The Medical Home Compilation is a comprehensive three-volume set illustrating how medical home projects and pilots are being used to improve primary care access and use. You'll get case studies on programs 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.

• The Medical Home: Pathway to Patient-Centric Primary Care
• Framing the Medical Home Model of Care: Blueprint from Early Adopters
• Case Studies from Diabetes Medical Home Pilots: Key Processes, Tools, Metrics and Outcomes

In theory, assigning a medical home—accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective healthcare—to every individual should pay off in more effective, patient-centric care. In practice, however, establishing medical homes can be time-consuming and challenging, especially for those with chronic conditions and in high-disparity and underserved populations.

Congress passed legislation in late 2006 that adds financial weight to the idea of the patient-centered medical home, which has its roots in pediatrics. By funding the Medicare Medical Home Demonstration as part of the Tax Relief and Health Care Act of 2006, Congress authorized the payment of a “care coordination fee” to participating physicians in eight states who manage patients with multiple chronic conditions.

"The Medical Home: Pathway to Patient-Centric Primary Care," addresses the value and challenges of medical homes from the viewpoints of organizations already trying to establish medical homes for their populations. Covered in this 40-page special report are funding and implementation hurdles, successful methods for identifying members and redesigning office practices to move toward an advanced medical home model.

This report also summarizes the results of a 2006 HIN e-survey that identified opportunities for educating the healthcare industry on medical homes. More than half of survey respondents were either unfamiliar with medical home terminology or confused it with a physical structure.

In "The Medical Home: Pathway to Patient-Centric Primary Care," HIN's accomplished panel of contributing authors furnish details on the following:

• Enhancing chronic care programs through medical homes and modifying this approach for other populations;
• Building partnerships that foster a community care model;
• Commentary and suggestions from early adopters of medical home models who responded to the 2006 e-survey;
• The role of health coaches, case workers and the patient in the establishment of a medical home;
• How to triangulate interventions to achieve best-practice outcomes;
• Funding, identification and program launching strategies; and
• Reallocating resources to optimize program success.

Throughout this 40-page report, these respected thought leaders detail their findings:

• Elizabeth Reardon, consultant with the Office of Community Programs, Commonwealth Medicine, a division of the University of Massachusetts Medical School;
• Anne Hernandez, director of operations of APS Healthcare;
• Dr. George Rust, senior consultant for APS Healthcare and interim director of the National Center for Primary Care at Morehouse School of Medicine.

Table of Contents

• Survey Identifies Medical Homes Knowledge Gap
  • The Medical Home’s Pediatric Roots
  • Targeted Populations
  • Medical Homes Increase Patient Satisfaction and Improve Outcomes
  • Early Adopters Share Strategies for Success
  • The Role of the Primary Care Provider
• An Overview of Medical Homes, the Hub of Healthcare
  • Key Components of Medical Homes
  • Enhancing Chronic Care Programs Through Medical Homes
  • Modifications for Other Populations
  • Challenges to Medical Homes
  • Tools and Resources
• APS Healthcare Helping to Establish Medical Homes for Members
  • Georgia Disease Management Program
  • Strong Partnership Leads to Community Care Model
  • Why Members Don’t Use Medical Homes
  • Health Coaches Can Guide Members to Medical Homes
  • Bringing Best Practice Perspectives Where They’re Needed Most
  • The Value of a Primary Care Home
  • Primary Care Homes and High Disparity Populations
  • Usual Care Does Not Provide the Best Outcome
  • Triangulate Interventions to Achieve Best-Practice Outcomes
• Q&A: Ask the Experts
  • Funding Medical Homes and Implementing Measures
  • Successful Methods for Identifying People and Initiating Care Management
  • Redesigning the Office to Move Toward an Advanced Medical Home
  • The Trend Toward Retail Clinics
• Glossary
• For More Information
• About the Authors

Framing the Medical Home Model of Care: Blueprint from Early Adopters

In the face of a primary care crisis, Framing the Medical Home Model of Care: Blueprint from Early Adopters chronicles the provider and payor experiences on the road to establishing medical homes for their respective populations. This 45-page resource describes the skills, technology, cultural change and financial incentives necessary to transform a physician practice into a medical home. It also presents a game plan for health plans that are ready to embrace and reimburse this model of care.

Dawn Bazarko, senior vice president of clinical innovations for UnitedHealthcare, offers a payor's perspective as agent for the medical home based on UnitedHealthcare's experience from its medical home pilot. She shares feedback from consumer focus groups and suggests methods for dispelling consumers' misperceptions about the medical home. She provides guidance on consumer education and activation strategies and tips for marketing the medical home and measuring its outcomes. She also discusses opportunities for value-added partnerships for medical homes in care and disease management programs offered by external entities.

From the physician standpoint, the medical home provides multiple opportunities to reframe traditional care delivery, reshape medical professionals' attitudes, improve practice processes and share innovations with other providers. Dr. Lonnie Fuller, medical director for the Pennsylvania Medicaid ACCESS Plus PCCM-DM Program, describes 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. He weighs in on the workload, staff training and technology required to support the medical home model in a practice, and suggests how payment reform and collaboratives can help move practices toward clinical excellence.

In "Framing the Medical Home Model of Care: Blueprint from Early Adopters," Ms. Bazarko and Dr. Fuller furnish details on the following:

• Defining the payor's role as agent of the medical home;
• Helping practices meet the medical home designation;
• Distinguishing the medical home model from the traditional HMO "gatekeeper" model;
• Understanding the patient's role in the medical home partnership;
• Enabling patient activation and education;
• Marketing the medical home to consumers;
• Measuring the medical home's outcomes;
• Supporting the medical home model with training, technology and disease management;
• Meeting the four requirements of the advanced medical home for successful practice transformation;
• Avoiding the "master craftsman" syndrome in medicine;
• Using "Diffusion of Innovation" theories to spread best practices;

This report also summarizes the results of a 2008 HIN e-survey that captured medical home awareness and implementation levels by healthcare industry sector. The survey analysis also reveals the motivation, strategies and outcomes behind medical home adoption.

Table of Contents

• Advancing The Patient-Centered Medical Home with UnitedHealthcare
  • Primary Care in Crisis
  • Defining & 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
• Case Study in Practice Transformation: The Medical Home for the Medicaid Population
  • HEDIS Data Indicates Need for Improvement
  • Prescription for Primary Care
  • Advanced Medical Home Requirements
  • Practice Transformation Skills and Support
  • Collaborations and Best Practice Diffusion
• Q&A: Ask the Experts
  • Measuring Improvement Outcomes
  • Managing Communications Among Providers
  • Developing Transition Payment Strategies
  • Grants and Funding Opportunities
  • Diffusing Best Practices to Remote Sites
  • Engaging Reluctant Practices
  • Launching the Program
  • Care Advocate Job Description
  • Handling Confidential Information
  • Building a Communications and Marketing Strategy
  • Coordination Across Multiple Payors and Health Plans
• Glossary
• For More Information
• About the Authors

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.

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;

Table of Contents

• Partners in Care Diabetes Medical Home Pilot
  • Key Principles of the Patient-centered Medical Home
  • Care Coordination and Integration are Critical
  • Goal-directed Management Plans
  • Pilot Structure and Process
  • The Physician’s Incentive
  • Interventions Used by Partners in Care
  • Results to Date
• Care Coordination and Case Management of Diabetics with the Medical Home
  • Quality Improvement
  • Identifying Community Buy-in
  • Engaging the Physician and the Client
  • Diabetes Education
  • Identifying Candidates for Case and Disease Management
  • Case Identification Data Base
  • Measure Outcomes and Cost-effective Savings from Diabetics in the Medical Home
• Q&A: Ask the Experts
  • Pharma Costs
  • Sharing Member Information
  • Partners in Care
  • The Medical Home Model
  • Marketing the Medical Home
  • Engaging the Medicaid Population
  • Tracking and Referring Patients
  • Lessons Learned
  • Time Requirements for Physicians
  • Including Patient’s Family in Medical Home
  • Information and Training
  • Inside the Provider’s Toolkit
  • The Role of Case Manager
  • Patient Education
• Glossary
• For More Information
• About the Authors