Medical Home Monitor
Medical Home Monitor
May 17, 2010
Vol. III, No. 3

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Health Risk Screening
  2. Group Health Year 2 Results
  3. New Chart: Measuring Medication Adherence
  4. Podcast: Home Visit Priorities
  5. PCMH and ER Visits
  6. E-Survey: Care Transition Programs
  7. Benchmarks: Case Management Trends
  8. Editor's Pick

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Medical Home Q&A's:
Screening Tools,
Home Visits

Medical Home Monitor

Screening Health Risks

Q: What is the best tool to screen for health risks?

A: As part of the Assessing Care of Vulnerable Elderly (ACOVE), a team of Rand, UCLA and VA researchers developed the Vulnerable Elders Study (VES-13), which can be accessed at The VES-13 is a simple function-based tool for screening community-dwelling populations to identify older persons at risk for health deterioration.

Dr. Marcia Wade, senior medical director at Aetna Medicare.

For more on assessing risk in elderly patients, please visit:

When Home Visits
Are Refused

Q: Have there been any unintended consequences from your care transitions program?

A: The one unintended consequence is that people sometimes refuse the home care portion. We worked very closely with our inpatient partners and home care partners to message the importance of that home care visit post-discharge, and to engage the physicians in the hospital (whether their own physician or a hospitalist) to recommend that post-hospital home care visit. Initially, we were only getting 50 percent acceptance of the home care visit and now we’ve been able to raise that with appropriate messaging and partnering.

(Mary Cooley, R.N., B.S.N., M.S., C.C.M., manager of case and disease management at Priority Health. )

For more on interventions that reduce readmissions, please visit:

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5 Tips for Medical Home Transformation

Group Health Cooperative's transformation of primary care into a patient-centered medical home model has paid off in improved care quality, less clinician burnout and fewer ER visits and hospitalization. Results from a two-year evaluation, published in the May 2010 Health Affairs, compared the medical home prototype to Group Health’s other medical centers, showing:

  • The quality of care was higher, patients reported having better experiences, and clinicians said they felt less “burned out.”
  • Patients had 29 percent fewer emergency visits and 6 percent fewer hospitalizations, resulting in a net savings of $10 per patient per month.
  • For every dollar Group Health invested, mostly to boost staffing, it recouped $1.50.
As part of the transformation, Group Health reduced the number of patients per salaried primary care doctor from 2,300 to 1,800, which left more time for planning, outreach, coordination, daily "team huddles," patient contact by e-mail and phone, and longer office visits -- 30 minutes instead of 20. Group Health also invested $16 more per patient per year in extra staffing for its medical home prototype, which did not include the robust health IT infrastructure already in place.

For others considering PCMH adoption, Robert J. Reid, M.D., Ph.D., an associate investigator at Group Health Research Institute and Group Health's associate medical director for preventive care, suggests the following:

  • Invest in primary care by hiring enough clinicians so they can serve their patients well.
  • Involve patients in designing care that comprehensively meets their needs.
  • Have strong leaders who focus on what patients want, clearly articulate those wants, and let care teams take charge of their change process.
  • Have good managers who break big changes into carefully staged parts, so teams aren’t overwhelmed.
  • Invest in health IT and thoughtfully integrate it into the daily practice of the medical home.

For more details on the evaluation, please visit:

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New Chart: Tools That Measure Medication Adherence
Medication adherence programs can improve patient care and lower healthcare costs by more effectively managing chronic medication utilization. We wanted to see how healthcare organizations with medication adherence programs measure adherence and compliance levels in their populations.

View the chart at:

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HealthSounds Podcast: Home Visits for the Medicaid Population
Medicaid patients present their own unique set of needs during home visits, explain Dr. Larry Greenblatt, medical director, Chronic Care Program, Durham Community Health Network, Duke University Medical Center, and Jessica Simo, program manager, Durham Community Health Network for the Duke Division of Community Health. The duo explains the two types of patients that benefit most from home visits, the priorities of the home visit and the most common problems identified during home visits.

To listen to this HIN podcast, please visit:

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Pediatric Medical Home Cuts ER Visits in Half
In the first quantitative study to look at the benefits of the medical home in a resident-education outpatient clinic at a specialized children's hospital, UCLA researchers found that participation significantly reduced families' use of the ER.

The medical home program at UCLA includes four basic components: a formal 60-minute intake appointment, follow-up appointments of 40 minutes (twice the length of standard appointments), access to a bilingual family liaison to help families navigate the medical system, and a family binder that keeps all a child's medical information in one place.

Study data was collected between 2004 and 2007 from the Pediatric Medical Home Project at UCLA for Children With Special Healthcare Needs, which was founded at Mattel Children's Hospital UCLA in 2003. Researchers examined ER, urgent care and inpatient encounters for 30 medical home patients for one year prior to enrollment in the program and for one year after enrollment. They found that among program participants, ER visits decreased by 55 percent. The findings appear in the March 11 online edition of the peer-reviewed Journal of Pediatrics.

Participating parents told UCLA that they felt empowered by the pediatric residents, supervising faculty and medical home staff to use scheduled outpatient primary care and specialty visits rather than using the emergency department to get care.

Despite the decrease in ER visits, the study data showed no significant change in urgent care visits or hospital admissions, suggesting that the patients' overall burden of illness was not decreased during the study period. There was a trend toward greater use of scheduled outpatient appointments, which may have resulted from the program's emphasis on coordinating all of the care required by patients.

The UCLA study also focused on the need to train future pediatricians — current medical residents and students — in the principles of the medical home and found this could also be done successfully.

Plans for future research include studying parent and patient satisfaction and developing a model for delivering care according to medical home principals to a larger number of children with special health care needs.

To learn more, please visit:

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HIN Survey of the Month: Managing Care Transitions Across Sites
Who's launched a formal care transitions management program? Which populations and conditions do these program target? What are the results? More than 40 organizations have already provided this data in their responses to HIN's second annual e-survey on Managing Care Transitions Across Sites. Complete the survey by May 31 and you'll receive a free executive summary of the results. Your responses will be kept strictly confidential.

Complete the survey by visiting:

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Healthcare Benchmarks: Case Management in 2010
Healthcare case managers are playing a larger role in the coordination of all phases of patient cares. This HIN white paper examines the expanding focus, responsibilities and impact of case management in healthcare, from populations benefiting from case management to metrics on case loads, ROI and performance measurement through responses provided by 187 healthcare organizations.

To download this complimentary white paper, please visit:

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EDITOR'S PICK: Save 10% on This Week's Webinars

May 19: Physician Practices in the Medical Home: Recruiting, Evaluating, Supporting and Measuring the Patient-Centered Team

As more private and public payors test the patient-centered medical home model of care, there is a growing need to identify and select physician practices to participate in the delivery of this type of care. During this 45-minute webinar on May 19, Dr. Marjie Harbrecht will examine how practices are recruited, selected and supported in medical home. programs.

May 20: Home Visits in the Patient-Centered Medical Home

While costly to conduct, home visits to patients with complex care needs can provide huge returns by identifying patient compliance barriers that are only apparent when seeing a patient in their home. Many patient-centered medical home initiatives are using home visits as part of a care transition program to reduce avoidable hospital readmissions and emergency room utilization. This 45-minute webinar on May 20 will examine the features of a successful home visit initiative.

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

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

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