The Medical Home Case Manager:
Profiting from Patient-Centered Care Coordination

Dear Healthcare Executive,

In a survey of healthcare organizations on the patient-centered medical
home model, 60 percent of respondents include case managers on the medical
home care team, with more than half of these respondents reporting that
they have embedded these case managers in the primary care practice.

An early adopter of this trend is Geisinger Health Plan, whose placement of
case managers inside selected primary care practices is paying off in better
identification and management of high-risk individuals and improved quality
indicators in areas such as medication compliance and hospital readmissions.

The Medical Home Case Manager: Profiting from Patient-Centered Care
Coordination provides an inside look at the selection, training, skill set,
processes and benefits of the Geisinger Health Plan case managers
embedded within the payor's medical home practices.

Order your copy today at:
http://store.hin.com/product.asp?itemid=3998

Wording within the ProvenHealth Navigator(SM) —
Geisinger's home-grown medical home model —
case managers are carefully matched with
primary care practices, where they help the
practice to identify its highest-risk population
and develop customized care plans to guide those
individuals better self-management of their condition
and more judicious use of healthcare resources.

How does the physical presence of a case manager in
a physician practice affect practice design, processes,
efficiency, patient health status, healthcare utilization
and patient and provider satisfaction? In this 40-page
resource, Diane Littlewood, R.N., and Joann Sciandra, R.N., both regional
managers of case management for health services at Geisinger Health Plan,
drill down to the specifics of the embedded case manager program, including:

• Engaging and incenting physician practices to embed case managers to
  assist with care transitions and patient compliance;
• The case manager selection and training process;
• Identifying the patients that would benefit best from this type of
  case management;
• Skill sets, roles, tools and responsibilities of the embedded case manager;
• Case load management;
• Real-life examples of patient self-management patient action plans;
• Results from the Geisinger Health Plan's embedded case manager program,
  including its impact on patient compliance, care transition management,
  medication adherence, hospital readmissions and more; and
• Planned expansion of the embedded care manager to other types of care sites.