Medical Home Monitor
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February 1, 2010
Vol. II, No. 19

Medical Home Monitor Archives

Medical Home Q&A's:
Medical Home ROI,
Four Care Transition Pillars

Medical Home Monitor

Measuring ROI
in a Multi-Payor Pilot

Q: What are the challenges of evaluating ROI and patient satisfaction in multi-payor programs and how can these be addressed?

A: The first challenge is that we have 16 practices, 17 cities, and anywhere from a single doc practice to an eight-doc practice. Building enough patient lives within those practices to get to data that feels statistically significant has been challenging. Because of that, we decided to pool the practices for utilization metrics such as ER, hospitalization and generic e-prescribing use. We did decide to keep their clinical measures separate; each practice will be evaluated on how they are doing related to their own clinical measures.

The other challenge is having multiple payors at the table and making sure that we don’t impact antitrust considerations. We also need to consider which components need to be consistent among all payors and providers and which components can have a little flexibility.

For example, when we first started, we thought we would want one standard contract that each health plan would use with each participating pilot practice. Because of each health plan's systems, we found that this was probably not doable. We then stepped back and determined which components we would want in an addendum or contract with each of the practices.

(Julie Schilz, BSN, MBA, manager, IPIP and PCMH for the Colorado Clinical Guidelines Collaborative )

For more on multi-payor medical home pilots, please visit:

Care Transitions &
Readmission Rates

Q:What effect did Baptist Health's care transition intervention have on readmission rates?

A: Our care transitions intervention is based on a program at the University of Colorado by Eric Coleman that focused on what has been termed "four pillars of care." Coleman found that if you address these four pillars of care, you can drastically reduce readmission rates. In his study, he saw a 20 percent reduction in readmission rates for chronic patients, which was very similar to the five chronic conditions that we are looking at. Those four pillars are medication reconciliation, making sure that that patient has a medical home that they are in contact with, making sure that the patient has a care plan and understands that care plan, and helping the patient with self-education and understanding the identifiers for decompensation.

(Keith Norsym, Senior Director of Care Management Strategy for McKesson Health Solutions)

For more on managing care transitions to reduce readmission rates, please visit:

New CMS Demos Test Medical Home for Dually Eligible, Multi-Payor Health Information Exchange

CMS has launched two new demonstrations — a community-wide health information exchange in Indiana and a consortium of community care physician networks in North Carolina — to improve the delivery of quality care to an estimated 130,000 beneficiaries in those states. Both demos allow the organizations to share in a portion of Medicare savings achieved once quality of care and cost objectives are met.

The Indiana Health Information Exchange (IHIE) demo is the first large-scale Medicare study to examine the impact of a multi-payor, quality reporting and improvement, and pay-for-performance (PFP) program. Medicare data will be used by the IHIE along with outside clinical and administrative data to provide participating physicians with better information on the patients they are treating and to use common quality measures to create incentives to improve the quality and cost of care for patients covered by private insurers, employer-sponsored group health plans, Medicare and Medicaid. IHIE’s program will test whether quality improvement and PFP initiatives are more effective in a multi-payor environment.

The North Carolina Community Care Networks (NC-CCN) demo will extend the medical home concept to the dually eligible — low-income beneficiaries eligible for both Medicaid and Medicare. Consisting of eight regional healthcare networks in several North Carolina counties, the NC-CCN combines community-based care coordination and health IT to support more effective care management for a population whose care can sometimes be fragmented.

The demos are part of the national five-year Medicare Health Care Quality (MHCQ) demo mandated by Congress in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). The Indiana and North Carolina demos will make more effective use of best practice guidelines, encouraging shared decision-making between providers and patients, and altering incentives for care delivery.

For more information, please visit:

HealthSounds Podcast: Heading Off High-Risk Complications in the Elderly

Even though more than a third of the elderly are online, they're not necessarily using the Internet to seek health assistance, explains Marcia Wade, M.D., F.C.C.P., senior medical director at Aetna. That's why Aetna delivers its health risk assessment for the elderly in an alternate format while making available other Web-based tools to web-savvy boomer beneficiaries. Dr. Wade also describes Aetna's user-friendly strategy for heading off high-risk complications among its elderly and how this contributes to an overall reduction in hospital readmissions.

To listen to this HIN podcast, please visit:

Guided Care Participants Rate Quality of Healthcare High

Chronically ill older adults closely supported by a nurse-physician primary care team are twice as likely to rate their healthcare as high-quality than those who receive usual care, according to a study by researchers at the Johns Hopkins Bloomberg School of Public Health. The study found that after 18 months of a randomized controlled trial, Guided Care recipients rated their primary care significantly higher than usual care recipients with regard to coordination with specialists, support for self-management, and help with setting goals, making decisions and solving health-related problems.

Guided Care is a model of proactive, comprehensive healthcare provided by physician-nurse teams for patients with several chronic health conditions — a type of “medical home” for this rapidly growing population.

Guided Care patients were also 70 percent more likely to rate the time they had to wait for an appointment when sick as “excellent” or “good,” and 50 percent more likely to rate the ability to get phone advice as “excellent” or “good,” according to the study. The multi-site trial of Guided Care included 49 physicians, 904 older patients and 308 family members in eight locations in the Baltimore-Washington, D.C. area.

This model is designed to improve complex patients’ quality of life and quality of care while improving efficiency of treatment. The care teams include a registered nurse, two to five primary care physicians, and other members of the office staff who work together for the benefit of each patient. Following a comprehensive assessment and planning process, the Guided Care nurse educates and empowers patients and families, monitors their conditions monthly, and coordinates the efforts of healthcare professionals, hospitals and community agencies.

Previously published data suggested that, compared to usual care patients, Guided Care patients tended to spend less time in hospitals and skilled nursing facilities and had fewer ER visits and home health episodes, producing an annual net savings for healthcare insurers (after accounting for the costs of Guided Care) of $1,365 (11 percent) per patient, or $75,000 per nurse.

Source: Johns Hopkins Bloomberg School of Public Health, January 19, 2010

For more information, please visit:

HIN Survey of the Month: Health & Wellness Incentives Use

The use of economic incentives to drive engagement and results from wellness and prevention programs continues to proliferate, both as a response to escalating healthcare costs and a shift of more health ownership to consumers. Please share how your organization uses incentives to promote health and wellness by completing HIN's second annual Survey of the Month on this topic by February 28, 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: Patient Education and Engagement in 2009

How prevalent are patient and member education programs, and which health areas are addressed by these efforts? How are healthcare organizations delivering health education, and who is the primary health educator? What is the chief impact of patient education programs, and how do organizations measure ROI from patient education efforts? The Healthcare Intelligence Network set out to answer these questions and others during its 2009 Patient Education and Outreach Benchmarks e-survey. This executive summary of responses from 134 healthcare organizations offers lessons in the value of educating patients and members about disease management and self-care.

To download this complimentary white paper, please visit:

Save 10% on Benchmarks in Reducing Hospital Readmissions

As many payors begin to tie reimbursement to hospital readmission data, Benchmarks in Reducing Hospital Readmissions provides actionable information from 107 healthcare organizations on their efforts to reduce avoidable readmissions in their most vulnerable and highest-utilization populations. This 50-page resource provides metrics and measures on current and planned initiatives as well as lessons learned and results from early adopters of readmission reduction strategies. With hospital readmission trends under the microscope in healthcare reform, organizations will benefit from a review of these data to evaluate and plan programs and compare performance and utilization data.

Use ordering code MHMP to save 10 percent on this specially priced resource by visiting:

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