Medical Home Monitor
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December 21, 2009
Vol. II, No. 16

Medical Home Monitor Archives

Medical Home Q&A's:
The Hospital Discharge,
Health IT in the ACO

Medical Home Monitor

Best Practices for
The Hospital Discharge

Q: What are the rudiments of an effective hospital discharge process?

A: Many requirements for successful discharge have been in place for some time. A successful discharge is one in which all elements of a successful discharge are taken into consideration and assured. Itís not a matter of a ward clerk bringing a set of discharge instructions to the patientís family before they leave, obtaining a signature and putting it in the chart. Itís assuring that the infrastructure necessary to ensure successful discharge is in fact in place. Particularly with the elderly, who have multiple conditions and face psychosocial barriers, this may require a more thorough evaluation and more use of home evaluations than we currently see. (Dr. Randall Krakauer, National Medical Director of Medicare at Aetna)

For more on aligning reimbursement to reduce hospital readmissions, please visit:

Health IT in
the ACO

Q: Do primary care practices in your accountable care organization (ACO) use point-of-care technology like Web-based visits, e-mail access and telemedicine, and who pays for the care and the technology?

A: We donít do telemedicine or e-visits at this time, but are exploring both. E-mail to doctors is actively used through our EHR system. In many cases, communicating with patients this way is more efficient. We have found that for many patients who could be cared for and treated by e-mail but who come in for a visit, the cost of that visit actually exceeds the revenue from that visit. Even in fee-for-service (FFS) practices, this type of care should probably not be brought into the office. Home care should be left at home, leaving the capacity of the office for higher complexity illness. We do not receive reimbursement for this form of care. For our capitated population, we want to be as efficient as possible, but even in our FFS population, we want to do right by the patient. We donít want to ask our doctors to practice two different ways. We are encouraging our doctors to provide better care at a lower cost irrespective of the payor. (Dr. Craig Samitt, president and CEO of Dean Health System)

For more on the relationship of the accountable care organization to the medical home, please visit:

HRSA, CMS to Co-Launch Medicare Medical Home
Demo for FQHCs

More than 500 federally qualified health centers (FQHCs) are expected to participate in a three-year demonstration to evaluate the impact of advanced primary care on Medicare beneficiaries. The demo, announced earlier this month by President Obama, will be co-managed by the Health Resources and Services Administration (HRSA) and CMS. The demo will evaluate the impact of the advanced primary care practice model on access, quality and cost of care provided to Medicare beneficiaries served by FQHCs, which provide primary and preventive healthcare for the medically underserved.

FQHCs that wish to participate must demonstrate that their clinic sites have the capacity to deliver continuous and coordinated care across providers and settings, including improving access to care by expanding service hours, facilitating referrals and managing medications prescribed by different physicians. Demo sites will receive a monthly care management fee for each Medicare FFS beneficiary they enroll into the demonstration, in addition to payment for other covered Medicare services they provide.

CMS will solicit applications in the spring and launch the demo in January 2011. CMS will conduct an independent evaluation of this demonstration.

Overseen by the HRSA, the FQHC program is a national network of more than 1,100 community, migrant, homeless and public housing health center grantees that provide healthcare at more than 7,500 clinical sites, ranging from large medical facilities to mobile vans. In 2008, health centers served more than 17 million medically underserved people, providing an environment to demonstrate the benefits that medical homes can offer to Medicare beneficiaries.

For more information, please visit:

HealthSounds Podcast: Risk-Adjusted Reimbursement

Social and demographic factors can complicate care coordination for patients as much as clinical factors, explains Jeff Schiff, M.D., M.B.A., medical director of Minnesota Health Care Programs for the Minnesota Department of Human Services. He identifies the two key social/demographic factors getting close attention in Minnesota's new primary care reimbursement model and explains how the engagement of patient and family at the clinical level is paying off in improved patient safety, satisfaction and health outcomes.

To listen to this HIN podcast, please visit:

New Learning Collaborative to Prepare
Clinicians for Better Chronic Care

HealthSciences Institute will sponsor a new learning collaborative for healthcare organizations who serve individuals at risk of or affected by chronic disease. The collaborative will offer free webinars on key aspects of chronic disease prevention, management and care improvement that will include a brief presentation, ask-the-expert segment, and targeted discussion on the application of new learning to participant job roles. Discussion will continue online between sessions.

The collaborative is part of a new HealthSciences Institute-sponsored Partners in Improvement initiative that will offer free online chronic care improvement resources and tools to healthcare organizations and professionals. Topics planned for the first quarter of 2010 include benchmarking population health programming and disease management expertise, patient activation and a collaborative primary care cardiovascular disease and diabetes program.

For more information, please visit:

HIN Survey of the Month: Healthcare Case Management

More than 75 healthcare companies have already described how their case managers contribute to care coordination, cost management and quality improvement. 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: Medical Homes in 2009

According to a 2004 report in the Annals of Family Medicine, if every American had a medical home, healthcare costs would decrease by 5.6 percent, resulting in national savings of $67 billion per year and improved care. This white paper summarizes the results from HINís Medical Homes in 2009 e-survey, in which more than 220 healthcare organizations described the role of the PCMH in their organizations.

To download this complimentary white paper, please visit:

Medication Therapy Management in the Medical Home ó Save 10% on Registration

From free and discounted prescription drug costs to medication reconciliation in the office, medical home programs are taking a number of steps to ensure patient medication compliance.

During this 45-minute webinar on January 6, 2010, Beth Chester, PharmD, MPH, BCPS, senior director of clinical pharmacy services and quality, Kaiser Permanente Colorado, will share the key components of medication therapy management programs in the medical home. Youíll get details on the roles of the physician practiceís staff and the pharmacist in medication management, the use of technology and how financial incentives and reimbursement can play a role in improving medication compliance.

Use ordering code MHMP to reserve your specially priced admission 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 ó with a special focus on reducing rehospitalizations among the Medicare population.

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