Bitton et al.: Patient Centered Medical Home Demonstration Projects
Appendix 2. Transformation, Part IName / State / Transformation based on: / Facilitator / New Practice Personnel / Learning Collaborative
United Health / AZ / Consultative model/needs assessment. / 7 practices share 1 external facilitator from TransforMED and 1 care advocate RN staffed by insurer. / No. / Yes.
Colorado Multi-Stakeholder / CO / Chronic care model and Model for Improvement. / One FTE coach from CCGC/IPIP for 16 sites. / Care Coordinator Role within each practice. / Yes.
Wellstar Health System (Humana) / GA / None. / No. / Patient navigator hired by practice. / No.
New Orleans PCASG / LA / None. / No. / No. / Optional.
Maine PCMH / ME / Learning collaborative and consultative (QI coaching) models. / PCMH Pilot staff and practice coaches funded by PHOs or demos. / No. / Yes- IHI style learning collaborative with 3 one-day learning sessions annually.
Carefirst BCBS / MD / Consultative. / TransforMED; 2 consultants for the 11 practices. / No. / Yes.
Priority Health Medical Home Program / MI / Consultative. / TransforMED for 5 of 16 practices. / Both; some used funds to hire staff, others did not. / Yes, two learning collaboratives.
BCBS of Michigan / MI / Consultative (Lean, 6 sigma approach), IHI improvement model. / 6 facilitators support 19 clinics. / No. / Quarterly program meetings.
New Hampshire Multi-Stakeholder / NH / Consultative. / New Hampshire Citizens Health Initiative. / No. / Informal monthly meetings.
Cigna Dartmouth Hitchcock / NH / None. / No. / Patient data coordinators and embedded case managers for high-risk patients added to each / Quarterly steering committee and monthly operational work group calls to identify gaps in care processes,
Name / State / Transformation based on: / Facilitator / New Practice Personnel / Learning Collaborative
Cigna Dartmouth Hitchcock (continued) / practice. / improve chronic care management, and follow patient experience.
CDPHP / NY / Consultative. / TransforMED. 1 change manager for 2 practices. 1 practice using internal consulting resources. / No. / Yes, 2 learning collaboratives designed by TransforMED, resourced by insurer. Insurer additionally develops and supports another 2 PCMH learning collaboratives.
New YorkHudsonValley P4P/Medical Home Project / NY / Consultative. / TransforMED, Masspro. / No. / Yes.
Emblem Health Medical Home High Value Network Project / NY / Consultative. / Enhanced Care Initiatives. 1 facilitator for 5 practices. / Embedded case manager supported at 0.2 FTE per 200 Emblem patients. / Yes, in second year of project. Quarterly meetings and feedback.
BCBS North Carolina / NC / None. / Consultant available for completing PPC. QI consultants available through plan and IPIP, but not specifically part of the demo. / No. / No.
Community Care of North Carolina / NC / Chronic Care Model and PCMH. / Some networks have hired internal facilitator. / Yes-nurse care managers and quality improvement specialists are hired at the network level. / Yes, focus on rapid PDSA cycles.
MediQHome (BSBCS) / ND / None. / No. / No. / Yes. Quarterly quality collaboratives anticipated in the future.
Greater Cincinnati Aligning Forces / OH / Consultative. / Planned for TransforMED. / No. / Yes.
Name / State / Transformation based on: / Facilitator / New Practice Personnel / Learning Collaborative
Cincinnati Medical Home Pilot Initiative (Humana) / OH / None. / No. / No. / No.
SoonerCare Choice / OK / Collaborative. / No. / No. / Yes, pending funding from CMS.
CareOregon / OR / IHI Improvement Model and Breakthrough Series Collaborative Model. / Yes- internal facilitator. / Behavioral health clinicians embedded in practice. / Yes.
Geisinger / PA / Consultative. / Yes – internal facilitator. / Embedded case manager (1: 800
Medicare enrollees, 1: 2500 commercial). / Yes.
Southcentral,
Southwestern,
Northeastern PA / PA / Chronic care model. / 1 External facilitator per 15-20 practices. / Embedded care manager paid for by health plans. / Yes.
Southeastern PA / PA / Chronic care model. / 1 External facilitator per 15-20 practices. / Embedded care manager paid for by health plans. / Yes.
Rhode Island (CSI-RI) / RI / Chronic care model. / External, organized by RI QIO and State Health Dept. / Embedded nurse case manager paid for by health plans. / Yes.
BCBS Tennessee / TN / None. / No. / On-site LPN paid for by health plan. / Informal learning collaboratives.
Patient Centered Medical HomeVermont / VT / Chronic care model. / No. / Community care teams. / No. Regular meetings.
Appendix 2 Key (abbreviations used are presented in alphabetical order)
BCBS= Blue Cross Blue Shield / CCGC= Colorado Clinical Guidelines Collaborative / CDPHP= Capital District Physician’s Health Plan
CMS= Centers for Medicare and Medicaid Services / CSI-RI=Rhode IslandChronic Disease Sustainability Initiative / FTE= Full-Time Equivalent
IHI= Institute for Healthcare Improvement / IPIP= Improving Performance in Practice / LPN=Licensed Practical Nurse
PCASG= Primary Care Access Stabilization Grant / PCMH= Patient Centered Medical Home / PDSA= Plan-Do-Study-Act
P4P= Pay for Performance / PHO= Provider Health Organization / PPC= National Committee for Quality Assurance’s Physician Practice Connections Patient-Centered Medical Home tool
QI= Quality Improvement / QIO= Quality Improvement Organization / RN= Registered Nurse