The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination


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Understanding excess mortality in persons with mental illness: year follow up of a nationally representative US survey. Med Care.

The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination

Pattern of mortality in a sample of Maryland residents with severe mental illness. Psychiatry Res. Physical illness in patients with severe mental disorders. Prevalence, impact of medications and disparities in health care. World Psychiatry. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. Minding our own bodies: reviewing the literature regarding the perceptions of service users diagnosed with serious mental illness on barriers to accessing physical health care.

Int J Ment Health Nurs. Disparities in health care utilization and functional limitations among adults with serious psychological distress, — Psychiatr Serv. Mechanic D. More people than ever before are receiving behavioral health care in the United States, but gaps and challenges remain. Health Aff Millwood. Aging Ment Health. Exploring barriers to primary care for patients with severe mental illness: frontline patient and provider accounts. Issues Ment Health Nurs. Medical homes may help improve care for people with mental health issues [Internet].

Commonwealth Fund. Perspectives on providing and receiving preventive health care from primary care providers and their patients with mental illnesses. Am J Health Promot 15; Barriers to primary medical care among patients at a community mental health center. Schizophrenia and potentially preventable hospitalizations in the United States: a retrospective cross-sectional study. BMC Psychiatry [Internet]. Adoption of patient-centered care practices by physicians: results from a national survey. Arch Intern Med. A vision of patient-centered primary care. J Gen Intern Med.

Collaborative care for patients with depression and chronic illnesses. N Engl J Med. Impact of a national collaborative care initiative for patients with depression and diabetes or cardiovascular disease. VHA Patient-Centered Medical Home associated with lower rate of hospitalizations and specialty care among veterans with posttraumatic stress disorder. J Healthc Qual.

Practice redesign and the patient-centered medical home: history, promises, and challenges.

Medical Home [Internet]. American Academy of Family Physicians. Patient-Centered Primary Care Collaborative. Patient-centered medical home adoption: results from aligning forces for quality. Health Homes [Internet]. The patient-centered medical home: a systematic review. Ann Intern Med. Implementation of the patient-centered medical home in the veterans health administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use.

Patient-centered medical home intervention at an internal medicine resident safety-net clinic. Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees. Measuring the medical home infrastructure in large medical groups. Characteristics and disparities among primary care practices in the United States.

J Gen Intern Med [Internet]. Quality of medical care for persons with serious mental illness: a comprehensive review.

Patient Centered Medical Home - Mary Campbell

Schizophr Res Jul; 0 — Hong CS. Relationship between patient panel characteristics and primary care physician clinical performance rankings. Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Agency for Healthcare Research and Quality. Stagnitti M, Dowd K. Medical Expenditure Panel Survey. Characteristics of primary care physicians in patient-centered medical home practices: United States, Natl Health Stat Rep.

Int J Methods Psychiatr Res. Screening for serious mental illness in the general population. Arch Gen Psychiatry. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. The relationships of physician practice characteristics to quality of care and costs. Health Serv Res. Patient Centered Primary Care Collaborative. Racial, ethnic, and gender disparities in health care access and use among U.

Computerized clinical decision support for prescribing: provision does not guarantee uptake. J Am Med Inform Assoc. Performance measurement in the small office practice: challenges and potential solutions. Use of quality improvement strategies among small to medium-size US primary care practices.

Ann Fam Med. Kaiser Family Foundation [Internet]. Does the patient-centered medical home model change staffing and utilization in the community health centers? Mauer B. The collaborative care model: an approach for integrating physical and mental health care in Medicaid health homes [internet]. The patient-centered medical home: an evaluation of a single private payer demonstration in New Jersey. Effect of a multipayer patient-centered medical home on health care utilization and quality: the Rhode Island chronic care sustainability initiative pilot program.

The effects of pay-for-performance programs on health, health care use, and processes of care: a systematic review. Dickinson WP. Health Quality Partners , a Pennsylvania-based not-for-profit research and development organization, employs an advanced preventative care model targeting elderly complex patients. The webinar explored their efforts to refine and tailor their model to incorporate coordinated care, health education, and self-management of care, as well as challenges and successes in the spread and scale of the model.

Health Share of Oregon , a Portland-based coordinated care organization, discussed their work to improve care for high-need patients. The conversation highlighted unique aspects of their models of care for children with complex needs and for children in foster care, their work to link medical care with community services, and their efforts and successes in the spread and scale of their model.

Sponsored by the Peterson Center on Healthcare, the National Academy of Medicine held three public workshops and a special publication release event to engage stakeholders in a discussion of the issues, challenges, and approaches that present the greatest opportunity to creating models of care for high-need patients. Robust discussions throughout the workshop series informed the final Special Publication in which the planning committee explores how to better serve high-need individuals, improve their health outcomes, and reduce costs.

The National Academy of Medicine held a public meeting to formally launch the special publication, which summarizes the findings from the three-part workshop series. The meeting also provided an opportunity to discuss action priorities for improving the effectiveness and efficiency of care for high-need patients. Building Effective Care for High-Need Patients, the National Academy of Medicine hosted a webinar series to provide insight on the components of successful models of care for specific groups of high-need patients.

The series provided clear and actionable impetus for health system leaders, front-line clinicians, researchers, policymakers, and patient and family caregivers, among others, to actively work to improve care for high-need patients in their local communities. Health Quality Partners , a Pennsylvania-based not-for-profit research and development organization employs an advanced preventative care model targeting elderly complex patients. Building on the Special Publication focusing on Effective Care for High-Need Patients, the National Academy of Medicine hosted a webinar series to provide insight on the components of successful models of care for specific groups of high-need patients by featuring programs across the country that have seen success in their efforts to improve care.

This project was made possible with funding from the Peterson Center on Healthcare. The Peterson Center on Healthcare is part of a six-foundation partnership working together to accelerate health system transformation and to maximize their individual investments and avoid duplication in efforts to scale and spread promising care models for high-need patients. Chan School of Public Health. All rights reserved. Effective Care for High-Need Patients. Effective Care for High-Need Patients Opportunities for Improving Outcomes, Value, and Health To advance insights and perspectives on how to better manage the care of the high-need patient population, the National Academy of Medicine , with guidance from an expert planning committee, was tasked with convening three workshops held between July and October Key Takeaway Improving care for high—need patients is not only possible—it also contributes to a more sustainable health system.

Tweet This. Key Characteristics.

The Shaky Foundation of the Patient-Centered Medical Home

Key Characteristics of High-Need Patients To date, there is no consensus on the defining characteristics of high-need patients. Criteria that could form a basis for defining and identifying high-need patients include: Total accrued health care costs Intensity of care utilized for a given period of time Functional limitations, such as limitations in activities of daily living e. Patient Taxonomy and Implications for Care Delivery. Care Models that Deliver While success of even the best care models will depend largely on the particular needs and goals of patients, all successful care models should foster effectiveness across three domains: health and well-being, care utilization, and costs.

Examples of Care Models Many health systems are beginning to use validated care models to successfully provide care for high-need individuals. View all Read More. Opportunities for Action Improving the care management for high-need individuals will require bold policy action and system and payment reform efforts by a broad range of stakeholders at multiple levels. Health Systems can Work with payers to develop interoperable electronic health records that can include functional and behavioral status and social needs. Identify the threshold for targeting programs to those elderly who are frail, since not all elderly need the intensive, coordinated care these programs provide.

Engage patients and caregivers in design, implementation, and evaluation of care models. Work with payers to better identify and target high-need patients and to test new practices and tools. Partner with community organizations, including schools and even prisons, as well as with patients, caregivers, and social and behavioral health service providers outside of the health care system to create patient-centered care plans.

INTRODUCTION

Use established metrics and quality improvement approaches to create an environment of continuous assessment and improvement for these models. Assess established culture and promote changes needed to institute new and successful care models, blending medical, social, and behavioral approaches. Work with care coordinator or care coordination team to amplify self-advocacy efforts and fully utilize care models.

Participate in active communication with providers regarding quality of care, needs, and services. Request formal recognition as part of the care team. Seek out formal training and education experiences to enhance care, understand complex medical situations, limit injuries and other errors, and identify problems earlier. Explore with a care team the potential benefits of home-based care, including improved financial, social, and psychological outcomes.

Contribute to the development of quality measures to assist in better decision making around care and care delivery.


  • Evidence-level.
  • Fonduementals.
  • Description?
  • Patient Centered Medical Home.
  • Healthcare Transformation and Changing Roles for Nursing.

Actively support the adoption of care models or specific elements of models that research has shown to be effective at improving care for high-need patients. Lead efforts to identify and share information about high-need patients and the potential for different models to positively affect the care of those populations. Work with policy makers to continue progress toward a value-based system, using alternative payment models, including those that work within a fee-for-service structure, to support more effective care for high-need patients.

Support recognition, training, and education for patients and caregivers as part of care teams. Expect that return on investment for most models of care for high-need patients will take time and that a return in 2 to 3 years is unlikely. Develop financing models to provide social and behavioral health services that will both improve care and lower the total cost of care for high-need patients, recognizing that even cost-neutral programs are worth supporting if the outcome is positive for patients. Increase and expand efforts to engage patient and caregiver involvement in discussions around policy options for improving care and reducing costs for high-need patients.

Incentivize adoption and use of interoperable electronic health records that include functional, behavioral health, and social factors. Harmonize and coordinate Medicare and Medicaid programs to increase access to needed services and to reduce the burden on patients and caregivers.

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Continue payment policy reforms and alignment initiatives to incentivize pay-for-performance instead of fee-for-service. Create state- and community-level data-sharing tools which include integrated claims databases that link and share information across payers, service sectors, and provider networks, such as the Predictive Risk Intelligence System PRISM that Washington State developed to support care management for high-risk Medicaid patients.

Work collaboratively and understand that many successful care models work best when everyone works at the top of their licenses. Engage with patients, care partners, and their caregivers in the design and delivery of care. Diabetes Management. Disease Management. Emergency Medicine. Health Risk Assessments.

Health Risk Stratification. Healthcare Reform. Healthcare Trends. HIN Benchmark Reports. HIN Case Studies. Hospital Readmissions. Infection Control. Information Technology. Medical Neighborhood. Medical Practice. Medication Adherence. Nurse Management. Patient Engagement. Patient Experience. Patient Registry. Pay for Performance. Physician Practice Transformation.

The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination
The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination
The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination
The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination
The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination
The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination
The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination
The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination
The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination

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