Medical Home Monitor
Follow us on Twitter Medical Home Monitor
March 1, 2010
Vol. II, No. 20

Medical Home Monitor Archives

Medical Home Q&A's:
Quality Improvement Coach,
Spreadsheet Registry

Medical Home Monitor

Quality Improvement Coach

Q: What is the role of the quality improvement coach in Colorado's multi-payor medical home pilot?

A: The quality improvement coach is an on-the-ground facilitator. We like to describe their role as "teaching practices to fish." Our role is to help ingrain quality improvement within their practice. The reality of this work is that it is population management, meaning you need to look at your metrics of measures to understand the needs of your population. By supporting the practices and implementing systematic approaches to quality improvement, we help embed within the practice quality improvement principles in management. Registry functionality is almost a dashboard at the level of the practice per quality improvement.

The quality improvement coaches start out by talking about, what is a team meeting? What do they look like? What are the components of a team meeting? How do you work together as a team? We work on helping them implement self-management support skills, motivational interviewing, systematic protocols within the practice for patient care delivery, and Plan-Do-Study-Act (PDSA) cycles so that they understand if processes are still accomplishing what they need them to accomplish. We also have an incredibly strong component on the monthly measures. We believe that the data is your lens of whether the systems you have put into place are having the desired outcomes.

(Julie Schilz, manager of the Improving Performance in Practice (IPIP) Program and the Colorado multi-stakeholder Patient-Centered Medical Home (PCMH) pilot for the Colorado Clinical Guidelines Collaborative.)

For more on multistakeholder collaborations in the medical home, please visit:

The Spreadsheet

Q:Which software did you use to build your patient registry?

A: A simple Excel® spreadsheet is easier to use than something sophisticated like Access®, SPSS or other data harvesting tool. You create columns and enter the patient data: the patient name, the patient number, the date you saw them, the date their cholesterol was checked, the cholesterol result and when they need to come back in. We do collect that through a separate registry. We are looking to integrate that more within our EMR by pulling data out.

(Barbara Luskin, quality manager at Grand Valley Health Plan.)

For more on achieving recognition from NCQA’s Physician Practice Connections® (PPC), please visit:

Year 1 of MetCare Medical Home:
Utilization Down, Prevention & Compliance Up

Readmissions running 6 percent below Medicare benchmarks, a 3 percent drop in hospital admissions and 4.5 percent decrease in length-of-stay per 1,000 customers as well as 94 percent of diabetic patients in compliance with A1C screening targets are some of the outcomes from the first year of the Metropolitan Health Networks, Inc. (MetCare) Patient-Centered Medical Home (PCMH) pilot program.

MetCare and Humana studied the impact of the PCMH model in a Medicare Advantage capitated group, establishing specific utilization, financial and quality metrics. This group represented Medicare Advantage HMO customers seen by primary care physicians within the same markets under a capitated risk arrangement but in a traditional medical practice model. Baseline measures were determined from medical claims for the period November 1, 2007 to October 31, 2008, and a matched control group was identified and tracked for similar measures. The pilot ran from November 1, 2008 to October 31, 2009.

Additional 12-month financial and quality results included the following:

  • Emergency room expense rose by only 4.5 percent for the Metcare group compared to an increase of 17.4 percent for the control group.
  • Diagnostic imaging expense dropped 9.8 percent compared to an increase of 10.7 percent for the control group.
  • Pharmacy expense increases were limited to 6.5 percent versus a 14.5 percent increase for the control group.
  • Overall medical expense for the Metcare group rose by only 5.2 percent compared to 26.3 percent increase for the control group.
  • Preventive breast and colorectal cancer screening was 13.3 percent and 6.3 percent higher respectively, compared to the control group.
  • Seasonal influenza vaccination rates increased 9 percent to 64 percent, compared to the national average of 43 percent.
  • Average LDL cholesterol levels dropped by 1.8 percent, and customers with levels below 100 (a target level) rose by 4.0 percent.
  • Ninety-four percent of diabetic patients had an A1C level of less than 9 percent.
  • Customer satisfaction results improved or stayed the same in 45 of 61 categories.

For more information, please visit:

HealthSounds Podcast: Meet the Medical Home Neighbor - The ACO

The accountable care organization (ACO) — a network of primary care physicians, one or more hospitals, and subspecialists that provide patient-centered care — is receiving increasing attention as healthcare reform unfolds. Not only do ACOs complement the medical home model, but they are inextricably linked, says Dr. Craig Samitt, M.B.A., president and CEO of Dean Health System. Dr. Samitt discusses how ACOs complement the medical home model, the pros and cons of mandatory and voluntary ACOs and creating reimbursement strategies for ACOs.

To listen to this HIN podcast, please visit:

Omaha Hospitals Launch Accountable Care Alliance

Methodist Health System, The Nebraska Medical Center and their affiliated physicians have formed the Accountable Care Alliance, a partnership to reduce costs to patients and to improve quality and efficiency of patient care across the two health systems.

The Accountable Care Alliance will be structured like an accountable care organization (ACO), one of the models being considered by the federal government under healthcare reform as a way to reduce healthcare costs. An ACO is an integrated healthcare delivery system that relies on a network of primary care physicians, specialists and hospitals that are held responsible for the quality and cost of healthcare to a defined patient population.

Patients with chronic conditions (diabetes, congestive heart failure, cystic fibrosis, etc.) and patients who are frequently readmitted to the hospital will especially benefit. The Accountable Care Alliance can help to increase communication between doctors and hospitals, reduce duplication of services, limit unnecessary tests, make sure transitions from hospital to home are better managed, and help patients maintain good health in their homes to reduce hospital utilization.

The Accountable Care Alliance is committed to improving the health of patients long after the doctor’s appointment or hospitalization has concluded. For a diabetes patient, this may mean a daily phone call or text after the patient is discharged from the hospital to make sure the patient is taking her medications and monitoring her blood sugar levels.

Closely monitoring a patient’s care could also include making sure the patient has a complete and accurate list of prescribed medications along with proper instructions as well as booking a follow-up appointment for a patient and making sure that the patient has transportation.

Finally, the Accountable Care Alliance will allow both health systems to share knowledge and performance criteria to ensure both health systems are performing at their best and providing the highest level of quality care. The Accountable Care Alliance will be operated by a 12-member board of directors (six representatives, mostly physicians, from each hospital system).

For more information, please visit:

HIN Survey of the Month: Health & Wellness Incentives Use

Last day! 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. Join the more than 130 organizations that have already described how they use incentives to promote health and wellness by completing HIN's second annual Survey of the Month on this topic by March 1, 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 Benchmarks: Telehealth & Telemedicine - Wired for Access and Efficiency

How prevalent is remote monitoring, and which medical conditions are most often monitored? How has telehealth impacted levels of healthcare access, efficiency, cost and patient compliance? The Healthcare Intelligence Network set out to answer these questions and others during its 2009 Telehealth e-survey. This executive summary of responses from 134 healthcare organizations identifies emerging trends in the use of telehealth and telemedicine and offers a glimpse into a healthcare future where no patient is left behind because of a lack of access.

To download this complimentary white paper, please visit:

Save 10% on March 31 Webinar: Shared Savings in the Medical Home

During this 45-minute webinar, David West, MD, Hospitalist, St. Mary's Hospital, Grand Junction, Colorado, will examine how to structure a shared savings agreement. Grand Junction, with its high-quality and lower healthcare costs, has been cited by many as an example of how health reform should be structured. A key component of its system is a shared vision and shared incentives.

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

Join Our Community:

Twitter Facebook LinkeIn

Please pass this along to any of your colleagues or, better yet, have them sign up to receive their own copy at where you can also learn about our other news services.

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

HIN's Medical Home Monitor Archives put at your fingertips complimentary video, podcasts, white papers and blog posts on the advancement of the PCMH — plus back issues of this e-newsletter and links to additional medical home resources. Please bookmark this site and check back often for new content:
There are other free email newsletters available from HIN!

Disease Management Update provides weekly updates of news articles, trends and Q&A on disease management. In addition, we'll provide you with links to white papers, podcasts and case studies on disease management. The Disease Management Desktop also links you to some of the top resources used by healthcare executives responsible for disease management.

For products and services available from the Healthcare Intelligence Network, contact us at (888) 446-3530 / (732) 528-4468, fax (732) 292-3073 or email us at

All contents of this message Copyright 2010