Medical Home Monitor
Medical Home Monitor
October 18, 2010
Vol. III, No. 12

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Care Gaps, ACOs
  2. Health IT in Mental Health
  3. New Chart: 13 Ways to Cut Readmissions
  4. Podcast: Opportunities in Healthcare Reform
  5. Which PCMH Strategy is Best?
  6. E-Survey: Healthcare in 2011
  7. Benchmarks: Health Coaching Trends
  8. Editor's Pick

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Medical Home Q&A's:
Care Gaps, ACO Metrics

Medical Home Monitor

Closing Gaps in Primary Care

Q: What are some gaps in primary care that can be filled by social service organizations and public health agencies?
A: Case management services end up being one of the major gaps in primary care. Community health centers are a little unique because many of them have those types of services in place. But many of our other safety net providers, such as free clinics, rural house clinics and family planning agencies, may not have case management services available on site. Interpretation and translation and making sure that patient education materials are culturally competent are all areas in which public health agencies can assist primary care providers.

We have also started to think about ways that health IT can be a shared solution among communities. For example, in Nebraska, the community came together and made use of a shared case management health IT solution where a number of case managers could access information about patients to ensure that patients were getting what they needed, but also that services weren’t being duplicated.

Sarah Dixon Gale, lead contract manager for the Iowa/Nebraska Primary Care Association.

For more lessons from the Iowa Collaborative Safety Net Provider Network, please visit:

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Measuring the Success of a Medicaid ACO

Q: What are the utilization measures for the first year of the Colorado Medicaid Accountable Care Organization (ACO)?

A: We identified three very simple and basic utilization measures, beginning with ER utilization and hospital readmissions. For the third, we were debating between hospital admissions and poly-pharmacy. These very simple utilization measures identify where we’ve had a lot of growth in our expenditures and where we know there’s lots of variation and unnecessary or duplicative services. We want to quickly have our providers and regional entities tackle these to bring down that utilization.

Laurel Karabatsos is the deputy Medicaid director with the Colorado Department of Healthcare Policy and Financing.

For more background on Colorado's ACO for Medicaid beneficiaries, please visit:

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Can Health IT Improve Care Coordination for Mental Health Patients?
Six New York patient-centered medical home (PCMH) primary care practices will test whether the use of health IT will improve care coordination for mental health patients.

The pilot is part of the Taconic Health Information Network and Community (THINC) HEAL 17 Mental Health Care Coordination Project, which will address care coordination among patients with affective disorders, including depression. Some 8,500 patients in three New York counties will benefit from the project, which will coordinate care among 120 primary care providers, 36 psychiatrists and 174 psychologists.

The participating practices, which include three large community health centers as well as smaller and solo practices, already use comprehensive EHR systems with features that support the project and report patient quality outcomes. In the mental healthcare coordination effort, clinicians will help to develop new uses of EHRs, improve ways to share secure information among providers and construct a better approach to the delivery of care.

All six practices worked with THINC in a pay-for-performance project in 2009 that led to their recognition as NCQA Level 3 PCMH practices, the most advanced level possible. The Hudson Valley has one of the highest concentrations of independent physician practices that have achieved NCQA Level 3 medical home recognition in the country.

The project is funded by an $8.7 million grant awarded to THINC from the New York State Department of Health and the Dormitory Authority of the State of New York. THINC is a not-for-profit organization that seeks to convene providers, payors, employers, public health agencies, quality organizations, consumers and local leaders to improve the quality, safety and efficiency of healthcare for the Hudson Valley community.

To learn more, please visit:

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New Chart: 13 Ways to Reduce Readmissions
To avoid leaving reimbursement money on the table, healthcare organizations are working hard to reduce avoidable rehospitalizations, especially among Medicare patients. We wanted to identify the top strategies for reducing readmissions.

View the chart at:

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HealthSounds Podcast: Healthcare Trends in 2011
Healthcare reform offers two major opportunities for healthcare to bend the spend curve and improve profitability, says Steven Valentine, president of The Camden Group. Valentine also weighs in on the current state of healthcare, and why organizations can't think about healthcare reform without considering the current economy.

To listen to this HIN podcast, please visit:

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MSU to Compare Two Medical Home Approaches

Michigan State University (MSU) will use a $1.2 million HHS AHRQ grant to compare the effectiveness of PCMH pilots at Priority Health and Independent Health, a health benefits company in Buffalo, New York.

The research will evaluate each pilot on patient experience, cost, quality and outcomes. The three-year grant will analyze claims data from the pilot practices of each plan from 2009, when the pilots were launched, through 2011.

Priority Health and Independent Health offer an ideal comparison opportunity since both are community-based health plans (members of the Alliance of Community Health Plans) that began pilot projects in 2009. Both projects have common evaluation data elements but differing approaches:

  • Priority Health implemented payment reforms to encourage practice transformation and the adoption of improved access for primary care patients. In addition, Priority Health offered grant opportunities to primary care practices to facilitate transformation with consultative services from an external expert for a small subset of practices.

  • Independent Health provided monthly prospective payments to practices to support implementation of specific structures and processes and annual retrospective payments based on the achievement of quality measures. Independent Health provided support from experts within the plan to each of its pilot practices.

The HHS grant is funded by the American Recovery and Reinvestment Act of 2009, which included $1.1 billion to support patient-centered outcomes research.

For more information, 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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Health Coaching in 2010: Results from Third Annual Survey
How are more than 160 healthcare organizations using health coaching to boost clinical and financial outcomes? This white paper summarizes results from HIN's third annual Health Coaching survey, conducted in August 2010.

To download this complimentary white paper, please visit:

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

Guide to Physician Engagement

Building physician buy-in for clinical and financial initiatives is a significant roadblock for healthcare organizations. The 150-page Guide to Physician Engagement deconstructs the physician culture and suggests tactics for converting reluctant physicians into champions for healthcare improvement.

  • Chapter 1: Overview
  • Chapter 2: Keys to Physician Engagement
  • Chapter 3: Physician Culture and Decision-Making
  • Chapter 4: Engagement in Wellness and Prevention
  • Chapter 5: Engagement in Pay for Performance
  • Chapter 6: Engagement in Practice Transformation
  • Chapter 7: Q&A

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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ReadmissionsRx is a monthly e-newsletter delivering strategies to reduce hospital readmissions that encompass care plan development, case management, care transitions, pre- and post discharge planning, medication reconciliation and much more — with a special focus on reducing rehospitalizations among the Medicare population.

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