As the patient-centered medical home (PCMH) model moves from blueprint to implementation, there is some debate over its ability to deliver quality care and coordination while reducing healthcare cost and utilization. Overburdened physicians are also unsure how to meet the PCMH's time and technology demands under current reimbursement formulas. While the conversation continues, results from recently completed medical home pilots show promise for patients with diabetes as well as lower costs for those who treat and insure these patients.

Part of the Medical Home Compilation, a three-volume series with medical home case studies from APS Healthcare, the Commonwealth of Massachusetts, Community Care of North Carolina, Horizon Blue Cross Blue Shield of New Jersey, the Pennsylvania Medicaid Access Program and United Healthcare -Save 20% when you order the Medical Home Compilation Series.

Case Studies from Diabetes Medical Home Pilots: Key Processes, Tools, Metrics and Outcomes offers a detailed look at two physician-health plan partnerships in diabetes disease management — a care coordination pilot for New Jersey state employees with diabetes and a hands-on case manager-driven initiative for Medicaid beneficiaries with diabetes in North Carolina.

The first case study in this 40-page special report describes how diabetes patients benefited when Horizon Blue Cross Blue Shield of New Jersey — one of the first insurers in the nation to reimburse physicians for the medical home model of care — shared health-related data with Partners In Care, a coordination entity that created comprehensive member profiles for physicians treating these patients. At the end of the one-year diabetes medical home pilot, physicians' applications of these actionable health profiles resulted in dramatic spikes in clinical outcomes and compliance for key diabetes markers among these patients. Dr. James Barr, medical director for Partners in Care, recounts the processes and outcomes that were part of this care coordination pilot, which evolved from a simple registry system developed 10 years ago.

In the second case study, doctors with Community Care of North Carolina serve as medical homes for Medicaid patients with diabetes. The ongoing care, information and support that physicians and caseworkers gave these patients made a huge difference in patient compliance, clinical outcomes and healthcare utilization. Roberta Burgess, a nurse case manager with Community Care Plan of North Carolina with Heritage Hospital in Tarboro, North Carolina, shares best practice care coordination strategies for diabetic patients with special emphasis on the challenges of delivering disease management to Medicaid beneficiaries.

In "Case Studies from Diabetes Medical Home Pilots: Key Processes, Tools, Metrics and Outcomes," Dr. Barr and Ms. Burgess provide profiles of patients from each medical home initiative, as well as a host of checklists and tools for a diabetes medical home. They also furnish details on the following:

• Transforming a physician practice into a diabetes medical home;
• Defining the roles and responsibilities of a successful diabetes medical home team;
• Facilitating the cultural shift from patient managers to population managers;
• Applying the NCQA's "Must Pass" elements of the patient-centered medical home to a diabetes-focused initiative;
• Developing goal-directed patient management plans;
• Identifying the practice buy-in to support a diabetes medical home and engaging practices in the effort;
• Reducing hospital admissions and ER utilization through the medical home model;
• Launching a comprehensive multi-phase diabetes disease management program for Medicaid patients — from selecting a diabetes quality improvement champion to developing patient and provider education materials;
• Identifying potential patients for the diabetes medical home and engaging them in the program;
• Developing a case identification database;
• Measuring outcomes and cost savings from the diabetes medical home;