May 2013 Newsletter

Pennsylvania Aims to Develop Health Care Innovation Plan With $1.5 Million Federal Grant


Pennsylvania aims to improve health care by developing a plan this summer for transforming how health care is delivered and paid for. The planning process, which is being supported by a $1.5 million grant from the Center for Medicare & Medicaid Innovation (CMMI), will culminate in a Health Care Innovation Plan to be submitted to CMMI this fall.


"This grant gives us an opportunity to transform the healthcare system in Pennsylvania to one that achieves the goals of better health, better patient experience and reduced healthcare costs for current and future generations," Governor Tom Corbett said, in announcing the grant.


The Department of Health is coordinating the planning process in collaboration with the Departments of Public Welfare, Insurance, Aging, and Drug & Alcohol Programs, as well as the eHealth Partnership Authority.


This summer, multi-stakeholder work groups will meet to discuss payment methodologies, delivery system transformation, IT infrastructure, performance measures, workforce development, and public health integration.


Pennsylvania is one of 16 states to receive a planning grant from CMMI. States have until September 30 to submit their plans to CMMI. Upon approval, states then have the opportunity to apply for a larger testing and implementation grant. 

Practices Share Lessons Learned

The 17 practices participating in PA SPREAD's Learning Collaboratives in Northwest and Southcentral PA earlier this month finished a year of work toward becoming Patient Centered Medical Homes. They shared their successes and lessons learned with numerous special guests, including Secretary of Health Michael Wolf and others from the state and county Departments of Health, state Department of Public Welfare, insurers, state and federal legislators and employers.

Key lessons learned included the value of:
  • Pre-Visit Planning -Identifying what evidence-based care patients need before they arrive for their visit and being prepared to deliver these services during visits. Even practices with EMRs initially found paper forms to be helpful with pre-visit planning.
  • Standing Orders - Allowing nurses, medical assistants, and others to automatically provide any evidence-based services, such as immunizations, blood and urine tests, or foot exams, for diabetics without needing to wait for a provider to order them.
  • Risk Stratification - Identifying the highest risk patients (e.g., those whose chronic diseases are most out of control) and scheduling them for more frequent visits, while opening up appointment slots by seeing well-controlled patients less frequently.
  • Motivational Interviewing - Asking patients open-ended questions to understand what concerns them most about their health/disease and what changes they might consider to be healthier. Note that even small changes in habit or behavior can boost confidence and lead to large improvements in health.
Tips for Achieving PCMH Recognition

A list on  recently featured 10 tips for achieving Patient Centered Medical Home (PCMH) recognition. The list originated from a webinar for Allscripts Regional User Groups. It was posted on The Allscripts Blog and developed by Barbara Johnson, nursing director at Elmwood Health Center in New York, and Deb Donovan, operations director at Derry Medical Center in New Hampshire.


Hope you find it helpful!
  1. Remain calm.
  2. Read the entire survey before you start.
  3. Involve your whole team from the beginning.
  4. Phrase your questions with "How" instead of "If."
  5. Stay organized.
  6. Be prepared to change your workflow and job descriptions.
  7. Use screen shots to document your processes.
  8. Get to the intent of standards.
  9. Don't over think it.
  10. Ask for help.   

 Best Practices Spotlight 

Physicians Alliance, Ltd. In Lancaster, PA has developed a series of care guides for patients who smoke or have diabetes or asthma. Providers and their care teams create the care guides in their EMR (Allscripts) by selecting from a variety of check boxes, including evidence-based disease goals, advice for self-management and medication management, and links to various educational resources.


Hamilton Health Center in Harrisburg, PA has developed a process for a Medical Assistant to ask about medication adherence in diabetes patients with an A1C>11.0. They have found that patients who are not taking their medications as prescribed may be more  willing to admit that to a Medical Assistant than to the physician.


Both Crescent Park Family Practice in Warren, PA and the Semeyn Family Practice in New Bethlehem and Brookville, PA provide diabetes patients with a "scorecard" that shows them where they are in relation to evidence-based goals. The scorecards are simple and concise and facilitate discussions with patients on self-management goals.


Oil Valley Internal Medicine in Titusville, PA has now stocked each exam room with a monofilament, so that is always available for diabetic foot exams.

In The Literature 
Annals of Family Medicine recently published a supplement on "Transforming Primary Care Practice," which includes findings from 14 individual studies funded by the Agency for Healthcare Research and Quality (AHRQ). The articles discuss factors that drive practice change, lessons learned in medical home implementation, cultivating leadership, assessment and measurement of medical home implementation, medical home recognition, and practice transformation support, among other topics.

One of the articles is from a research team at Penn State, RAND, and the University of Pennsylvania that studied medical home implementation in southeast Pennsylvania. The study used a positive deviance approach to explore why some practices improve clinical care quality more than others. Read more at:

  A Positive Deviance Approach to Understanding Key Features to Improving Diabetes Care in the Medical Home 
Join Our Mailing List