Medical Home Monitor
Medical Home Monitor
January 19, 2009
Vol. I, No. 10

Medical Home Monitor Archives

Medical Home Q&A:
Home Visits and Caseloads
in a Medical Home Network

Home Visits and Caseloads

Q: Who deploys DM at Palmetto Health's medical home network and what is the average caseload?

A: DM is handled by our nurse case manager and an L.P.N. who serves as a community health coordinator. Their caseload fluctuates, but they can have anywhere from 20 to 30 participants on their caseload. Some are visited weekly and some are visited every two or three weeks depending upon the situation. They follow these patients by telephone even when they're not visiting them. We also have a step-down program where, once the participant is maintaining their hypertension or diabetes at a fairly safe level, we transition them to a less intensive program. Then, our employees call them monthly to see how they're doing and to determine whether we should re-enter them in our intense DM program. (Marcus Barnes, program director of Palmetto Health's Richland Care 12-site medical home network.)

For more details on this medical home network, please visit:


The Leading Forum on the Development and Implementation of the Patient Centered Medical Home

A Hybrid Conference, Internet Event and Training Tool
March 2 - 3, 2009
Hyatt Regency Philadelphia at Penn's Landing
Philadelphia, PA

Virtual Medical Home Can Bridge Mental, Physical Health Needs

A new report from the National Association for State Mental Health Program Directors (NASMHPD) underscores the need to create a PCMH for individuals living with mental illness. The PCMH would bring together a PCP, the bio-psychosocial-spiritual model of care, behavioral health services and DM strategies based on the chronic care model. This collaborative care could occur in a "virtual" healthcare home, rather than a single physical location, where everyone involved in a person's care would coordinate their services and specify responsibility for care management activities.

The 37-page report also outlines an ambitious plan to collect physical health data that will inform the clinical care of each person served in the mental health system and to aggregate this data to allow close monitoring of the health of this population. The report is available at

For more information, please visit:

HealthSounds Podcast: Toward a Patient-Centered Physician Practice

Redesigning a practice into one that is more efficient and patient-centered begins with a readiness assessment tool and goal-setting with key organization members, says Dr. John Michos, medical director of the Virginia Health Quality Center. Smaller practices may find it easier to implement change, while larger practices may need to launch innovations on a small scale, then foster the spread of that success to other departments.

To listen to this complimentary HIN podcast, please visit:

GVHP First Health Plan in Michigan to Attain PCMH Status

Grand Valley Health Plan (GVHP) is the first health plan in Michigan to receive NCQA certification as a PCMH. The Grand Rapids-based provider of family medicine and health benefits is a staff-model HMO that has embraced this philosophy of care since its inception in 1982. “Approaching wellness from an integrated, team-based and patient-centered perspective has been a core principle of our business since our founding in 1982,” said Pam Silva, GVHP’s chief operating officer. “We see certification by the NCQA as further affirmation of our approach to care and we are committed to pursuing efforts that demonstrate value for our members, stakeholders and staff,” Silva concluded.

In Michigan, both Blue Cross Blue Shield and Priority Health support the concept and have committed significant resources to physician practices who pilot PCMH programs. CMS has committed over $100 million in funding to support the development of the PCMH concept through 2010. In addition, the incoming Obama administration has pledged its support to PCMH as a component of its healthcare plan.

For more information, please visit:

Patient Registries: The Track to Better Quality Healthcare

Besides creating realistic views of clinical practices, patient outcomes, safety and comparative effectiveness, patient registries support evidence development and decision-making and are associated with improved management of chronic illness. The use of patient registries also puts physician practices on the path to becoming a medical home.

To download this complimentary white paper, please visit:

Save $50 when you register by February 6:

February 12, 2009 Webinar: Patient Assignment into the Medical Home: Building a Collaborative Patient-Centric Approach

When assigning patients to their medical homes, healthcare organizations can use a number of different approaches — from patient or physician selection to a claims-based strategy. During this 90-minute webinar on February 12, 2009, Dr. Anita Murcko, medical director of clinical informatics and provider adoption with the Arizona Health Care Cost Containment System (AHCCCS) and Dr. Charles DeShazer, Humana's vice president and market medical director, will examine the various approaches to medical home assignment and the factors that can impact effective assignment.

Reserve your specially priced participation in this February 12 webinar today by visiting:

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