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The patient-centered medical home is a centerpiece of health reform and a critical catalyst for improving quality and containing costs across all sectors of the healthcare industry — from Medicare and Medicaid populations to commercial products. The 11 profiles in Medical Home Case Studies: Profiles in the Patient-Centered Approach document experiences on the adoption, organization, delivery, funding and outcomes of the medical home model.

This 100-page special report profiles the efforts of 11 healthcare organizations as they explore the benefits, opportunities and challenges of the patient-centered medical home model from the viewpoints of payor, hospital, physician, nurse practitioner, case manager and C-suite executive. Supplemented with key graphs and data, these case studies provide details on:

• Disease-specific medical home approaches;
• Care management transition teams;
• Emerging reimbursement models like the accountable care organization (ACO) and a three-tiered payment model;
• The hospital as medical home;
• Multi-payor pilots and collaborations;
• Early ROI in the form of reduced hospital readmissions and healthcare utilization;
• Medical homes for high-risk patients;

Medical Home Case Studies: Profiles in the Patient-Centered Approach contains detailed case studies of the medical home experience from the following 11 healthcare organizations:

• Palmetto Health: Marcus Barnes, director of Richland Care Medical Home, describes 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;
• Partners In Care Physician Organization: James Barr, M.D., family physician and medical director for the Central Jersey Physician Network IPA, explains 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;
• UnitedHealthcare: Dawn Bazarko, senior vice president of clinical innovation, offers a payor's perspective as agent for the medical home based on a medical home pilot;
• Community Care Plan of Eastern Carolina: Roberta Burgess, registered 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;
• Pennsylvania Medicaid ACCESS Plus PCCM-DM: Lonnie E. Fuller Jr., M.D., medical director, defines the four requirements of the advanced medical home, including a critical cultural shift in the practice from "physician as boss" to one of collaboration and support;
• APS Healthcare: Anne Hernandez, LCSW, operations director for Georgia, describes how to effectively and comprehensively serve a population in a primary care medical home in a low resource setting;
• Colorado Department of Health Care Policy and Financing: Lesley Reeder, R.N., B.S.N., quality improvement, suggests an enhanced medical home reimbursement model for preventive care;
• Geisinger Health Plan: Doreen Salek, B.S., R.N., C.C.S./C.P.C., director, business operations of health services, and Janet Tomcavage, R.N., M.S.N., vice president of health services, share the responsibilities of 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;
• Dean Health System: Craig Samitt, M.D., M.B.A., president and CEO, describes how Dean Health System reengineered its practice as an ACO — a network of primary care physicians, one or more hospitals and subspecialists that provide patient-centered care — and noticed tremendous improvements in patient satisfaction and access, HEDIS and quality scores and membership numbers;
• Henry Ford Health System: Katherine Scher, R.N., C.C.M., program manager for the Center for Clinical Care Design on an advanced medical home that monitored high-risk patients and reduced all-cause hospital admissions among enrollees with heart failure by 36 percent after six months;
• Colorado Multi-Stakeholder Patient Centered Medical Home (PCMH) Pilot: Julie Schilz, R.N., B.S.N., manager of Colorado Clinical Guidelines Collaborative IPIP Program, describes a partnership between employers and public and private payors to fund medical homes through a three-tiered reimbursement model.

This 100-page special report is designed for healthcare organizations that want to benefit from the experiences of early adopters of the PCMH.

Table of Contents

• Geisinger Health Plan Care Transitions Program Enhances Care Coordination
  • The Medical Home’s Role in Care Transitions
  • Five Components of Geisinger’s Medical Home Approach
  • Case Managers: Keys to Success
  • Patient Self-Management Action Plans
  • Program Impact on Readmission Rates
  • Moving 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\
• North Carolina’s Medical Homes for Medicaid Patients with Diabetes
  • Quality Improvement
  • Obtaining Community Buy-in
  • Engaging the Physician and the Client
  • Diabetes Education and Outreach
  • Core Elements of Diabetes Disease Management
  • Identifying Candidates for Case and Disease Management
  • Case Identification Database
  • Measure and Process Outcomes, Savings from the DMH Pilot
• Actionable Patient Profiles Drive Payor-Provider Diabetes Medical Home Pilot
  • Key Principles of the PCMH
  • NCQA’s Physician Practice Connections
  • Care Coordination and Accountability
  • Pilot Structure and Process
  • The Physician’s Incentive
  • Interventions Used by Partners in Care
  • Results to Date
• APS Healthcare Helping to Establish Medical Homes for Members
  • Georgia Disease Management Program for Medicaid Members
  • Strong Partnership Leads to Community Care Model
  • Why Members Don’t Use Medical Homes
  • Health Coaches Can Guide Members to Medical Homes
• Improving Outcomes with the Advanced Medical Home
  • Big U.S. Healthcare Spending Doesn’t Yield Big Results
  • HEDIS® Data Indicates Need for Improvement
  • Primary Care — Will It Survive?
  • Advanced Medical Home Requirements
  • Process of Care and Technology
  • Process Improvements, Cultural Changes Critical
  • Fostering the Advanced Medical Home
• How Hospitals Benefit from Partnerships in Patient-Centric Primary Care
  • The Richland Care Model
  • Service Components of the Model
  • PCMH’s Effect on Utilization and Self-Reported Health Status
  • Variable Cost Avoidance
  • Hospital’s Role in the Integrated Healthcare Delivery System
  • What’s Working in the Medical Home Network
  • Why a Hospital Should Develop a Medical Home Network
• Advancing the Patient-Centered Medical Home with UnitedHealthcare
  • Primary Care in Crisis
  • Defining and Evaluating the Patient-Centered Medical Home
  • A Proven Approach to Patient-Centered Medical Homes
  • Patient Relationship, Care Coordination Critical to Consumers
  • Stakeholders’ Roles in the Medical Home Partnership
  • Physicians and Patients Evaluate the Experience
  • Marketing the Medical Home
• Reimbursement Models for Medical Homes: From Pilot to Practice
  • Gauging Your Success
  • Enlisting the Physician Champion
  • Challenges and Collaborations
  • Identifying Early “Gets”
  • Alternate Models for Consideration
• Multi-Stakeholder Collaboration in Medical Home Reimbursement
  • Payment Methodologies and Structure
  • Reimbursement Models That Adjust for Risk
• Meet the Medical Home Neighbor: The Accountable Care Organization
  • The Eight Realities of Healthcare Today
  • Defining the ACO
  • 10 Strategies for a Successful ACO
  • Fitting the ACO into the Medical Home Model
  • Results from Dean Health System ACO
• About the Authors