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Core Value Community Connections: Care Coordination in the Medical Home

This comprehensive report was prepared by the Patient-Centered Primary Care Collaborative (PCPCC). It begins by firmly placing the patient at the center of the patient-centered medical home. It contains expert articles, which offer insight into what is known and tested about care coordination, and are designed to offer a roadmap for new and emerging programs. Also included are case examples that represent a range of programs at various stages in the journey.

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Accountable Care Organizations and The Medicare Shared Savings Program

Population Health Management, Enabled by Information Technology, Will Be Critical To Success. In 2012, the Centers for Medicare and Medicaid Services (CMS) will launch a shared-savings program with accountable care organizations (ACOs). ACOs that meet specified quality goals will be able to split with CMS any savings that surpass a minimum level. The challenge facing ACOs is choosing the right information technologies so they can track the health status of and the care provided to every one of their patients to produce significant savings or meet the quality benchmarks of CMS.

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Automated Post-Discharge Care: An Essential Tool to Reduce Readmissions

Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients that are discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.

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Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System

The over arching goal of the meaningful use requirements of the 2009 American Recovery and Reinvestment Act (ARRA) is to facilitate the transition to real quality improvement and population health management. Most physician practices will need supplemental information technology that automates the basic tasks of identifying, contacting, and tracking patients who need preventive and chronic care services, coupled with reports that care teams can use for quality improvement and reporting.

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The Patient Centered Medical Home

The patient-centered medical home (PCMH), an approach designed to rebuild primary care and improve care coordination, has become a major focus of healthcare reform. Thousands of physicians are already participating in medical home pilot projects across the country. Now is the time for practices to investigate the information technology tools that will help them medical home certification requirements.

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The Promise of Population Health Management

New Technologies Are Required To Automate Expanded Physician Workflow. To create a sustainable healthcare system that provides affordable, high-quality healthcare to all, we will have to adopt a population health management (PHM) approach. While the transition to PHM will be difficult for providers and patients alike, the change could be facilitated and accelerated through the use of health information technology, self management tools, and automated reminders that are persistent in changing behaviors.

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Improving Compliance to Diabetes and Hypertension Protocols Using Coordinating, Proactive Outreach

A Study of the Effects of Physician-Led Communication on Patient Health. Prevea Health, a multispecialty group dedicated to Patient Centered Medical Home principles, utilized Phytel outreach services to target diabetes and hypertension patients, achieving a near 50% drop in patient non-compliance within a period of only six months. The outreach program was also extremely cost effective. By eliminating expensive, time-consuming manual phone calls and mailings, the outreach effort significantly reduced staff time and associated expenses.

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Improving Patient Compliance With Flu Vaccination Protocols Using Automated Messaging Methodologies

A Study of the Quality Improvement Benefits of Physician-Led Proactive Outreach. A large Midwestern integrated health system used an automated recall effort for its 2008-09 flu vaccination program to successfully lower outreach costs and raise patient responsiveness in high-risk populations. The organization achieved a 15% increase in patient turnout for flu vaccinations, and 86% response within 60 days for patients who received vaccinations.

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Influencing the Quality of Care Through Physician-Led Patient Motivation For Improved Health Outcomes

A study of patient compliance using proactive outreach. A large, nationally recognized multi-specialty group conducted a study to test the impact of a colon screening protocol on the organization’s gastroenterology patient population. In this study 77% of the patients identified for cancer screening were successfully contacted using Phytel services, which resulted in 655 appointments for necessary services.

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