Medical Home Monitor
Medical Home Monitor
July 20, 2009
Vol. II, No. 6

Medical Home Monitor Archives

Medical Home Q&A:
Contacting Hard-to-Reach
Medical Home Residents

Medical Home Monitor

Q: How do you maintain contact with patients for care management when credible contact information is difficult to obtain?

A: We start case management from the facility where the person was receiving treatment. For example, most of our consumers were engaged with a case manager at the community mental health center. We used that connection to do the outreach and find out whether people wanted to get more involved in wellness activities. Also, you may have better luck if you do have connections with other social service agencies that the patient may be involved with. They can be the case finders for you, but be aware that you may run into some confidentiality issues. Figure out where people tend to go most, and have that site be where they are seen. Some managed care organizations have outposts in emergency rooms (ERs) for that exact reason. When individuals are using the ER as their source of primary care, that is the place to connect with them to do care management. (Liz Reardon, President of Reardon Consulting and former managed care director for Vermont Medicaid.)

For more ideas on integrating primary and mental healthcare in the medical home, please visit:

Medical Home's Role in New York's
Healthcare Transformation

The present and future of medical home-related initiatives and incentives in New York are highlighted in the new report,"Transforming New York’s Public Health Insurance Programs: Expanding Access, Improving Quality and Controlling Costs." The report cites how New York’s Medicaid program has been reformed through the reduction of inpatient rates, investment in primary and preventive care and ambulatory care services and by providing incentives to practitioners who work in medically underserved areas and meet PCMH standards that advance integrated and coordinated care.

The state's investment in primary care includes reimbursing physicians in medically underserved areas for providing weekend and after-hours service, implementing a program in 2010 to incentivize the development of PCMHs, and Medicaid's participation in a multi-payor medical home pilot in the Adirondack region of the state.

To read the report in its entirety, please visit:

HealthSounds Podcast: Cutting Uncompensated Care Costs with a Medical Home Model

Faced with a 40 percent year-over-year increase in uncompensated care costs, Baptist Health turned to a medical home approach to tightly manage uncompensated care for five chronic diseases. Baptist's Robin Barca describes how this move has resulted in a 2:1 ROI and educated its medical residents on the healthcare system and the medical home model in the process.

To listen to this complimentary HIN podcast, please visit:

PCMH's Potential for Reducing Hospitalizations
Boosts Business Case for Medical Homes

Key interventions for the chronically ill delivered via the medical home — such as patient education, self-management support and immunizations — result in significant reductions in hospital admissions and readmissions, according to Harold Miller, president and CEO of the Network for Regional Healthcare Improvement and executive director of the Center for Healthcare Quality and Payment Reform. Speaking at a recent forum on physician payment reform sponsored by the Robert Wood Johnson Foundation, Miller noted that PCMHs should take responsibility for reducing hospital readmissions to demonstrate the true value of the medical home and create a clear business case for adequately funding the PCMH model. Few physician payment systems reimburse for these types of interventions, even though these types of services also can reduce hospital admissions, Miller said.

For more of Miller's comments, please visit:

HIN Survey of the Month: Healthcare Coaching
Trends in 2009

The health coach is an essential player on the medical home team as well as an MVP in effecting behavior change in health improvement programs. 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:

Reducing the Financial Toll of the Uninsured and Underinsured

In response to a surge in uninsured and underinsured Americans, healthcare organizations are launching products and services to reduce the financial impact of these populations. Learn what's working for hospitals, health plans and providers in this new executive summary based on HIN’s May 2009 e-survey on the impact of the uninsured and underinsured.

To download this complimentary white paper, please visit:

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

  • 7/29/09: Care Transitions That Reduce Hospital Admissions
Geisinger Health Plan shares the secrets behind its successful Transitions of Care initiative and how its embedded care managers are helping Medicare patients avoid rehospitalization.

Other Open House sessions:

  • 7/29/09: Meet the Medical Home Neighbor: Accountable Care Organizations
  • 8/5/09: Patient Engagement and Education in the Medical Home: Perspectives from Several Pilots
  • 7/8/09: Medical Home Contracting: Building a Solid Framework (recording available)
  • 7/1/09: Under One Roof: Integrating Primary Care & Behavioral Health in the Medical Home (recording available)
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,;

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