Patient-centered medical homes (PCMHs) have the potential to improve patient experience of care. Since 2006, Geisinger Health System has implemented its own version of an advanced PCMH model, referred to as ProvenHealth Navigator (PHN). To evaluate the impact of PHN on patient experience of care, the authors conducted a survey of patients whose primary care clinics had been transformed to "PHN sites" and were under case management at the time of the survey. A comparable survey of patients from non-PHN sites also was conducted for comparison. The results suggest that patients in PHN sites were significantly more likely to report positive changes in their care experience and quality; moreover, they were more likely to cite the physician's office as their usual source of care rather than the emergency room (83% vs. 68% for physician's office; 11% vs. 23% for emergency room). However, the results also suggest that there was no significant difference between PHN and non-PHN patients in their perceptions of access to care or primary care physician performance in terms of patient-centered care (eg, listening, explaining, involving patients in decision making). These findings are consistent with the expectation that transformation of primary care into PCMH can lead to improved patient experience of care.

The Patient Protection and Affordable Care Act of 2010 provides for a number of major payment and delivery system initiatives. These potential changes need to be tested, scaled, and adapted with an urgency not evident in previous demonstration projects of the Centers for Medicare and Medicaid Services. We discuss lessons learned from our iterative tests of care reengineering at Geisinger--specifically, through our advanced medical home model, ProvenHealth Navigator, and the way we continuously modified the model to improve quality and value. We hypothesize that the most important ingredient in our model has been the embedding of nurse case managers into our community practices and the real-time feedback of data on the use of health services by the most complex patients.

One of the primary goals of the patient-centered medical home (PCMH) is to provide higher quality care that leads to better patient outcomes. Currently, there is only limited evidence regarding the ability of PCMHs to achieve this goal. This article demonstrates the effect of PCMHs in improving certain clinical outcomes, as shown by the ProvenHealth Navigator (PHN), an advanced PCMH model developed and implemented by Geisinger Health System. In this study, the authors examined the claims data from Geisinger Health Plan between 2005 and 2009 and estimated the effect of PHN on reducing amputation rates among patients with diabetes, end-stage renal disease, myocardial infarction, and stroke. The results show that, despite its relatively short period of existence, PHN has led to significant improvements in certain outcomes, further illustrating its potential as a care delivery model to be adopted on a wider scale.

Early evidence suggests that the patient-centered medical home has the potential to improve patient outcomes while reducing the cost of care. However, it is unclear how this care model achieves such desirable results, particularly its impact on cost. We estimated cost savings associated with Geisinger Health System's patient-centered medical home clinics by examining longitudinal clinic-level claims data from elderly Medicare patients attending the clinics over a ninety-month period (2006 through the first half of 2013). We also used these data to deconstruct savings into its main components (inpatient, outpatient, professional, and prescription drugs). During this period, total costs associated with patient-centered medical home exposure declined by approximately 7.9 percent; the largest source of this savings was acute inpatient care ($34, or 19 percent savings per member per month), which accounts for about 64 percent of the total estimated savings. This finding is further supported by the fact that longer exposure was also associated with lower acute inpatient admission rates. The results of this study suggest that patient-centered medical homes can lead to sustainable, long-term improvements in patient health outcomes and the cost of care.

Investing in automated monitoring systems may reduce hospital readmission rates among primary care case-managed patients. Evidence from this quasi-experimental study demonstrates that the combination of telemonitoring and case management, as compared with case management alone, may significantly reduce readmissions in a Medicare Advantage population.

A provider-driven pay-for-performance process for CABG, enabled by an electronic health record system, can reliably deliver evidence-based care, fundamentally alter reimbursement incentives, and may ultimately improve outcomes and reduce resource use.

Methotrexate has been used to treat several rheumatic diseases when conventional therapy has failed (1,2). Recently, several articles have extolled the efficacy of this agent in refractory definite or classic rheumatoid arthritis (RA) (3)(4)(5). Response rates in excess of 50% have been noted in uncontrolled series (3-5). A great deal of enthusiasm has been generated by this high response rate, especially in view of the minimal side effects which have accrued with lowdose methotrexate regimens used in the treatment of RA and other disorders (1,(3)(4)(5)(6)(7)(8)(9). We report a case of Pneirmocystis curinii pneumonia occurring in a patient with RA who was receiving low-dose methotrexate. To our knowledge this complication has not been previously reported.A 74-year-old white woman with a 10-year history of seropositive RA presented with fever, chills, and a productive cough of 2 weeks' duration. Gold and penicillamine had been discontinued previously due to lack of efficacy. Her current regimen consisted of therapeutic doses of salicylates, 5 mg prednisone daily (continuous low-dose prednisone for the preceding 6 years), and 15 mg methotrexate weekly, given orally at 12-hour intervals over a 24-hour period. Methotrexate had been well tolerated since initiation 8 months earlier.Physical examination revealed a slightly cushingoid 74-year-old woman in moderate respiratory distress. Temperature was 38.8"C, respiratory rate 44, pulse 112, and blood pressure 110/70. She was agitated and mildly confused; cyanosis was absent. Cardiac examination results were remarkable only for a grade I/IV systolic ejection murmur along the left sternal border. There was no neck vein distention. Bibasilar rales and end inspiratory wheezes were heard diffusely throughout the lung fields. Her examination findings were otherwise unremarkable except for synovitis of the ankles, wrists, and metacarpophalangeal joints.Chest roentgenogram revealed mild cardiomegaly and heavy interstitial markings throughout both lung fields. The white blood cell count was 8,200/mm3 with 80% neutrophils and 2% bands. Arterial blood gas on 2 liters oxygen per minute showed a pH of 7.42, Pcoz of 36, and Po2 of 64. Sputum Gram stain and culture failed to reveal any pathogens.A regimen of erythromycin, tobramycin, and trimethoprim/sulfamethoxazole was started. Results of routine cultures, stains for acid-fast bacilli and fungi, and direct fluorescent antibody test for Legionella pneirmoplzilia on specimens obtained at bronchoscopy on the second hospital day were negative. Transbronchial biopsy revealed nonspecific inflammation in interstitial areas. Progressive respira-1291 tory insufficiency ensued, necessitating mechanical ventilation. Open lung biopsy, on hospital day 3, showed active interstitial pneumonitis with some alveolitis. Grocott stains were positive for sparse P curinii organisms compatible with a partially treated pneumocystis pneumonia. All antibiotics were discontinued except for trimethoprim/sulfamethoxazole, which was given for 3 weeks. Serum pneu...

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