Evidence is mounting that low-cost interventions by primary care practices — as basic as making a phone call to a patient — can dramatically reduce hospitalizations and readmissions among individuals with chronic disease. Patient-centered medical home (PCMH) activities focused on patient education, engagement and empowerment are custom-built to reduce readmissions of the chronically ill and the healthcare spend associated with these hospitalizations.

Low-Cost Low-Tech Medical Home Approaches to Reducing Readmissions presents case studies from four healthcare organizations whose use of low-cost, low-tech tools in their medical homes is already reducing hospitalizations by up to 36 percent and improving care for Medicare beneficiaries in general and for patients with heart failure and diabetes in particular.

In this 60-page special report, get details on:

• The Group Health Cooperative medical home pilot, which relies heavily on what a Group Health executive calls "the most underutilized technology in modern medicine, the telephone," and that reduced preventable hospitalizations by 11 percent, ER visits by 29 percent and in-person visits by 6 percent, according to results published this year in the American Journal of Managed Care. Michael Erikson, Group Health's VP of primary care services, walks through the Group Health primary care practices, staffing models and program rollout tips that have many calling the cooperative "a model for healthcare reform."

• Geisinger Health System's medical home Transitions of Care teams, who have seized the opportunity to improve care delivery and outcomes. Janet Tomcavage, Geisinger's VP of health services, and Doreen Salek, director, business operations of health services for the health plan, share the essentials behind the transition teams for Geisinger's medical home pilot that have reduced 30-day hospital readmissions by 15 to 20 percent and overall healthcare costs by 7 percent while improving patient satisfaction and clinical quality indicators. Get the details on Geisinger's case manager staffing model, patient self-management action plans and more.

• Henry Ford Health System's monitoring of high-risk patients by its advanced medical home that reduced all-cause hospital admissions among enrollees with heart failure by 36 percent after six months and a return of 2.3:1 vs. program costs. Katherine Scher, R.N., C.C.M., program manager for the Center for Clinical Care Design at Henry Ford Health System, shares the specifics of the Michigan non-profit's medical home initiative that improved outcomes while relieving some of the burden on Henry Ford's case managers, freeing them to work more closely with patients to try to move them into a healthier state.

• The Community Care of North Carolina (CCNC) medical home case manager approach for Medicaid beneficiaries with diabetes that improved process measures and implementation of evidence-based best practice guidelines. Roberta Burgess, CCNC nurse case manager 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. This diabetes program was part of a larger CCNV initiative that saved the state an estimated $231 million in healthcare costs in 2005 and 2006. The benefit of CCNC's medical homes in the area of cancer screening and prevention were recently documented in the Archives of Internal Medicine.

Table of Contents

• Group Health Reduces Downstream Utilization through the Medical Home
  • Six Principles of the Group Health Medical Home Pilot
  • Call Management and Virtual Medicine Practices
  • Pre-Visit Preparations
  • Training Patients and Providers to be Interactive
  • Care Team Roles
  • Results from the One-Year Study
  • Impact on Utilization
• Geisinger Sees Care Transitions as Opportunities to Enhance Coordination
  • The Medical Homes Role in Care Transitions
  • Five Components of Medical Home Approach
  • Integrated Population Management Shows Providers Their Populations
  • Case Managers: Keys to Success
  • Program Impact on Readmission Rates
  • From Pilot to Practice
• Henry Ford Health System Monitors High-Risk Patients in the Medical Home
  • Patient Profiles in a Four-Story Medical Home
  • Identifying the Appropriate Population of Patients
  • Partnership Removes Enrollment Burden from Case Managers
• CCNC Medical Homes for the Medicaid Patient with Diabetes
  • Quality Improvement
  • Obtaining Community Buy-in
  • Engaging the Physician and the Client
  • Diabetes Education
  • Identifying Candidates for Case and Disease Management
  • Case Identification Database
  • Measure and Process Outcomes, Savings from the DMH Pilot
• Q&A: Ask the Experts
• Glossary
• For More Information
• About the Presenters