Medical Home Monitor
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January 4, 2010
Vol. II, No. 17

Medical Home Monitor Archives

Medical Home Q&A's:
Medical vs Financial Risk,
Home Visit How-To's

Medical Home Monitor

Home Visits
for Enrollees

Q: What is assessed during home visits for medical home enrollees and who is conducting the assessment?

A: An RN does the first home visit for each participant, and then the LPN picks up some of the caseload. They assess different areas — blood pressure, A1C numbers — and provide a lot of education as well. They discuss healthy dieting and proper medications and let the patients know how important it is to stick to what the doctor says regarding the medication. We find that the participants are very receptive in that role. They pay attention.

Our nurse managers work with their doctors. There’s a lot of communication to let the doctor know what's going on. They also work to set goals for these participants, and the doctors are made aware of the goals they should be working toward. (Marcus Barnes, director of the Richland Care Medical Home Network, Palmetto Health)

For more on the hospital's role in the medical home network, please visit:

Medical Risk vs.
Financial Risk

Q: How should an organization think of and handle medical risks as opposed to financial risk?

A: There isn’t a fine line between medical risk and insurance risk. Medical risk includes things that are actionable and impactable by the medical system. Insurance risk covers those things that are not. We are hoping that through a risk-adjusted model, over time some of the things that we have thought of as insurance risks actually become things that medical providers can take more part in. For example, our community clinics have done a very good job getting diabetics under control. In doing so, they have beat the numbers of some who pay for or have much larger private insurance products.This has blown apart a little bit the myth that language and some other aspects of social complexity cannot be impacted by the healthcare system. An organization should look at medical risk; if I was a provider organization, I’d try to negotiate along those lines. And then I would look at financial risk with my payors to see how they want to handle that going forward. We have to be careful that we don’t transfer too much risk to provider groups that they can’t handle — for example, some of the financial risks of a patient needing a transplant or other things like that. You don’t want to inappropriately put the providers at risk for insurance product. But on the other hand, you want to ask providers to do as much intervention as they can, even on things that may not immediately be seen as medical risks. (Dr. Jeff Schiff; Medical Director of Minnesota Health Care programs for the Minnesota Department of Human Services )

For more on risk adjustment in the medical home, please visit:

Connecticut Expands Primary Care Case Management Pilot for Medicaid Children, Families

Connecticut's Department of Social Services has expanded its Primary Care Case Management (PCCM) pilot program to additional clients in the state's HUSKY A (Medicaid for children and families) program.

The state's HUSKY A clients enroll directly with their primary care providers (PCP), who in turn coordinate their care. The pilot pays participating PCPs $7.50 per member per month (in addition to fees paid for direct service) to coordinate care of patients who enroll with their PCP directly, rather than with a Medicaid managed care health plan.

PCPs then provide case management services in addition to their direct patient services, which include care coordination, developing care plans for enrolled clients, managing patients’ diseases and offering after-hours availability to patients for telephone advice. PCPs can be pediatricians, internists, family medicine practitioners, OB-GYNs, nurse practitioners and physician assistants (PAs), as well as specialists who obtain prior approval.

Launched in February 2009 with PCPs in the greater Waterbury and Windham/Willimantic areas, the program is now available in the greater New Haven and Hartford areas for member enrollments effective this month.

For more information, please visit:

HealthSounds Podcast: Medication Therapy Management in the Medical Home

The pharmacist has a natural and important role in patient medication reconciliation and review, explains Dr. Beth Chester, senior director of clinical pharmacy services and quality, Kaiser Permanente Colorado. She describes the dramatic effect of a pilot pharmacist intervention on ED visits and mortality rates among patients just discharged from skilled nursing facilities (SNFs) once pharmacists stepped in to monitor medication therapy in this population.

To listen to this HIN podcast, please visit:

Updated NCQA PPC®-PCMH™ Standards to Include ACOs

The National Committee for Quality Assurance (NCQA) has appointed two committees to help revise its landmark evaluation of medical practices through the Physician Practice Connections®-Patient-Centered Medical Home™ (PPC®-PCMH™). A 23-member advisory committee will help the NCQA to revise standards that continue to be feasible for individual practices and that also encourage better coordination and integration across systems. A second task force will explore how to apply the medical home standards and other quality requirements to accountable care organizations (ACOs) and provide guidance to the broader committee.

The PPC-PCMH advisory committee will apply findings from research and practical application of the medical home model in demonstration projects. The committee will explore how to define aspects of the model that can improve quality and save money, incorporate patient experience and clinical care results into the evaluation of practices, recognize the role of non-physician clinicians and align standards with federal “meaningful use” requirements for EHRs.

The advisory committee will propose draft changes to PPC-PCMH standards in the first quarter of 2010. Public comments will be sought in the second quarter of 2010, and NCQA will approve final recommendations in late 2010 and publish them in January 2011. Since its introduction in 2008, NCQA’s PPC-PCMH program has recognized more than 300 medical practices across the United States.

For more information, please visit:

HIN Survey of the Month: Healthcare Case Management

Just two days remain to join the more than 110 healthcare companies that have already described how their case managers contribute to care coordination, cost management and quality improvement. Submit your responses to HIN's Survey of the Month on Healthcare Case Management by January 6 and receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

Complete the survey by visiting

Healthcare Trends Update: Reducing Hospital Readmissions

With public and private payors sharpening their focus on and realigning reimbursement with hospital readmission rates, particularly among Medicare patients with heart attack, heart failure and pneumonia, more healthcare organizations are taking a hard look at readmission rates and launching programs to reduce these rates. This white paper summarizes the responses of 107 healthcare organizations to HIN's November 2009 Reducing Hospital Readmissions e-survey, which set out to identify the rudiments of readmission reduction efforts in the healthcare industry, from target populations and conditions to responsibilities, roles and ROI.

To download this complimentary white paper, please visit:

Save 10% on Medical Home Desktop Learning

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  • Three 45-minute video and PowerPoint® tutorials by leading medical home experts;
  • 11 detailed case studies of medical home adoption; and
  • Ten in-depth audio interviews with leading medical home experts on crucial topics.
Use ordering code MHMP to save 10 percent on this specially priced resource. Learn more by visiting:

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ReadmissionsRx LAUNCHING IN JANUARY 2010! A new 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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