Medical Home Monitor
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December 7, 2009
Vol. II, No. 15

Medical Home Monitor Archives

Medical Home Q&A's:
Case Management
Beyond the Office;
Setting Patient Goals

Medical Home Monitor

Taking Case Management
Outside the Primary Care Office

Q: Do Geisinger Health Plan case managers conduct home visits with patients or is everything completed at the primary care site?

A: Besides the home, our case managers will attend specialty visits. If a patient has some complex problems or confusion with a treatment plan, our case managers will go along on specialty visits. Also, for patients in skilled nursing facilities (SNFs), expecially those that are a bit more complex and experience more of a problem with discharge, our case managers will go to the SNF, visit the patient and possibly participate in the care conference on that patient. (Joann Sciandra, a regional manager of case management for health services at Geisinger Health Plan)

For more of Geisinger's strategies for case management in the medical home, please visit:

Setting Goals
with Patients

Q: When setting goals with patients, should goals be evidenced-based or behavioral?

A: Group Health Cooperative has long been into the tradition of evidence-based medicine. We have usable evidence-based tools that care teams can access via the Web right from their electronic medical record (EMR). Our clinical experts review evidence-based guidelines and update them on at least an annual basis. Those evidence-based tools live close to the care team. The physician will pull in those guidelines. Often, it's a behavioral goal, which could either be an exercise goal for a diabetic patient or the rate and frequency at which they should take their insulin. Both of those goals can live on that care plan. Patients that are activated electronically can access their care plans from their home computers by dialing into MyGroupHealth. They can see the care plan and modify it. It is both evidence-based in terms of support and often behavioral-specific to the patient. (Michael Erikson, vice president of primary care services for Group Health Cooperative)

For more low-cost low-tech techniques in the medical home, please visit:

Free Toolkit Helps Safety Net Providers
Qualify as Medical Homes

The Primary Care Development Corporation (PCDC) has released a free how-to manual that will help safety net providers become recognized as patient-centered medical homes (PCMH). "Obtaining Patient-Centered Medical Home (PCMH) Recognition: A How-To Manual" was released at the National Association of Community Health Centers' (NACHC) 27th annual conference.

The free toolkit is designed to guide safety net providers through the process of obtaining PPC-PCMH recognition from the National Committee for Quality Assurance (NCQA). It provides a comprehensive project management framework to complete the NCQA survey process, including how to set goals, identify project teams and develop an action plan. The manual also helps users navigate the complex documentation process that provides evidence of a provider's "medical homeness."

The manual was funded by the New York Community Trust and is specifically tailored to fit the unique needs of providers in low-income communities that often lack access to primary care. The manual is available from the PCDC’s Web site:

"With more than a 40-year track record providing comprehensive community based primary care to high-risk underserved populations, federally qualified health centers (FQHCs) are America's healthcare homes," said David M. Stevens, M.D., NACHC’s associate medical officer and a member of PCDC’s medical home expert advisory panel. "PCDC’s manual enables health centers both to achieve recognition and to identify ways to strengthen the care they provide to patients and communities."

For more information, please visit:

HealthSounds Podcast: 4 Ways to Reduce Readmissions

Priority Health members play an active role in keeping themselves out of the hospital, explains Mary Cooley, manager of case and disease management at Priority Health. She describes the four-point strategy that is reducing readmissions at Priority Health, the challenges that still exist and the essential tool that Priority supplies to providers to help them identify and close care gaps.

To listen to this HIN podcast, please visit:

Diabetes Health Plan Incents Patients for Adherence,

United Healthcare's first-of-its-kind Diabetes Health Plan provides patients with financial incentives for adhering to certain routine preventive care compliance requirements such as having regular blood sugar checks, routine exams and preventive screenings, which can result in better self-management of their care. Plan benefits, which can include some free diabetes supplies and diabetes-related prescription drugs, as well as lower co-payments for related doctor visits, can potentially save individuals up to $500 a year in addition to their regular healthcare benefits.

UnitedHealthcare's Diabetes Health Plan and its PCMH programs were recently given a 2009 eValue8 Health Plan Innovation Award by the National Business Coalition on Health (NBCH) for their ability to help enhance healthcare safety and quality while reducing costs. The awards recognize programs that help engage physicians and patients to achieve better health outcomes.

The Diabetes Health Plan is designed to help employers control the escalating costs of insuring diabetic and pre-diabetic employees and their families while improving their health. According to the American Diabetes Association (ADA), one out of every five healthcare dollars is spent caring for someone diagnosed with diabetes, while one in 10 healthcare dollars is attributed directly to diabetes. In addition to helping people live healthier lives, the preventive steps under the Diabetes Health Plan can help significantly lower a diabetic employee's total healthcare costs, which average more than $22,000 a year, according to UnitedHealthcare data.

For more information, please visit:

HIN Survey of the Month: Healthcare Case Management

Case managers are playing a larger role in the coordination of all phases of patient care, from management of the chronically ill in primary care offices to monitoring hospitalized patients from admission through discharge to overseeing care of residents of long-term care facilities. Complete HIN's Survey of the Month on Healthcare Case Management by January 4, 2010 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: Trends for 2010

As 2009 draws to a close, which products and services served healthcare companies best this year? What were the greatest operational challenges they faced in 2009? Looking ahead, are healthcare organizations more or less optimistic about the 12 months to come? Which aspect of healthcare reform will have the greatest impact on their business, and will there be a new healthcare bill by the new year? This executive summary of responses from 100 healthcare organizations to HIN's November 2009 Healthcare Trends for 2010 e-survey identifies reform priorities, top-of-mind concerns for the year ahead and best and worst business decisions in 2009.

To download this complimentary white paper, please visit:

Healthcare Trends & Forecasts in 2010 — Save 10% on Purchase

Healthcare in 2009 focused mainly on the three "Rs" — reform, reimbursement and readmissions — and wrapped up with two 2,000-page reform bills on the table. Looking ahead, will the new healthcare year toss out old cost reimbursement concepts and ring in an evidence- and value-based vision of reimbursement? What did CMS's shelving of its Medicare medical home pilot really mean? What influence do employers really wield in benefit and reimbursement design, and how will the consumer era change the dynamics of provider performance measurement and rewards?

In Healthcare Trends & Forecasts in 2010: Performance Expectations for the Healthcare Industry, two key thought leaders take on these issues and more, predicting likely winners and losers from pending healthcare reform legislation and describing its implications for key stakeholders in the coming year.

In HIN's sixth annual healthcare industry forecast, William DeMarco, president and CEO of DeMarco and Associates and Jim Knutson, risk manager and human resources director, Aircraft Gear Corporation, analyze the changing reimbursement conversation and suggest ways to rethink payment and benefit design to reflect today's healthcare delivery systems.

Use ordering code MHMP to reserve your specially priced resource by visiting:

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