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Medical Home Monitor
Medical Home Monitor
July 6, 2010
Vol. III, No. 5

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Staff Transformation
  2. Telephonic Transition Coaching
  3. New Chart: Home Visit Tasks
  4. Podcast: Kaiser Reduces Avoidable ER Use
  5. PCMH is Big Challenge
  6. E-Survey: Reducing Avoidable ER Visits
  7. Benchmarks: Managing Care Transitions Across Sites
  8. Editor's Pick

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Medical Home Q&A's:
Staff Transformation

Medical Home Monitor

Physician Practice Responsibilities

Q: How has your physician practice transformation project shifted the responsibilities of staff in the practices?

A: People began to understand the issue of practicing to the top of their license or ability. There was a recognition that much of the work that physicians were doing could be done by nurses. Much of the work that nurses were doing could be done by others. The biggest change was the time it took for physicians to understand that they could let go and still be responsible for the performance of the panel of patients. It varies from practice to practice. In a small one-two person practice, it will be a more subtle shift of who does what. In the larger community health centers and the larger practices, specific roles such as patient navigator, patient care partner or referral specialist were developed and implemented.

Dr. Paul Kaye, Medical Director at Taconic IPA and Susan Stuared, Executive Director at THINC.

For more on improving physician performance, please visit:

Care Coordination Roles

Q: Should a practive hire a care coordinator who manages a particular percentage of patients?

A: You would have to consider your staffing in the context of your organization in how your revenues are determined. The model works perfectly for us in a fully capitated environment. Our offices have a medical assistant (MA) for every physician and typically a licensed practical nurse (LPN) who takes care of the follow-up and the transitional care objectives. In addition, we have hired nurse practitioners (NP) for most of our offices to offload some of the acute care and maintenance care from the physicianís workload so that they can focus on the more challenging complex chronic disease cases. However, every model is different. You must have a method to identify who is at risk, whether you do it by an established ICD-9 condition or on a per-visit determination. There should be a process where you identify who is at risk, and those patients should have additional follow-up or follow-through in between their office visits. Certainly, there is no substitute for a frequent follow-up with the physician and that needs to be part of the treatment plan. However, it depends on the organization.

Dr. Jose Guethon, president and COO of MetCare of Florida.

For more on overcoming the hurdles of medical home transformation, please visit:

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Telephonic Transition Coaching Cuts Readmissions

Alicare Medical Management (AMM) has expanded an existing program to reduce readmissions and help patients make a safe and effective transition from the hospital to their homes. The telephonic Patient Transition Coaching Program is specifically intended to address the post-discharge needs of patients who are at risk for hospital readmission.

AMMís telephonic Patient Transition Program service begins with outreach by one of AMMís RN health coaches. Immediately after patients leave the hospital, they are contacted by an RN health coach who assesses their health status, identifies potential problem areas, informs patients about essential follow-up care and self-management requirements and educates them about their medications. When appropriate, the RN health coach will contact the physician for additional information, intervention and coordination of follow-up care.

Fees for AMMís Patient Transition Coaching Program are based on a one-time case rate for each enrolled patient, which covers all short-term services including the full assessment and evaluation of the patientís status and needs by a RN health coach, patient education and patient monitoring in the first four-week period following hospital discharge.

Under the Patient Protection and Affordable Care Act, reducing readmissions has been identified as a key cost management initiative, even mandating reductions in Medicare payments for preventable hospital readmissions.

For more details, please visit:

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New Chart: Home Visit Tasks
Sometimes it takes a home visit to a patient with complex chronic conditions to understand the barriers to care compliance that they face. We wanted to see which tasks are being performed during home visits.

View the chart at:

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HealthSounds Podcast: Kaiser Reduces Avoidable ER Visits
When primary care isn't available, several proxy healthcare services can sometimes fill the bill for certain conditions, helping to reduce the number of avoidable ER visits, explains Sara Gray, senior manager of emergency services at Kaiser Foundation Health Plan of Colorado. Ms. Gray describes two important steps hospitals can take when discharging patients to keep those patients from seeking post-discharge care in the ER, and suggests a hospital-SNF partnership to reduce preventable ER visits by SNF patients.

To listen to this HIN podcast, please visit:

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Patient-Centered Medical Home Key Challenge for Group Practices
Implementing a PCMH model of care went from number 22 in 2009 to number 12 in 2010 on the list of top challenges of running a group practice, according to research by the Medical Group Management Association (MGMA).

The MGMA identified the top three challenges of running a group practice as: dealing with rising operating costs, managing finances with the uncertainty of Medicare reimbursement rates, and selecting and implementing a new electronic health record system.

The study found that when compared with independent medical practices, hospitals and health system respondents were more likely to find the following issues "challenging:"

  • Implementing a PCMH model of care;
  • Recruiting physicians;
  • Dealing with rising operating costs;
  • Modifying physician compensation methodology.

The survey found the effects of the recession on practices are:

  • Improved billing collections and/or denial management processes;
  • Decreased revenue;
  • An increase in uninsured patients;
  • Postponed capital expenditures;
  • Operating budget cuts.

"Practices are clearly balancing the very serious issue of keeping their practices afloat amid unprecedented financial uncertainty with the more delicate practice management issues such as managing group dynamics and overseeing their organizations' strategic direction," said William F. Jessee, MD, FACMPE, president and CEO of MGMA.

To learn more, please visit:

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HIN Survey of the Month: Reducing Avoidable Emergency Room Visits
Inappropriate and preventable use of the hospital ERs is a nationwide problem and a serious drain on healthcare resources. Many healthcare organizations have launched programs to reduce avoidable use of the hospital ER. Complete this month's survey on reducing avoidable ER visits by July 31, 2010 and we will e-mail you a copy of the compiled survey results in August.

Complete the survey by visiting:

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JUST PUBLISHED! 2010 Benchmarks in Managing Care Transitions Across Sites
Tighter management of transitions in care ó particularly for older adults with complex acute or chronic conditions ó can help to close care gaps, avoid unnecessary hospitalizations, readmissions and ER visits, reduce medication errors and raise the bar on care quality. This white paper captures the top programs and activities by 87 healthcare organizations to coordinate key care transitions in response to the Healthcare Intelligence Network May 2010 Managing Care Transitions Across Sites 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 Medication Adherence Through the Medical Home Model

With approximately half of the population using at least one prescription medication and nearly three-quarters of all physician office visits involving medication therapy, how can the medical home raise medication adherence and compliance levels, and what are the potential financial gains to be realized? Improving Medication Adherence Through the Medical Home Model answers these questions by prescribing effective tactics and disease-specific success stories for in-house management of medication therapy ó from the use of technology to drafting a pharmacist ó virtual or co-located ó to the medical home team.

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

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Contact HIN:
Guest Editor: Jackie Lyons,;
Publisher: Melanie Matthews,;

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