Archive for the ‘Patient-Centered Medical Home’ Category

Home Visits for the High-Risk: Targets, Timelines and Training

July 29th, 2014 by Patricia Donovan

Many patient-centered medical home (PCMH) initiatives have added home visits to care transition management to reduce avoidable hospital readmissions and ER utilization. Jessica Simo, program manager with Durham Community Health Network for the Duke Division of Community Health, describes likely candidates for home visits, the structure of a typical home visit and recommended staff training.

HIN: Which diagnosis or patient profile benefits most from a home visit?

(Jessica Simo) As a general rule for the patient population we serve, the people who get the most home visits are middle-aged individuals with at least two chronic health conditions. These are not generally healthy individuals who had one adverse event that brought them to our attention. These are people living day in and day out with chronic health problems they struggle with managing. Those people benefit the most from the amount of time it takes to do a home visit.

HIN: What is the average length and typical format of a home visit?

(Jessica Simo) The average home visit lasts 45-60 minutes. It would be longer for the initial home visit when an assessment is being done—where the Care Partner (a partnering stakeholder from across the Duke University health system and the Durham community) collects information for the first time about medications the patient takes, their sources of support, ADL deficits, etc. Those visits tend to be a bit longer, certainly an hour at a minimum, but once that rapport has been established, the weekly visits are often less than an hour. They become briefer as a patient transitions from phase one to phase two of the Care Partners Pathway because there is less to talk about at that point. This is a good thing; it means they are improving.

The home visits are structured around assessments and protocols, but as the home visits progress and the care partner becomes more familiar with the patient, there is less reliance on assessments and more on follow-up from the previous week.

HIN: How do you prepare and train staff to conduct home visits?

(Jessica Simo) The best way to prepare somebody to do home visits is to have them shadow a more experienced staff person. There are too many independent variables at play when you go into somebody’s home and you just don’t have control over that environment. Nor should you. It’s impossible to anticipate every possible scenario. Therefore, we do a lot of shadowing for at least a month before someone does a home visit on their own.

Excerpted from: Home Visit Handbook: Structure, Assessments and Protocols for Medically Complex Patients

4 Ways to Pinpoint High-Risk, High-Cost Candidates for Case Management

June 24th, 2014 by Patricia Donovan

case management patients

Doctors don't always know when their patients are in the hospital.

Providers in a physician practice are a good starting point for case managers to identify high-risk or high-cost patients for case management, explains Annette Watson, RN-BC, CCM, MBA, senior VP of community transformation for Taconic Professional Resources (TPR).

The process of identifying high-risk, high-cost patients can be formal or informal. You can use internal sources; when TPR goes in, that is one of the baselines of understanding. We understand who the patients are and what the population is, because if they have not been using data or have not been in an Advanced Primary Care initiative, it is highly unlikely the practice will have a quantitative method in place when we arrive.

We begin by asking the practice providers who the sickest patients are. Second, we can use data available at the practice level, such as registries or reports that can be run from the EHR.

Third, we also look at the kind of data they get from external sources. For example, do they receive reports from payors that show some utilization activity? Many of those reports may be somewhat aged. They are not necessarily timely, which raises actionability questions. However, we found there are reports coming out from payors, particularly about recent ER use or hospital discharges, that are more timely, which allow the practices to look at data—still retrospectively in most cases but much more quickly than they were able to in the past.

And finally, hospital admission and discharge information is important. Depending on the model in a PCP, if a physician is not the admitting physician— that is, if the admission is from a specialist, hospitalist, or through the ER—it cannot be assumed the PCP has the admission and discharge information.

People may think physicians know about their patients being in the hospital, but that is not always the case.

(Note: Taconic Professional Resources offers professional training and practice optimization to organizations aspiring to become a patient-centered medical home and/or join a medical neighborhood.)

Excerpted from: Advancing Primary Care with Embedded Case Management: Lessons from the Taconic IPA Pilot

HINfographic: 10 Things to Know About Patient-Centered Medical Homes in 2014

June 23rd, 2014 by Jackie Lyons

Having established a firm foundation over two decades of patient-centered care, the patient-centered medical home (PCMH) model is poised for renovation, expanding into medical neighborhoods and opening the door to specialists' enhanced role in care coordination, according to a new infographic from the Healthcare Intelligence Network.

This HINfographic presents 10 metrics documented by HIN's seventh PCMH survey in March 2014, including the rise in medical homes, involvement of remote care management and case management, biggest challenges, future outlooks and more.

Want to know more about patient-centered medical homes? 2014 Healthcare Benchmarks: The Patient-Centered Medical Home, a 40-page report now in its seventh year, is designed to meet business and planning needs of physician practices, clinics, health plans, managed care organizations, hospitals and others by providing critical benchmarks in medical home implementation and results.

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Clinical Health Coaching Transforms Care Conversation

May 27th, 2014 by Patricia Donovan

Evidence-based health coaching drives the population health management processes required to succeed in a value-based system—the industry's quantum shift to 'Healthcare 3.0,' advises William Applegate, executive director of the Iowa Chronic Care Consortium.

How do we change to this Healthcare 3.0? One way is to create real patients that are in patient-centered medical homes. NCQA level three medical home recognition is great, but there are still a number of those medical homes that need to add 'meat and potatoes' to what they have achieved.

Next, we need to build a true population health capacity. We need to develop differentiated health teams. You can’t really create a robust health coach as a professional in an organization and then not change the position description of others. The trained clinical health coach can actually improve the ability of a physician to operate at the highest level of their license. That’s part of how a health coach fits into a healthcare team. It’s not just an addition. It’s a kind of reformation of how we’re approaching healthcare with patients.

You need to use trained performance health coaches to make this shift. And you need to activate patients towards self-care. And as I say over and over, we really need to inspire their own accountability.

There are two big features in transforming care. One is transforming the conversation, and the other one is transforming the care process. In transforming the conversation, we need to employ a performance-oriented health coaching. That’s more than motivational interviewing.

We need to rely on the science of behavior change. An awful lot of healthcare professionals deep down don’t believe that we can move individual behaviors. I don’t think we can change people’s lives dramatically. But we certainly can change some of their health outcomes, because we know that our chronic diseases are essentially learned; they’re exacerbated by things that we do to ourselves.

Excerpted from: Evidence-Based Health Coaching: Patient-Centered Competencies for Population Health

Care Coordination Compacts: Establishing Accountability, Clarity between Physicians and Specialists

May 22nd, 2014 by Cheryl Miller


It's a scenario that occurs time and time again, and is a deep source of frustration for all involved: a physician refers a patient to a specialist, but hears nothing back from that specialist. In fact, they learn that the visit happened only when the patient returns for his primary care visit, but without any necessary information.

Or, a specialist receives a patient who has none of the pre-work or test results necessary for an effective visit, which ends up delaying care for the patient. Or, on the flip side, the specialist receives patients that had numerous unneeded and avoidable tests done prior to the referral.

The culprit? Lack of accountability and clarity, the foundations of the Care Compact, an agreement between two practices that outlines the roles and responsibilities of each in order to promote patient-centered care, says Robert Krebbs, director of payment innovation at WellPoint, Inc., during Care Compacts: Forming the Foundation of Care Teams with PCPs and Specialists, a May 2014 webinar now available for replay from the Healthcare Intelligence Network.

The Care Compacts (also known as Care Coordination Agreements and/or Referral Agreements) are key to WellPoint’s patient-centered medical home neighborhood (PCMH-N) pilot, Patient-Centered Specialty Care (PCSC). The program was launched in January 2014 with a select number of pilot practices, ranging in size from solo practices to large group practices in markets where there is a strong patient-centered medical home (PCMH) foothold, says Krebbs.

PCSC is a value-based reimbursement program developed for three types of specialties with clear care coordination alignment opportunities with PCMHs: cardiology, endocrinology, and OB/GYN. These specialists work with existing patient-centered medical home partners to improve quality and coordinate care guided by cost and efficiency measures, Krebbs continued, ensuring the following:

  • Effective two-way communication between primary and secondary providers;
  • Appropriate and timely referrals and consultations with prompt feedback of findings / recommendations;
  • Effective co-management of patients when necessary; and
  • Commitment to practice in a patient-centered fashion across all physicians delivering care to a patient.

The reason these care agreements work is because they provide a standard set of processes for roles in care coordination, truly defining what care coordination is between two practices. While many practices across the country agree they need care coordination, they don't always agree on what the concept of care coordination is, Krebbs continues.

At their simplest, they help to clearly outline who's going to do what in a referral or consult situation. By cutting out inappropriate duties and maintaining appropriate ones, they help to curb healthcare spend and improve patient care, Krebbs says.

“The care compact isn't intended to solve all the world's problems. It’s not going to make care coordination perfect, but it's a starting point. Just like the patient-centered medical home (PCMH) provides a foundation for the medical neighborhood, the care compacts provide a foundation for care coordination between practices. It's an essential starting point to further care coordination expectations across that medical neighborhood," says Krebbs.

Listen to an interview with Robert Krebbs.

BCBS Michigan PGIP Value Partnership Translates to Quality Improvement, Cost Savings

May 6th, 2014 by Patricia Donovan

Donna Saxton: BCBSM's PGIP has resulted in primary care-specialist collaborations that improved care coordination and reduced unnecessary utilization and spend.

Blue Cross Blue Shield of Michigan's Physician Group Incentive Program (PGIP) is so studded with acronyms it's almost a separate language, jokes Donna Saxton, BCBSM's field team manager of BCBSM's value partnerships program.

And while not everyone speaks PGIP-tian, it's easy to translate the savings and benefits the medical home reward and incentives program portends for the insurer, its PCMH practices and its health plan members.

Ms. Saxton described PGIP's place in BCBSM's Value Partnerships program during Generating Medical Home Savings and Quality Improvements Through Outcome-Based Measures, including the structure of rewards and incentives that have produced results for the plan, which operates the largest network in Michigan.

"PGIP incentivizes providers to enhance the delivery of care by encouraging them to be responsible and proactive in their behaviors, and ultimately driving better health outcomes and also increasing the fee for value that we also desperately need to get to," said Ms. Saxton.

In return, BCBSM provides financing tools and support for the nearly 18,500 primary care physicians and specialists who participate—more than half of BCBSM's physician population.

Aimed at some root causes of high cost healthcare, including a weak primary care foundation, PGIP, which Ms. Saxton described as the organization's "pinnacle" initiative, expects physician organizations (POs) to take responsibility for developing systems of care, motivating its physicians from within and adopting a culture of process improvement. In return, BCBSM places resources and a PGIP field team representative at the POs' disposal.

Some PGIP activities eligible for incentives range from e-prescribing and patient registries to specialist referrals and medical homes' linkage to community services, Ms. Saxton explained. Further, BCBSM has amped up three key medical home initiatives for its organized systems of care (OSC), "putting them on steroids," as Ms. Saxton said, to raise the performance bar and offer more chances for POs to earn incentives.

BCBSM coined the term OSC, which, while conceptually aligned with the goals of an accountable care organization (ACO) is designed to give providers more latitude in detemining their priorities, she noted. "The OSC is where the neighborhood concept comes into play, where you focus on implementation of PCMH neighborhood capabilities in your specialty offices to further address fragmented care." BCBSM specialists are eligible for one-time incentives plus enhanced fees for collaboration with primary care practices.

A counterpart to PGIP incentives is the PGIP PCMH designation program, an opportunity for practices to earn BCBSM's internally developed medical home designation and the added incentives that go with that distinction, such as increased reimbursement for PCMH office visits. The designation comprises 140 capabiities across a dozen areas.

To date, the biggest challenge of PGIP appears to be its extended access initiative, but practices who adopt more open scheduling often have much lower rates of ED and radiology utilization, noted Ms. Saxton.

Connectivity is also an issue for some, especially practices in rural areas of the state or organizations that have not yet adopted EHRs, which will ultimately be required for participation.

Compared to non-BCBSM-designated PCMHs, the organization's medical homes have produced some significant results, including an 11.2 percent decrease in primary-care related ED visits and a 6.7 percent reduction in low-tech radiology usage.

Ms. Saxton shares more on physician incentives and rewards and some outstanding primary care collaborations that have resulted from the engagement of specialists in BCBSM’s medical home program in this audio interview.

9 Things to Know About Patient-Centered Medical Homes in 2014

April 29th, 2014 by Patricia Donovan

Having established a firm foundation by providing over two decades of patient-centered care, the medical home model is poised for a makeover, expanding into medical neighborhoods and opening the door to specialists’ enhanced role in care coordination—two new metrics documented in the seventh comprehensive Patient-Centered Medical Home (PCMH) survey by the Healthcare Intelligence Network (HIN).

Here are nine benchmarks gleaned from the 2014 PCMH survey:

  • The annual percentage of respondents implementing the medical home model continues to rise, with a high of 58 percent reporting PCMH adoption, up from 52 percent in 2012, when the survey was last conducted.
  • The percentage of respondents with at least a fifth of patients assigned to medical homes more than doubled in the last two years, from 27 to 50 percent.
  • Today’s medical home is especially welcoming to Medicaid beneficiaries, who were targeted by only 3 percent of medical homes in 2012 but now are included in 37 percent of respondents’ patient-centered approaches.
  • Prepared to take their medical homes to the next level of care in the year to come, almost half—48 percent—have joined or expect to join a medical home neighborhood, defined by TransforMED℠ as “a strong foundation of transformed primary care practices aligned with health systems and specialists to ensure that care is maximally coordinated and managed."
  • At the same time, 37 percent of 2014 respondents identified practice transformation, or the process of adopting the attributes of the patient-centered medical home model, as the most formidable challenge of medical home creation.
  • In new metrics from this year’s survey, nearly half of respondents (46 percent) include specialists in their patient-centered medical homes.
  • With an eye toward care coordination, the inclusion of case managers in medical homes jumped from 56 percent in 2012 to 76 percent in 2014.
  • Today’s medical homes are a little more crowded, with three-quarters of respondents reporting 21 or more physicians participating, up from 58 percent in 2012.
  • Undaunted by recent studies to the contrary, all 2014 respondents with medical homes believe the model can reduce cost and improve care delivery.

Excerpted from 2014 Healthcare Benchmarks: The Patient-Centered Medical Home.

How to Engage Specialists in the Patient-Centered Medical Home

April 1st, 2014 by Patricia Donovan

Primary care's relationship with specialists will influence quality and reimbursement.


Florida Blue's primary care focused pay-for-performance program transitioned in 2012 into a statewide patient-centered medical home (PCMH) initiative. Here, Barbara Haasis, RN, CCRN, senior clinical lead for quality reward and recognition programs at Florida Blue, describes the role of primary care in engaging specialists in the PCMH program.

Engagement of specialists happens through the primary care physician (PCP). The PCP will be judged on the total cost of care, and his percentage of the shared savings is based on working with specialists that are efficient, and that report back to him or her, so that they are aware of what is going on. That is the development between the PCP and the specialist. They have to go to a specialist in the network, but we are not specifying who.

There is a huge incentive for the PCP, because when we look at a member’s total cost of care, we are looking at inpatient/outpatient, specialty, primary, lab, x-ray, total cost of care—it is everything. If there are two specialists, and one orders every test under the sun, whether it is needed or not, and the other goes into the ER to see the member and takes care of them efficiently and effectively, that primary care doctor is going to change his referral pattern to go to the more efficient. That is the incentive.

We are setting up other arrangements with specialists that will marry up to the PCMH. For example, we may do some kind of preferred cardiology network in the Orlando area into which the PCPs will probably refer. We cannot do that here. We have contractual language with many of our facilities and physicians that prevent us from doing any steerage.

It is up to the physicians to work through relationships to find the most effective for their practice.

Excerpted from: New Models in the Patient-Centered Medical Home: Incentives, Infrastructure and IT to Support Accountable Care

8 Challenges to Medical Home Success

March 12th, 2014 by Jessica Fornarotto

"What's important about patient-centered medical homes (PCMHs) is that they're patient-centered. PCMHs are a partnership among practitioners, patients and their families that ensures and respects the decisions of the patients. And patients have the education and support they need," explains Terry McGeeney, MD, MBA, director of BDC Advisors. Dr. McGeeney lists below the eight challenges in successfully changing to a PCMH.

The first challenge to PCMH success is that many physicians are reluctant to change. Physicians have been trained to be change-averse and variable-averse to avoid making mistakes at two o’clock in the morning, etc. Second, physician leadership and physician champions are critical. Sometimes this has to be trained and taught.

Next, there's a culture that is very traditional in healthcare; we need to think and talk about that. There is also a culture within individual practices and health systems that creates barriers to successful transformation. Another challenge is that some providers are not able to function effectively in a team environment. This needs to be supported and transformed with the appropriate training provided.

The next challenge is communication, which is critical at multiple levels. Successful medical neighborhoods and clinically integrated neighborhoods (CINs) are built around communication, care plans, care that's delivered, data, quality metrics, lab data, etc. The sixth challenge is that there has to be trust between all of the entities as systems are transforming and payor data becomes more critical. Partnerships with payors around shared savings or shared risk are becoming more common. Trust is critical and that hasn’t always existed.

Next, we need to make sure there are aligned incentives; you can't ask people to do more work for the same compensation. You can't ask them to assume more risk for the same compensation. Incentives need to be aligned around what is now called 'value-proposition' or 'pay-for-value,' or to where there is an expectation to improve quality and lower cost.

The final challenge is there needs to be full recognition that PCMH transformation is not easy. It's very difficult and time consuming, but in the end it's highly rewarding.

Excerpted from: Driving Value-Based Reimbursement with Integrated Care Models

Medical Neighborhood Bridges Gap Between Health Systems and Physicians

February 18th, 2014 by Patricia Donovan

The medical neighborhood is one approach to defragmenting care coordination in the United States.


The need for better coordination within the U.S. healthcare system cannot be refuted, notes Terry McGeeney, MD, MBA, director of BDC Advisors, who introduces the trend toward medical neighborhoods.

We need to start talking about the solution to bridge the gap between health systems and physicians. We can do that as we talk about the medical neighborhood concept and the integrated network concept. I have come to realize that the medical neighborhood in many environments is a physician term that’s been embraced widely by both specialty organizations and primary care organizations.

A clinically integrated network (CIN) is a hospital term. These CINs have been around since the late nineties, when they were established by the Federal Trade Commission (FTC) and Federal Communication Commission (FCC). And you will often hear hospitals talking about clinical integration. The difference is that until the last couple of years, clinical integration has often been within the four walls of the hospital, where now it’s being expanded to broader networks around population management.

What are these medical neighborhoods that we are talking about and where are they? When you want to look for a medical neighborhood, look no further than your CIN for the foundation of that network. The challenge you often see is that the CIN or clinically integrated entity was set up as a legal entity and is not necessarily a high functioning medical neighborhood. It may have been set up by a law firm, or an accounting organization. It meets all the legal requirements, but it may not meet the requirements needed for improving quality of care in lowering cost.

But that existing CIN does create a foundation from which you can work. What you want to work and think about is transitioning your clinically integrated entity to a high functioning medical neighborhood. And to me that’s the real opportunity, but also a significant challenge.

Excerpted from: Driving Value-Based Reimbursement with Integrated Care Models