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August 3, 2009
Vol. II, No. 7

Medical Home Monitor Archives

Medical Home Q&A:
Top Priority of Geisinger
Care Transition Teams

Medical Home Monitor

Q: What should be the critical focus when managing a patient's transition from one care site to another?

A: To insure a clean and clear handoff of the patient from the hospital to the next level of care, the care manager must focus on medication reconciliation. Our case managers have found that there is confusion regarding new medications that are prescribed, and errors regarding medications that were stopped during a hospitalization. We have found that this focus is key to possibly preventing some readmissions to the hospital. Hospitalization is a nervous and scary time; patients are unwell and not themselves. (Doreen Salek, Geisinger Health Plan's director of business operations of health services.)

For more ideas on retooling care transitions with the goal of reducing hospital stays, please visit:

Case Managers Play Key Role in South Carolina
Medical Home Pilot for Diabetics

In the first three months of a year-long PCMH pilot for diabetics in South Carolina, case managers have contacted 60 percent of eligible patients to explain the concept, gather baseline health data and encourage use of an online portal whose tools help them to manage their disease and have e-visits with a physician. Patient response is positive to outreach by the case managers, whose aim is to reduce gaps in care, such as missed appointments with specialists, and handle lifestyle issues like medication adherence. The case managers also register patients for diabetic education, schedule appointments with specialists, provide discount vouchers for medications and exercise programs and monitor quality processes and outcomes measures to help increase patient compliance. There is no copayment or extra charge to the patients for participation in the pilot.

The project, which completed its first quarter with 1,110 patients enrolled, focuses on diabetic patients who are members of BlueCross BlueShield of South Carolina, BlueChoice HealthPlan of South Carolina and the State Health Plan and who are patients of Palmetto Primary Care Physicians in the Charleston, S.C., area.

For more on the pilot, please visit:

HealthSounds Podcast: Anatomy of an
Accountable Care Organization

Accountable care organizations (ACOs) — a network of primary care physicians, one or more hospitals, and subspecialists that provide patient-centered care — not only complement the medical home model but are inextricably linked, says Dr. Craig Samitt, M.B.A., president and CEO of Dean Health System. Dr. Samitt discusses the medical home-ACO correlation, the pros and cons of mandatory and voluntary ACOs and ideas for creating ACO reimbursement strategies.

To listen to this complimentary HIN podcast, please visit:

Swedish Community Medical Home Clinic Dispenses
Innovative Reimbursement, Patient Services

Premera Blue Cross has partnered with Swedish's new Community Health Medical Home Clinic in Seattle to offer its members unlimited access to physician teams — including 30- to 60-minute visits and phone and e-mail access — that provide not only preventive care, but also wellness services, chronic disease management and other health services. Patients at the family medicine clinic at Swedish/Ballard can access their own medical charts through a secured Web site. Swedish's Web-based service also allows patients to request medical appointments, view their health summaries from the EHR, request prescription renewals and communicate electronically and securely with their medical care team.

Swedish is waiving co-pays for visits by participating Premera members. Additionally, the payor and provider have agreed on an innovative model of reimbursement for care provided at the clinic that will emphasize quality of care and healthy patient outcomes – including incentives for Swedish in delivering quality care to Premera’s participating members.

For more information, please visit:

HIN Survey of the Month: Patient Education and Outreach

Patient education is one of payoffs of a successful medical home partnership. Educating patients about their health conditions, plan of care and wellness and prevention strategies not only empowers them to manage their condition and care but also can reduce medical complications, medication costs and unnecessary healthcare utilization. Complete HIN's Survey of the Month on Patient Education and Engagement by August 31 and receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

Complete the survey by visiting:

Providing Caregiver Education and Support

Download this white paper to learn how 129 healthcare organizations provide caregiver support and/or education programs, the challenges of developing these programs and the impact the programs have had on their employees, patients and organizations.

To download this complimentary white paper, please visit:

Readers Save 10% on Any Session in Medical Home Open House Summer Webinar Series

  • 9/9/09: Group Health's Medical Home Staffing Models: Group Health Cooperative medical home staffing strategies that reduced downstream utilization costs.

  • 9/16/09: Baptist Health Explores Bundled Payments: Baptist Health System's experience and early feedback from CMS's bundled payment pilot.

Other Open House sessions:

  • 8/5/09: Patient Engagement and Education in the Medical Home: Perspectives from Several Pilots
  • 8/26/09: Care Transitions That Reduce Hospital Admissions
  • 7/29/09: Meet the Medical Home Neighbor: Accountable Care Organizations (online, CD or DVD)
  • 7/8/09: Medical Home Contracting: Building a Solid Framework (online, CD or DVD)
  • 7/1/09: Under One Roof: Integrating Primary Care & Behavioral Health in the Medical Home (online, CD or DVD)
Use ordering code MHMP for specially priced admission to one or more sessions in the Medical Home Open House series. Missed a session? Order the on-demand, training DVD or CD version. For more information, visit:

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Publisher: Melanie Matthews,;

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