Medical Home Monitor
Medical Home Monitor
June 21, 2010
Vol. III, No. 5

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Narcotics Contracts
  2. PCMH Care Improvement
  3. New Chart: Medical Home Team Players
  4. Podcast: Recruiting Physician Practices
  5. Results from BCBSM's Medical Home
  6. E-Survey: HRAs
  7. Benchmarks: Obesity & Weight Management
  8. Editor's Pick

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Medical Home Q&A's:
Narcotics Contracts,
Home Visit Candidates

Medical Home Monitor

Patient Profiles for
Home Visits

Q: Is there a particular diagnosis or patient profile that would benefit most from a home visit?

A: As a general rule for the patient population that we are serving, the ones that get the most home visits that we have profiled over the years are middle-aged individuals that have at least two chronic health conditions. These are not individuals who are generally healthy that maybe had one adverse event that has brought them to our attention. These are people that live day in and day out with chronic health problems that they struggle with managing. Those are the people that benefit most from the amount of time it takes to do a home visit.

Jessica Simo, program manager with Durham Community Health Network for the Duke Division of Community Health.

For more ideas on conducting home visits in the medical home, please visit:

Using Narcotics Contracts to
Reduce Avoidable ER Visits

Q: How does Kaiser use narcotics contracts to reduce avoidable ER visits?

A: We have a one-page contract stating that the physician is going to engage in narcotic therapy with the member for some type of pain issue and includes the provisions under which we will prescribe narcotics for the member. Those provisions can vary, but generally state that we will prescribe you “X” number of whatever drug and it must last you so many weeks or so many days. The contract states that “we will not refill medications that are lost, stolen, flushed down the toilet, etc. We will not replace those. We will not do early refills. It states that if you go to the ED, you must tell them that you are on a narcotics contract. If you don’t tell them that, then you are in violation of your contract. It also states that taking narcotics is not without risk and that you agree to enter into this contract with the primary care provider. Should you not agree to do this, it is suggested that the member find another primary care provider.

Sarah Gray, senior manager of emergency services at Kaiser Foundation Health Plan of Colorado.

For more details on Kaiser Foundation Health Plan strategies to reduce avoidable ER visits, please visit:

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PCMH Adoption Improves Condition-Specific Care

Adoption of PCMH components is associated with small improvements in condition-specific quality of care, according to a new report on TransforMED’s National Demonstration Project (NDP) — a two-year, physician practice redesign initiative that ran from June 2006 to May 2008.

The report, compiled by an independent evaluation team, observed these improvements in both facilitated and non-facilitated practices. Practices that adopted more PCMH components achieved better scores for quality-of-care, chronic disease care, prevention and condition-specific outcomes. There were trends for very small decreases in coordination of care in both groups.

Other key findings that appeared in "Evolution of the American Academy of Family Physicians’ Patient-Centered Medical Home National Demonstration Project" included the following:

  • Transforming from a physician-centric practice to a team-based, patient-centered model is challenging for physicians who are accustomed to being responsible for the entire patient encounter.
  • Developing care teams requires substantial cross-training efforts, as well as developing a shared vision among front- and back-office staff of how care teams affect the patient experience.
  • Most practices will need additional financial and human resources to achieve full medical home transformation.
  • Intense facilitation can enhance a practice’s ability to manage and sustain change. It also can increase its success rate of implementing PCMH model components.
  • In most cases, it will take longer than two years to implement and assess the sustained and evolving effects of PCMH transformation.

The report is published as a series of manuscripts in a special supplement to the May/June 2010 Annals of Family Medicine. For more details, please visit:

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New Chart: Medical Home Team Players
The medical home care team provides patient-centered, coordinated and high-quality care for its members. We wanted to see which medical professionals besides the physician are players on the medical home care team.

View the chart at:

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HealthSounds Podcast: Recruiting Physicians for Medical Home Pilots
As more payors test the patient-centered medical home model of care, what are the pros and cons of participation for physician practices? Dr. Marjie Harbrecht, medical and executive director of Health TeamWorks (formerly the Colorado Clinical Guidelines Collaborative), describes the financial middle ground that is likely to satisfy payors and providers who sign on for medical home pilots and offers some additional selection criteria her organization may use in the future.

To listen to this HIN podcast, please visit:

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Early Data Show Michigan Blues' PCMH Cuts Utilization, PMPM Costs
Preliminary data show that Blue Cross Blue Shield of Michigan's (BCBSM) innovative PCMH program is meeting its goals for improved care and cost management, with PCMH-designated doctors succeeding in managing their patients' care to keep them healthy and prevent complications that require expensive medical services to treat.

In addition, physicians are successfully transforming their practices to allow them to operate as medical homes. Of the 68 capabilities that were part of the BCBSM PCMH program in 2009, designated PCMH practices had an average of 59 capabilities in place by the end of 2009, compared to an average of 44 the prior year.

Preliminary analysis of 2009 claims data shows that BCBSM PCMH practices:

  • Have a 2 percent lower rate of adult radiology usage than non-PCMH practices, and a per member per month (PMPM) cost that is 1.2 percent lower.
  • Have a 1.4 percent lower rate of adult ER visits than non-PCMH practices, and a PMPM cost that is 0.6 percent lower.
  • Have a 2.6 percent lower rate of adult inpatient admissions than non-PCMH practices, and a PMPM cost that is 2.6 percent lower.
  • Have a 2.2 percent lower rate of pediatric ER visits than non-PCMH practices, and a PMPM cost that is 4.2 percent lower.
BCBSM first designated physician practices as PCMHs on July 1, 2009. This program encourages more coordination between primary care providers and specialists to ensure appropriate tests are ordered and results shared, avoiding duplication of service. A major goal of the program is to better manage patient care, reducing unnecessary tests, drug prescriptions, doctor visits, and avoidable hospital admissions and emergency department visits.

For example, PCMH practices should provide patients with 24-hour telephone access to the physician practice. While it often requires process changes for the medical practice, the benefits to patients of 24-hour access means they are more likely to receive the care they need in the appropriate setting, decreasing their use of the ED for non-emergency conditions. This PCMH program is the largest in the nation, with 1,200 designated doctors in 45 communities across the state. In total 5,800 doctors have been working toward designation. BCBSM's PCMH program encompasses close to 2 million Michigan residents. In the BCBSM PCMH model, physicians receive an enhanced fee for office visits, allowing them to spend more time with patients to keep them healthy, or to better manage a chronic condition.

To learn more, please visit:

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HIN Survey of the Month: Health Risk Assessments
Almost 100 healthcare companies have already told us how they use the aggregate data from health risk assessments (HRAs) to shape health promotion and disease management interventions for their populations — with the goal of improving clinical and financial outcomes. You can get a free summary of their responses by completing the survey on HRAs by June 30. Your responses will be kept strictly confidential.

Complete the survey by visiting:

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Benchmarks: New Trends in Obesity and Weight Management
JUST PUBLISHED! Download this complimentary white paper that provides program details, targeted populations and conditions and results from obesity and weight management programs in place at 131 healthcare organizations who responded to the April 2010 Healthcare Intelligence Network Obesity and Weight Management e-survey.

To download this complimentary white paper, please visit:

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

Improving Physician Performance and Value-Based Reimbursement Levels Through Meaningful Data Sharing

Through a community transformation program, Taconic IPA is leveraging performance reporting data to engage physicians in quality improvement while increasing reimbursement rates for its physicians. To date, 238 Taconic physicians at 11 sites have received Level III PPC®-PCMH™ recognition from the NCQA. During Improving Physician Performance and Value-Based Reimbursement Levels Through Meaningful Data Sharing, a 45-minute webinar on June 23 at 1:30 pm Eastern, Paul Kaye, M.D., medical director at Taconic IPA and Susan Stuard, executive director, THINC, will describe how the sharing of data across its organization is improving physician performance and value-based reimbursement levels.

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

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

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