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The Healthcare Intelligence Network's Medical Home Monitor

Primary care is changing, and thanks to the Accountable Care Act, the patient-centered medical home (PCMH) is at the epicenter of this transformation to a value-based model. The Healthcare Intelligence Network has been monitoring developments of the medical home for the last seven years, and is uniquely poised to cover the conversation on care coordination in primary care. HIN's Medical Home Monitor brings you the latest news and resources on the PCMH model to facilitate change in care delivery, healthcare quality, physician training and reimbursement, management of chronic illness and more.


Medical Home Expert Insight

Audio Interview

Terry McGeeney If payment inequities can be addressed, communication and technology tools in place in large physician multispecialty groups make them ideal candidates for a medical neighborhood, suggests Terry McGeeney, MD, MBA, director of BDC Advisors. Dr. McGeeney, who spent 13 years of his practice career in a large multispecialty group, has also seen some FQHCs and managed Medicaid programs that do a good job of linking community and social supports required in medical neighborhoods.

As for engaging patients in this emerging integrated care delivery system, try explaining the medical neighborhood's value proposition for them, he suggests. Patients already get why the integrated approach is good for physicians and insurance companies but need to hear why they should buy in to team care, patient portals and other aspects of centralized care coordination.

Length: 6:16
Click here to listen


Recent Audio Interviews on the Medical Home

Barbara Haasis: The Patient-Centered Medical Home — Lessons from a Statewide Rollout Click here to listen.

Kathy Brieger: Diabetes Management in the Medical Home — A Diabetes Collaborative Takes Team-Based Approach Click here to listen.

Melanie Matthews: Fifth Annual Medical Home Benchmarks — PCMH Stepping Stone to ACO Click here to listen.

Dr. Bruce Nash: Rewarding Primary Care Practice Reform with Physician Payment Reform — A Medical Home's Experience Click here to listen.

Sarah Dixon-Gale and Michelle Stephan: Coordinating a Virtual Medical Home in Your Community — Lessons from the Iowa Collaborative Provider Network Click here to listen.

Dr. Jose Guethon: Patient-Centered Medical Home Transformation — How Data Sharing Improves Physician and Business Performance Click here to listen.

Dr. Marjie Harbrecht: Recruiting Physician Practices for a Medical Home Pilot Click here to listen.

Dr. Larry Greenblatt and Jessica Simo: Home Visits in the Patient-Centered Medical Home Click here to listen.

Michael Earley and Dr. Jose Guethon: Patient-Centered Medical Home Transformation — 9 Key Hurdles for Physician Practices To Overcome Click here to listen.

Dr. David West: Shared Savings in the Medical Home Click here to listen.

Julie Schilz: Multi-Payor Medical Home Programs — Addressing Funding and Organizational Challenges Click here to listen.

Beth Chester: Medication Therapy Management in the Patient-Centered Medical Home Click here to listen.

Jeff Schiff: Risk Adjustment in the Medical Home — Building an Effective Reimbursement Strategy Click here to listen.

Geisinger Health Plan: Effective Case Management in the Medical Home Click here to listen.

Medical Home Open House: Medical Home Open House Highlights Part 2 — Physician Practice Innovations To Improve Care Delivery Click here to listen.

Barbara Luskin: Achieving NCQA's Patient-Centered Medical Home Recognition Click here to listen.

Dr. Richard J. Baron: Applying Evidence-Based Guidelines in the Medical Home Click here to listen.

Michael Erikson: Successful Models of Care for the Medical Home — Staffing and Roles of the Care Team Click here to listen.

Michael Zucker: Medical Home Reimbursement — Exploring Bundled Payment Options Click here to listen.

Webinar Highlights: Medical Home Open House Highlights Part 1 — Focus on Care Continuity, Quality and Access Click here to listen.

Barbara Wall: Patient Engagement and Education in the Medical Home — Perspectives from Several Pilots Click here to listen.

Dr. Craig Samitt: Accountable Care Organizations, the New Medical Home Neighbor Click here to listen.

Dr. Ricardo Guggenheim: Why Healthcare Should Invest in Management of Uninsured Care Costs Click here to listen.

Dr. Barbara Walters: Bringing Clinical Credibility to the Medical Home Contract Negotiating Table Click here to listen.


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Infographic: 10 Things to Know About Patient-Centered Medical Homes in 2014

Infographic: 10 Things to Know About Patient-Centered Medical Homes in 2014


Video: 2012 Medical Home Benchmarks


Produced: August 2012

The rise in patient-centered medical home starts over the last six years has been accompanied by a steady climb in patient satisfaction, according to the sixth annual Healthcare Intelligence Network survey on Patient-Centered Medical Homes (PCMH). Watch this video for highlights from survey results: patient satisfaction and engagement tactics, time needed to construct a medical home, technologies witring the PCMH, and much, much more. Narrated by Melanie Matthews, with commentary by Barbara Haasis, senior clinical lead for Florida Blue's quality reward and recognition programs, which recently rolled out a statewide PCMH.


Medical Home Q&A: What Are Best Practices in Post-Discharge Telephonic Follow-Up?

This week's expert is Kelsey P. Mellard, vice president of partnership marketing and policy with naviHealth

Question: What are some naviHealth examples of telephonic follow-up after hospital discharge in the bundled payment pilots?

Response: (Kelsey Mellard) CMS has offered several waivers, including a patient incentive waiver and also a telephonic care management waiver. You'd use telehealth, which goes beyond the research ends of the real health cause within typical CMS reimbursement for telehealth services.

If you think about how you target your population, you have high risk and low risk. Maybe you have a medium risk, depending on the way your analytics and your clinical team is split. Telehealth doesn't have to be this complex platform. It could be as simple as a phone call every other day to make sure that the patient is taking their medication, that they have a ride to their appointment, and that their son, daughter or caregiver has been by that day to help engage.

This is not rocket science. It is a lot of work. It's a lot of use of analytics against a target, but once you've identified that target population, it's a question of how do you turn up or turn down the engagement based on where that patient is. Again, it can be very simple telephonic care management that are brief conversations. Often we found that some of our beneficiaries re-admit because they simply want social interaction with someone else, and a telephone call can sometimes be gratifying enough for that beneficiary that they don't seek social engagement back at the hospital again.

For more information on opportunities from CMS bundled payment pilors, please visit the HIN bookstore.



Download Free Medical Home White Paper

Patient-Centered Medical Homes in 2014


Comprehensive Medical Home Resources

Driving Value-Based Reimbursement with Integrated Care Models examines WellPoint's practice transformation effort and the reimbursement models that support it, while providing a framework in which to evaluate the patient-centered medical neighborhood (PCM-N) model.

Healthcare Innovation in Action: 19 Transformative Trends examines a set of pioneering efforts supporting the industry's seismic shift from a volume-based culture to one rewarding value and patient-centeredness.

2012 Healthcare Benchmarks: The Patient-Centered Medical Home, now in its sixth year, is designed to meet business and planning needs of physician practices, clinics, health plans, managed care organizations, hospitals and others by providing critical benchmarks in medical home implementation and results.

New Models in the Patient-Centered Medical Home: Incentives, Infrastructure and IT to Support Accountable Care offers snapshots of thriving medical home initiatives and their particular area of focus.

Click here for additional medical home resources
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