Embedded Care Manager, ACO Metrics
Medical Home Monitor
Medical Home Monitor
March 21, 2011
Vol. III, No. 22

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Total Cost of Care, Patient Expectations
  2. THINC's Embedded Care Manager
  3. New Chart: Tactics to Curb Avoidable ER Use
  4. Video: Reducing Avoidable ER Use
  5. 13 Guidelines for PCMH Recognition Programs
  6. E-Survey: Health & Wellness Incentives
  7. Benchmarks: Case Management in 2011
  8. Editor's Pick

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Medical Home Q&A's:
Total Cost of Care,
Patient Expectations

Medical Home Monitor

Total Cost of Care

Q: What has been the physician reaction to HealthPartners' total cost of care initiative?
A: HealthPartners has embedded the Triple Aim, improving health populations, the experience and quality of care of the individual and total cost of care for several years. It’s been our strategic platform for several years. The culture of our organization has embraced this work and approach. At least in Minnesota over the last year or two, we have seen a sea change from our care delivery systems in embracing the Triple Aim and engaging much more in understanding performance on total cost of care, how it can be improved and how it can simultaneously improve quality health and cost. There are many opportunities that really address all three goals simultaneously — for example, supporting people at hospital discharge and in those first few days as they’re taking care of themselves at home and making sure they understand all their meds to prevent readmission. It is improving the patient’s health, it's better quality of care and it reduces cost. In Minnesota, we have seen physicians engaged and looking for opportunities to make changes for improvement.

Babette Apland, senior vice president of health and care management for HealthPartners.

For more on aligning physician incentives for shared risk and reward, please visit:

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Patient Expectations

Q: How do you set patient expectations and responsibilities in a redesigned physician practice?

A: We have really tried to maximize the physician time with the patient. For example, with motivational interviewing, the idea is is that when patients leave the office, they actually want to make changes in their health and in their life, they want to take their medications and want to take care of chronic health problems. That’s something that has to occur in that office visit. When we have office visits that are too cluttered with a physician trying to refill the meds and they’re entering orders in front of them, patients really aren’t motivated.

From a physician’s standpoint, you need the free time to be able to motivate patients. That’s where the responsibility starts. When you preplan that next visit, there’s expectations when they come back that we would like for you to have set some sort of goal and have worked towards that goal.

Dr. David Eitrheim, family physician with Red Cedar Medical Center, part of the Mayo Health System.

For more advice on physician practice transformation, please visit:

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Geisinger's ProvenHealth Navigator Is Model for
THINC Embedded Care Manager Pilot
On the heels of its successful medical home incentive program, the Taconic Health Information Network and Community (THINC) will pilot a model of embedded care management at several of its Hudson Valley primary care sites. The pilot will be conducted with Taconic IPA and supported by Geisinger Health System, whose ProvenHealth Navigator care management program will be tailored to meet the needs of the Hudson Valley.

THINC seeks to bring a model of embedded care management within its National Committee for Quality Assurance (NCQA) Level 3 patient-centered medical homes (PCMHs) to achieve gains in efficiency and quality.

The program will be piloted at several sites, with a planned rollout to medical home-recognized primary care providers across the community. THINC expects this program to generate significant improvements in cost and quality of care for high-risk patients while testing the model's applicability outside of an integrated health system.

Earlier this month, THINC announced that six health plans paid $1.5 million to 236 primary care physicians in 11 practices for transformation to a PCMH and for the enhanced, more robust services that its half a million patients receive in medical homes.

Aetna, CDPHP, Hudson Health Plan, MVP Health Care, UnitedHealthcare and Empire BlueCross Blue Shield, which represent 65 percent of the commercial insurance market in the Hudson Valley and 43 percent of Medicaid managed care, rewarded the providers that achieved PCMH recognition from the NCQA, which served as an objective measure of medical home-ness.

The one-year PCMH transformation project was managed by THINC in collaboration with Taconic IPA. THINC is dedicated to improving the quality, safety and efficiency of healthcare for the benefit of the people of the Hudson Valley region of New York. The primary purpose of THINC is to advance the use of health IT through the sponsorship of a secure health information exchange network, the adoption and use of interoperable EHRs and the implementation of population health improvement activities.

For more information, please visit:

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New Chart: Top Tactics to Curb Avoidable ER Use
As public and private payors look more closely at resource utilization, healthcare organizations are targeting avoidable emergency room use. We wanted to see the top tactics in use to prevent inappropriate use of the ER.

View the chart at:

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HealthSounds Podcast: 2011 Metrics in Accountable Care Organizations
Are accountable care organizations (ACOs) the new wave of healthcare delivery? In this month's healthcare performance benchmarks podcast, Healthcare Intelligence Network's Melanie Matthews analyzes the industry's acceptance of and participation in ACOs derived from HIN's February 2011 survey results. This podcast also features Jeffrey Ruggiero, Esq., who advises ACO participants to prepare for the legal and regulatory hurdles.

To listen to this HIN podcast, please visit:

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13 Guidelines for Medical Home Recognition or Accreditation Programs

First came the 2007 Joint Principles for a Patient-Centered Medical Home. Now, building on those principles, four organizations representing more than 350,000 primary care physicians have released 13 guidelines to ensure some standardization among programs offering medical home recognition or accreditation.

Created by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association, the guidelines say that programs should attempt to assess all of the primary care domains outlined by the Institute of Medicine — comprehensiveness, coordination, continuity, accessibility and patient engagement and experience.

Four non-profit groups either have established or will soon launch a recognition, accreditation or other relevant program. According to the new guidelines, all PCMH recognition or accreditation programs should:

  1. Incorporate the Joint Principles of the PCMH;
  2. Address the complete scope of primary care services;
  3. Ensure the incorporation of patient and family-centered care emphasizing engagement of patients, their families and their caregivers;
  4. Engage multiple stakeholders in the development and implementation of the program;
  5. Align standards, elements, characteristics, and/or measures with meaningful use requirements;
  6. Identify essential standards, elements, and characteristics;
  7. Address the core concept of continuous improvement that is central to the PCMH model;
  8. Allow for innovative ideas;
  9. Acknowledge care coordination within the medical neighborhood;
  10. Clearly identify PCMH recognition or accreditation requirements for training programs;
  11. Ensure transparency in program structure and scoring;
  12. Apply reasonable documentation/data collection requirements; and
  13. Conduct evaluations of the program’s effectiveness and implement improvements over time.

“If we are to know the value of a patient-centered medical home’s accreditation, we need to be assured the accrediting program itself has met appropriate standards,” said Roland Goertz, MD, MBA, FAAFP president of the AAFP. “These guidelines help define those standards for accreditation programs.”

For more information, please visit:

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HIN Survey of the Month: Third Annual Health Incentives Survey
Healthcare companies have grown increasingly creative in their use of incentives to drive engagement and participation in health and wellness programs. Join the more than 65 companies that have already shared their experiences with incentives by completing HIN's third annual survey on this topic by March 31, 2011. You'll receive a free executive summary of the compiled results, and your responses will be kept strictly confidential.

Complete the survey by visiting:

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Healthcare Case Management in 2011
Not only are more organizations utilizing healthcare case managers, but the practice of embedding case managers at the point of care is becoming de rigueur, according to the second annual Healthcare Case Management e-survey conducted by the Healthcare Intelligence Network. This white paper documents the details of contemporary case management and the evolving responsibilities of today’s case manager from the 201 healthcare organizations that responded to HIN's January 2011 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

Best Practices in Contemporary Case Management

Consider these outcomes from real-world case management programs:
  • 25 percent reduction in specialist visits.
  • Percentage of individuals at highest level of patient activation more than doubles.
  • $400 PMPM savings for case management enrollees and 4:1 ROI.
  • Fewer admissions denials and reduced lengths of stay for ED treat-and-release and admitted patients.
Best Practices in Contemporary Case Management examines three separate case management initiatives that generated these results and others, detailing the impact of these programs on health outcomes, care delivery and resource utilization.

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

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Contact HIN:
Editor: Patricia Donovan, pdonovan@hin.com;
Publisher: Melanie Matthews, mmatthews@hin.com;

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