Stakeholder Changes for Involvement in Medical Homes [2012-13]

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Update on the Patient Centered Medical Home Movement


The medical home, also known as the patient-centered medical home (PCMH), is a team based health care delivery model led by a physician, PA, NP or ANP 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 of medical homes may 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).



With a medical home, 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-face patient encounter may help encourage coordination.



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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact:



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10 Responses

  1. Teen goes to YouTube to Tell Docs: “I am the patient and I need to be heard”

    Morgan Gleason was 11 years old when diagnosed with Juvenile Dermatomyositis – a systemic, autoimmune inflammatory muscle disorder affecting just 3 out of every 1 million children.

    Last week, Morgan, now 15, was admitted to the hospital after contracting meningitis from an infusion.

    Patient centered care, team care and medical homes – I think not yet!



  2. Is the medical home really worth it?

    Patient-centered primary care medical homes (PCMHs) are all the rage. A frequently-touted part of the Affordable Care Act (ACA), they have received literally hundreds of millions of dollars in federal incentive and demonstration-project funding.

    But, in this article Jan Gurley MD asks, are they really “a good idea?”



  3. Maybe – Maybe NOT

    More on the Medical Home conundrum.

    Ann Miller RN MHA


  4. Chronically Ill and Patient Centered Medical Homes

    According to results from a three-year study by Independence Blue Cross (IBC) demonstrating reduced costs and utilization for high-risk patients cared for by patient-centered medical homes from 2009 to 2011, the group of high-risk patients treated in primary care practices that made the commitment to transform into a patient-centered medical home (PCMH) had fewer hospital admissions than the matched control patients not treated in medical homes: 10.8 percent fewer in 2009, 8.6 percent fewer in 2010, and 16.6 percent fewer in 2011. In addition, in 2009 and 2010, there was a savings in total medical costs of 11.2 percent and 7.9 percent, respectively, for the PCMH high-risk group.

    The study involved approximately 700 IBC members – most with multiple chronic illnesses including congestive heart failure, chronic obstructive pulmonary disease, diabetes, and asthma – who experience a disproportionately high number of hospital stays and costly health care services. Nearly 40 percent of primary care practices in IBC’s network are NCQA-recognized medical homes. For the last four years, IBC has offered a direct financial incentive to practices that achieve recognition as a patient centered medical home.

    Source: Independence Blue Cross


  5. Jennifer Bresnick on the Challenges of the Patient-Centered Medical Home

    1. Ensuring that patients come to the PCMH first requires high levels of education, engagement, and satisfaction with the healthcare provider
    2. Creating a robust health IT infrastructure requires significant financial investment and strong buy-in from leadership and clinical staff
    3. Achieving accreditation takes dedication, time, and teamwork

    Source: Health IT Analytics


  6. Medical Homes

    Ask what technology is needed to transform primary care practices and patient centered medical homes – and often suggested is the Electronic Medical Record [EMR].

    However, technology skills and technological tools needed in the outpatient environment often exceed the EMR alone. Leveraging technology can improve care quality and facilitate delivery of proactive care. In order to deliver proactive care, skilled professionals need allocated time and they need data.

    Yet, having access to data does not necessarily equate with using data in an informed manner. In some cases, additional technological solutions are needed. In other cases, the people working in a practice need training and coaching to close the technological skill gaps in their organization.

    Any more thoughts?



  7. “Medical homes” may be raising Medicare’s costs

    Within five years after the PCMH fad appeared, CMS had begun three demonstrations to test the ability of PCMHs to lower Medicare costs while simultaneously improving quality.

    The first of these demos, the FQHC Advanced Primary Care Practice Demonstration , ended in October 2014. The other two, the Comprehensive Primary Care (CPC) Initiative and the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration, will end this year.

    Dr. David Marcinko MBA


  8. Are CMS’s “Medical Homes” Underfunded or Unfocused?

    OR … AN EPIC FAIL by 2016?



  9. 2017 – The Share Who Lacked a Regular Provider Dropped 2.7% in Expansion States

    The Commonwealth Fund recently released the report Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition.

    Here are some key findings on the impact of Medicaid expansion between 2013 and 2015:

    • The uninsured rate among low-income adults dropped 14.1% in expansion states.
    • Kentucky had the biggest decline in uninsured working-age adults.
    • Those who went without care because of cost dropped 5.5% in expansion states.
    • The share who lacked a regular provider dropped 2.7% in expansion states.
    • California climbed the most in the rankings from 2013-2015, from 26th to 14th.
    • The uninsured rate among low-income adults dropped 8.9% in nonexpansion states.

    Source: Commonwealth Fund, March 16, 2017


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