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September 21, 2009
Vol. II, No. 10

Medical Home Monitor Archives

Medical Home Q&A:
Geisinger's Medication
Reconciliation Process

Medical Home Monitor

Q: How do Geisinger case managers handle medication reconciliation during care transitions?

A: The case manager does medication reconciliation at every visit. First, for an outpatient visit, we ask them to bring their medications with them, including over-the-counter. We go through every medication bottle to understand the purpose and timing of each medication. Secondly, we use our predictive modeling tool to report their refill rate of medications and alert the case managers to instances when someone says they’re taking their medications but they’re really not. We always try to find out which pharmacy they’re using. If we suspect that someone is not taking their medications, we call the pharmacy to find out their refill pattern. On the inpatient side, we work hard to get the hospital discharge summary because that gives us a starting point for medications. We go through each medication on the list and reconcile it: Should they be taking it on the outpatient side? Is there any duplication of medications? (Janet Tomcavage, vice president of health services with Geisinger Health Plan.)

For more advice on retooling care transitions to reduce hospitalizations, please visit:

Remote Monitoring for Heart Failure Reaps ROI, Reduces Admissions in Medical Home Pilot

Remote monitoring of heart failure patients by Henry Ford Health System's patient-centered team care program shows a 36 percent reduction in expected all-cause hospital admissions for enrollees after six months and a return of 2.3:1 vs. program costs. The Michigan non-profit healthcare enterprise began using Tel-Assurance®, Pharos Innovations’ device-free remote patient monitoring (RPM) platform, at its clinics on July 21, 2008 as part of its patient-centered medical home (PCMH) model; the reporting period ran through December 31, 2008.

In describing the telemedicine outreach during a recent HIN webinar, Katherine Scher, a program manager for Henry Ford Health System, said that the remote monitoring effort relieved the burden on Henry Ford's case managers, who were "busy contacting and working with patients with various conditions and trying to move them into a healthier state." She also shared a program strategy that likely contributed to enrollment and engagement rates of greater than 60 percent.

"We made sure that when we delegated the enrollment to the Pharos team, that they knew the correct pronunciation of the physicians' names. That seems like a small thing, but it’s not. If you’re a patient receiving a call from someone asking you to participate in a program and the person doesn’t pronounce your physician’s name correctly, it takes all credibility away. That’s the level of detail and preparation that went into developing this outreach process."

For more information on the study, please visit:

HealthSounds Podcast: Applying Evidence-Based Medicine in the Medical Home

Despite the challenges, cost and uncertain return of EHRs, practices should move quickly to adopt these tools, recommends Dr. Richard J. Baron, president and CEO of Greenhouse Internists, where the EHR is the backbone that supports the implementation of evidence-based practices.

To listen to this complimentary HIN podcast, please visit:

CIGNA Multi-State Player in Medical Home Pilots

A pilot program that incorporates components of the medical home model launched by CIGNA and Medical Clinic of North Texas (MCNT) is the fifth PCMH collaboration for the private payor, which already participates in several medical home initiatives throughout the country, including multi-payer pilots in Colorado, Pennsylvania and Vermont and a CIGNA-only pilot in New Hampshire.

In the first commercially sponsored medical home program in Texas that involves a multi-site medical practice and a single private payor, CIGNA will fund the development of a process of care coordination led by a registered nurse working with a team of professionals supported by MCNT and CIGNA data and clinical tools. The program is focused on the more than 10,000 individuals covered by a CIGNA health plan who receive care from MCNT’s PCPs.

MCNT-affiliated PCPs will be paid as usual for the medical services they provide and may also be rewarded through a pay-for-performance structure for improving quality and enhancing access to appropriate healthcare.

For more details on the CIGNA-MCNT pilot, please visit:

HIN Survey of the Month: Telehealth in 2009

The appropriate use of health IT to optimize patient care is wired into the widely endorsed PCMH joint principles. And as rising healthcare costs fuel much of the healthcare reform debate, healthcare organizations are turning to telehealth to lower costs and improve efficiencies while expanding patients' access to services. Complete HIN's Survey of the Month on Telehealth in 2009 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:

Treating ER Overcrowding: An Emergency in Urgent Care

An overcrowded ER can create a myriad of problems — from an increase in wait times to a decline in the quality of care being given to patients in need. In a recent e-survey from the Healthcare Intelligence Network (HIN), 73 healthcare organizations described how they are responding to ER overcrowding and the effect of this trend on their organizations.

To download this complimentary white paper, please visit:

Depression Management Benchmarks: Trends in Integration of Behavioral and Physical Health — MHM Readers Save 10 Percent

There is a growing recognition in the medical home that depression needs to be identified and treated because of its comorbidity with other chronic conditions and its impact on patient adherence to treatment recommendations. Depression Management Benchmarks provides actionable information from 260 organizations that are targeting depression in their populations. This exclusive report analyzes the responses of 260 healthcare organizations to HIN's 2008 Industry Survey on Depression Management, presenting trends in participant identification methods, preferred depression screening tools, formats and modalities for program delivery and key educational, clinical and IT components of programs. This resource also presents current developments in the PCMH model with evidence-based approaches to integration of primary care and behavioral health.

Use ordering code MHMP to reserve your specially priced copy by visiting:

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Publisher: Melanie Matthews,;

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