The Medical Home Model and Dual Eligible

Last week we discussed the two main types of Financial Alignment Demonstrations sponsored by CMS and for full dual Eligible. These are:

  • The Capitated Model. This is a model that pays private health plans that contract with the state a PMPM rate to provide all Medicare and Medicaid benefits to full dual eligible on behalf of the state.
  • Patient Centered Medical Home Model. This model allows states to design systems to coordinate care for full dual eligible while Medicare and Medicaid continue to pay providers directly for delivered services.

This week let’s take a deeper look at the Patient Centered Medical Home Model in Missouri. Like we discussed last week, Missouri submitted in its proposal on May 31st, 2012 for a Patient Centered Medical Home Financial Alignment Demonstration.

Missouri proposed to build their Patient Centered Medical Home demonstration around their existing Medicaid Health Home initiatives. You may know, the state of Missouri applied for and received approval from CMS for two Health Home programs under Section 2703 of the Affordable Care Act (ACA) in January 2012. We were actually the 1st in the United States to be approved. These health homes currently provide care coordination services state-wide to 11,996 dual eligible Missourians. The first of the two programs, the Community Mental Health Center (CMHC) Health Home program, targets individuals who have serious mental illness in combination with another chronic condition. The second approved program, the Primary Care (PC) Health Home, targets individuals who have multiple and chronic conditions. There are currently 29 Community Mental Health Center based health homes and 24 Primary Care Health Homes mostly located in Missouri’s FQHC.

Missouri’s Financial Alignment Demonstration requests to extend Missouri’s existing Health Home initiative for select, full- dual eligible within the state. So what are the hallmarks of the Patient Centered Medical Home Model?

1. Strategies to target high-need, high cost beneficiaries. Missouri identifies eligible not already enrolled in a health home and who have 2 or more chronic conditions and/ or serious mental health issues through analysis of healthcare claims data and via referral from providers.

2. Care team led by a Care Coordinator who is the patient’s Physician or Advanced Practice Nurse.

3. Coordination of Multidisciplinary care teams that integrate behavioral and physical health. The care coordinator unites the disparate pieces of the health care delivery system and makes them work collaboratively for each beneficiary. Additional physicians (specialist), Nurse Practitioners, Psychiatrists, Behavioral Health Consultants, Nurse Care Managers, Dietitians, Diabetes Educators, Pharmacist, labs and other ancillary care providers work as governed by the beneficiaries personal plan of care as coordinated by their health home care coordinator. The Patient Centered Health Home locates, conducts outreach to and manages the ongoing treatments of all the extended team members. In Missouri these health homes receive a per member, per month payment of approximately $60 for the Primary Care Health Home Program and $80 PMPM for the Community Mental Health Center Health Home.

4. Enhanced access. This is early identification of need for and connection to community services that can avoid higher cost and usually facility based services after an acute event.

5. Provider and Payer Alignment. This is accomplished through PMPM case management fees and in some cases additional provider participation in shared savings.

6. The ability to drive Medicare and Medicaid Savings. In Fiscal year 2012 alone the Missouri State Budget was benefited by $44 million in avoided healthcare expenditures from existing Patient Centered Health Home initiatives.

Home Health and HCBS services can greatly extend the inherent benefits of the Patient Centered Health Home model. By effecting an ongoing relationship with the patient and the their health home based practitioners, a home health partner can ensure the dual eligible patient’s physician has a more granular understanding of the daily challenges a patient faces where adherence to recommended behavior and compliance with physician orders is concerned. HCBS services can assist as well to educate and train the patient’s friends and family in providing the supports necessary to better their adherence to the plan of care.

Additionally, where more complex co-morbidities exist, for example, a diabetic with open wounds, a home care provider with an expertise in advanced wound healing can add exponentially to the effectiveness of the health home team by bringing specific expertise in the form of knowing how to deploy, at home, support surfaces, wound vacuums, advanced debridement techniques and alternative dressings. This reduces the need for inconvenient and more expensive out of home trips for follow-up care and minimizes the potential for infection which often results in avoidable hospitalization and SNF rehabilitation.

Pyramid Home Health Services Wound Healing Program consists of the following:

  • WOCN, a credentialed specialist RN, who reviews each patient’s H&P, initial assessment/ wound etiology, electronic wound photos, and consults on a holistic POC recommendation with the treating physician. They are also available for patient, physician and family in-home and in-office consultations and case conferences.
  • Case Manager that tracks compliance with POC, monitors healing progress, coordinates the communications of treating clinicians, the patient’s physician(s) and Pyramid’s WOCN using electronic medical record updates and digital transmission of wound care photos and treatment notes.
  • Treating Clinicians that are trained in and receive continuing education on advanced wound treatments, dietary and behavioural management techniques and patient education.

If Pyramid Home Health Services can assist you Medical Home Model please contact us at 888-880-6565 or visit us at

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