Medical Home Monitor
Medical Home Monitor
May 3, 2010
Vol. III, No. 2

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Care Continuity
  2. Motivating Minorities
  3. New Chart: Case Manager Work Locations
  4. Podcast: Medicare Care Transitions
  5. Members-Only Medical Home
  6. E-Survey: Care Transitions
  7. Benchmarks: Medical Homes 2010
  8. Editor's Pick

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Medical Home Q&A's:
Care Continuity,
Enforcing Guidelines

Medical Home Monitor

Continuity of Care

Q: What is the essential component of a successful medical home?

A: Continuity of care is the magic in medicine and somehow needs to be built into effective medical homes. As a family physician, I see my aging patient with 10 medical problems on 10 different drugs. Having taken care of this person for many years, I can provide better care and more cost-effective care than any other physician in the country because I know him, I know his spouse and perhaps I even know his children. Iíve treated him for decades, and when he says he is not feeling good, I can often make the most cost-effective decision.

Successful medical homes also need to provide truly comprehensive care 24 hours a day, 7 days a week.

David West, M.D., hospitalist, family physician and healthcare consultant in Grand Junction, Colo.

For more on shared savings in the medical home, please visit:

Simple Rule for
Guidelines Enforcement

Q: How do you help to ensure that patients follow evidence-based guidelines?

A: We reliably give patients information about their health status. For example, in many offices in the country, doctors will routinely say to patients, ďWeíre going to do these blood tests. No news is good news; youíll hear from me if itís abnormal. But if itís normal, you wonít hear from me.Ē As one of my colleagues says, ďIf you donít hear from me, that means either I lost it or I never got it, because I want you to be sure that you know that I will always communicate results.Ē

We share lab results routinely with our patients. We spend some time getting the EMR to help us with that so that we communicate in writing to patients. The EMR pulls out their most recent LDL or A1c and it drops the data into a letter format, so that itís in a context that makes sense to the patient.

(Dr. Richard Baron is president and CMO of Greenhouse Internists. )

For more on using evidence-based guidelines in the medical home, please visit:

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Motivating Minorities with Chronic Disease

A new community-based project is designed to motivate low-income minorities with chronic diseases to include cancer screening in their medical care. Patient Voices to Improve Primary Care will assess barriers to and motivators for preventive cancer screening and will design a patient-driven intervention to incorporate cancer screening into chronic disease management.

Funded through a $1 million Recovery Act grant from the National Center for Minority Health and Health Disparities, Patient Voices will pair researchers from University at Buffalo's schools of Medicine and Biomedical Sciences and Public Health and Health Professions and Roswell Park Cancer Institute with two community-based organizations, two primary care practices and a team of patients with complex chronic conditions.

Project collaborators will develop a registry of patients with complex chronic disease for each study site that will document screening for colorectal, breast and cervical cancer, along with smoking cessation advice and treatment, and correlate this data with patients' diagnostic history and demographics. These statistics then will be compared to national screening rates.

Based on this data and on patients' opinions on factors that encourage or discourage cancer prevention screening, the study group will design a pilot cancer-prevention intervention that will be tested with patients with complex chronic disease from the surrounding low-income, predominately minority community.

The pilot intervention will be tested over a 12-month period with 200 patients recruited from the registry to gauge its ability to improve cancer prevention measures, compared to the baseline data. The researchers also will assess the impact of the intervention on participants' social support, active involvement in the study, self-management skills and quality of life.

This pilot study will create five new jobs for minorities in the community and lay the groundwork for a larger multi-year participatory research study.

For more information, please visit:

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New Chart: Case Manager Work Locations

Case managers' inflluence has expanded beyond the health plan office. We wanted to see how many healthcare organizations are embedding case managers at care sites and which care sites merit the most case manager effort.

View the chart at:

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HealthSounds Podcast: Managing Medicare Care Transitions
In the first of several conversations with Metcare of Florida chief executives on its continuing medical home pilot with Humana, CEO Mike Earley and President and COO Dr. Jose Guethon describe Metcare's longstanding commitment to the management of care transitions for its Medicare patients, how its 10 medical home practices keep a handle on patient care in hospital settings, and the clinical and business returns that result from these efforts.

To listen to this HIN podcast, please visit:

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Membership-Based Medical Home Operator Plans Expansion

Taking advantage of a provision in the Patient Protection and Affordable Care Act for direct primary care medical homes, Qliance, an operator of insurance-free, flat-fee direct primary care medical home clinics in Washington State, plans to add new clinics in Washington and nationally and further develop its technology platform.

Qliance patients pay a monthly membership fee between $44 and $84, depending on age, for its core service level, which provides unrestricted primary and preventive care. Services include checkups, vaccinations, pneumonia, minor fractures, routine womenís health exams, and ongoing care for chronic illnesses such as diabetes, hypertension or obesity. Qliance providers also coordinate any necessary outside specialist or hospital care for their patients, serving as their medical home.

The Qliance model has attracted investors such as Bezos Expeditions, the personal investment company of founder Jeff Bezos with participation from MSD Capital, L.P., the private investment firm of Michael Dell, Drew Carey, actor and co-owner of the Seattle Sounders soccer team and other venture fund investors.

In 2007, Washington State legislature recognized direct primary care as an innovative healthcare delivery model not to be regulated as insurance, paving the way for practices such as Qliance's and providing all residents access to affordable, quality healthcare. In 2009, the legislature passed a law to allow employers and self-insured plans to pay direct primary care providers on behalf of their employees and members. Since then, Qliance has enrolled more than 70 employers that pay the Qliance membership fees on behalf of their employees.

To learn more, please visit:

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HIN Survey of the Month: Managing Care Transitions Across Sites
Tighter management of transitions in care — particularly for older adults with complex acute or chronic conditions — can help to close care gaps, reduce avoidable hospital readmissions and medication errors and raise the bar on care quality and satisfaction indicators. Please share how your organization is coordinating key care transitions by completing HIN's second annual e-survey on Managing Care Transitions Across Sites. You'll receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

Complete the survey by visiting:

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Healthcare Benchmarks: Medical Homes in 2010
Patient-centered medical home (PCMH) pilots are in high gear around the country and high on the healthcare reform agenda. This just-published Healthcare Intelligence Network (HIN) white paper measures adoption of the PCMH in 2010 as compared to HIN's first medical home survey in 2006, the targeted populations that would benefit from this model of care, the components of a medical home and the effects of this model in the healthcare industry.

To download this complimentary white paper, please visit:

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Save 10% on new medical home resource:
MORE Medical Home Reimbursement Models: ROI from Risk Adjustment, Shared Savings and Multi-Payor Partnerships

The newest strategies for generating revenue from the PCMH are documented in MORE Medical Home Reimbursement Models: ROI from Risk Adjustment, Shared Savings and Multi-Payor Partnerships. In this 45-page resource, learn how the identification of high-risk patients, meaningful distribution of healthcare data and collaborations with like-minded organizations are increasing medical home profitability for three healthcare organizations.

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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