Medical Home Monitor
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April 5, 2010
Vol. II, No. 22

Medical Home Monitor Archives

Medical Home Q&A's:
3 Steps to a PCMH,
Engaging Patients

Medical Home Monitor

3 Steps to a PCMH

Q: How can a physician practice get started with the transformation to a medical home?

A: First, make sure that the physicians are coding diagnoses to the fullest extent they can. Second, transform the role of the nurse from triager or phone adjunct to the physician to a health coach who does care coordination and outreach to those patients who have gaps in either chronic disease care or preventive care. Patients like being contacted and having all of their lab work done before they go into the visit with the PCP. Third, create registries. Whether you have an EMR or an index card, having a registry ó a list of your patients who are fragile or who have complex chronic care or are in need of preventive services ó will help you stay organized until you can move to the full medical home model.

(Barbara Walters, D.O., M.B.A., is the senior medical director of Dartmouth-Hitchcock Medical Center.)

For the newest medical home reimbursement models, please visit:

Patient Compliance

Q: What is the most effective way to get a patient to follow through on education, make an appointment with a physician or take medicine as ordered?

A: Itís not that easy. At any given day and time, getting us to take a medication or make an appointment may have different barriers. However, making what you want people to do easy in a way that they understand, can afford, feel is going to help them and feel they will be successful at is going to maximize that. If I have to sit on hold for 45 minutes to talk to my doctor's office and then find that the doctor is only available form 9 to 5 Monday to Friday and I would have to take time off from work, I am less likely to make that appointment. If I donít understand why my medication is going to help me — if it is too expensive, if I feel like it could make me sicker more than healthy again — I am not going to take it. Making what we want patients to do understandable, easy and affordable is going to help in all of those areas.

(Jan Berger, M.D., M.J., is chief medical officer of Silverlink Communications, Inc.)

For more on improving compliance through an integrated care team, please visit:

For Medical Home Success, Emphasize
Care Over Technology

Most medical home pilot projects place too much emphasis on EHRs at the expense of primary care's unique physician-patient relationship, according to a new study published in the March/April issue of Annals of Family Medicine.

Researchers for the study "Principles of the Patient-Centered Medical Home and Preventive Services Delivery" noted that it is the relationship-centered aspects of primary care that are more highly correlated with the delivery of preventive care services in community-based primary care practices.

According to the study, however, PCMH recognition programs such as the NCQA's tend to emphasize technology over the core principles of primary care, which could create future problems for the medical home model of care. "By not adequately measuring and emphasizing key PCMH principles, particularly the core primary care attributes, these projects risk generating null results which may lead to premature abandonment of the PCMH concept by major payors," the authors concluded.

The research involved 568 patients from 24 primary care practices. Researchers used multiple data sources, including patient surveys, chart audits, practice member questionnaires and medical director surveys.

The primary outcome measured was the rate at which patients were up-to-date on a package of preventive services, including cancer screening, lipid screening, influenza vaccination and behavioral counseling. On average, the rate at which patients were on schedule with receipt of those preventive services was nearly 43 percent.

Study authors found that the frequency with which patients visited a practice made a difference in preventive services received. For example, having 13 or more visits was associated with an average increase in preventive services received of more than 15 percent.

Other factors that significantly increased rates of preventive services included seeing the same physician, completing a well-patient visit within the past five years and having a practice referral system to link patients to community programs. "Having more contacts with the primary care practice and having a visit dedicated to preventive care are important strategies to increase preventive services," noted the authors.

However, on the health IT front, researchers found a practice's use of clinical decision-support tools to be the only "high-tech" indicator clearly linked to patients receiving preventive services.

For more information, please visit:

HealthSounds Podcast: Benefits of the Embedded Case Manager

Contributions of a case manager embedded in a physician practice quickly become evident, explains Diane Littlewood, R.N., regional manager of case management for health services, Geisinger Health Plan, which in turn bolsters physician buy-in for the program. She describes the upfront basics that help to ensure that health plan and provider expectations for embedded case management are met.

To listen to this HIN podcast, please visit:

New Jersey Testing Multi-Payor Portal to
Improve Healthcare Efficiencies

New Jersey has launched a yearlong study of the benefits of electronic health information exchange between healthcare providers and health insurers. The assessment will research the benefits of NaviNet® Insurer Connect, a multi-payor Web portal used by more than 50,000 providers to exchange data about New Jersey patients with health insurers in the state and elsewhere.

The initiative is organized by leading health insurers in New Jersey in collaboration with Americaís Health Insurance Plans (AHIP), the Blue Cross Blue Shield Association (BCBSA) and NaviNet. The pilot showcases how multi-payor portals streamline and automate key healthcare processes to improve care delivery and save time and money. Sponsoring health insurers offer providers access to NaviNet at no cost, enabling them to interact electronically with leading insurers via hundreds of real-time administrative, financial and clinical transactions, including eligibility and benefit inquiries, claims submission,claims status inquiries and referral and authorization submissions.

Nationwide, more than 800,000 healthcare providers, hospitals and ancillary care organizations use thepor tal to communicate with multiple health insurers from one Web site, increasing office efficiencies, reducing administrative and medical costs, improving providersí revenue cycles and enhancing the patient experience.

NaviNet Insurer Connect is available at no cost to healthcare providers nationwide. Providers interested in joining the NaviNet Network can visit

To learn more about this pilot, please visit:

HIN Survey of the Month: Obesity Prevention and Management

Despite early indicators of success, obesity is tied to an estimated $117 billion in healthcare costs. New healthcare reform will reward prevention-related initiatives, and first lady Michelle Obama's Let's Move campaign hopes to solve the childhood obesity epidemic within a generation. Describe how your organization is working to reduce and prevent obesity and obesity-related conditions and costs in your population by taking the Obesity Prevention and Management survey by April 30. You'll receive a free e-summary of the results, and your responses will be kept strictly confidential.

Complete the survey by visiting:

Healthcare Benchmarks: Medication Adherence Survey Results

Poor medication adherence is tied to as much as $290 billion annually in increased medical costs — as well as 33 to 69 percent of all medication-related hospital admissions in the United States, at a cost of about $100 billion per year. This white paper captures the efforts of 107 healthcare companies to improve medication adherence in their populations, from targeted populations and conditions of medication adherence programs to the components of a successful medication adherence program, as reflected by their responses to the January 2010 Medication Adherence e-survey.

To download this complimentary white paper, please visit:

Save 10% on new medical home resource:
The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination

In a new survey of healthcare organizations on the patient-centered medical home model, 60 percent of respondents include case managers on the medical home care team, with more than half of these respondents embedding these case managers within the primary care practice. Working within the ProvenHealth Navigator(SM) ó Geisinger's home-grown medical home model ó Geisinger carefully matches case managers with primary care practices, where they help the practice to identify its highest-risk population and develop customized care plans to guide those individuals better self-management of their condition and more judicious use of healthcare resources.

The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination provides an inside look at the selection, training, skill set, processes and benefits of the Geisinger Health Plan case managers embedded within the payor's medical home practices.

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

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

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