Primary care physician practices focus on improving patient outcomes

Janet Tomcavage of Geisinger Health Plan will present a model care coordination program at Taconic IPA's Spring Collaborative April 17

Patients need help to navigate the health care system and to better manage their own chronic health conditions. New health care delivery models that effectively provide those services have been shown to both lower overall costs and improve patient health. That hands-on guidance is found in new models of care like the patient centered medical home, and will be the topic for physician practices working to improve how health care is delivered at Taconic IPA's Spring Collaborative, set for April 17, from 9 a.m. to 3 p.m. at Poughkeepsie's Grand Hotel.

"Many primary care physician practices in the Hudson Valley are keenly focused on how to improve patient outcomes using care coordination and case management models," said A. John Blair III, MD, president of Taconic IPA. "Helping patients better manage their own chronic health conditions, and taking a team approach to smooth transitions and work with specialists and hospitals as an extended team, are essential elements of the patient centered medical home practice."

The April 17 event is hosted by TransforMED with the assistance of Masspro. Both companies work with primary care physician practices to adopt more efficient, effective care delivery models, and both have worked with practices in the Hudson Valley Medical Home Project. As a result of that work, 11 medical practices at 51 sites received Level 3 medical home recognition from the National Committee for Quality Assurance (NCQA).

"Primary care practices serve as the focal point of patient care coordination across health care delivery, working within their own walls and outside as they coordinate patient care with hospitals and specialists," said Terry McGeeney, M.D., MBA, president and CEO of TransforMED. "As the leaders of care teams within their own practices, physicians are in a critical position to decide how care coordination is leveraged to improve health outcomes and lower health care costs."

The Spring Collaborative will feature a presentation by Janet Tomcavage, RN, MSN, vice president of health services for Geisinger Health Plan in Danville, Penn. Tomcavage is responsible for development and implementation of innovative medical management strategies for Geisinger, including medical home, disease management and case management approaches.

The use of "embedded case managers" in primary care practices is at the heart of the patient centered medical home model that Geisinger Health Plan launched in 2006.

Geisinger engages 61 nurse case managers who work as part of the health care team at 37 physician offices. These case managers identify patients with multiple chronic health conditions, see patients, work with physicians to develop and manage each patient's care plan, and coordinate care the patient receives from specialists or in the hospital. The program has yielded a 15 to 20 percent decrease in hospital readmissions at every measurement phase of the program.

"We believe that an important factor of the success of Geisinger's medical home model is found in the value the case manager brings to the highest risk patient population," Tomcavage said. "The embedded case manager is a part of the primary care team and can walk down the hallway and talk to each member of the health care team. There is a bond that develops between the case manager, the patient and the primary care physician that becomes the foundation supporting the patient centered medical home model."

The Spring Collaborative will also include a review of the role of care coordination in other medical home projects, and an update of Taconic IPA's Medical Home project. Afternoon breakout sessions will delve into the nuts and bolts of care coordination in the physician practice, and how using care coordination can effectively improve efficiency.



The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of News Medical.
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