Medical Home Monitor
Medical Home Monitor
April 18, 2011
Vol. III, No. 24

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Heart Failure Readmissions, Quality Profile
  2. 4 Value Drivers of Patient-Centered Care
  3. New Chart: Health Coaching ROI
  4. Podcast: Analyzing the ACO Rule
  5. Medicaid Medical Homes
  6. E-Survey: Fifth Annual Medical Homes Survey
  7. Benchmarks: Tobacco Cessation Programs
  8. Editor's Pick

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Medical Home Q&A's:
Heart Failure Readmissions,
Quality Indicators

Medical Home Monitor

Heart Failure Readmissions

Q: Has your care coordination network with SNFs identified transition protocols specific to heart failure patients that might influence adverse outcomes?
A: Summa Health System's ACO model has started with heart failure. Step one was heart failure admission from hospital to home. That’s our first level while we’re working with the practices to get them up into the medical home model. We will be looking at that condition with the facilities as part of our next efforts.

We’re now bringing everybody back together to work on our quality numbers that we’re going to be giving back to the hospital. Heart failure will be one of those numbers, as that’s a key focus for both Medicare and managed care when it comes to readmission rates.

Carolyn Holder, manager of transitional care for Summa Health System, and Mike Demagall, administrator with Bath Manor and Windsong Care Center.

For more ways to improve hospital-SNF transfers, please visit:

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Care Quality Indicators

Q: What utilization measures will THINC incorporate in the quality profile?

A: We’re looking at a number of measures of outpatient utilization, office visits with the PCP and specialists, laboratory tests, radiology and other diagnostic tests, a number of ancillary services and generic prescribing rates. We will look at EDs and hospital utilization, number of ED visits, admissions, length of stay and number of skilled nursing days. And we will also be looking at referral care, number of skilled home care visits and number of custodial home care visits.

Susan Stuard, executive director, Taconic Health Information Network and Community (THINC).

For more trends in physician performance-based reimbursement, please visit:

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4 Value Drivers of Patient-Centered Care Delivery Models
New models of care such as patient-centered medical homes (PCMH) and accountable care organizations (ACOs) must emphasize four value-driving elements of advanced primary care — enhanced access, better care coordination, use of health IT to support care transformation and payment models that reward coordinated care.

The findings were released in a new report prepared jointly by the Patient-Centered Primary Care Collaborative, The Commonwealth Fund and the Dartmouth Institute for Health Policy and Clinical Practice: Better to Best: Value-Driving Elements of the Patient Centered Medical Home and Accountable Care Organizations

Two of the four value-driving elements identified in the report — enhanced access and care coordination — are elements of healthcare delivery that require urgent overhaul to maximize health outcomes at lower costs. The others, health IT and payment reform, are essential tools, without which widespread implementation of new care delivery models will not succeed.

Download the full report at:

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New Chart: Health Coaching ROI
Despite the fragile economy, health and wellness coaching programs are flourishing. We wanted to see what ROI was generated from health coaching programs.

View the chart at:

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HealthSounds Podcast: Business Opportunities from the ACO Rule
Now that the wait for CMS's ACO regulations is over, Greg Mertz, senior project director with the Healthcare Strategy Group, has advice for both providers and payors on how to maximize returns from ACO participation.

To listen to this HIN podcast, please visit:

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South Carolina Launches Medical Home Networks for Medicaid Patients

Palmetto Physician Connections is establishing medical home networks to coordinate care for Medicaid beneficiaries in the South Carolina Healthy Connections program. Primary care physicians and other providers work with case and disease managers to identify at-risk Medicaid beneficiaries and provide proactive care management and monitoring to improve outcomes and quality of life. Patient education on self-care and healthy lifestyles is also provided.

Central to the success of Palmetto Physician Connections is the ability to manage and share comprehensive, actionable information with all participants along the care spectrum. Access to contextually appropriate data that provides a real-time, 360-degree view of the patient is critical for identifying risk and severity levels.

To accomplish this, Palmetto Physician Connections utilizes MedHOK solutions, which leverage cloud computing, Google technologies, smart interfaces and advanced analytics to collect patient data from disparate systems, which is then aggregated, cleansed, standardized and optimized for use. This enables Palmetto Physician Connections to manage and measure care against national quality standards for optimal outcomes.

For more information, please visit:

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HIN Survey of the Month: Fifth Annual Medical Home Survey
What is the shape of patient-centered care today? One year post-healthcare reform, we're taking our fifth annual look at adoption and support of the PCMH model. Describe your organization's progress and outcomes in this area by April 30 and you'll receive a free e-summary of the results — and be entered in a drawing to win our newest healthcare resource, Guide to Physician Performance-Based Reimbursement.

Complete the survey by visiting:

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New Benchmarks: Tobacco Cessation Efforts
This white paper summarizes the efforts of 84 healthcare organizations to curb and prevent smoking in their populations, providing details on program availability, intervention components and reimbursement trends.

To download this complimentary white paper, please visit:

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

Patient Registries: A Cornerstone in Creating and Delivering Accountable Care

This 45-minute webinar on April 28, 2011 will cover patient registry best practices to ensure that a healthcare organization is delivering recommended care and identifying ways to improve outcomes.

Dr. Gregory Spencer, chief medical officer of Crystal Run Healthcare, will provide the inside details on:

  • Redesigning internal processes so that a registry can be used most effectively;
  • Using registry data to identify gaps in care;
  • Steps to improve accuracy and completeness of registry data; and
  • The evolving role of patient registries in delivering accountable care.

Use ordering code MHMP to save 10 percent on webinar registration by visiting:

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

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