Medical Home Monitor
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August 17, 2009
Vol. II, No. 8

Medical Home Monitor Archives

Medical Home Q&A:
Physicians Redesign Care

Medical Home Monitor

Q: How does the accountable care organization (ACO) model define roles for its players and how do you get individuals to perform the higher level tasks within their scope?

A: Our vision has been to get everyone to work at their level of expertise and not higher or lower, which can increase the intensity of some of our practitioners’ days. Some doctors want more of the bread and butter work, and to say that we want them to do physician work only — not nursing or nurse practitioner work — has been a battle in some settings. However, we have been persistent mostly by allowing the practices to redesign their care. Right now we are piloting six medical homes, and each practice is redesigning the home differently. We ask them to look at the skill set of each employee, reallocate the responsibilities as they see fit and involve the physicians in the design process.

An externally imposed change won’t work, and a single model site to site won’t work. We have allowed the practices to define their own solution. Sometimes it goes well. Sometimes we need to be a bit more participatory in getting them to a good solution. (Dr. Craig Samitt, president and CEO of Dean Health System.)

For more information on the best practices that led Dean Health System to create an ACO that provides a high-value patient-centered care experience, please visit:

Study Shows Medical Home for Older Adults
Reduces Cost of Chronic Care

The nation’s sickest and most expensive patients need fewer healthcare resources and cost insurers less when they are closely supported by a nurse-physician primary care team that tracks their health and offers regular support, according to a study from Johns Hopkins Bloomberg School of Public Health. Researchers found that in the first eight months of a randomized controlled trial, patients in a primary care enhancement program called “Guided Care” spent less time in hospitals and skilled nursing facilities (SNFs) and had fewer ER visits and home health episodes.

“Guided Care patients cost health insurers 11 percent less than patients in the control group,” said Chad Boult, M.D., M.P.H., M.B.A., the principal investigator of the study and creator of the Guided Care model. Compared to patients who received usual care, Guided Care patients experienced, on average, 24 percent fewer hospital days, 37 percent fewer SNF days, 15 percent fewer ER visits and 29 percent fewer home healthcare episodes, according to the study.

For more details on the Guided Care Model and this study, please visit:

HealthSounds Podcast: Medical Home Open House Highlights

The opening sessions of the Medical Home Open House webinar series delivered tips for improving care continuity, quality and access for patients assigned to a medical home. Healthcare thought leaders describe how the medical home offers opportunities to improve patient education, transitions in care and the integration of behavioral and primary health.

To listen to this complimentary HIN podcast, please visit:

Physician Networking Site Just What Doctor Ordered for PCMH Education

A new paid social networking site that PCPs can access to enhance their progress toward practice transformation and the PCMH has been launched by TransforMED, a wholly owned subsidiary of the AAFP. The $30-per-month Delta Exchange member fee includes access to a variety of tools, including online discussions, interactive webinars, how-to articles on practice improvement, an expert panel of practice facilitators and customizable forms that streamline policies and procedures.

Members can sign up for online discussions in separate work zones, including zones for physicians, clinical staff members, office staff members and residency programs. Users also can set up a notification system to track specific discussions and topics.

The physician online learning tool was developed in response to physician requests for an inexpensive and time-efficient way to learn about practice transformation, according to Terry McGeeney, M.D., M.B.A., TransforMED's president and CEO.

For more information, please visit:

HIN Survey of the Month: Patient Education and Outreach

Patient education is one of the payoffs of a successful medical home partnership, helping to reduce medical complications, medication costs and unnecessary healthcare utilization. More than 70 organizations have already responded to HIN's Survey of the Month on Patient Education and Engagement efforts. Add your responses by August 31 and you'll receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

Complete the survey by visiting:

Health and Wellness Coaching in 2008

The medical home team is called upon to dispense preventive and wellness information as well as traditional primary care. In this white paper, learn how 235 responding organizations are using health coaching, as well as its effect on patient outcomes, factors that contribute to a successful coaching program and the challenges of calculating ROI in health coaching.

To download this complimentary white paper, please visit:

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

JUST ADDED: NCQA Certification Strategies!
  • 9/26/09: The Certified Medical Home from NCQA: Practical Advice from Taconic IPA

    For more information, click here.

Other upcoming Open House sessions:

  • 8/26/09: Care Transitions That Reduce Hospital Admissions
  • 9/9/09: Group Health's Successful Models of Care for the Medical Home: Staffing and Roles of the Care Team
  • 9/16/09: Baptist Health Explores Bundled Payments: Baptist Health System's experience and early feedback from CMS's bundled payment pilot.

Past sessions available online or on DVD or CD:

  • 8/5/09: Patient Engagement and Education in the Medical Home: Perspectives from Several Pilots
  • 7/29/09: Meet the Medical Home Neighbor: Accountable Care Organizations
  • 7/8/09: Medical Home Contracting: Building a Solid Framework
  • 7/1/09: Under One Roof: Integrating Primary Care & Behavioral Health in the Medical Home
Use ordering code MHMP for specially priced admission to one or more sessions in the Medical Home Open House series. For more information, visit:

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