Medical Home Monitor
Medical Home Monitor
February 22, 2011
Vol. III, No. 20

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Medical Home at Work, Clinical Integration
  2. HIE for Care Transitions
  3. New Chart: Top 5 HRA Outputs
  4. Podcast: Reforming Primary Care and Payments
  5. Patient Portal Expands
  6. E-Survey: Healthcare Case Management in 2011
  7. Benchmarks: Health Risk Assessments in 2010
  8. Editor's Pick

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Medical Home Q&A's:
Medical Home at Work,
Clinical Integration Metrics

Medical Home Monitor

Medical Home at Work

Q: Which incentive works best for increased uptake of disease management, specifically for the chronically ill?
A: You need to think about value-based design to make a difference at the individual level. Along with that, for a larger employer, I am also very much in favor of moving the care and changing the structure of care, in terms of an incentive for chronic illness. In the market, we’ve seen that when you can create medical homes at the workplace, make them free for the consumer, salary the physician and then only incent the physicians or provider, it creates a set of incentives that drive the physician and the member together. It eliminates a lot of specialty care cost, because it’s reestablishing a primary care relationship. The incentives are now lying between the consumer, the provider and the employer to drive much better adherence around chronic care management. They are only incented around quality incomes like levels of participation in chronic care, levels of participation in pharmaceutical support, completing preventive care screenings and participating in health assessment biometrics.

Neal Sofian, director of member engagement at Premera Blue Cross.

For more ways to use incentives to change health behaviors, please visit:

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Clinical Integration Metrics

Q: How are Advocate Physician Partners' quality and performance measures changing and evolving as your clinical integration program progresses?

A: This is a very deliberative process. We start early each year getting feedback from our physicians and from our hospital managers; we reach out to all of the managed care organizations, getting their ideas about important measures. We look at the national sources such as the National Quality Forum and National Committee for Quality Assurance. We then have a vetting process led by our quality improvement committee with practicing physicians to help prioritize those. We then have a tentative list that our board approves but then we spend time looking at the data collection challenges and our baseline performance, because we really don’t want to do a measure where there’s not a significant opportunity for improvement. Once we have gone through those processes, we come up with a final set of measures and then put together quality improvement tools that physicians and their staff can use to drive performance.

Mark Shields, MD, MBA, senior medical director for Advocate Physician Partners and vice president of medical management for Advocate Health Care.

For more details on clinical integration, please visit:

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Tightening Care Transitions with Health Information Exchange
For innovation in care improvement and cost reduction for patients transitioning between hospitals, long-term care facilities and other post-acute care providers, the Colorado Regional Health Information Organization (CORHIO) has received $1.7 million from the Health Information Exchange (HIE) Challenge Grant Program.

CORHIO, the state-designated entity for HIE, collaborates with Colorado physicians, hospitals, clinics, public health, long-term care, laboratories, health plans and patients to develop secure systems and processes for sharing clinical information. CO-REC, a CORHIO initiative, assists primary care providers in adopting and becoming meaningful users of EHRs. The Challenge Grant run by the Office of the National Coordinator for Health IT (ONC) allows CORHIO to support long-term and post-acute care providers in select regions as they implement processes to improve care transitions to and from hospitals in their communities.

Nearly one of every five patients discharged from hospitals in the United States is readmitted within 30 days, according to New England Journal of Medicine. HIE is a powerful tool for improving communication and coordination across care settings, which can improve quality of care and help reduce costs.

Following completion of the grant, CORHIO will share processes and outcomes resulting from this project with communities throughout Colorado and across the nation.

The CORHIO award is part of $16 million that ONC has awarded in new Challenge Grants to encourage breakthrough innovations for HIE that can be leveraged widely to support nationwide HIE and interoperability.

For more information, please visit:

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New Chart: Top 5 HRA Outputs
Aggregate data from health risk assessments (HRAs) provides a roadmap for the delivery of health promotion and disease management interventions to targeted individuals — with the goal of improving clinical and financial outcomes. We wanted to see the top applications for aggregate HRA data.

View the chart at:

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HealthSounds Podcast: Rewarding Primary Care Practice Reform with Physician Payment Reform
Capital District Physicians' Health Plan’s (CDPHP) medical home pilot began in 2008, with the dual goals of reforming both the practice of primary care in the CDPHP network and payments to these physicians. Dr. Bruce Nash, CDPHP's senior vice president of medical affairs and chief medical officer, explains what sets the two-phase CDPHP program apart from other medical home pilots, how participants met the challenge of practice transformation, and why preliminary pilot results mirror what's going on in the industry today.

To listen to this HIN podcast, please visit:

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Vanderbilt Adds Flu Assessment Tool to Patient Portal

If your patients come down with flu-like symptoms, do they know how to tell if they should see their healthcare provider?

The My Health at Vanderbilt team has launched a new online flu tool that provides personalized guidance based on answers to a few questions about symptoms and underlying health conditions.

The flu tool will be available through, and

The tool builds on the strong informatics infrastructure and culture available at VUMC, said S. Trent Rosenbloom, MD, MPH, assistant professor of Biomedical Informatics, Medicine and Pediatrics.

“My Health at Vanderbilt is one of the best-used patient portals in the country,” Rosenbloom said. “The flu tool will provide a tremendous service to our patients, and will help their healthcare provider efficiently personalize their care.”

The CDC warned earlier this month that the flu season has not yet peaked and advised that there is still time to have a flu vaccine.

“Sometimes it can be difficult to know whether you should see a healthcare provider,” said Jim Jirjis, MD, MBA, director of the Adult Primary Care Center and chief medical information officer for Vanderbilt University Medical Center.

“Our goal is to help patients make the right decisions about whether basic home care will be sufficient. They might benefit from anti-viral therapy and should see a physician, or they might be suffering from something more serious and need to be seen right away.”

For more information, please visit:

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HIN Survey of the Month: Healthcare Case Management in 2011
Are case management efforts helping to improve care coordination and health outcomes at your organization? Tell us about your program by completing HIN's second annual Survey of the Month on Healthcare Case Management by February 22, 2011. You'll receive a free executive summary of responses from more than 80 healthcare companies. Your responses will be kept strictly confidential.

Complete the survey by visiting:

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Health Risk Assessment in 2010
This white paper captures trends in the use of HRAs by 116 healthcare organizations to design and deliver health promotion and disease management interventions to targeted individuals in response to the Healthcare Intelligence Network June 2010 Health Risk Assessments e-survey.

To download this complimentary white paper, please visit:

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

Rewarding Primary Care Practice Reform with Physician Payment Reform: A Medical Home's Experience

During this 45-minute webinar on February 23, 2011, Bruce Nash, MD, MBA, senior VP of medical affairs and CMO for Capital District Physicians' Health Plan Inc. (CDPHP), will describe how CDPHP met the challenge of developing a novel risk adjustment methodology that would drive a global payment combined with a significant bonus structure to attract physician participation and encourage future growth by medical students to enter primary care.

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

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

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