Medical Home Monitor
Medical Home Monitor
November 15, 2010
Vol. III, No. 14

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Readmissions, Treatment Options
  2. Diabetes Pilot Goes Statewide
  3. New Chart: Key Case Manager Duties
  4. Podcast: Health Plan Rate Setting
  5. NPs Given Provider Status
  6. E-Survey: Tobacco Cessation
  7. Benchmarks: Medication Adherence
  8. Editor's Pick

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Medical Home Q&A's:
Heart Failure Readmissions, Treatment Options

Medical Home Monitor

Heart Failure Readmissions

Q: How does your ED case manager focus on heart failure readmissions and alternatives to admissions for those patients?
A: Our program is called STELR — Smooth Transitions Equal Less Readmissions. We’re focused on a number of different elements; the ED is the first time in which we interact with the patient and possibly can prevent a readmission. The ED case manager has to work very closely with the physicians to make sure that if the patient doesn’t need to be admitted, we can provide an alternative to admission. On the floors, we’ve trained our staff nurses to do patient education on heart failure, or we give patients pill boxes, scales and other tools to help them care for themselves when they go home.

We’re also working with a home care agency so that every heart failure patient gets a referral for at least one initial visit at home. This visit particularly focuses on medication reconciliation in the home so that the patient is not confused when they get home about which medications they are and are not supposed to take. And finally, we make sure that every discharged patient has an appointment with a healthcare provider within seven days of discharge. The literature tells us that is the most vulnerable time frame for readmission. So we’re really making a big push for our clinic, as well as our private patients, that they get seen by somebody in the community within seven days of discharge.

Toni Cesta, senior vice president of operational efficiency and capacity management at Lutheran Medical Center.

For more on embedding a case manager in the emergency department, please visit:

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Determining Treatment Options

Q: What criteria are used to determine if a condition could be treated by urgent care or by a PCP?

A: We looked at the different diagnoses. There are studies that show certain diagnoses that can be seen within two hours, certain ones within 24. We mainly looked at hypertension and some chronic care conditions that didn’t seem to need urgent visits to the ER, and determined whether those were ones that could be seen in urgent care or the next day. Our data is based on claims data, which is not as ideal as data based on medical records. However, instead of doing the non-urgent/urgent intervention, we mainly focused on frequency. If someone has been in the ER four times in a year, whether all four were urgent or none of them were urgent, it would still be beneficial to have an intervention. If they have been in even once a year, they could still get a call, but maybe not as intensive of an intervention.

Barsam Kasravi, M.D., M.P.H., managing medical director for state-sponsored programs, WellPoint.

For more tactics to reduce avoidable ER use, please visit:

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Diabetes Medical Home Pilot Goes Statewide After Impressive Results
A yearlong patient-centered medical home pilot project in South Carolina for patients with diabetes improved health outcomes and reduced utilization so successfully that insurers are rolling out the model across the state. A similar pilot for patients with congestive heart failure may be next.

The pilot, a collaboration between BlueCross BlueShield of South Carolina, BlueChoice® HealthPlan of South Carolina and Charleston, S.C.-area Palmetto Primary Care Physicians (PPCP), focused on the two companies’ members who have diabetes and were patients of PPCP’s 22 sites and 55 providers in Charleston, Dorchester and Berkeley counties.

They analyzed the data for 809 participants continuously enrolled through the year. Results showed 10.4 percent fewer inpatient hospital days and 12.4 percent fewer ER visits when compared with the same population’s previous year. Additionally, the participants had better control of cholesterol and glucose levels, improved their BMI and measures of potential kidney damage, as well as had higher rates of recommended eye exams.

The organizations also compared the pilot participants with a control group of continuously enrolled diabetic patients treated by all other primary care providers in the Charleston area. Age and gender mix were similar.

The pilot group’s results compared favorably to the control group’s results on a number of measures, including 10.7 percent fewer hospital admissions, 36.3 percent fewer inpatient hospitals days and 32.2 percent fewer emergency room visits.

Though the pilot and control groups started with the same costs, the pilot group had 6.5 percent lower total medical and pharmacy costs after one year in the patient-centered medical home. Both groups’ healthcare costs rose with progression of the members’ conditions and with medical inflation.

“We’re delighted these patients saw improved health and better access to a complicated health care system,” said BlueCross Vice President for Clinical Quality and Health Management, Dr. Laura Long. “We intend to more aggressively roll out this approach around the state. The results convinced us that we need to get this out of the pilot phase and into practice.”

The two insurers launched their second diabetes medical home pilot on July 1 with the University of South Carolina Department of Family Medicine. Their third project, with Mackey Family Practice in Lancaster, was started recently. BlueCross and BlueChoice HealthPlan will continue the model for diabetes patients at PPCP in the Charleston area, and will add patients with congestive heart failure in the fourth quarter.

For more information, please visit:

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New Chart: Key Case Manager Duties
As the case manager's contribution to healthcare delivery and quality grows, so, too, do the responsibilities of that position. We wanted to see the duties that occupy the time of the healthcare case manager.

View the chart at:

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HealthSounds Podcast: Health Plan Rate Setting - Balancing Premium Increases Against Regulatory Oversight
In an atmosphere of increased state and federal oversight of health plan rates, healthcare organizations need a sound strategy for determining premium rate increases that meet regulatory approval. HealthScape Advisors managing directors Steve Young and John Steele describe the challenges of setting rates in this environment and the essential experience that can best prepare health plans for dealing with commercial plans.

To listen to this HIN podcast, please visit:

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Nurse Practitioners Granted Primary Care Provider Status in
CareFirst Blue Cross Blue Shield Networks

In a move that is expected to enhance primary care access, CareFirst BlueCross BlueShield (CareFirst) will permit nurse practitioners (NPs) to participate in its healthcare provider networks as independent primary care providers. Previously, CareFirst permitted NPs to participate in its networks, but they were only permitted to practice independently of physicians in certain medically underserved areas with limited access to primary care physicians.

Under the revised policy, NPs may enroll in its provider networks to serve as independent primary care providers throughout the company’s Maryland, Northern Virginia and District of Columbia service area. NPs will have to meet CareFirst credentialing criteria, be certified by their relevant approved national certification board, and meet all of the licensing/certification guidelines of the state in which the NP practices. In addition, the NP must attest that they have a written collaborative agreement with a physician of the same specialty who is a member in good standing of the same CareFirst provider networks as the NP. Similarly, NPs who meet network participation criteria will be able to participate with primary care physicians as part of a medical panel or form their own medical panels as part of CareFirst’s PCMH.

“Federal healthcare reforms will over the next few years result in more residents of our region being covered by health insurance, and that will increase demand for primary care services,” said Bruce Edwards, CareFirst senior vice president for networks management. “In addition, CareFirst is placing an increased emphasis on primary care through our primary care medical home program, which will launch in January 2011. With these developments ahead and an existing need to expand access to these services, allowing nurse practitioners to practice independently as primary care providers is a logical move to serve our members better.”

For more information, please visit:

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HIN Survey of the Month: Tobacco Cessation and Prevention Programs
How is your organization promoting tobacco cessation and prevention? Complete HIN's Survey of the Month on tobacco cessation and prevention by November 30 and receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

Complete the survey by visiting:

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Benchmarks in Improving Medication Adherence
Poor medication adherence is tied to as much as $290 billion annually in increased medical costs and responsible for 33 to 69 percent of all medication-related hospital admissions in the United States. This white paper from the Healthcare Intelligence Network captures the efforts of 107 healthcare companies to improve medication adherence in their populations, from targeted populations and conditions of medication adherence programs to the components of a successful medication adherence program, as reflected by their responses to the January 2010 Medication Adherence 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

Essential Guide to Accountable Care Organizations

Provider partnerships forged through accountable care organizations (ACOs) hit all of the marks for healthcare delivery reform set forth by the Patient Protection and Affordability Act (PPACA) and offer a key opportunity to boost revenue.

The Essential Guide to Accountable Care Organizations: Challenges, Risks and Opportunities of the ACO Model answers key questions surrounding ACOs so that hospitals, PHOs, IPAs and other physician organizations, networks or group practices can weigh the merits now of creating an ACO and complete the necessary groundwork before CMS's ACO operation date of January 2012.

This 60-page guide delivers a detailed analysis of CMS's Medicare ACO Shared Savings Program, the short- and long-term financial opportunities afforded by ACOs and an inside look at several existing ACOs and the lessons learned from their development and launch.

Use ordering code MHMP to save 10 percent on this special report by visiting:

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

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