Medical Home Monitor
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October 5, 2009
Vol. II, No. 11

Medical Home Monitor Archives

Medical Home Q&A:
From Pilot to Practice:
Rollout Tips from Group Health

Medical Home Monitor

Q: How did Group Health Cooperative roll out a medical home pilot to practices that might not have the benefit of strong leadership and a history of successful transformations?

A: Substantial resources are needed. To do this amount of change management for 250 physicians and another 1,000 individuals, nurses, LPNs, medical assistants, pharmacists and mid-level affiliate professionals, Group Health pulled heavily for our organization to use clinical experts to do doctor-to-doctor chair-side training. For any physician who requests training on the use of care planning tools, we deploy a doctor to that care site to do chair-side training with that physician. We do a standard introduction at the beginning of every new phase of the standard work elements. A team of four to five people arrive at the care site in the first few weeks of implementation, supporting implementation of each work element. Nursing leaders train RNs. When you’re doing this amount of substantive change by role and by content, you must also design how you’re going to implement and support those teams through education and training.

We hooked all of this work to a lean management infrastructure, which was new for us. That makes every process visible and allows leadership a consistent way on a weekly and more frequent basis to see how the work is progressing at the individual doctor level, as well as the total clinic level. It is substantially changing our management model as much as it’s changing the practice of medicine in our care team. (Michael Erikson, vice president of primary care services for Group Health Cooperative.)

For more details on successful staffing models for the medical home, please visit:

Health IT Grants Wired Into $436 Million 'HEAL NY' Program

New York has awarded nearly $60 million to fund community-based health IT projects to streamline the sharing of patient information — especially for patients transferring from one medical center to another. These funds are part of $436 million in grants awarded under the Health Care Efficiency and Affordability Law of New York State (HEAL NY) that will go to health facilities across the state to advance health IT and support capital restructuring and long-term care improvements.

Studies demonstrate that effective use of health IT reduces medical errors, improves clinical quality and leads to better patient outcomes by enabling real-time access to patient records, medical information and best practices, and electronic connectivity to all healthcare stakeholders, including patients.

The HEAL NY reforms are based on the patient-centered medical home (PCMH) model, which establishes a partnership among doctors, nurses, patients and their families to ensure that patients have the support they need to participate in their own care.

For more information on HEAL NY, please visit:

HealthSounds Podcast: Reducing Heart Failure Admissions through Remote Health Monitoring

A recent study of remote monitoring efforts by Henry Ford Health System showed a 36 percent reduction in expected all-cause hospital admissions for enrolled heart failure patients after six months of enrollment and a return of 2.3:1 vs. program costs. Daily engagement in self-care health monitoring programs can help healthcare organizations overcome many of the challenges of working with underserved populations, explains Dr. Randall Williams, CEO of Pharos Innovations, a partner in Henry Ford's remote monitoring effort.

To listen to this complimentary HIN podcast, please visit:

Medicare Moves into Multi-Payor Medical Home

Medicare is moving into the medical home in a big way. Last month, HHS gave Medicare the go-ahead to join Medicaid and private insurers in state-based efforts to improve the way healthcare is delivered. The PCMH model is being tested by public and private insurers, including at least 30 state Medicaid programs, Blue Cross and Blue Shield, United Healthcare, CIGNA and Aetna as well as systems like Geisinger, Kaiser and Group Health.

Also, CMS will solicit applications this fall for its own three-year PCMH demo that will pay eligible physicians a monthly care management fee for medical home services for high-need patients — those with prolonged or chronic illnesses that require regular medical monitoring, advising or treatment. The Medicare demo is only open to states, which must be able to certify that they:

  • Have established effective PCMH models that include Medicaid as well as private payors;
  • Can demonstrate that a majority of PCPs in demo areas would participate;
  • Have stringent requirements for designating PCMH providers, including independent accreditation and requirements for the use of health IT;
  • Have integrated public health services to emphasize wellness and prevention; and
  • Have secured the participation of a sufficient number of private payors.
The demo would test whether these projects improve access to and delivery of evidence-based care in underserved areas; reduce unjustified healthcare utilization and spend, particularly by Medicare beneficiaries; improve the safety, effectiveness, timeliness and efficiency of healthcare; and increase beneficiaries' participation in care decisions.

For more details on the CMS pilot, please visit:

HIN Survey of the Month: Healthcare Trends in 2010

Healthcare reform, a fragile economy, high numbers of uninsured, the lingering threat of H1N1 and emerging care delivery models are just a few factors that promise to drive changes in the healthcare industry in the coming year. To learn how other healthcare organizations are preparing for 2010, complete HIN's fifth annual survey on Healthcare Trends in 2010 by October 30 and receive a free executive summary of the compiled results.

Complete the survey by visiting:

Healthcare Trends Update: Preventing Hospital Readmissions

With payors and regulators paying closer attention to hospital readmission rates, the healthcare industry is taking notice. Download this executive summary of responses from more than 200 healthcare organizations on their strategies for minimizing hospital readmissions in their populations.

To download this complimentary white paper, please visit:

Achieving NCQA's Patient-Centered Medical Home Recognition — Save 10% on October 21 Webinar

Grand Valley Health Plan, a staff-model HMO ranked fourth on U.S. News & World Report's 2008 List of America's Best Health Plans, will share its experience to date on preparing for and achieving recognition from NCQA's Physician Practice Connections® - Patient-Centered Medical Home™ during an October 21, 2009 webinar at 1:30 p.m.

Get the basics on the daily workflow changes and processes that support patient access, communication, education and tracking, care management and performance reporting and improvement, as well as advice on the application of evidence-based guidelines — the most challenging aspect of recognition for many practices. The webinar will be presented live at 1:30 Eastern on October 21, 2009; on-demand, CD-ROM and DVD versions will also be available.

Use ordering code MHMP to reserve your specially priced webinar admission by visiting:

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