurses, a practice implementation manual and technical assistance in meeting the requirements of the three-year CMS Medicare Medical Home Demo.

In the Guided Care model, a specially trained RN is based in a primary care office and works closely with physicians and chronically ill patients to improve quality of life and reduce the need for expensive inpatient health services. The nurse assesses patient needs in their home, develops a care plan, monitors conditions, educates and empowers the patient, supports family caregivers, smoothes transitions between sites of care and works with community agencies to ensure that the patient’s healthcare needs are met.

For more details on the Johns Hopkins initiative, please visit:

How Medical Net Systems EncounterSuite Creates the Framework for the PCMH

The PCMH is a concept for the ideal medical practice of the future. The AAFP’s TransforMed program has reported that the technology to create the PCMH framework is not ready and is fragmented. New solutions must be identified. Medical Net Systems EncounterSuite, an online integrated EMR and PHR, provides a unified turnkey software framework for the PCMH. This is accomplished through its integrated PHR/EMR, point of care wellness and DM guidelines and best practices application, and three tracking modules: patient registries, Inbox (order tracking) and Tracking the Patient at Home module.

To download this complimentary white paper, please visit:

Pre-Publication Discount on Patient Registries Guide

Simple Steps to a Patient Registry: Ticket to Care Coordination, Quality Reporting and Pay for Performanceillustrates how even the solo practitioner can simply and inexpensively implement a population-based registry that provides actionable information on patient needs. From a set of index cards in a shoebox to a clinical information system auto-populated from an electronic medical record, the patient registry guides the entire care team in the management of chronic illness and preventive care. Registries also have been shown to decrease per-member costs and reduce hospital admissions.

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