Constructing Care Transitions to Reduce Hospital Admissions


Geisinger Health Plan’s successful Transitions of Care program is the health plan’s response to rising rehospitalization rates among Medicare patients, a major concern of both CMS and private payors. Geisinger Health Plan’s Doreen Salek defines the transition teams’ key area of focus when providing a “clean and clear handoff” of a patient from one care site to another, with the goal of avoiding readmission to the hospital. The health plan’s director of business operations of health services also defines the plan’s ideal home health partner, its blueprint for a universal plan of care to improve care coordination and expectations for patients and their families and caregivers.

Salek, along with Janet Tomcavage, R.N., M.S.N., vice president of health services for Geisinger Health Plan, explained how a focus on transitions of care across the continuum can enhance care quality and reduce readmissions during the August 26, 2009 webinar, Constructing Care Transitions to Reduce Hospital Admissions. The 45-minute session is part of HIN’s continuing Medical Home Open House webinar series.


Length: 10:29 minutes

Patient Engagement and Education in the Medical Home: Perspectives from Several Pilots


Looking to jump-start patient outreach in the medical home? The appointment calendar is a great place to start, recommends Barbara Wall, a healthcare consultant who advises organizations on adoption of the patient-centered model of care. She describes the simple steps that medical home staff can follow to turn the appointment calendar into a patient teaching, recall and outreach tool.

A featured presenter during HIN’s Medical Home Open House webinar series, Wall explained the essential process changes that improve patient outreach and keep the patient at the center of the medical home during the August 5, 2009 webinar, Patient Engagement and Education in the Medical Home: Perspectives from Several Pilots.


Length: 3:43 minutes

Meet the Medical Home Neighbor: Accountable Care Organizations


The accountable care organization (ACO) — a network of primary care physicians, one or more hospitals, and subspecialists that provide patient-centered care — is receiving increasing attention as healthcare reform unfolds. Not only do ACOs complement the medical home model, but they are inextricably linked, says Dr. Craig Samitt, M.B.A., president and CEO of Dean Health System. Dr. Samitt discusses how ACOs complement the medical home model, the pros and cons of mandatory and voluntary ACOs and creating reimbursement strategies for ACOs.

Dr. Samitt shared how Dean Health System uses its best practices to create an accountable care organization that provides a high-value patient-centered care experience during the July 29, 2009 webinar, Meet the Medical Home Neighbor: Accountable Care Organizations, part of the Medical Home Open House webinar series.


Length: 6:46 minutes

Reducing Uncompensated Care Costs for the Chronically Ill Through a Medical Home Approach: A Health System Case Study

There are many ways to administer the Patient Activation Measure™ (PAM) and many socioeconomic factors that influence its outcomes, explains Dr. Judith Hibbard, developer of the PAM and professor of health policy at the University of Oregon. Dr. Hibbard identifies the PAM scores that signal a behavior change and the value of adding patient activation assessment to a health improvement initiative.

American Health Holding relies on the Patient Activation Measure™ to assess a patient’s level of engagement in their own overall disease management (DM), but it does more than just that. PAM scores are also used to gauge the success of the DM program and its coaches. Director of DM and wellness services Diane Bellard discusses PAM — who is using it, how to deal with a decrease in PAM levels, how it fits with a patient’s readiness to change and PAM’s role in an organization’s overall quality improvement.

Dr. Hibbard and Bellard shared the research behind the development of the PAM, its potential for improving a patient’s healthcare self-efficacy and examples of its use in a DM setting during the June 18, 2009 webinar, Patient Activation Measure™: Assessing the Engaged Healthcare Consumer for Self-Efficacy.

Dr. Judith Hibbard



Length: 4:16 minutes
Diane Bellard



Length: 5:31 minutes

Medical Home Contracting: Building a Solid Framework


There are several ways a healthcare organization can bring clinical credibility to the medical home contract negotiating table, explains Dr. Barbara Walters, senior medical director for Dartmouth-Hitchcock Medical Center. She describes the ways in which the medical home contracting process differs from the standard payor contracting experience and highlights some typical performance guarantees to include in a medical home contract.

In a July 8, 2009 webinar, Medical Home Contracting: Building a Solid Framework, Dr. Walters shared how to effectively prepare, negotiate and contract with payors for the medical home model of care to better prepare organizations for a seat at the negotiating table. The 45-minute session is part of HIN’s continuing Medical Home Open House webinar series.


Length: 3:21 minutes