Commonwealth Coordinated Care

Commonwealth Coordinated Care is a new initiative to coordinate care for individuals who are currently served by both Medicare and Medicaid and meet certain eligibility requirements.  It is an important component of the Virginia Medicaid innovation agenda, and it is one example of the national movement toward more integrated systems of care for Medicare and Medicaid enrollees.  According to the DMAS website:

The program is designed to be Virginia’s single program to coordinate delivery of primary, preventive, acute, behavioral, and long-term services and supports.  In this way, the individual receives high quality, person centered care that is focused on their needs and preferences.

The goals of this initiative include: improved quality and health outcomes, streamlined Medicare and Medicaid requirements, increased accountability, reduced burden for enrollees and providers, providing care in each individual’s setting of choice, and reduced avoidable services. Supplementary benefits will include care coordination, interdisciplinary care teams, and person-centered care plans.

Click here to learn more about Commonwealth Coordinated Care at the DMAS website.


From PCMH to Community-Centered Health Home

Research shows that the PCMH model has potential to improve access to quality healthcare.  An important next-level question is whether the PCMH model has potential to support community health improvement.  The ‘Community-Centered Health Home’ model is an interesting concept for bridging the gap between clinical services and community health promotion and prevention.  We have posted a brief overview of the Community-Centered Health Home model under PCMH Insights.

Mobile Health Holds Promise for Improving Care of Homeless Patients


Shared by Peter Prizzio, The Daily Planet: Although this article cites the use of this app with the Homeless population, it could have the same merit with all of the underserved population.

People who are homeless have poor access to primary care and often experience high levels of unmet health needs. As a result, it’s not surprising that the homeless make up a disproportionate share of emergency department patients. But a new study suggests that mobile health has great potential to increase communication within that patient population, boost preventive care, and ultimately improve health outcomes and lower costs.

The Patient Centered Medical Home: Mental Models and Practice Culture driving the Transformation process

This recently published article from researchers at U-Penn spotlights the importance of culture change in PCMH development. From the abstract: “Key factors driving the PCMH transformation process require shifting mental models at the individual level and culture change at the practice level. Transformation is based upon structural and process changes that support orientation of practice mental models towards perceptions of population health, self-assessment, and the development of shared decision-making. Staff buy-in to the new roles and responsibilities driving PCMH transformation was described as central to making sustainable change at the practice level; however, key barriers related to clinician autonomy appeared to interfere with the formation of team-based care.”

A Pharmacist Visit Improves Diabetes Standard in a Patient Centered Medical Home

Shared by Cathy Wheeler, Fan Free Clinic:   Article from the American Journal of Medical Quality, A Pharmacist Visit Improves Diabetes Standard in a Patient Centered Medical Home

Click PCMH Impact Research in the top menu to browse more studies and evaluations.

Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication

1.coverA Very Important Study. In January’s issue of Health Affairs there is a very important study on the topic of primary care provider capacity. Researchers from Columbia Business School and Wharton have developed a simulation model showing how practice innovation could potentially eliminate primary care physician shortages both now and under full implementation of health care reform. The specific innovations include physician pooling, appropriate use of non-physicians, and electronic communication. Their simulation shows that if these innovations were widely adopted, we could potentially offset the increase in demand for physician services while actually improving access to care, thereby averting a primary care physician shortage. Among many important implications of this work is an affirmation of what free clinics are already doing to pool physicians and make appropriate use of nurse practitioners and other non-physician professionals. Here is a link to the abstract:

We will try to get permission to distribute a reprint of the full article.

Health Homes: What Healthcare’s “One Stop Shopping” Models Mean for Behavioral Health

Shared by Peter Prizzio, The Daily Planet:

Medicaid Health Homes: Care Coordination in the States

Charles Ingoglia, MSW, Senior Vice President for Public Policy and Practice Improvement, and Laira Roth, Policy Associate, National Council for Community Behavioral Healthcare

Individuals with multiple chronic conditions represent our healthcare system’s most costly and complex cases. Recent studies show that comorbid behavioral and medical conditions are the expectation — not the exception. In fact, 68% of people with a mental illness also have a physical health condition such as cardiovascular disease, diabetes, and hypertension. These high-need individuals often receive uncoordinated, inefficient care, resulting in higher costs and poorer health outcomes. If we want to improve the care of patients and the overall health of our nation, we must focus on improving care for this population.

Section 2703 of the Affordable Care Act allows us to focus on this population through the Medicaid “health home” option to help states manage and improve care for beneficiaries experiencing two or more chronic conditions, including behavioral health disorders. A health home must provide beneficiaries “one-stop shopping” by maintaining responsibility of providing the full range of services. States with approved Medicaid health home state plan amendments (SPAs) will now receive a 90% federal match for services not previously covered under Medicaid such as care coordination, comprehensive care management, and patient and family support. This approach has the potential to reduce emergency room usage, hospital admissions, and reliance on long-term care facilities, as well as to improve the experience and quality of care for those beneficiaries targeted under the state’s health home.

The Medicaid health home option presents a unique opportunity for behavioral health. With strong focus on Medicaid beneficiaries’ behavioral health needs and emphasis on care coordination, behavioral health organizations could play a vital role in establishing these new service delivery models. The Medicaid option is largely modeled on the patient-centered medical home (PCMH) — which builds on the chronic care model — and supports five key themes for quality care in a health home: (1) self-management support, (2) shares decision-making, (3) delivery system redesign, (4) embedded clinical guidelines, and (5) the use of client registries to organize data.

It is particularly important for behavioral health organizations to prioritize data collection when considering health home participation. As new service delivery models such as health homes and accountable care organizations become more prominent and funding streams become increasingly aligned with health outcomes, healthcare providers will need to demonstrate the ability to collect, organize, and use data to inform treatment. The collection and use of data will prove beneficial as providers strive to market themselves as potential partners in these new service delivery models. They will need to demonstrate the ability to improve health outcomes in a financially efficient manner.

Small Primary Care Practices Face Four Hurdles- Including A Physician-Centric Mind-Set In Becoming Medical Homes

Shared by Sally Graham,  Goochland Free Clinic and Family Services:

This article, “Small Primary Care Practices Face Four Hurdles—Including A Physician-Centric Mind-Set—In Becoming Medical Homes“reviews four characteristics of small primary care practices that inhibit their ability to adopt new models of care including the PCMH model. It then discusses internal factors that will enhance a practice’s ability to redesign their approach to care and expands the recommendations to include the health care neighborhood and its role, payment reform, and new mental health models.