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Population Health News

Patient-Centered Medical Home Wins $100K for Medicaid Work

Patient-centered medical home Community Care of North Carolina has won the first Hearst Health prize of $100,000 for its population health management work with Medicaid beneficiaries.

By Jacqueline LaPointe

- Hearst Health and the Jefferson College of Population Health at Thomas Jefferson University recently announced that Community Care of North Carolina (CCNC) has won the inaugural Hearst Health Prize of $100,000 for their population health management program.  The patient-centered medical home (PCMH) focused on helping Medicaid beneficiaries with care transitions after a hospitalization.

Patient-centered medical home and population health management

Hearst Health recognized Raleigh-based CCNC for assisting 2600 Medicaid beneficiaries with adjusting to daily life after hospitalization and managing their health through patient-centered care.  The program focused on individuals with chronic conditions, who are more likely to be readmitted to the hospital.

“The use of robust health analytics along with a statewide infrastructure and a network of physicians and hospitals has allowed us to manage the toughest patients well,” the President and CEO of CCNC, L. Allen Dobson Jr., MD, said.

“Our drive to improve the health of North Carolinians has been grounded in collaboration and the use of data that have shown us how to improve outcomes and to reduce costs.”

The program connects participants to health management, education, and communication tools.  Participants are educated about medications and treatments, chronic disease management skills, and outpatient communication.

The program also emphasizes how the patient-centered medical home can help patients communicate about behavioral health and socioeconomic issues that may affect their health, such as substance abuse, transportation, cost, inadequate health knowledge, medication schedules, and isolation.

The program responds to the national healthcare goal to provide quality care at affordable prices as CMS transitions to a value-based reimbursement system for providers.

Patients with chronic conditions face a unique challenge because they are frequently in and out of hospitals and need to manage their conditions in daily life.  Medical and daily costs add up with each hospitalization, doctor’s visit, and therapy.

The patient-centered medical home is designed to increase access to patient-centered care using a network of physicians.  The model centers on personalized care through more communication, care coordination, and patient support.

The model aims to reduce costs to patients and providers by preventing expensive visits to the emergency room, unnecessary hospitalization, and redundant medical procedures.  

For CCNC, the PCMH reduced the rates of readmission and hospitalization for program participants by 10 percent and 16 percent since 2008.  The North Carolina Office of the State Auditor reported that Medicaid costs were cut by 9 percent since CCNC started their program.

The organization was also recognized for creating a network of 87 hospitals, which represents an estimated 78 percent of Medicaid hospitalizations in North Carolina.  The network established data connections among hospitals for increased interoperability and care coordination.

The first Hearst Health prize was awarded based on population health management impact, innovation, application of evidence-based and best practices strategies to advance quality of care, sustainability, patient and provider engagement, collaboration, and communication.

Gregory Dorn, MD, MPH, president of Hearst Health, along with David Nash, MD, MBA, dean of Jefferson College of Population Health, made the announcement on March 8, 2016. The prize was awarded at the 16th annual Population Health Colloquium in Philadelphia.

"We are delighted that Community Care of North Carolina has been awarded the first-ever Hearst Health Prize for its transitional care management program that improves clinical outcomes for Medicaid beneficiaries and lowers costs in a healthcare system that serves 1.4 million people," Dorn said.

“Community Care of North Carolina's program is highly scalable and replicable and it is our hope that the Hearst Health Prize provides a new national forum to share these practices with other programs to improve the health of vulnerable populations.”

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