In Hospitals in a Medical Home: Partners in Enhancing Access, Health Status and Cost Avoidance, the director of a medical home network demonstrates how hospitals can partner with medical homes to deliver patient-centered care to uninsured and low-income patients while reaping the financial benefits associated with decreased utilization and duplication of services.

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Each week, healthcare professionals respond to a reader's query on an industry issue. This week's experts are Dr. James E. Barr, medical director at Partners in Care, and Roberta Burgess, CCNC nurse case manager with Heritage Hospital in Tarboro, North Carolina.

Question: The Medicaid population has many social barriers to care. How do you increase their engagement to allow the diabetes medical home model to be successful?

Response: (Roberta Burgess) It is hard, but population management is something I do with my diabetic population or any other population that we work with. I send out materials on a monthly basis to my diabetics, and most of the time it’s just education. I'll say that this is an educational flier about your diabetes. I’ll also have at the bottom, "If you would like more information, contact me, and I can come see you one-on-one and we can talk about some other things." I get responses back from those letters saying, “I got a letter from you about my diabetes. I need to know more about it." I also pick up the phone and call them, one at a time until I get somebody. There is a barrier, but I pick up the phone and say, "My name is Roberta and I’m your case manager. I work for your medical home. Is there anything I can help you do today? How are you doing with your diabetes? Are you having any other problems that I might be able to help you with? I know all about the resources." That opens the door and lets them know they can get care or help. Many times they may not get out because of transportation. I can provide them with transportation. But it is one-by-one, and it’s treacherous.

(Dr. James Barr) The process map that we utilize identifies every person that is in contact with this patient. The list includes the medical home doctor, all the specialists involved and a case manager if one exists. That list can continue and can involve the family member who might have the most influence over this patient or will help with compliance, transportation or finances. There may be a financial assistance plan that can be implemented inside that patient's profile in order for them to get certain medications. It could involve a faith-based organization, a minister, or somebody with whom they have a relationship. It's good to include anybody who has had a relationship with that patient so that when you’re having a problem, the map indicates resources to use to help this patient obtain the type of care they need.

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