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As more organizations road-test the patient-centered medical home (PCMH) model of care, the need for a PCMH quick-reference intensifies. Enter Medical Home Improvement Guide Vol. III: Even More FAQs on Patient-Centered Care.

Picking up where Volumes I and II leave off, the queries in Volume III reflect the PCMH's newly minted status as a preferred care delivery model — one frequently touted in the 2010 Patient Protection and Affordable Care Act.

The 35-page Medical Home Improvement Guide Vol. III: Even More FAQs on Patient-Centered Care provides insight on emerging reimbursement models such as the accountable care organization (ACO) and bundled or episodic payments. It also delves more deeply into the PCMH's care coordination responsibilities for its elderly patients with complex chronic illnesses — including the management of care transitions, medication reconciliation and reducing the possibility of readmission to the hospital.

Responses are provided by such medical home heavy hitters as Group Health Cooperative, Geisinger Health Plan, Baptist Health System, Aetna Medicare, and many others.

A sampling of questions answered by the Medical Home Improvement Guide Vol. III: Even More FAQs on Patient-Centered Care include:

• Funding Fundamentals:
  • What payment modeling either has been done or is in pilot supporting sustainable accountable care organization (ACO) infrastructure?
  • What is the best way to distribute bundled payments?
  • How should reimbursement from payors be structured in a medical home to take into account care management responsibilities?
• Physician Practice Essentials:
  • Which patient education tools provide the greatest ROI — disease self-management, wellness, appropriate ER use?
  • What are some best practices for medical home physicians or practices to help patients better manage their wellness and chronic disease?
  • What patient engagement strategies help to ensure that patients follow evidence-based guidelines?
  • How should a practice pick the three chronic conditions for NCQA tracking and medical home recognition?
• Care Transition Management:
  • What types of patient education programs does Geisinger use to help with the patient’s role in the transition of care?
  • What strategies is Aetna using to predict risk at transitions in care?
  • Of the various entities that can be responsible for hospital discharge planning, which one is the most likely to have the greatest impact and why?
• Case Management:
  • What are some guidelines for staffing a case management call center?
  • Should case managers conduct home visits with patients?
  • What is the educational background and experience level of the medical home case manager?
  • How can an organization build physician buy-in for an embedded case manager?
• Medication Adherence:
  • What is a best practice for medication reconciliation?
  • How can primary care providers (PCPs) help to improve medication adherence in patients?
• Reducing Readmissions:
  • How can retail pharmacies help to reduce avoidable hospital readmissions and how can they partner with health systems and hospitals to reduce readmissions?
  • How can a telephone case manager most effectively assist hospital discharge planners and social workers with reducing repeat hospitalizations?

• Richard Baron, M.D., F.A.C.P., president and founder of Greenhouse Internists;
• Connie Commander, president, Commander’s Premier Consulting Corporation;
• Michael Erikson, M.S.W., vice president of primary care services, Group Health Cooperative;
• Larry Greenblatt, medical director for the chronic care program at Durham Community Health Network;
• James Kerby, M.D., vice president of medical affairs, Grand Valley Health Plan;
• Diane Littlewood, RN, BSN, CDE, regional manager of case management for health services at Geisinger Health Plan;
• Barbara Luskin, quality manager, Grand Valley Health Plan;
• Doreen Salek, B.S., R.N., C.C.S./C.P.C., director, business operations of health services for Geisinger Health Plan;
• Craig Samitt, M.D., M.B.A., president and CEO of Dean Health System;
• Julie Schilz, co-chair of the Center for Multi-stakeholder Demonstrations and IPIP manager for Health TeamWorks (formerly the Colorado Clinical Guidelines Collaborative);
• Joann Sciandra, RN, BSN, CCM, regional manager of case management for health services at Geisinger Health Plan;
• Susan Shepard, director of patient safety education at the Doctors Management Company;
• Jessica Simo, program manager, Durham Community Health Network for the Duke Division of Community Health;
• Thom Stambaugh, chief pharmacy officer and vice president of clinical programs and specialty pharmacy, CIGNA® Pharmacy Management;
• Janet Tomcavage, R.N., M.S.N., vice president of health services for Geisinger Health Plan;
• Marcia Wade, M.D., F.C.C.P., M.M.M., senior medical director at Aetna Medicare;
• Barbara Wall, J.D., president of Hagen Wall Consulting;
• Barbara Walters, D.O., M.B.A., senior medical director at Dartmouth-Hitchcock Medical Center;
• Michael Zucker, F.A.C.H.E., chief development officer of Baptist Health System;