Diabetes Management in the Medical Home: A Diabetes Collaborative Takes Team-Based Approach

Hudson River HealthCare (HRHC) takes a team approach to disease management in the 3,400 adult patients with diabetes it serves, explains Kathy Brieger, RD, CDE, HRHC’s chief operations officer. Ms. Brieger describes the multiple levels of care available to patients served by the HRHC Diabetes Collaborative, a four-point strategy for weight management that targets the most challenging aspect of managing diabetes, and HRHC’s upcoming trial of telepsychiatry at selected FQHCs.

Ms. Brieger presented during Diabetes Management in the Medical Home, a 45-minute webinar on January 26, 2012, providing the inside details on HRHC’s diabetes management program and the program’s impact on its diabetic patients. Brieger shared how to: identify and assess patients for diabetes management, including an analysis of literacy and learning and social barriers that could impact outcomes for complex patients; train staff and report quality data to drive further performance improvement; and much more.


Length: 4:58 minutes

Fifth Annual Medical Home Benchmarks: PCMH Stepping Stone to ACO

HIN’s fifth annual survey on the patient-centered medical home (PCMH) recorded the highest PCMH adoption levels to date, reports Melanie Matthews in this benchmarks podcast. A substantial number of medical homes expect to participate in an accountable care organization (ACO); Ms. Matthews also shares key metrics from the 2011 survey, including time required for medical home conversion and the PCMH effect on medication adherence and patient satisfaction.

The survey also identified an impressive jump in the embedding of case managers in medical homes. Dr. Bruce Nash, senior VP of medical affairs and CMO for CDPHP, where embedded case managers are at the heart of CDPHP’s clinical transformation, describes what sets his program apart from other medical home pilots.

Need more information on this topic? Download an executive summary of the survey results.


Length: 3:59 minutes

Rewarding Primary Care Practice Reform with Physician Payment Reform: A Medical Home’s Experience


Capital District Physicians’ Health Plan’s (CDPHP) medical home pilot began in 2008, with the dual goals of reforming both the practice of primary care in the CDPHP network and payments to these physicians. Dr. Bruce Nash, CDPHP’s senior vice president of medical affairs and chief medical officer, explains what sets the two-phase CDPHP program apart from other medical home pilots, how participants met the challenge of practice transformation, and why preliminary pilot results mirror what’s going on in the industry today.

Dr. Nash described how CDPHP met the challenge of developing a novel risk adjustment methodology that would drive a global payment combined with a significant bonus structure to attract physician participation and encourage future growth by medical students to enter primary care during Rewarding Primary Care Practice Reform with Physician Payment Reform: A Medical Home’s Experience, 45-minute webinar on February 23, 2011.




Length: 3:39 minutes

Coordinating a Virtual Medical Home in Your Community: Lessons from the Iowa Collaborative Provider Network


To create a virtual medical home — also called a virtual healthcare home — primary care providers partner with community organizations to deliver a full continuum of healthcare services in a manner that is transparent to patients and health plan members. Sarah Dixon-Gale, lead contract manager for the Iowa/Nebraska Primary Care Association, explains how Iowa’s virtual medical home program has improved access at Siouxland Community Health Center. Also in this podcast, Siouxland CEO Michelle Stephan describes a major challenge faced by the virtual medical home. Learn how this unique community partnership helps to position these organizations for federal Medicaid expansion in 2014.


Dixon-Gale and Stephan shared more lessons learned from the virtual medical home during Coordinating a Virtual Medical Home in Your Community: Lessons from the Iowa Collaborative Safety Net Provider Network, a 45-minute webinar on September 23, 2010.




Length: 3:47 minutes

Patient-Centered Medical Home Transformation: How Data Sharing Improves Physician and Business Performance

In another excerpt from a conversation with Metcare of Florida chief executives on its continuing medical home pilot with Humana, COO Dr. Jose Guethon describes the mechanics of sharing utilization and financial data with its physicians, and the impact of this practice and friendly competition between physicians has had on workflow, patient access, customer service and other key metrics.

Dr. Guethon and Metcare CEO Mike Earley described how Metcare practices have made the transformation to patient-centered medical homes, with an eye on maintaining the profitability of their practices, during Patient-Centered Medical Home Transformation: 9 Key Hurdles for Physician Practices To Overcome, a 45-minute webinar on May 12, 2010.




Length: 5:10 minutes

Recruiting Physician Practices for a Medical Home Pilot


As more payors test the patient-centered medical home model of care, what are the pros and cons of participation for physician practices? Dr. Marjie Harbrecht, medical and executive director of Health TeamWorks, describes the financial middle ground that is likely to satisfy payors and providers who sign on for medical home pilots and offers some additional selection criteria her organization (formerly the Colorado Clinical Guidelines Collaborative) may use in the future.

Dr. Harbrecht examined how practices are recruited, selected and supported in medical home programs during Physician Practices in the Medical Home: Recruiting, Evaluating, Supporting and Measuring the Patient-Centered Team, a 45-minute webinar on May 19, 2010.


Length: 4:28 minutes

Home Visits in the Patient-Centered Medical Home


Medicaid patients present their own unique set of needs during home visits, explain Dr. Larry Greenblatt, medical director, Chronic Care Program, Durham Community Health Network, Duke University Medical Center, and Jessica Simo, program manager, Durham Community Health Network for the Duke Division of Community Health. The duo explains the two types of patients that benefit most from home visits, the priorities of the home visit and the most common problems identified during home visits.


Dr. Greenblatt and Ms. Simo examined the features of a successful home visit initiative during Home Visits in the Patient-Centered Medical Home, a 45-minute webinar on May 20, 2010.


Length: 6:26 minutes

Patient-Centered Medical Home Transformation: 9 Key Hurdles for Physician Practices To Overcome


In the first of several conversations with Metcare of Florida chief executives on its continuing medical home pilot with Humana, CEO Mike Earley and President and COO Dr. Jose Guethon describe Metcare’s longstanding commitment to the management of care transitions for its Medicare patients, how its 10 medical home practices keep a handle on patient care in hospital settings, and the clinical and business returns that result from these efforts.


Earley and Dr. Guethon described how Metcare practices have made the transformation to patient-centered medical homes, with an eye on maintaining the profitability of their practices, during Patient-Centered Medical Home Transformation: 9 Key Hurdles for Physician Practices To Overcome, a 45-minute webinar on May 12, 2010.


Length: 5:08 minutes

Shared Savings in the Medical Home


The patient-centered medical home is at the heart of Mesa County, Colorado’s shared savings model, explains David West, M.D., a hospitalist, family physician and healthcare consultant from Grand Junction, Colorado. Dr. West describes how the shared savings model can be adapted across markets, including the conditions and factors that must be present for this approach to be feasible. He also shares a unique provider incentive that is keeping hospital stays of Medicare patients at less than one-third the national average, one of the factors that has the nation touting this area as a model for efficient healthcare delivery.

Dr. West examined how to structure a shared savings agreement during Shared Savings in the Medical Home, a 45-minute webinar on March 31, 2010.


Length: 5:20 minutes

Multi-Payor Medical Home Programs: Addressing Funding and Organizational Challenges


A year into the Colorado multi-payor medical home pilot whose practices provide care to 30,000 patients, Julie Schilz, B.S.N., M.B.A., prescribes a single tool that can help transform practices, improve quality and deliver evidence-based care. It’s NOT an EHR, says the manager of the Improving Performance in Practice and Patient-Centered Medical Home (PCMH) initiatives for the Colorado Clinical Guidelines Collaborative, who lists this tool’s four key functionalities. Also in this interview, Schilz describes the influence of other reimbursement models on the Colorado pilot and identifies two opportunities for NCQA to enhance its PCMH recognition process.

Schilz shared Colorado’s experience to date in creating this multi-payor initiative — from the development of the program to the challenges of working with multiple payors — during the January 20, 2010 webinar, Multi-Payor Medical Home Programs: Addressing Funding and Organizational Challenges.


Length: 6:29 minutes