Medical Home Monitor
Medical Home Monitor
September 7, 2010
Vol. III, No. 9

Medical Home Monitor Archives

In This Issue:

  1. Q&A: AVR, Pharmacist's Role
  2. Medical Home Payoffs
  3. New Chart: Medication Adherence
  4. Podcast: Virtual Medical Home
  5. URAC's New PCMH Toolkits
  6. E-Survey: Telehealth in 2010
  7. Benchmarks: Avoidable ER Use
  8. Editor's Pick

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Medical Home Q&A's:
Automated Voice Response, Changing Role of Pharmacist

Medical Home Monitor

AVR for Patient Contact

Q: Are you using any automated voice response systems to call patients?

A: We use automated calls for our anticoagulation programs. When patients are late or havenít gone to the lab, thatís an automatic call. Most of the time, we use our support staff. It is the role of the disease management specialist to do the ongoing monitoring. There is a place for monitoring, especially for heart failure. There is a cost for this type of service, and because we donít charge for our programs, at this point in time we have been able to do it less expensively with staff automation.

Jan Van der Mei is continuum case manager for Sutter Health Sacramento Sierra Region.

For more advice on case management patient contact, monitoring and follow-up, please visit:

How Pharmacists Can Help to Reduce Readmissions

Q: How can retail pharmacies help to reduce avoidable hospital readmissions?

A: Pharmacists are key in medication reconciliation. A pharmacist is critical in helping the patients with their medications, reducing the cost where they can and counseling them. Retail pharmacists are busy, but if theyíre in contact with either the health system or the hospitalís reimbursement plans, many times those areas have somebody who counsels their patients to make sure theyíre getting the correct medications at the lowest cost that they possibly can.

Susan Shepard is director of patient safety education at the Doctors Management Company.

For more ways to improve the hospital discharge process, please visit:

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Geisinger Medical Home Reduces Readmissions,
Care Costs for Medicare Patients

Geisinger Health System's own medical home model, ProvenHealth Navigator(SM), is capable of simultaneously improving the quality of healthcare and reducing the cost, according to the results of a Geisinger study published in last month's American Journal of Managed Care.

The observational study, which looks at four years of claims data pre- and post-intervention for approximately 15,000 of Geisinger Health Planís Medicare Advantage members at 11 community practice sites, shows that ProvenHealth Navigator is capable of significantly reducing admissions (18 percent) and readmissions (36 percent) for Medicare Advantage members. The study also found that total care costs for the entire PHN population decreased 7 percent.

The PHN model has five functional program components: patient-centered primary care team practice; integrated population management; micro-delivery systems; quality outcomes program; and a value reimbursement system. Central to the ProvenHealth Navigator model is the embedding of population management capabilities, including nurse case managers, within the practice sites. Geisinger has an electronic health record (EHR) for all ambulatory and inpatient care that is also used by GHP case managers and patients.

Other highlights of the PHN model include the following:

  • Geisinger Health Plan provided case managers for each practice at a ratio of 1 nurse for every 800 Medicare patients to serve as the hub for population-based activities.
  • The model requires the primary care physicians (PCPs) to develop systems of care for their patients when they are seen by other physicians or in other settings.
  • GHP paid for some new services in the PCP office, such as dedicated phone lines to allow high-risk patients to contact their case managers directly.
  • Performance reports documenting the quality, utilization and overall cost-of-care results were provided to the practice.
  • A shared savings incentive model was added to the GHP reimbursement arrangement. Quality outcomes were aligned with preexisting preventive and chronic disease care quality initiatives. Shared savings incentive payments then were based on improvement in bundled metrics for these services and other agreed-upon metrics.

ProvenHealth Navigator is a collaboration between Geisinger Health Plan and Geisinger Clinic that is designed to improve the quality of care provided in physician offices through the implementation of patient-centered, physician-guided, cost-efficient and longitudinal protocols that are evidence-based, coordinated and integrated.

To read the study in its entirety, please visit:

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New Chart: Top Times for Medication Adherence Efforts
Medication adherence programs can improve patient care and lower healthcare costs by more effectively managing chronic medication use. We wanted to see at which points in care organizations most heavily focus on improving medication adherence.

View the chart at:

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HealthSounds Podcast: Lessons from Iowa's Virtual Medical Home
A virtual medical home is created when primary care providers partner with community organizations to deliver a full continuum of healthcare services in a manner that is transparent to patients and health plan members. Sarah Dixon-Gale, lead contract manager for the Iowa/Nebraska Primary Care Association, explains how Iowa's virtual medical home program has improved access at Siouxland Community Health Center. Also in this podcast, Siouxland CEO Michelle Stephan describes a major challenge faced by the virtual medical home.

To listen to this HIN podcast, please visit:

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URAC Medical Home Toolkits Focus on Patient Satisfaction, Performance Measures
Two new URAC toolkits for its new Patient-Centered Health Care Home (PCHCH) program are designed to help improve both patient satisfaction and healthcare quality. The toolkits can be used alone or in combination by health plans, insurers, health agencies or pilot programs.

The PCHCH program has already finalized its Health Care Practice Assessment Toolkit. The two new toolkits now open for comment include:

  • Patient Survey Toolkit: This toolkit is designed to provide healthcare practices with patient, family and personal caregiver feedback on their effectiveness in providing a high level of patient-centered care and customer satisfaction to be used in quality improvement activities, as well as for public reporting and marketing programs. Over time, this toolkit will expand to include surveys evaluating patient-reported outcomes, practice care team satisfaction, and other areas of interest to the PCHCH.

  • Performance Measures Toolkit: This toolkit is designed to provide practices with a set of selectable measures that would generate data on care processes and clinical outcomes to facilitate continuous internal practice quality improvement, public reporting, and meeting incentive payment program requirements.
The toolkits are intended to assist practices in evaluating how well they are delivering truly patient-centered care and to provide actionable information practices can use to guide their internal quality improvement activities.

The Patient Survey and Performance Measures toolkits are available for review and comment until October 14, 2010 at

To learn more, please visit:

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HIN Survey of the Month: Telehealth in 2010
Powered by provisions in the Patient Protection and Affordability Act, healthcare delivery via telehealth and telemedicine is transforming wellness, disease management, medication management services and illness prevention while extending access to critical healthcare services. Complete HIN's second annual e-survey on Telehealth and Telemedicine by September 30 and receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

Complete the survey by visiting:

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Benchmarks in Reducing Avoidable ER Visits
Learn the top three ways healthcare organizations prevent inappropriate use of the ER plus other actionable data in this free downloadable white paper, which captures efforts by 90 healthcare organizations to reduce avoidable ER visits as reported in the July 2010 Reducing Avoidable ER Visits 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

Home Visit Handbook: Structure, Assessments and Protocols for Medically Complex Patients

This 25-page guide outlines an innovative home visit pilot for Medicaid and dually eligible patients that reduced unplanned hospital admission days by 71 percent in three months and provides key performance benchmarks on home visit activity in the healthcare industry.

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

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Contact HIN:
Editor: Patricia Donovan,;
Publisher: Melanie Matthews,;

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