Medical Home Monitor
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January 18, 2010
Vol. II, No. 18

Medical Home Monitor Archives

Medical Home Q&A's:
Pharmacist in the
Medical Home,
Care Transition ROI

Medical Home Monitor

Dispensing Pharmacists
to Medical Homes

Q: How can a community clinic piloting the medical home model include a community pharmacy in its medication reconciliation process?

A: First, think about physician groups or physician practices with whom you already have well established relationships with in other areas. Because you’ve already got some credibility established with that group, they may be more open to a proposal that’s a little bit innovative for your area. Among these good provider relationships, identify needs that are similar.

Community pharmacies are in excellent positions to do work in that area because often when a patient leaves a provider, one of the first stops they or a caregiver may make is to the community pharmacy to get new or refilled prescriptions based on provider or discharge medication instructions. That represents an excellent opportunity for the pharmacy to help providers with this. There’s evidence in other areas of medical practice to suggest that this makes the physicians lives' easier. Then, start exploring how best to communicate with physicians. For example, if you did medication reconciliation in the pharmacy, what’s the best mechanism to feed that information to the physician — fax, letter, EMR or a Web portal?

Community pharmacies usually see patients from numerous different health plans, payors and different systems. Focus on one system or one provider group and start small. Go for the providers that are willing to pilot a new program and don’t worry about convincing the providers that are a little reluctant. As you get experience and measure the impact and satisfaction that you can bring both to the physician practice and the members, other people will jump on board. (Beth Chester, Senior Director of Clinical Pharmacy Services and Quality at Kaiser Permanente Colorado)

For more on medication therapy management in the medical home, please visit:

Care Transitions
Funding & ROI

Q: Who funds your care transitions program and do you have any data on financial benefits that can be realized?

A: Relative to care transitions, we’re looking at the reduction in hospitalizations, then backing out the cost of the care transitions initiative and the elevated time spent by the case management team to come to an overall ROI. The ROI will be positive because our readmissions are down.

Also, with our telehealth initiative, even in just a few months we have some incredible success stories. When you have a “just in time” initiative that’s monitoring a patient daily and watching for small fluctuations in weight, symptom management, exercise, sleep, activity and blood pressure, you’re able to intervene almost daily. In the course of a month, the admission avoidance becomes very clear. The data that we have on the frequency with which our home care agencies are intervening with red flags is amazing. (Mary Cooley, manager of case and disease management at Priority Health)

For more on coordinating patient-centered care delivery to reduce readmission rates, please visit:

Meeting 'Meaningful Use' Guidelines: EMRs Lack Reporting, Data-Sharing

Eighty-five percent of healthcare providers believe their ambulatory EMR software will enable them to meet CMS's proposed meaningful use deadlines, according to a report from KLAS. Despite the confidence, however, providers also noted a number of functional areas that are still lacking — EMR reporting tools, patient access to medical records and the ability to share key clinical data. More than 17 percent of providers say reporting is difficult or impossible with their current tools, and another 24 percent report needing specific technical expertise to manipulate the tools provided, said Mark Wagner, director of ambulatory research for KLAS and author of the new report.

For Ambulatory EMR: On Track for Meaningful Use?, KLAS interviewed more than 1,400 providers about 26 EMR vendors to assess each solution’s readiness to meet meaningful use requirements, based on guidance from the HIT Policy Committee in July 2009.

“To help their clients meet the substantial reporting requirements for meaningful use, many vendors will need to increase the number and complexity of their canned reports, provide a standalone reporting application or add a third-party tool that can pull the required data,” Wagner added.

The KLAS study also looks closely at the EMRs that excel or struggle with other proposed requirements, such as the digital transmission of pharmacy orders. Also important in the discussion of digital pharmacy orders is the pharmacy itself. While there are performance differences from one EMR to another, the biggest obstacle to date has been a pharmacy’s ability to receive digital transmissions. Most large pharmacy chains are now using systems that can receive transmissions, but many smaller or independent pharmacies lack either the means or the inclination to go digital.

For more information, please visit:

HealthSounds Podcast: Checking In on the Colorado Multi-Payor Medical Home Pilot

A year into the Colorado multi-payor medical home pilot whose practices provide care to 30,000 patients, Julie Schilz, B.S.N., M.B.A., prescribes a single tool that can help transform practices, improve quality and deliver evidence-based care. It's NOT an EHR, says the manager of the Improving Performance in Practice and Patient-Centered Medical Home (PCMH) initiatives for the Colorado Clinical Guidelines Collaborative, who lists this tool's four key functionalities. Also in this interview, Schilz describes the influence of other reimbursement models on the Colorado pilot and identifies two opportunities for NCQA to enhance its PCMH recognition process.

To listen to this HIN podcast, please visit:

Use of Care Management Tools for Chronic Illness Varies Widely

Use of care management tools — such as group visits or patient registries — varies widely among primary care physicians (PCPs) whose practices care for patients with four common chronic conditions — asthma, diabetes, congestive heart failure and depression — according to a new national study by the Center for Studying Health System Change.

Among PCPs caring for adult patients in 2008, 91 percent were in practices treating patients with asthma, diabetes, congestive heart failure and depression, according to the study funded by the Robert Wood Johnson Foundation (RWJF). Yet, these physicians' use of care management tools varied widely, and interventions backed by the strongest evidence of effectiveness were used much less frequently.

The study also found that:

  • Three-quarters of physicians reported offering patients written educational materials, but use of other tools for patient education and improved self-care was much lower.
  • Practice size and setting were strongly related to the likelihood that physicians used care management tools, with solo and smaller group practices least likely to use care management tools.
  • About two-thirds of physicians reported receiving reports on the quality of their preventive and chronic care, and 40 percent used registries to identify patients with specific chronic conditions.
  • Overall, 47 percent of physicians were in practices that used two or fewer of the seven care management tools and 4 percent were in practices using six or seven care management tools.
Among PCPs whose practices treated patients with asthma, diabetes, depression and congestive heart failure, most used care management tools for patients with some conditions but not others. With the exception of written educational materials, less than 15 percent of physicians reported using any tool across all four of the chronic conditions.

Source: Center for Studying Health System Change, December 16, 2009

For more information, please visit:

HIN Survey of the Month: Medication Adherence

Of 1.8 billion prescriptions dispensed annually in the U.S., only 50 percent are taken correctly by the patient, according to the World Health Organization. Beyond increasing risk of death, 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 U.S., at a cost of about $100 billion per year. Please share your organization's efforts to improve medication adherence by completing HIN's Survey of the Month by January 31, 2010. You'll receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

Complete the survey by visiting:

Healthcare Trends Update: Disruptive Innovation for Primary Care

"The Medical Home: Disruptive Innovation for a New Primary Care Model" examines medical home models, their savings potential and the implications for policymakers and key industry stakeholders. The paper also offers compelling arguments in favor of medical home adoption.

To download this complimentary white paper, please visit:

Save 10% on 2010 Healthcare Benchmarks Yearbook

Despite some green shoots, the uncertainty of healthcare reform and the economy provides little guidance for healthcare executives charged with setting their organizational direction and agendas for the year ahead. To fill this void, the 2010 Healthcare Benchmarks Yearbook: Metrics, Measurements and Innovations delivers a comprehensive collection of benchmarks in key areas of healthcare activity and growth — from adoption of the PCMH to reduction of hospital readmissions to the use of health coaching, patient outreach, financial incentives and telehealth to foster behavior change and reverse healthcare spend.

Use ordering code MHMP to save 10 percent on this specially priced resource. Download a free executive summary of this resource 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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