Medical Home Monitor
Medical Home Monitor
April 20, 2009
Vol. II, No. 1

Medical Home Monitor Archives

Medical Home Q&A:
Discharge Planning
for Multimorbid Patients

Medical Home Monitor

Q: What are some discharge planning strategies for elderly patients with multiple comorbidities?

A: In [the Guided Care] model, the nurse doesn’t do the discharge planning. Every hospital has to have a discharge planner, and we rely on that person to make the plan. Our nurse interacts with that person to make sure the discharge planner knows everything they need to know about the patient for whom they’re making the plan. Most discharge planners have no idea of the patient’s home circumstances. However, our nurse has been to the home and makes sure the planners know the capabilities at home and tries to ensure that a good plan is made. Importantly, our nurses visit the home the day of or day after discharge. That’s when the opportunity is greatest to resolve the confusion that’s almost always going on with people who have complicated problems, have had their medications adjusted and then are sent home. (Chad Boult, M.D., M.P.H., M.B.A., professor of public health, medicine & nursing and director of the Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health.)

For information on care models for patients with comorbidities, please visit:

Payor-Provider PCMH Pilot with Diabetes Focus May Be Model for South Carolina

Blue Cross Blue Shield-South Carolina (BCBS-SC) and Palmetto Primary Care Physicians are launching a year-long PCMH pilot that could become a model for South Carolina. The pilot project will focus on diabetic patients who are members of BCBS-SC, BlueChoice HealthPlan of South Carolina and the State Health Plan. The program is a first for the payors, providers and patients involved in the pilot.

Case managers hired recently by Palmetto Primary Care Physicians will help reduce gaps in care, such as missed appointments with specialists, lack of transportation and medication non-compliance. They also will perform outreach, such as registering patients for wellness clinics, scheduling appointments with specialists and monitoring blood sugar levels and cholesterol levels.

EMRs will be key to delivering comprehensive care, as well as data that the PCPs have never received before. Palmetto uses software at the point of care that integrates data from the health plan, case manager and local ERs.

For more information, please visit:

HealthSounds Podcast: Medical Home Transformation
Takes More Than Technology

IBM spends about $2 billion a year on healthcare for its 500,000 employees but doesn't believe it's getting its money's worth from the current system, explains George Chedraoui, healthcare leader with IBM and immediate past president of Bridges to Excellence. Chedraoui explains why IBM is banking on the PCMH — with its focus on disease prevention and wellness — to deliver this value. He also explains the impact that $19 billion in health IT incentives will have on physician practices and why it will take more than technology to transform a physician practice into a medical home.

To listen to this complimentary HIN podcast, please visit:

Military to Test PHR to Support a Medical Home in Primary Care Setting

The Military Health Service (MHS) will partner with the National Naval Medical Center in Bethesda, Md., to test the ability of the Micare PHR to support a medical home in a primary care setting. The Micare PHR is a tool for care coordination as well as a mechanism for patients to share health records across a mix of military and commercial providers and payors.

With about 10,000 patients, Bethesda will test how well the PHR scales in large pool of healthcare consumers, said Col. Keith Salzman, chief of informatics at Madigan, which is hosting the pilot. The test will also give MHS experience in developing a patient-provider portal necessary for the kind of health information sharing necessary in the medical home setting.

“Right now, the patient can see their data; the provider can see what the patient sends to them,” Salzman said. The portal would allow for more “robust” communications between a physician and patient, he said. MHS plans to launch the PHR at Bethesda this summer.

For more information, please visit:

HIN Survey of the Month: Managing Care Transitions Across Sites

Planning a patient's care transitions and closing the gaps in care from one healthcare setting to another can have a significant effect on health outcomes, likelihood of readmission and ER visits, cost to patients, providers and insurers, and the burden on caregivers and family members. Please share your organization's experiences with care transitions by completing HIN's Survey of the Month. You'll receive a free executive summary of the compiled results.

Complete the survey by visiting:

Personal Health Records for Consumers

Whether paper-based or electronic, PHRs are helping individuals manage their conditions, diseases and overall health. A number of organizations — including WebMD,® Microsoft® and Google® — are trying their hand at PHRs. In April 2008, more than 200 health plans, hospitals and health systems, healthcare providers, employers and healthcare IT vendors told HIN how they use PHRs to benefit their populations.

To download this complimentary white paper, please visit:

Save 10 percent when you order by April 23:

Hospitals in a Medical Home: Partners in Enhancing Access, Health Status and Cost Avoidance

In Hospitals in a Medical Home: Partners in Enhancing Access, Health Status and Cost Avoidance, the director of a medical home network demonstrates how hospitals can partner with medical homes to deliver patient-centered care to uninsured and low-income patients while reaping the financial benefits associated with decreased utilization and duplication of services.

Reserve your specially priced copy by April 23 by visiting:

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Publisher: Melanie Matthews,;

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