Medical Home Monitor
Medical Home Monitor
September 20, 2010
Vol. III, No. 10

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Mobile Tools, Resistant Physicians
  2. In-Home Care Pilot
  3. New Chart: Impact of Patient Education
  4. Podcast: Medicaid ACO
  5. IT Grants for Mental Health
  6. E-Survey: Telehealth in 2010
  7. Benchmarks: Top HRA Uses
  8. Editor's Pick

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Medical Home Q&A's:
Mobile Tools, Physician Engagement

Medical Home Monitor

Patient Engagement: Is There an App for That?

Q: What potential do you see for using mobile or Web technology to engage individuals in advice?

A: We are looking at telemedicine technology for urgent care/ER. This is limited, as use requires knowledge of this tool and ability to access it with a computer or at a telemedicine center. Just as we have seen challenges using our nurse advice line, it might also be challenging to show the value of this resource versus going to the physical ER where tests can be done.

Barsam Kasravi, M.D., is managing medical director for state-sponsored programs for WellPoint.

For more interventions on reducing avoidable ER visits, please visit:

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Physician as Health Coach

Q: What positive psychology techniques can be employed to convince resistant physicians to collaborate with coaching programs?

A: It's important to focus on the positive. Physicians are very problem-focused. When you sit down with your doctor, rarely do they point out the 10 numbers on your report that are great. You start with, “This is where the issue is — you’ve got a problem here, you’ve got a problem here.” Similarly, physicians are usually looking at what’s not working, and we can help them think about, “What is working in your wellness, in your lifestyle? What good experiences have you had?” “What strengths have you used in other parts of your life that you could bring?” It’s getting out in an authentic way all the good stuff.

Margaret Moore is CEO of Wellcoaches Corporation.

For strategies to engage physicians in healthcare initiatives, please visit:

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Home Visits, Telehealth Hallmarks of In-Home
Care Management Pilot for Frail Elders

Partners in an in-home care management pilot program for Medicare's frail elders hope to improve clinical outcomes and quality of life while reducing avoidable hospitalizations for those with multiple chronic conditions.

The year-long SeniorBridge Care Management for Metcare pilot will test a multidisciplinary approach in which specially trained nurses and social workers will deliver ongoing assessments and care in the homes of 100 pre-selected Medicare Advantage members served by Metcare, a provider of healthcare services in Florida. Under the pilot, a partnership of Metcare and national health management company SeniorBridge, each qualified customer who enrolls will be assigned at no charge a nurse and social worker care management team. This team will work with the person's physician to develop an individual care plan tailored to the patient's functional, medical and emotional needs.

Unlike a telephonic disease management model, the pilot will include face-to-face visits with frail seniors and their caregivers in the comfort of their homes. Vital information will be stored and care coordinated through SeniorBridge's Web-based EMR.

Home safety assessments and evaluations of medical, functional and psychosocial status will identify such factors as expired medications and frayed rugs that leave older patients vulnerable to falls while monitoring for more critical issues such as cognitive decline that may not be readily apparent in a doctor's office or over the phone. Other in-home services to be available include health education and counseling, ongoing coordination of care with healthcare providers and family members and on-call care management support 24 hours per day, seven days per week.

The individual EMR will be used to manage and organize ongoing assessments, medical and professional notes, clinical and medical analyses, as well as care plans.

"Comprehensive assessment and ongoing in-home care management is the groundwork for improved compliance and quality care," said Jose Guethon, MD, MBA, president and COO of Metropolitan Health Networks. "By providing timely and reliable insights about the challenges, preferences and home environments of our customers, SeniorBridge Care Management for Metcare has the potential to minimize the time our doctors spend chasing medical information and empower them with an even more comprehensive understanding of their customers' needs so they can continually provide higher quality care to those often considered the most difficult to treat."

According to recent research published in the New England Journal of Medicine, one in five seniors are rehospitalized within 30 days of being discharged from a hospital.

For more information, please visit:

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New Chart: Impact of Patient Education
To paraphrase a popular commercial, an educated consumer is the healthcare industry’s best customer. We wanted to measure the impact of patient education programs on health outcomes, medication adherence, healthcare utilization and other key indicators.

View the chart at:

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HealthSounds Podcast: Measuring a Medicaid ACO
Colorado's accountable care organization (ACO) for Medicaid beneficiaries will use a select group of performance metrics to measure program quality and cost containment, explains Laurel Karabatsos, deputy Medicaid director. The ACO, which is rapidly approaching its January 2011 launch date, will provide health services for 60,000 Medicaid lives in the state.

To listen to this HIN podcast, please visit:

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Majority of NY State Health IT Grantees to Focus on
Coordination of Mental Healthcare
Nine of 11 healthcare organizations in New York State sharing $109 million in health IT grants will use the funds to improve care coordination for populations with behavioral health conditions such as depression and other affective disorders. The grants will advance the patient-centered medical home model of care and support projects that continue to build health IT infrastructure that improves coordination of healthcare for patients with complex health problems, with a focus on mental health, long-term care and home care.

Communication among providers and coordination of care that occurs as a patient moves among different care settings – such as primary care, medical imaging, and specialty care – has been shown to reduce medical errors and their associated costs and prevent unnecessary and costly duplication of services.

The ability of different providers in different settings to share clinical information in the treatment of patients with complex conditions requires the implementation of interoperable EMRs. By connecting to the Statewide Health Information Network for NY (SHIN-NY) healthcare providers can retrieve, store and share up-to-date patient information regardless of where care is delivered, while ensuring privacy and security of the patient's medical information. SHIN-NY is a specially designed Internet-based communications system that ensures the privacy and security of information shared among health care providers.

To learn more, please visit:

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HIN Survey of the Month: Telehealth in 2010
Which populations and conditions are being targeted by telehealth? Which devices and technologies are deployed in these programs, and what are the clinical and financial returns? Join the more than 70 healthcare companies that have taken HIN's second annual e-survey on Telehealth and Telemedicine; respond by September 30 and receive a free executive summary of compiled results. Your responses will be kept strictly confidential.

Complete the survey by visiting:

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Top 3 Uses for Aggregate HRA Data
Learn the top three ways companies are using aggregate data gleaned from health risk assessments in this free downloadable white paper, which captures trends in HRA use by 116 healthcare organizations as reported in the June 2010 Health Risk Assessments 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

Coordinating a Virtual Medical Home in Your Community: Lessons from the Iowa Collaborative Safety Net Provider Network

This 45-minute webinar on September 23, 2010 will explain the collaboration between primary care providers in the Iowa Collaborative Safety Net Provider Network and local, community-based organizations as part of a virtual medical home to improve access to and the quality of care.

Use ordering code MHMP to save 10 percent on webinar registration by visiting:

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

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