Early results from two groundbreaking pilots validate the benefits of the patient-centered medical home model for patients with diabetes:
First, a unique data exchange between the largest insurer in New Jersey and an 850-physician organization resulted in the creation of a member-specific profile for each diabetes patient accessible at the point of care. Partners in Care (PIC) Medical Director Dr. James Barr said the one-year pilot that joined the disease management efforts of Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) with those of PIC physicians dramatically improved compliance levels and clinical outcomes for patients with diabetes — from 43 percent to 91 percent for the key HbA1c blood test. The program focused on New Jersey State Health Benefits Program members with diabetes. Dr. Barr said participating practices spent approximately 15 to 30 additional minutes per month with each patient in the pilot. This could be time spent with the provider or a staff member, he explained. The payor-provider collaboration has been so successful that Horizon BCBSNJ plans to extend the model to other chronic illnesses. The patient-centered medical home model makes the personal physicial responsible for all the patient’s healthcare needs for all stages of life — and arranging this care with other qualified professionals.
A second pilot for Medicaid patients in North Carolina saved the state $231 million in healthcare costs in 2005 and 2006. Roberta Burgess, nurse case manager for Community Care Plan of Eastern North Carolina through Heritage Hospital in Tarboro, N.C., said that provider toolkits and patient diabetes action plans developed for the program were key communication vehicles in the diabetes medical home project. She also said that case managers were effective liaisons between provider and patient, suppporting patients with information and sometimes even transportation. As a result, patients were better educated about care and self-management and better prepared for their doctors’ appointments. The program was one of seven winners in Harvard University’s 2007 Innovations in American Government Awards.