Dr. Nwando Olayiwola, Associate Director, Center for Excellence in Primary Care, Assistant Professor, University of California, San Francisco addresses the 2014 Weitzman Symposium on The Patient-Centered Medical Home Impact on Cost and Quality: An Annual Review of Evidence
This presentation explains the concept of the patient-centered medical home (PCMH), its function and its intended effects. A brief overview of the history of PCMH is also provided, as well as a discussion of its operational characteristics, its principles and outcomes, and what is expected in the future for the PCMH model.
Dr. Edward Wagner, Director (Emeritus) MacColl Center, Senior Investigator, Group Health Research Institute addresses the 2014 Weitzman Symposium on The Future of Primary Care
Can we solve the adult primary care shortage without more physicians? CHC Connecticut
Tom Bodenheimer,of the Center for Excellence in Primary Care at UCSF Dep’t of Family and Community Medicine talks about addressing the primary care shortage at the 2014 Weitzman Symposium
Edwina Rogers, executive director of Patient-Centered Primary Care Collaborative, began her presentation by highlighting the movement to advance medical homes.
With the U.S. being the number one in the world for the cost of healthcare and ranked number 37 in the quality category, something needs to change. Rogers discussed the broad stakeholder support and participation for the movement, as well as the incredible volunteer involvement. The four ‘centers’ include: the Center to Promote Public-Payer Implementation, the Center for Multi-Stakeholder Demonstration, the Center for eHealth Information Adoption and Exchange and the Center for Health Benefit Redesign and Implementation. Medical Homes will provide superb access to care, patient engagament in care, clinical information systems, care coordination, team care, patient feedback and publically available information.
Edwards explained that the Obama administration believes the medical homes concept is the best way to approach healthcare reform. The U.S. House of Representatives has showed great support for the movement and is helping develop and allocate funds for a five-year pilot program. She expressed her enthusiasm for the movement and her prediction that the medical home model is certainly the future of health care.
A complete version of Rogers’ presentation on the Patient-Centered Primary Care Collaborative is available online.
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
This presentation explains the concept of the patient-centered medical home (PCMH), its function and its intended effects. A brief overview of the history of PCMH is also provided, as well as a discussion of its operational characteristics, its principles and outcomes, and what is expected in the future for the PCMH model.
Dr. Edward Wagner, Director (Emeritus) MacColl Center, Senior Investigator, Group Health Research Institute addresses the 2014 Weitzman Symposium on The Future of Primary Care
Can we solve the adult primary care shortage without more physicians? CHC Connecticut
Tom Bodenheimer,of the Center for Excellence in Primary Care at UCSF Dep’t of Family and Community Medicine talks about addressing the primary care shortage at the 2014 Weitzman Symposium
Edwina Rogers, executive director of Patient-Centered Primary Care Collaborative, began her presentation by highlighting the movement to advance medical homes.
With the U.S. being the number one in the world for the cost of healthcare and ranked number 37 in the quality category, something needs to change. Rogers discussed the broad stakeholder support and participation for the movement, as well as the incredible volunteer involvement. The four ‘centers’ include: the Center to Promote Public-Payer Implementation, the Center for Multi-Stakeholder Demonstration, the Center for eHealth Information Adoption and Exchange and the Center for Health Benefit Redesign and Implementation. Medical Homes will provide superb access to care, patient engagament in care, clinical information systems, care coordination, team care, patient feedback and publically available information.
Edwards explained that the Obama administration believes the medical homes concept is the best way to approach healthcare reform. The U.S. House of Representatives has showed great support for the movement and is helping develop and allocate funds for a five-year pilot program. She expressed her enthusiasm for the movement and her prediction that the medical home model is certainly the future of health care.
A complete version of Rogers’ presentation on the Patient-Centered Primary Care Collaborative is available online.
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
Partnering with Patients, Families and Communities for Health: A Global Imper...EngagingPatients
Engagement is an essential tool to improving global health. This report introduces a new framework for engagement to help countries assess current programs and think strategically about future engagement opportunities. It spotlights barriers to engagement and offers concrete examples of effective engagement from around the globe.
Closing the Loop: Strategies to Extend Care in the EDEngagingPatients
This HIMSS15 presentation discusses the challenges faced in hospital emergency departments and offers insights for implementing a process to follow up with discharged ED patients to enhance outcomes and satisfaction,while optimizing utilization and reducing risk.
National Conference on Health and Domestic Violence. Plenary talk Paul Grundy
explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967.
This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home.
The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.
This infographic speaks to the challenges Emergency Departments face in caring and following up with the growing population of patients they see, and demonstrates how some EDs are seeing measurable improvements in care, patient satisfaction and efficiency.
The Patient-Centered Medical Home in the Transformation From Healthcare to He...Paul Grundy
Surgeon General of the Navy VADM Matthew L. Nathan, MC USN
Fortunately, we have a way to address this crisis—the
Patient-Centered Medical Home (PCMH) model launched at Naval Hospital Pensacola and Walter Reed National Military Medical Center, Bethesda, Maryland (formerly the National Naval Medical Center) in 2008. It is now being implemented throughout the Military Health System (MHS) and carries great promise. It provides the clinical framework we need to meet our strategic objectives in terms of quality of care, impact on costs, population health, and readiness. One of the most significant benefits of the team-based, collaborative approach is that it allows us to embed within a primary care environment the psychologists, nutritionists, tobacco cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the “mental armor,” our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations. As we move ahead with this more comprehensive approach to health, we can begin to better address so many of our patients for whom we can find no specific reason for pain and discomfort. The PCMH model also provides a positive impact on our costs. Early data reporting from the PCMH clinics at Bethesda show reduced visits to the emergency room, lowered pharmacy costs, and significant per beneficiary per year savings and improved Healthcare Effectiveness Data and Information Set metrics, access, and patient satisfaction and trust. These positive impacts on the bottom line can be applied directly to improved costs or toward the reallocation of resources from reimbursing those who are sick to the population health-based programs that can make and keep our patients healthy.More significant, however, the PCMH environment allows us to go beyond mere collaboration and to a much more proactive approach to managing our patient populations. It is within the context of the medical home that we can begin to surround our patients with the tools and resources they need to move them from health care to health.
Clinical practice guidelines and quality metrics often emphasize effectiveness over patient-centered care. In this article, the authors offer three approaches to personalizing quality measurement to ensure patient preferences and values guide all clinical decisions.
In this presentation from the Beryl Institute's 2016 Patient Experience Conference, Edwards-Elmhurst Healthcare’s ED Chair and Patient Experience Director detail how they are leveraging technology to follow up with ED Patients and the exceptional results they’ve enjoyed.
Creating a standard of care for patient and family engagementChristine Winters
Nationally-recognized governance expert Beth Daley Ullem addresses the state of patient engagement in heathcare and provides a vision for establishing a minimum standard of care for patient engagement programs.
Patients and their loved ones often hold critical knowledge that informs diagnosis. This toolkit from the Institute of Medicine offers patients, families and clinicians guidance on how they can collaborate to improve diagnosis.
Building Patient-Centeredness in the Real World: The Engaged Patient and the ...EngagingPatients
This paper examines the separate but intertwined ethical, economic and clinical concepts of patientcenteredness and how ACOs provide a structure for turning those concepts into a functioning reality.
The Patient Centered Primary Care Collaborative has been working for years to build evidence and knowledge about how to improve healthcare by providing a medical "home" for each of us - a place where all our records reside, where the staff know us, etc. This April 2010 by Executive Director Edwina Rogers shows the phenomenal range of results they've produced.
Partnering with Patients, Families and Communities for Health: A Global Imper...EngagingPatients
Engagement is an essential tool to improving global health. This report introduces a new framework for engagement to help countries assess current programs and think strategically about future engagement opportunities. It spotlights barriers to engagement and offers concrete examples of effective engagement from around the globe.
Closing the Loop: Strategies to Extend Care in the EDEngagingPatients
This HIMSS15 presentation discusses the challenges faced in hospital emergency departments and offers insights for implementing a process to follow up with discharged ED patients to enhance outcomes and satisfaction,while optimizing utilization and reducing risk.
National Conference on Health and Domestic Violence. Plenary talk Paul Grundy
explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967.
This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home.
The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.
This infographic speaks to the challenges Emergency Departments face in caring and following up with the growing population of patients they see, and demonstrates how some EDs are seeing measurable improvements in care, patient satisfaction and efficiency.
The Patient-Centered Medical Home in the Transformation From Healthcare to He...Paul Grundy
Surgeon General of the Navy VADM Matthew L. Nathan, MC USN
Fortunately, we have a way to address this crisis—the
Patient-Centered Medical Home (PCMH) model launched at Naval Hospital Pensacola and Walter Reed National Military Medical Center, Bethesda, Maryland (formerly the National Naval Medical Center) in 2008. It is now being implemented throughout the Military Health System (MHS) and carries great promise. It provides the clinical framework we need to meet our strategic objectives in terms of quality of care, impact on costs, population health, and readiness. One of the most significant benefits of the team-based, collaborative approach is that it allows us to embed within a primary care environment the psychologists, nutritionists, tobacco cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the “mental armor,” our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations. As we move ahead with this more comprehensive approach to health, we can begin to better address so many of our patients for whom we can find no specific reason for pain and discomfort. The PCMH model also provides a positive impact on our costs. Early data reporting from the PCMH clinics at Bethesda show reduced visits to the emergency room, lowered pharmacy costs, and significant per beneficiary per year savings and improved Healthcare Effectiveness Data and Information Set metrics, access, and patient satisfaction and trust. These positive impacts on the bottom line can be applied directly to improved costs or toward the reallocation of resources from reimbursing those who are sick to the population health-based programs that can make and keep our patients healthy.More significant, however, the PCMH environment allows us to go beyond mere collaboration and to a much more proactive approach to managing our patient populations. It is within the context of the medical home that we can begin to surround our patients with the tools and resources they need to move them from health care to health.
Clinical practice guidelines and quality metrics often emphasize effectiveness over patient-centered care. In this article, the authors offer three approaches to personalizing quality measurement to ensure patient preferences and values guide all clinical decisions.
In this presentation from the Beryl Institute's 2016 Patient Experience Conference, Edwards-Elmhurst Healthcare’s ED Chair and Patient Experience Director detail how they are leveraging technology to follow up with ED Patients and the exceptional results they’ve enjoyed.
Creating a standard of care for patient and family engagementChristine Winters
Nationally-recognized governance expert Beth Daley Ullem addresses the state of patient engagement in heathcare and provides a vision for establishing a minimum standard of care for patient engagement programs.
Patients and their loved ones often hold critical knowledge that informs diagnosis. This toolkit from the Institute of Medicine offers patients, families and clinicians guidance on how they can collaborate to improve diagnosis.
Building Patient-Centeredness in the Real World: The Engaged Patient and the ...EngagingPatients
This paper examines the separate but intertwined ethical, economic and clinical concepts of patientcenteredness and how ACOs provide a structure for turning those concepts into a functioning reality.
The Patient Centered Primary Care Collaborative has been working for years to build evidence and knowledge about how to improve healthcare by providing a medical "home" for each of us - a place where all our records reside, where the staff know us, etc. This April 2010 by Executive Director Edwina Rogers shows the phenomenal range of results they've produced.
Patient Centered Medical home talk at WVUPaul Grundy
To employers the cost of healthcare is now a business issue and this talk is about what one large buyer IBM did to drive transformation via broad coalition with other large employers to form the Patient Centered Medical Home movement and the covenant between buyer and provider away from the garbage we now buy episodic uncoordinated disintegrated care. In the change of convenient conversation we have worked with the Primary care providers to give us coordinated, integrated, accessible and compressive care with a set of principles know as the Patient centered medical home.
A Patient Centered Medical Home (PCMH) happens when primary care healers keeping that core healing relationship with their patients step up to become specialists in Family and Community Medicine. The move is to the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system. PCMH happens when the specialists in Family and Community Medicine wake up every morning and ask the question how will my team improve the health of my community today?
All over the world three huge factors are in play that is driving the concept of Patient Centered Medical Home. They are:
1) Cost and demography
2) Information technology and data (information that is actionable will equal a demand for accountability by the payer or buyer of the care)
3) Consumer demand to engage healthcare differently (at least as well as they can their bank- on line) have a question about lab results why not e-mail?
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
Michigan Hospital Association Governance meetingMary Beth Bolton
Patient centered medical home activities in MI and Nationally and the opportunity to improve quality outcomes by increased access to primary care doctors who outreach members who are missing preventive and chronic care services.
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IBM Health and Social Programs Summit, October 2014
Craig Rhinehart’s Blog
Insights from NASHP Conference in Atlanta
Trick or Treating for State Healthcare Innovation Treats
http://craigrhinehart.com
Key Principles and Approaches to Populaiton Health mManagement - HAS Session 21Health Catalyst
Population Health Management is in its early stages of maturity, suffering from inconsistent definitions and understanding, and is overhyped by vendors and ill-defined by the industry. And yet, many systems are moving forward in innovative pioneering ways to address this growing trend. In this session, you will hear from two very different, successful health systems: a physician-led group and a large integrated delivery system. They will share their best practices, learnings, and different approaches to population health management.
Patient-Centered Medical Home: The Process and InitiativeGreenway Health
Learn more about the process and initiative of the Patient-Centered Medical Home model. This slideshow highlights the legislation, programs involved, and how to receive the PCMH certification and incentive funds.
Pharmacy's Emerging Role in Accountable Care Organizations (ACO)Parata Systems
Your pharmacy is an excellent partner for accountable care organizations. ACOs are formed by doctors, hospitals and other healthcare providers to improve health outcomes and lower overall medical expenses for a targeted patient population. Reimbursements are tied to patient outcomes.
ACOs’ highest-risk and highest-cost patients are those managing chronic illnesses and taking multiple medications a day. When your pharmacy can improve and track adherence – a key driver of readmission prevention and overall health – you are a valuable partner to help ACOs prevent unnecessary medical care.
Jamie Hale serves as the Chief Pharmacy Officer for Cornerstone Health Care where he is responsible for the development and integration of pharmaceutical care services in the Accountable Care Organization. He transitioned to Cornerstone in December 2012 after a 15 year career at Wake Forest Baptist Health, where he last served as Director of Pharmacy.
Download the full audio webinar at http://bit.ly/pharmacyACO.
Presentation: Leading the Change In Healthcare Education and Delivery: how to surmount the barriers.
Presented by: Dalal Haldeman, Senior Vice President, Marketing and Communications, John Hopkins Medicine
What does the triple aim really mean and how do we get there? How can strong brands in healthcare influence outcomes, research and patient wellbeing for a healthier future in America and in the world.
Marketing proposal to Hartford HealthcareArchit Patel
The presentation is a brief description to the proposed marketing strategy for the Hartford healthcare specifically targeting on the New Health Enhancement Program proposed for Connecticut state employees.
The COVID-19 pandemic has created several challenges for our country’s health care infrastructure, and the community health center workforce is no exception. Join us as we describe strategies to get patients back into dental care. Along with these strategies, participants will learn how to recognize challenges in dental practices, as well as how to engage the interdisciplinary care team through role redesign and integration to increase access to comprehensive care.
NTTAP Webinar Series - June 7, 2023: Integrating HIV Care into Training and E...CHC Connecticut
In order for health centers to provide compassionate and respectful HIV prevention, care, and treatment in comprehensive primary care settings, the clinical workforce must be knowledgeable, confident, and competent in their ability to do so.
We’ll explore the need to integrate HIV care into training and education for the clinical care team, as well as educational models to train the next generation. Using Community Health Center Inc.’s Center for Key Populations Fellowship for Nurse Practitioners (NPs) as a framework for best practices, experts will discuss how to implement specialty care for key populations in your training programs. Additionally, participants will gain awareness of the importance of training the clinical workforce on key population competencies in HIV programs (e.g. HCV, MOUD, LGBTQI+ health, homelessness, and harm reduction).
Utilizing the Readiness to Train Assessment Tool (RTAT™) To Assess Your Capac...CHC Connecticut
Improve educational training experiences at your health center by assessing your capacity and infrastructure to host health professions students.
Join the upcoming hands-on interactive activity session to learn how to utilize the Readiness to Train Assessment Tool (RTAT™). This tool was developed by HRSA-funded National Training and Technical Assistance Partners (NTTAP) at Community Health Center, Inc. (CHC) to understand organizational readiness to host health professions student training programs.
NTTAP Webinar Series - May 18, 2023: The Changing Landscape of Behavioral Hea...CHC Connecticut
The COVID-19 pandemic has resulted in significant shifts in the mode of care from face-to-face to virtual interactions. Join us as we discuss the challenges currently facing behavioral health care and at least one strategy for each. Along with these strategies, panelists will go over what integrated behavioral health care was and is before and following COVID-19, as well as what actions should be taken going forward to increase access to comprehensive care.
Panelists:
• Dr. Tim Kearney, PhD, Chief Behavioral Health Officer, Community Health Center, Inc.
• Melinda Gladden, LCSW, PMHC, Behavioral Health Clinician, Community Health Center, Inc.
• Jodi Anderson, LMFT, Virtual Telehealth Group Coordinator, Community Health Center, Inc.
NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Te...CHC Connecticut
Join us for a webinar on quality improvement in team-based care!
Building a quality improvement (QI) infrastructure within team-based care is an organizational strategy that will establish a culture of continuous improvement across departments and improve quality in all domains of performance.
Participants will learn about:
• QI infrastructure
• Facilitating QI committees
• Coach training within health centers
Faculty will also provide an example of how trained coaches use QI tools to test and implement changes within an organization.
Implementation of Timely and Effective Transitional Care Management ProcessesCHC Connecticut
Join us to discuss best practices for integrating daily follow-ups for patients recently hospitalized for health emergencies. Effectively following up with patients is a critical responsibility for integrated care teams.
Experts will share how their teams respond to patients to identify care gaps and support the transition of care. Workflow descriptions will provide participants with the tools to support their work to adapt specific steps into their model of team-based care.
Panelists:
• Mary Blankson, DNP, APRN, FNP-C, FAAN, Chief Nursing Officer, Community Health Center, Inc.
• Veena Channamsetty, MD, FAAFP, Chief Medical Officer, Community Health Center, Inc.
• Bibian Ladino-Davis, Behavioral Health Coordinator, Weitzman Institute
Implement Behavioral Health Training Programs to Address a Crucial National S...CHC Connecticut
Health centers are uniquely positioned to address the unprecedented need for behavioral health services but are challenged by the workforce shortage. Participants will gain the knowledge needed to begin conceptualization of a training pathway.
Join us to discuss the considerations of sponsoring an in-house training program across all educational levels, including the benefits, program structure, design, curriculum, supervisors' role, and required resources.
Experts will provide participants with examples from practicum and postdoctoral level training programs to help them gain confidence in developing a behavioral health training pathway.
HIV Prevention: Combating PrEP Implementation ChallengesCHC Connecticut
Expert faculty present case-based scenarios illustrating common challenges to integrating HIV PrEP in primary care. As part of improving clinical workforce development, this session will delve into a variety of specific PrEP implementation challenges. Participants will leave with strategies to overcome these obstacles to establish or strengthen their PrEP program.
Panelists:
• Marwan Haddad, MD, MPH, AAHIVS, Medical Director, Center for Key Populations, Community Health Center, Inc.,
• Jeannie McIntosh, APRN, FNP-C, AAHIVS, Family Nurse Practitioner, Center for Key Populations, Community Health Center, Inc.
NTTAP Webinar Series - December 7, 2022: Advancing Team-Based Care: Enhancing...CHC Connecticut
Join us as expert faculty outline the differences between case management, care coordination and complex care management to frame up a discussion on strategies to leverage effective models for both in-person and remote services.
Expert faculty will discuss the role of the medical assistant and the nurse in care management, as well as how standing orders and delegated orders support this work. This session will discuss how telehealth and remote patient monitoring enhancements can support complex care management for patients with chronic conditions.
Participants will leave this session with the knowledge and tools to begin or enhance implementation of chronic care management by enhancing the role of the medical assistant, nurse and the technology that supports the clinical care.
Panelists:
• Mary Blankson, DNP, APRN, FNP-C, Chief Nursing Officer, Community Health Center, Inc.
• Tierney Giannotti, MPA, Senior Program Manager, Population Health, Community Health Center Inc.
NTTAP Webinar: Postgraduate NP/PA Residency: Discussing your Key Program Staf...CHC Connecticut
Expert faculty will discuss the drivers, benefits, and processes of implementing a postgraduate residency training program at your health center. This session will dive deeper into a discussion on the responsibilities of key program staff, preceptors, mentors, and faculty for successful implementation. This webinar will equip participants with a road map to go from planning to implementation and offer an opportunity for coaching support.
Panelists:
• Program Director of the Nurse Practitioner Residency Program, Charise Corsino, MA
• Clinical Program Director of the Nurse Practitioner Residency Program, Nicole Seagriff, DNP, APRN, FNP-BC
Training the Next Generation within Primary CareCHC Connecticut
This webinar discussed the various avenues of workforce development including:
• training non-clinical roles
• the value of an administrative fellowship
• the key questions to ask before establishing a fellowship at your agency
The discussion referenced CHC Chief Operating Officer Meredith Johnson and CHC Project Manager Megan Coffinbargar’s publication “Establishing an Administrative Fellowship Program: A Practical Toolkit to Support and Develop Future Community Health Center Leaders” for the National Association of Community Health Centers (NACHC).
Panelists:
• April Joy Damian, PhD, MSc, CHPM, PMP, Vice President and Director of the Weitzman Institute, Community Health Center, Inc.
• Megan Coffinbargar, MHA, Project Manager, Optimizing Virtual Care Initiative, Community Health Center, Inc.
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This document is designed as an introductory to medical students,nursing students,midwives or other healthcare trainees to improve their understanding about how health system in Sri Lanka cares children health.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
COVID-19 PCR tests remain a critical component of safe and responsible travel in 2024. They ensure compliance with international travel regulations, help detect and control the spread of new variants, protect vulnerable populations, and provide peace of mind. As we continue to navigate the complexities of global travel during the pandemic, PCR testing stands as a key measure to keep everyone safe and healthy. Whether you are planning a business trip, a family vacation, or an international adventure, incorporating PCR testing into your travel plans is a prudent and necessary step. Visit us at https://www.globaltravelclinics.com/
KEY Points of Leicester travel clinic In London doc.docxNX Healthcare
In order to protect visitors' safety and wellbeing, Travel Clinic Leicester offers a wide range of travel-related health treatments, including individualized counseling and vaccines. Our team of medical experts specializes in getting people ready for international travel, with a particular emphasis on vaccines and health consultations to prevent travel-related illnesses. We provide a range of travel-related services, such as health concerns unique to a trip, prevention of malaria, and travel-related medical supplies. Our clinic is dedicated to providing top-notch care, keeping abreast of the most recent recommendations for vaccinations and travel health precautions. The goal of Travel Clinic Leicester is to keep you safe and well-rested no matter what kind of travel you choose—business, pleasure, or adventure.
Letter to MREC - application to conduct studyAzreen Aj
Application to conduct study on research title 'Awareness and knowledge of oral cancer and precancer among dental outpatient in Klinik Pergigian Merlimau, Melaka'
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Rate Controlled Drug Delivery Systems, Activation Modulated Drug Delivery Systems, Mechanically activated, pH activated, Enzyme activated, Osmotic activated Drug Delivery Systems, Feedback regulated Drug Delivery Systems systems are discussed here.
The global radiation oncology market size reached US$ 8.1 Billion in 2023. Looking forward, IMARC Group expects the market to reach US$ 14.5 Billion by 2032, exhibiting a growth rate (CAGR) of 6.5% during 2024-2032.
More Info:- https://www.imarcgroup.com/radiation-oncology-market
The Patient-Centered Medical Home Impact on Cost and Quality: An Annual Review of Evidence
1. CHCI Weitzman symposium May 2014
J. Nwando Olayiwola, MD, MPH, FAAFP
Associate Director, Center for Excellence in Primary Care
Assistant Professor, Department of Family & Community Medicine
University of California, San Francisco
The Patient-Centered Medical Home’s
Impact on Cost and Quality: A Review
of the Evidence from 2012-2013
2.
3. Authors
Marci Nielsen, PhD, MPH
Chief Executive Officer, PCPCC
J. Nwando Olayiwola, MD, MPH, FAAFP
Associate Director, Center for Excellence in Primary Care; Assistant Professor,
Department of Family and Community Medicine, University of California, San Francisco
Paul Grundy, MD, MPH
President, PCPCC; Global Director, Healthcare Transformation, IBM
Kevin Grumbach, MD
Professor and Chair, Department of Family and Community Medicine; University of
California, San Francisco
Lisa Dulsky Watkins, MD
Former Associate Director, Vermont Blueprint for Health
4. Reviewers
Melinda Abrams, MS
Vice President, Health Care Delivery System Reform; The Commonwealth Fund
Asaf Bitton, MD, MPH
Instructor, Division of General Medicine, Brigham and Women's Hospital; Instructor, Department
of Health Care Policy, Harvard Medical School
Mark Gibson
Director, Center for Evidence-Based Policy; Oregon Health & Science University
Bruce Landon, MD, MBA, MSc
Professor of Health Care Policy, Harvard Medical School; Professor of Medicine, Division of General
Medicine and Primary Care; Beth Israel Deaconess Medical Center
Len Nichols, PhD
Director, Center for Health Policy Research and Ethics; George Mason University
Kavita Patel, MD
Managing Director for Clinical Transformation and Delivery; Engelberg Center for Health Care
Reform; Fellow, Economic Studies The Brookings Institution
Mary Takach, MPH, RN
Senior Program Director; National Academy for State Health Policy
5. Take Home Points
PCMH evaluations over the past year reported
significant improvements across a broad range
of clinical and financial outcomes
The PCMH is playing an increasingly critical role
in delivery system reform, including ACOs and
the medical neighborhood
Significant payment reforms continue to
incorporate the PCMH
7. NCQA Recognized PCMH By State –
12/31/10
Source: Analysis by the National Committee for Quality Assurance, Dec. 2010.
8. NCQA-Recognized Practices Across the
United States
ME
VT
RI
NJ
MD
MA
DE
NY
WA
OR
AZ
NV
WI
NM
NE
MN
KS
FL
CO
IA
NC
MI
PA
OH
VAMO
HI
OK
GA
SC
TN
MT
KY
WV
AR
LA
AL
INIL
SD
ND
TX
ID
WY
UT
AK
CA
CT
NH
MS
61–200 sites
21–60 sites
0 sites
1–20 sites
201+ sites
Source: Analysis by the National Committee for Quality Assurance, Oct. 2012.
4,937 sites & 23,396 clinicians as of 10/31/2012
10. National Imperative: Triple Aim
Source : Berwick, Donald M., Thomas W. Nolan, and John Whittington. "The triple aim: care, health, and cost." Health Affairs
27.3 (2008): 759-769.
11. Methods
• Examined medical home/PCMH studies published
between August 2012 and December 2013
– Peer-reviewed scholarly articles
– Industry reports
• Explored relationship between “medical
home/PCMH” model of care and Triple Aim
outcomes
– Predictor variable: “Medical home” or “PCMH”
– Outcome variables: Cost & utilization; care experience
(access & patient satisfaction); health outcomes
(population health & preventive services)
• Resulted in 13 peer reviewed (academic) studies,
and 7 industry reports
12. 13 Peer-Reviewed (Academic) Studies
• Alaska Southcentral Foundation
• Colorado Multi-Payer PCMH Pilot
• BlueCross BlueShield Michigan
• Military Health System
• Veterans Health Administration
• New Hampshire Citizens Health Initiative
• Horizon BlueCross BlueShield
• EmblemHealth – New York
• WellPoint - New York
• UPMC Health Plan
• Rhode Island Chronic Care Sustainability Initiative
• University of Utah
• Group Health Cooperative
13. • BlueCross BlueShield Alabama
• Connecticut Health Enhancement Program
• Horizon Blue Cross Blue Shield
• BlueCross BlueShield Michigan
• CareFirst BlueCross BlueShield
• Oregon Coordinated Care Organizations
• Highmark PCMH Pilot
7 Industry generated Reports
14. Key Point #1:
PCMH evaluations report
improvements across a broad range
of clinical and financial outcomes
26. Policy Influences
Sustainable Growth Rate
(SGR)
• “Volume to Value”
• Federal legislation = long term
adoption
• Encourages more providers to
accept risk-based payments (5%
Medicare increase)
• Repeal calls for PCMH as
supportive framework
• Will lead to broader acceptance
of PCMH and ACOs
State Medicaid Activity and
Expansions
• “Volume to Value”
• State based = short term
adoption
• Oregon and Utah pioneers in
state Medicaid ACO
• Providers bear some risk while
meeting quality benchmarks
• State based reimbursements for
PCMH recognition important
driver
27. Payment Reforms
Source: S. Guterman, M. Zezza, C. Schoen, Paying for Value: Replacing Medicare's Sustainable Growth Rate Formula
with Incentives to Improve Care, The Commonwealth Fund, March 2013.
28. Private Sector Reforms
• Commercial health plans moving from traditional
fee-for-service models
• Transition from PCMH “demonstrations” to standard
business operations
– Incentives for primary care
– PCMH incentives
– Care coordination reimbursements
– PMPM add ons
29. Overview of Medicaid Medical Home Activity
42 State Medicaid/CHIP Programs Planning/Implementing PCMH
27 Making Medical Home Payments
Source: National Academy for State Health Policy State Scan, October 2012, http://www.nashp.org/med-home-map.
WA
OR
TX
CO
NC
LA
PA
NY
IA
VA
NE
OK
RI
AL
MD
MT
ID
KS
MN
MA
ME
AZ
VT
MOCA
WY
NM
IL
WI
MI
WV
SC
GA
FL
HI
UT
NV
ND
SD
AR
IN
OH
KY
TN
MS
AK
Significant activity for Medicaid/CHIP PCMH advancement (15 states)
No PCMH Medicaid activity (8 states)
States making payments for PCMH (27 states)
NJ
DE
NH
CT
30. Overview of Medicaid Medical Home Activity
47 State Medicaid/CHIP Programs Planning/Implementing PCMH
30 Making Medical Home Payments, 22 Involved in Multi-payer Pilots
WA
OR
TX
CO
NC
LA
PA
NY
IA
VA
NE
OK
RI
AL
MD
MT
ID
KS
MN NH
MA
ME
AZ
VT
MOCA
WY
NM
IL
WI
MI
WV
SC
GA
FL
HI
UT
NV
ND
SD
AR
IN
OH
KY
TN
MS
AK
Significant activity for Medicaid/CHIP PCMH advancement (26 states + DC)
Medicaid multi-payer activity/involvement (22 states)
States making payments for PCMH (30 states)
NJ
DE
Source: National Academy for State Health Policy State Scan, May 2014, http://www.nashp.org/med-home-map.
CT
DC
33. Veterans Health
Administration
Patient Aligned Care Team
• Optimize workflow and
coordinate care through the use
of an interprofessional “teamlet”
model
• Enact advanced scheduling, such
as same-day appointments
• Add phone consults and group
appointments
1. PCMH studies continue to demonstrate impressive improvements
range of categories including: cost, utilization, population health
access to care, and patient satisfaction, while a gap still exists in
on clinician satisfaction.
• Decreases in the cost of care,
PEER-REVIEW/ACADEMIA
61% 61% 31% 13% 31% 31%
57% 57% 57% 29% 29% 14%
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Improved
Access
INDUSTRY REPORTS
(n= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4)
(n= 4) (n= 4) (n= 4) (n= 2) (n= 2) (n= 1)
Total
Studies
(n= 7)
(n= 8)
Reported
outcomes
Reported
outcomes
udies continue to demonstrate impressive improvements across a broad
categories including: cost, utilization, population health, prevention,
o care, and patient satisfaction, while a gap still exists in reporting impact
an satisfaction.
EMIA
61% 61% 31% 13% 31% 31% 31%
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Improved
Access
Improvement in
Satisfaction
IncreaseinPreventive
Services
S
= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4) (n= 4)
23%
(n= 3)
otal
udies
(n= 8)
1. PCMH studies continue to demonstrate impressive improvements across a
range of categories including: cost, utilization, population health, prevent
access to care, and patient satisfaction, while a gap still exists in reportin
on clinician satisfaction.
PEER-REVIEW/ACADEMIA
61% 61% 31% 13% 31% 31% 31%
57% 57% 57% 29% 29% 14% 29%
Cost
Reductions FewerEDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Improved
Access
IncreaseinPrevent
Services
INDUSTRY REPORTS
(n= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4) (n= 4)
(n= 4) (n= 4) (n= 4) (n= 2) (n= 2) (n= 1) (n= 2)
Total
Studies
(n= 7)
(n= 8)
Reported
outcomes
Reported
outcomes
National program
5 million patients
ResultsPCMH Strategies
• 8% fewer urgent
care visits
• 4% fewer inpatient
admissions
• Decrease in face-to-face visits
• Increase in phone encounters,
personal health record use,
and electronic messaging to
providers
Source: Rosland, A.M., Nelson, K., Sun, H., Dolan, E.D., Maynard, C., Bryson, C.,
Stark, R., Schectman, D., (2013). The Patient-Centered Medical Home in the Veterans
Health Administration. American Journal of Managed Care. 1-4.
34. BlueCross BlueShield of
Michigan Physician Group
Incentive Program
Michigan
3 million patients
ResultsPCMH Strategies
• 13.5% fewer pediatric
ED visits
• 10% fewer adult ED
visits
• 17% fewer inpatient
admissions
• 6% fewer hospital
readmissions
1. PCMH studies continue to demonstrate impressive improvement
range of categories including: cost, utilization, population healt
access to care, and patient satisfaction, while a gap still exists i
on clinician satisfaction.
• Decreases in the cost of care,
PEER-REVIEW/ACADEMIA
61% 61% 31% 13% 31% 31%
57% 57% 57% 29% 29% 14%
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Improved
Access
INDUSTRY REPORTS
(n= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4)
(n= 4) (n= 4) (n= 4) (n= 2) (n= 2) (n= 1)
Total
Studies
(n= 7)
(n= 8)
Reported
outcomes
Reported
outcomes
1. PCMH studies continue to demonstrate impressive improvements across
range of categories including: cost, utilization, population health, preven
access to care, and patient satisfaction, while a gap still exists in reporti
on clinician satisfaction.
PEER-REVIEW/ACADEMIA
61% 61% 31% 13% 31% 31% 31%
57% 57% 57% 29% 29% 14% 29%
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Improved
Access
IncreaseinPrev
Services
INDUSTRY REPORTS
(n= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4) (n= 4)
(n= 4) (n= 4) (n= 4) (n= 2) (n= 2) (n= 1) (n= 2)
Total
Studies
(n= 7)
(n= 8)
Reported
outcomes
Reported
outcomes
1. PCMH studies continue to demonstrate impressive improvements across a broad
range of categories including: cost, utilization, population health, prevention,
access to care, and patient satisfaction, while a gap still exists in reporting impac
on clinician satisfaction.
PEER-REVIEW/ACADEMIA
61% 61% 31% 13% 31% 31% 31%
Cost
Reductions FewerEDVisits
FewerInpatient
Admissions
Fewer
Readmissions
Improvementin
PopulationHealth
Improved
Access
Improvement
Satisfaction
IncreaseinPreventive
Services
INDUSTRY REPORTS
(n= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4) (n= 4)
23%
(n= 3)
Total
Studies
(n= 8)
Reported
outcomes
1. PCMH studies continue to demonstrate impressive imp
range of categories including: cost, utilization, popula
access to care, and patient satisfaction, while a gap s
on clinician satisfaction.
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvem
Population
Total
Studies
• Savings of $26.37 PMPM
• $155 million in cost
savings
Source: Blue Cross Blue Shield of Michigan. Patient-Centered Medical Home
Fact Sheet. July 2013. Retrieved from http://www.valuepartnerships.com/wp-
content/uploads/2013/07/2013-PCMH-Fact-Sheet.pdf.
• Develop patient registries to track
and monitor patients’ care
• Offer 24-hour patient access to a
clinical decision-maker through
• extended office hours
• telephone access
• a linkage to urgent care
• Provide online patient resources that
allow for electronic communication
and greater patient access to medical
information
35. UPMC Health Plan Medical
Home Pilot
Pennsylvania
23,390 patients
ResultsPCMH Strategies
• 2.6% reduction in total costs
• 160% ROI
• 2.8% fewer inpatient
admission
• 6.6% increase in patients
with controlled HbA1c
1. PCMH studies continue to demonstrate impressive improvements across a broad
range of categories including: cost, utilization, population health, prevention,
access to care, and patient satisfaction, while a gap still exists in reporting impa
on clinician satisfaction.
• Decreases in the cost of care,
• Reductions in the use of unnecessary or avoidable services,
PEER-REVIEW/ACADEMIA
61% 61% 31% 13% 31% 31% 31%
57% 57% 57% 29% 29% 14% 29%
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Improved
Access
Improveme
Satisfact
IncreaseinPreventive
Services
INDUSTRY REPO RTS
(n= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4) (n= 4)
(n= 4) (n= 4) (n= 4) (n= 2) (n= 2) (n= 1) (n= 2)
23%
14%
(n= 3
(n= 1
Total
Studies
(n= 7)
(n= 8)
Reported
outcomes
Reported
outcomes
PAGE 6
1. PCMH studies continue to demonstrate impressive improveme
range of categories including: cost, utilization, population he
access to care, and patient satisfaction, while a gap still exist
on clinician satisfaction.
• Decreases in the cost of care,
• Reductions in the use of unnecessary or avoidable services,
PEER-REVIEW/ACADEMIA
61% 61% 31% 13% 31% 31
57% 57% 57% 29% 29% 14
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Imp
Ac
INDUSTRY REPO RTS
(n= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n
(n= 4) (n= 4) (n= 4) (n= 2) (n= 2) (n
Total
Studies
(n= 7)
(n= 8)
Reported
outcomes
Reported
outcomes
1. PCMH studies continue to demonstrate impressive improvements across a broad
range of categories including: cost, utilization, population health, prevention,
access to care, and patient satisfaction, while a gap still exists in reporting impact
on clinician satisfaction.
PEER-REVIEW/ACADEMIA
61% 61% 31% 13% 31% 31% 31%
57% 57% 57% 29% 29% 14% 29%
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Improved
Access
Improvement in
Satisfaction
IncreaseinPreventive
Services
INDUSTRY REPORTS
(n= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4) (n= 4)
(n= 4) (n= 4) (n= 4) (n= 2) (n= 2) (n= 1) (n= 2)
23%
14%
(n= 3)
(n= 1)
Total
Studies
(n= 7)
(n= 8)
Reported
outcomes
Reported
outcomes
CMH studies continue to demonstrate impressive improvements across a broad
ange of categories including: cost, utilization, population health, prevention,
ccess to care, and patient satisfaction, while a gap still exists in reporting impact
n clinician satisfaction.
EVIEW/ACADEMIA
61% 61% 31% 13% 31% 31% 31%
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Improved
Access
Improvement in
Satisfaction
IncreaseinPreventive
Services
TRY REPORTS
(n= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4) (n= 4)
23%
(n= 3)
Total
Studies
(n= 8)
ted
mes
1. PCMH studies continue to demonstrate impressive improvements across a broad
range of categories including: cost, utilization, population health, prevention,
access to care, and patient satisfaction, while a gap still exists in reporting impact
on clinician satisfaction.
PEER-REVIEW/ACADEMIA
61% 61% 31% 13% 31% 31% 31%
57% 57% 57% 29% 29% 14% 29%
Cost
Reductions Fewer EDVisits
FewerInpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Improved
Access
Improvement in
Satisfaction
IncreaseinPreventive
Services
INDUSTRY REPORTS
(n= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4) (n= 4)
(n= 4) (n= 4) (n= 4) (n= 2) (n= 2) (n= 1) (n= 2)
23%
14%
(n= 3)
(n= 1)
Total
Studies
(n= 7)
(n= 8)
Reported
outcomes
Reported
outcomes
• 18.3% fewer hospital
readmissions
• 23.2% increase in eye exams
• 9.7% increase in LDL
screenings
• Practice-based nurses provide care
management
• Create telehealth options for care
managers to connect to patients
when in-office visits are not
possible or necessary
• Offer incentives to payers to enter
into PCMH contracts
Source: Rosenberg, C.N., Peele, P., Keyser, D., McAnallen, S., & Holder, D.
(2012) Results from a patient-centered medical home pilot at UPMC Health
Plan hold lessons for broader adoption of the model. Health Affairs. 31(11).
36. CareFirst BlueCross
BlueShield Maryland
Maryland
1 million patients
ResultsPCMH Strategies
• $98 million in total cost
savings
• 4.7% lower costs for
physicians that received an
incentive award
1. PCMH studies continue to demonstrate impres
range of categories including: cost, utilization
access to care, and patient satisfaction, while
on clinician satisfaction.
PEER-REVIEW/ACADEMIA
61% 61% 31% 13%
57% 57% 57% 29%
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissi
INDUSTRY REPO RTS
(n= 13)
(n= 8) (n= 4) (n= 1
(n= 4) (n= 4) (n= 4) (n= 2
Total
Studies
(n= 7)
(n= 8)
Reported
outcomes
Reported
outcomes
ontinue to demonstrate impressive improvements across a broad
ories including: cost, utilization, population health, prevention,
and patient satisfaction, while a gap still exists in reporting impa
isfaction.
61% 61% 31% 13% 31% 31% 31%
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Improved
Access
Improveme
Satisfact
IncreaseinPreventive
Services
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4) (n= 4)
23%
(n= 3(n= 8)
• 3.7% higher quality scores
for panels that received
incentives
• Quality scores for PCMH
panels rose by 9.3% from
2011 to 2012
Source: CareFirst Blue Cross Blue Shield. Patient-centered medical home program trims expected health care
costs by $98 million in second year. Press Release, June 2013. Retrieved from
https://member.carefirst.com/wps/portal/!ut/p/c4/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hLbzN_Q09LYwN
• Use local care coordination
teams to track high-risk
members
• Create an infrastructure for
nursing support, easily-
accessible online tools and data,
and targeted health programs
• Offer increased reimbursements
to physicians based on
performance in the program
37. Oregon Health Authority
Coordinated Care
Organizations (CCOs)
Statewide Medicaid program
600,000 patients
ResultsPCMH Strategies
• 9% reduction in ED visits
• 14-29% fewer ED visits for
chronic disease patients
• 12% fewer hospital
readmissions
• 18% reduction in ED visit
spending
• Reduced per capital health
spending growth by >1%
1. PCMH studies continue to demonstrate impressive improvements
range of categories including: cost, utilization, population health
access to care, and patient satisfaction, while a gap still exists in
on clinician satisfaction.
• Decreases in the cost of care,
PEER-REVIEW/ACADEMIA
61% 61% 31% 13% 31% 31%
57% 57% 57% 29% 29% 14%
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Improved
Access
INDUSTRY REPORTS
(n= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4)
(n= 4) (n= 4) (n= 4) (n= 2) (n= 2) (n= 1)
Total
Studies
(n= 7)
(n= 8)
Reported
outcomes
Reported
outcomes
1. PCMH studies continue to demonstrate impressive improvements across a broad
range of categories including: cost, utilization, population health, prevention,
access to care, and patient satisfaction, while a gap still exists in reporting impact
on clinician satisfaction.
PEER-REVIEW/ACADEMIA
61% 61% 31% 13% 31% 31% 31%
57% 57% 57% 29% 29% 14% 29%
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvement in
PopulationHealth
Improved
Access
Improvement in
Satisfaction
IncreaseinPreventive
Services
INDUSTRY REPORTS
(n= 13)
(n= 8) (n= 4) (n= 1) (n= 4) (n= 4) (n= 4)
(n= 4) (n= 4) (n= 4) (n= 2) (n= 2) (n= 1) (n= 2)
23%
14%
(n= 3)
(n= 1)
Total
Studies
(n= 7)
(n= 8)
Reported
outcomes
Reported
outcomes
1. PCMH studies continue to demonstrate impressive impr
range of categories including: cost, utilization, populat
access to care, and patient satisfaction, while a gap st
on clinician satisfaction.
PEER-REVIEW/ACADEMIA
61% 61% 31% 13% 31%
Cost
Reductions Fewer EDVisits
Fewer Inpatient
Admissions
Fewer
Readmissions
Improvemen
PopulationHe
(n= 13)
Total
Studies
Reported
outcomes
Source: Oregon Health Authority. (2013). Oregon’s Health System
Transformation: Quarterly Progress Report. Retrieved from
http://www.oregon.gov/oha/Metrics/Documents/report-november-2013.pdf.
• Establish a primary care
infrastructure that includes 450
PCMH practices and clinics
• Increase the use of outpatient care to
promote prevention
• Increase well-care visits to
adolescents to reduce unnecessary
ED visits
• Provide follow-up care to patients
within 7 days of being discharged
38. The Challenge of Studying the PCMH:
The Right Metrics?
• Right metrics?
– Gap in clinician satisfaction measures – tied to
workforce needs
– Need for better/more patient satisfaction measures
of self-reported health status/well-being
– Measures need to account for patient diversity,
socioeconomics and social determinants of health
– Need for standard core measures – including
behavioral health and oral health integration
– Stronger case for connection to health equity
39. • Right methods?
– Study designs appropriate for investigating
complexity of health system reforms
– Recognition that the model/philosophy is evolving
– Evaluation often in the midst of multimodal
change processes
Source: Grumbach, Kevin. "The Patient-Centered Medical Home Is Not a Pill: Implications for Evaluating Primary Care
Reforms." JAMA internal medicine 173.20 (2013): 1913-1914.
The Challenge of Studying the PCMH: The Right
Methods?
40. Take Home Points
PCMH evaluations over the past year reported
significant improvements across a broad range
of clinical and financial outcomes
The PCMH is playing an increasingly critical role
in delivery system reform, including ACOs and
the medical neighborhood
Significant payment reforms continue to
incorporate the PCMH
41. Thank You!
Contact:
J. Nwando Olayiwola, MD, MPH, FAAFP
Associate Director, Center for Excellence in Primary Care
University of California, San Francisco
OlayiwolaJ@fcm.ucsf.edu
Twitter: @DrNwando
(415) 206-2970 (O)
Editor's Notes
Over 150 are Federally qualified health Centers
11.5 percent of all physicians