Community Care of North Carolina—: An Enhanced Medical Home Model

Elevated blood pressure can lead to serious patient morbidity and mortality. The aim of the study was to evaluate the implementation of a tailored multifaceted program, administered by care managers in a Medicaid setting to improve hypertension medication adherence. The program enrolled 558 Medicaid patients. Patients had at least one phone call by care managers. The individually tailored program focused on improving lifestyle and medication adherence. The primary outcome was the medication possession ratio (MPR), calculated using fill history from pharmacy claims. We observed an improvement of medication possession from 55% 9-12 months prior to program enrollment to 77% 9-12 months post initiation of the program. We demonstrated 12 month sustainability and increased MPR. Personal interaction by phone allows the intervention to be tailored to participants' current concerns, health goals, and specific barriers to achieving these goals.

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Do primary care medical homes facilitate care transitions after psychiatric discharge for patients with multiple chronic conditions?

Domino¹,

Jackson

Beadles

et al. 2016

General Hospital Psychiatry

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Objective Primary-care-based medical homes may facilitate care transitions for persons with multiple chronic conditions (MCC) including serious mental illness. The purpose of this manuscript is to assess outpatient follow-up rates with primary care and mental health providers following psychiatric discharge by medical home enrollment and medical complexity. Methods Using a quasi-experimental design, we examined data from NC Medicaid-enrolled adults with MCC hospitalized with an inpatient diagnosis of depression or schizophrenia during 2008-2010. We used inverse-probability-of-treatment weighting and assessed associations between medical home enrollment and outpatient follow-up within 7 and 30 days post discharge. Results Medical home enrollees (n=16,137) were substantially more likely than controls (n= 11,304) to receive follow-up care with any provider 30 days post discharge. Increasing patient complexity was associated with a greater probability of primary care follow-up. Medical complexity and medical home enrollment were not associated with follow-up with a mental health provider. Conclusions Hospitalized persons with MCC including serious mental illness enrolled in a medical home were more likely to receive timely outpatient follow-up with a primary care provider, but not with a mental health specialist. These findings suggest that the medical home model may be more adept at linking patients to providers in primary care rather than to specialty mental health providers.

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Community Care of North Carolina—: An Enhanced Medical Home Model

Abstract: System and chairman of the Board of Directors for North Carolina Community Care Networks, Inc., which is the statewide umbrella organization representing all 14 Community Care networks. He can be reached at adobson (at) cabarrusfamily.com.

Cited by 9 publications

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Evaluation of a self-management implementation intervention to improve hypertension control among patients in Medicaid

Do primary care medical homes facilitate care transitions after psychiatric discharge for patients with multiple chronic conditions?

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