Medical Home Monitor
Medical Home Monitor
July 6, 2009
Vol. II, No. 5

Medical Home Monitor Archives

Medical Home Q&A:
Determining Optimal
Patient Panel Size

Medical Home Monitor

Q: In an internal medicine medical home, how many patients can be managed by the physician and the team?

A: We struggled with panel size. When we started out, we assumed a panel size for internal medicine of 1,500 to 2,500. When we implemented that model with Kaiser in Cleveland, we kept the panel size there. There was some thought that with the additional team capabilities and efficiencies gained from the EMR, you could expand that. But itís just too early to call at this point. Weíve done a lot of work on that, and itís hard to come up with the perfect number. However, over time there will be efficiencies gained as you re-do work flows and establish the teams and the fully leveraged technology. (Charles DeShazer, M.D., market vice president, clinical innovations, Humana.)

For more ideas on medical home improvement and implementation, please visit:

Colorado Programs Move Medical Home into Med Schools,
Test New Reimbursement Model

Two new PCMH programs in Colorado will incorporate the medical home model into med school curriculums, provide medical homes for thousands of underserved Coloradans and serve as a national collaborative model for implementing the medical home concept:
  • A three-year $2.8 million program funded by The Colorado Health Foundation will integrate the PCMH model of care into the curriculum and medical practices of Coloradoís nine family medicine residency programs, which serve as a healthcare safety net for underserved populations. The residency programs will jointly develop curriculum and share best practices to improve patient care for more than 75,000 Coloradans who receive care from these residency practices each year.
  • In a second $1.4 million two-year initiative funded by The Colorado Trust, five of the state's largest health plans — Aetna, Anthem Blue Cross and Blue Shield, CIGNA, Humana, UnitedHealthcare — and Colorado Medicaid will provide enhanced compensation for 17 Colorado internal or family medicine practice sites that have agreed to serve as PCMHs for approximately 25,000 patients. Participating practices will receive added incentive payments for meeting high-quality benchmarks for patient care.

The two programs, considered among the largest and most innovative medical home programs in the nation, are being coordinated by the Colorado Clinical Guidelines Collaborative and several partners.

For more information, please visit:

HealthSounds Podcast: Integrating Behavioral Healthcare & Primary Care Under the Medical Home Roof

Individuals with severe and persistent mental illnesses are likely to die 20 years earlier than people without such conditions, says Liz Reardon, president of Reardon Consulting and a member of the National Council for Community Behavioral Healthcare (NCCBH) Integration Consulting Team. Putting the right medical home services in place for adults with chronic mental illness can help to reduce this disparity, suggests Reardon, explaining why the earliest medical homes for children with complex health needs are great models for behavioral healthcare organizations.

To listen to this complimentary HIN podcast, please visit:

PCMH Pilot Payoffs: Group Health's Investment in Care Coordination Reduces Downstream Utilization Costs

Encouraged by the rapid return on its investment in increased care coordination staffing, Group Health will implement best practices from its medical home pilot at all 26 of its medical centers by 2010. As a result of doctors and care teams proactively engaging patients in their health and investing more in care coordination, Group Health reported reductions in ER visits and hospitalizations related to chronic illness, improved quality of care and increased patient and staff satisfaction at the end of the one-year pilot.

Compared to controls, in one year, Group Health's PCMH pilot:

  • Broke even on its primary care staffing investment through reduced downstream utilization costs. ER/urgent care visits were 29 percent less and inpatient hospital stays for patients with conditions including diabetes, chronic obstructive pulmonary disease, congestive heart failure and asthma were 11 percent less.
  • Improved indicators of quality of care. Overall improvements were 1.6 times greater across 22 measures than in controls. In seven out of 22 measures, the proportion of people meeting their target increased by more than 5 percent over one year. One example is cholesterol management (LDL less than 100mg/dl) for people with heart disease.
  • Enhanced patients' experience, including better bonding between patients and their physicians and care teams as well as better care coordination.
  • Improved care teams' work satisfaction and reduced their emotional burnout.

For more information, please visit:

HIN Survey of the Month: Healthcare Coaching Trends in 2009

The health coaching field is evolving, as it is becoming more widely accepted as a means of helping patients better manage their health conditions. HIN's Survey of the Month revisits this field to find out how and to what extent healthcare organizations are implementing health coaching into their organizations. Complete HIN's Survey of the Month on Health Coaching in 2009 by July 31 and receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

Complete the survey by visiting:

Handling Care Transitions Across Sites: Opportunities for Cost Reduction and Care Improvement

Geisinger Health Plan's successful medical home pilot instructs its patient navigators to focus on care transitions to reduce potential care gaps, reduce avoidable hospitalizations and improve patient safety. A new HIN white paper summarizes responses to HINís April 2009 e-survey in which respondents shared details on their care transition programs.

To download this complimentary white paper, please visit:

Medical Home Open House Summer Webinar Series — Save 10% On Any Session

  • 7/29/09: Meet the Medical Home Neighbor: Accountable Care Organizations
Dean Health Systems President and CEO Dr. Craig Samitt will describe the best practices behind Dean's accountable care organization that provides a high-value patient-centered care experience.

Other Open House sessions:

  • 7/1/09: Under One Roof: Integrating Primary Care & Behavioral Health in the Medical Home
  • 7/8/09: Medical Home Contracting: Building a Solid Framework
  • 8/5/09: Patient Engagement and Education in the Medical Home: Perspectives from Several Pilots
Use ordering code MHMP for specially priced admission to one or more sessions in the Medical Home Open House series. Missed a session? No problem. Order the on-demand or DVD version. For more information, visit:

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Publisher: Melanie Matthews,;

HIN's Medical Home Monitor Archives put at your fingertips complimentary video, podcasts, white papers and blog posts on the advancement of the PCMH — plus back issues of this e-newsletter and links to additional medical home resources. Please bookmark this site and check back often for new content:
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The HealthSounds Podcasts delivers a free weekly audio interview with a healthcare innovator to your e-mailbox. Listen to thought leaders answer key questions about the most pressing issues and trends in healthcare ó pending healthcare reform, medical home implementation, health improvement ROI and much more.

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