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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;
and much more.
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
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