Medical Home Lesson 12: Coordinate PCMH Roles Between Practice and Health Plan Partners

Tuesday, June 9th, 2009
This post was written by Melanie Matthews

Barbara Wall, J.D., a consultant who advises healthcare organizations on development and implementation of patient-centered medical homes (PCMH), shares one of 15 lessons learned from her recent consulting roles with two separate medical home models used in pilots in the Northwest. It’s a viewpoint enhanced by more than 10 years in health plan management.

“Many health plans are looking at the medical home as a way to supplement some of the things that disease management (DM) programs are not doing or cannot do. The health plans that I’ve worked with on these pilots are looking for ways to support the practice in information exchange. This works as long as the practice had identified the patients currently enrolled with each carrier and both parties consider privacy rules.

Once you have gotten past that hurdle, you have a way to send information back and forth. There are often DM programs in place that are owned or coordinated with the health plan. The medical home practice can do things that the health plans and the DM and case management vendors cannot do — that is, call the patient and say, ‘I want you to come in and see the doctor,’ or ‘You need to come in and get this blood work done.’”

That’s the piece that the health plans have recognized that they can’t do through a telephonic approach, says Wall. “The physician can see and touch and examine the patient. The health plans that I’ve been involved with are making sure that there’s an information flow point of contact — usually nurse to nurse — between the medical home practice and the health plan care management department so that when there are episodes of acute crisis, the practice and health plan can immediately coordinate on the plan of care.

“In the Northwest, health plans are increasingly looking for ways to integrate with the practices on patients that they have in common to improve quality of care and outcomes,” Wall concludes.

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