Medical Home Monitor
Medical Home Monitor
December 20, 2010
Vol. III, No. 116

Medical Home Monitor Archives

In This Issue:

  1. Q&A: ACO Players, Clinical Integration
  2. New Medical Home Patient Services
  3. New Chart: Medication Adherence Targets
  4. Podcast: Co-Located Case Managers
  5. More Evidence on Medical Home Savings
  6. E-Survey: Reducing Readmissions
  7. Benchmarks: 2011 Healthcare Trends
  8. Editor's Pick

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Medical Home Q&A's:
ACO Players, Clinical Integration

Medical Home Monitor

Community Providers in the ACO

Q: What is the role of essential community providers, such as providers of women’s health services, in an accountable care organization (ACO)?
A: If you are a provider of women health services and a PCP, your patients would become part of the ACO. I am speaking specifically about the Medicare opportunity. You can reach out to burgeoning ACOs and offer to work together to coordinate care. They may say, “We know you are out there as a provider. Some of our physicians refer patients to you, and some don’t. We don’t need to change anything in that relationship. We don’t need to work together closely.” Or they might say, “Coordinating care more closely with you would be more beneficial and we want to do that.”

It will really depend on the specific set of services, the market that you have and the degree to which you are servicing Medicare Part A and B patients.

John Harris, principal with the consulting firm of DGA Partners.

For more guidelines on ACOs, please visit:

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ACO Payment Models

Q: Advocate Health's use of efficiency measures in its clinical integration program increased dramatically between 2009 and 2010. Why the focus on efficiency this year, and what has been the impact to date from these measures?

A: Those programmatic changes in our clinical integration program reflect our preparation for being an ACO. You have to manage on a budget and you have to deliver high quality, safe care. We’ve had a heavy emphasis on the coordination of care, avoidance of readmissions and on other hospital use, length of stay and other resources in the hospital. We have had some preliminary success such as avoiding readmissions for heart failure patients, though it’s really too early to tell you the outcomes of our 2010 program.

Dr. Mark Shields, senior medical director with Advocate Physician Partners.

For more basics on clinical integration, please visit:

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New Medical Home Patient Services Aimed at Utilization, Compliance and Transitions

House calls, a dedicated pharmacist and expanded weekend hours are among new services offered to patients of Rhode Island's fifth medical home initiative launched by Blue Cross Blue Shield of Rhode Island (BCBSRI). The insurer is collaborating with Coastal Medical, one of the largest primary care providers in the state, to create another patient-centered medical home (PCMH).

Coastal Medical patients covered by BCBSRI will now receive many services not currently available in a standard primary care setting, such as:

  • Weekend access to Coastal Medical services for urgent needs. In addition to improving access to care for BCBSRI members, this service is intended to reduce expensive ER visits, which will help moderate long-term healthcare costs.
  • Dedicated pharmacist support for members with complex medical conditions such as diabetes to help prevent adverse drug-drug interactions and improve a member’s compliance with prescribed drug regimens.
  • House calls from Coastal Medical nurse case managers who will visit BCBSRI members at home upon discharge from acute care hospitals or skilled nursing facilities. The nurse case manager will assist in a safe transition home and help prevent members from requiring future readmissions.

BCBSRI and Coastal Medical have also committed to significant enhancements in the use of EHRs between providers of care. The new agreement will reward Coastal Medical for dramatically improving the way their medical care team electronically shares patient health information with other medical providers, such as hospitals and specialists.

Coastal has 91 healthcare providers located in 17 offices in Rhode Island. About a third of the practice's 105,000 patients are BCBSRI members.

For more information, please visit:

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New Chart: Targeted Conditions for Medication Adherence
Medication adherence programs can improve patient care and lower healthcare costs by more effectively managing chronic medication utilization. We wanted to see which targeted conditions pose the greatest opportunity to improve medication adherence.

View the chart at:

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HealthSounds Podcast: Co-Locating Case Managers in the Healthcare Continuum
Co-locating healthcare case managers in care settings can improve communication with patients as they move through the continuum of care, says Jan Van der Mei, regional director of continuum case management for Sutter Health Sacramento Sierra Region. Ms. Van der Mei describes the major issues that case managers face while helping patients to navigate the Sutter system, as well as the key role of case managers in reducing hospital readmissions.

To listen to this HIN podcast, please visit:

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Medical Home Yields Better Care, Bends Cost Curve, Collaborative Finds
The primary care patient-centered medical home (PCMH) results in improved quality of care and patient experiences and reduces costs from hospital and emergency department utilization, according to evidence presented in a new brief from the Patient-Centered Primary Care Collaborative (PCPCC).

The brief, "Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the United States" is available for download at

The PCPCC is a coalition of more than 700 major employers, consumer groups, organizations representing primary care physicians and other stakeholders who have joined to advance the PCMH model.

For more information, please visit:

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HIN Survey of the Month: Reducing Hospital Readmissions in 2010
Spurred on by incentives from public and private payors, healthcare organizations are working hard to reduce avoidable rehospitalizations, especially among Medicare patients. Describe your organization's efforts to reduce hospital readmissions by taking HIN's second annual Reducing Hospital Readmissions Benchmark Survey. Respond by December 31 and receive an e-summary of the results once the survey is completed.

Complete the survey by visiting:

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Healthcare Trends for 2011
Ready for reform? This white paper summarizes results of the Healthcare Intelligence Network’s sixth annual Healthcare Trends for the Year Ahead e-survey conducted in October 2010, which reveals how 73 healthcare organizations perceived the business environment in 2010, are preparing for 2011 and anticipate implementation of the Patient Protection and Affordable Care Act (PPACA).

To download this complimentary white paper, please visit:

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EDITOR'S PICK: Save 10% on This Week's Medical Home Resource

Guide to Patient-Centered Case Management

The 110-page Guide to Patient-Centered Case Management presents best practices in identifying, stratifying and monitoring individuals for case management and documents the returns generated by targeted case management interventions in place at Geisinger Health System, Community Care of North Carolina and other organizations. The Q&A chapter answers more than 50 questions on patient-centered case management.
  • Chapter 1: Overview
  • Chapter 2: Long-Term Complex Case Management
  • Chapter 3: Best Practices in Patient Contact
  • Chapter 4: The Embedded Case Manager
  • Chapter 5: Case Management In a Diabetes Medical Home
  • Chapter 6: Case Management in the Emergency Department
  • Chapter 7: Q&A

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

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

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