Medical Home Monitor
Medical Home Monitor
October 4, 2010
Vol. III, No. 11

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Patient Handoff, ED Use
  2. 6 Findings on Medical Homes
  3. New Chart: Time Needed to Build Medical Home
  4. Podcast: How to Reduce ER Visits
  5. Joint Commission to Launch PCMH
  6. E-Survey: Healthcare Trends for 2011
  7. Benchmarks: Care Transition Tactics
  8. Editor's Pick

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Medical Home Q&A's:
Patient Handoffs, ED Frequent Flyers

Medical Home Monitor

What constitutes a 'warm handoff' from an outreach or transitions team to case management?

Q: In the worst case scenario, it is a case manager saying, “Based on our conversation and the information we have talked about, it sounds like you would benefit from spending some more time developing a relationship with one of our case managers.” In the worst case scenario it sets them up for a phone call and maybe even making an appointment.

In the best case scenario, most of our teams are co-located. If the clinician in that team is available, they can do a warm transfer on the phone right then. With that warm transfer, the nurse or behavioral health specialist will pick up the phone, introduce themselves and make an appointment to talk with the patient. We don’t want to bombard the patient, since the healthcare guide has already been on the phone with the patient for some time. There is a warm handoff where the call is transferred and an introduction is made.

Rebecca Ramsay, BSN, MPH, is senior manager of care support and clinical programs at CareOregon.

For more case management strategies to use when monitoring target populations, please visit:

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Business Case for ED Efforts

Q: What is the business case for extra services provided to ED high utilizers such as a 24/7 nurse line? Are referrals to social services, such as supporting housing, made for these patients?

A: We are writing the business case for a specific person to manage the high utilizers because we have a subset of our population, dual eligibles, that have Medicaid or a socioeconomic component. We have relationships with the community to be able to refer people out. Our population is somewhat unique given that they are all insured through Kaiser Permanente. But the care coordinators that manage our dual eligibles have access to housing for senior resources in the community — transportation resources — so we do provide those to our members.

Sara Tracy is senior manager of emergency services at Kaiser Foundation Health Plan of Colorado.

For 27 interventions that curb avoidable ER use, please visit:

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Joint Commission to Launch Medical Home Option in 2011
Beginning next July, the Joint Commission will expand its accreditation process to organizations also interested in electing the Primary Care Home option.

A Primary Care Home is a model of care in which services are provided to patients by a primary care provider or team that increases access to its services, tracks and coordinates a patient’s care delivered by other providers and facilities, uses evidence-based treatment protocols, and focuses more on patient and family education and self-management. This helps to ensure the patient receives timely and appropriate treatment.

This initiative complements the Joint Commission's ambulatory care accreditation program and is consistent with new healthcare reform efforts to improve the coordination, quality and efficiency of healthcare services. This initiative is designed to combine the improvements in quality of care and patient safety achieved through accreditation with reimbursement from third-party payors when the additional requirements of a Primary Care Home are met.

The Joint Commission will post standards for the Primary Care Home Initiative for a field review next month, and begin pilot testing early next year. The final standards should be available in March, and on-site surveys will begin in July.

In the meantime, an expert panel is providing input on topics such as:

  • Roles and responsibilities of the primary care provider;
  • Roles, responsibilities and composition of the care team;
  • Processes to ensure and support continuity of care;
  • Processes to support and incorporate patient self-management; and
  • Operational topics such as scheduling of patient appointments to ensure adequate access to care.
A broader advisory and resource group will provide additional guidance and assistance in the implementation of the initiative. The Joint Commission is also seeking feedback from Medicare and Medicaid officials and insurance companies to ensure that the Primary Care Home standards will enable organizations to be recognized as a Primary Care Home provider.

To learn more, please visit:

New Chart: How Long Does It Take To Build a Medical Home?
Patient-centered medical home (PCMH) pilots are in high gear around the country and high on the healthcare reform agenda. We wanted to see how long it takes a physician practice to transform itself into a full-fledged patient-centered medical home.

View the chart at:

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HealthSounds Podcast: How to Reduce Avoidable ER Use
In a new monthly podcast, Healthcare Intelligence Network executive VP and COO Melanie Matthews shares the latest market metrics, derived from HIN's July 2010 survey on Reducing Avoidable ER Visits, with commentary from Dr. Barsam Kasravi, managing medical director for state-sponsored programs for WellPoint and Sara Tracy, senior manager of emergency services at Kaiser Foundation Health Plan of Colorado.

To listen to this HIN podcast, please visit:

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New Report Shares 6 Secrets to Medical Home Success

A new report from the Deloitte Center for Health Solutions indicates that while the clinical and economic potential of the patient-centered medical home (PCMH) is promising, the precise features of an optimally successful PCMH are somewhat elusive.

Deloitte's new issue brief, "Medical Home 2.0: The Present, The Future," outlines the current state of the PCMH under the new health reform legislation. The report reviews several PCMH pilots and provides insights on the future evolution of the medical home. It highlights the expansion of medical home pilots as part of the Patient Protection and Affordable Care Act of 2010 (PPACA) to help reduce costs and improve population-based health by leveraging clinical information technologies, care teams and evidence-based medical guidelines.

Deloitte's research further indicates the following:

  • With significant investment, the PCMH yields results.
  • Physician adoption is a major challenge.
  • Healthcare information technology (IT) is the essential front-end investment.
  • One size does not fit all.
  • Access to an adequate supply of primary care service providers is an issue.
  • Incentives must be aligned and realistic.

For more information and to download the full report, please visit:

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HIN Survey of the Month: Healthcare Trends for 2011
Following this year's passage of the Patient Protection and Affordable Care Act, the real work of healthcare reform is underway. To learn how fellow healthcare companies are preparing for 2011, complete HIN's sixth annual survey on Healthcare Trends in 2011 by October 31. You'll receive a free executive summary of the compiled results, and your responses will be kept strictly confidential.

Complete the survey by visiting:

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How Healthcare Coordinates Care Transitions
This white paper captures top programs and interventions by 87 healthcare organizations to coordinate key care transitions in response to the Healthcare Intelligence Network May 2010 Managing Care Transitions Across Sites e-survey.

To download this complimentary white paper, please visit:

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EDITOR'S PICK: Save 10% on This Week's Medical Home Resource

The Colorado Accountable Care Collaborative: Practical Lessons from an ACO

In case you missed it last week, the on-demand and DVD training versions of this 45-minute webinar are now available. During this September 29 webinar, members of the Colorado ACO described the development process, from the practical challenges to the processes for addressing these challenges. Get all of the details on this emerging reimbursement model that has received frequent mention in the Patient Protection and Affordable Care Act, including the following:
  • The system changes required before launching an ACO;
  • Developing performance measures and an incentives program for year one of the pilot and how these will differ in the expansion year;
  • Balancing between prescriptive and permissive in enlisting healthcare providers to be accountable to their outcomes;
  • Determining provider payments and payment levels to support an ACO;
  • Specific strategies for gaining stakeholder support early in the process;
  • Identifying and addressing marketplace resistance; and
  • Creating the ACO roll-out plan.

Use ordering code MHMP to save 10 percent on this webinar training by visiting:

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Contact HIN:
Editor: Patricia Donovan,;
Publisher: Melanie Matthews,;

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