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Case Studies from Diabetes Medical Home Pilots: Key Processes, Tools, Metrics and Outcomes


Description: 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.


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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