Understanding Perceived Barriers to Care Among Suburban Super-Utilizers Who Have an Identified Primary Care Provider.

Patients who are admitted to the hospital frequently (>3 admissions in a 6-month period) are a large driver of health care costs. Recently, research has focused on these groups of super-utilizing patients to try to find ways to meet their care needs in the outpatient setting. However, most research so far has focused on the urban underserved population who do not have a usual source of care.

Implementing effective care management in the patient-centered medical home.

Background: There is growing evidence that practice-based care management can improve clinical quality and reduce costly healthcare utilization.

Objectives: To explore how a disparate group of patient-centered medical homes (PCMHs) embedded care management in their team care environment to identify best practices.

Study Design: A positive deviance approach was used to contrast care management implementation in practices having the greatest and least improvement on clinical measures of diabetes, the initial target disease for a multipayer-supported statewide initiative involving 25 National Committee on Quality Assurance-recognized PCMH practices participating in a regional learning collaborative.

Strategies for achieving whole-practice engagement and buy-in to the patient-centered medical home.

Purpose: The current model of primary care in the United States limits physicians' ability to offer high-quality care. The patient-centered medical home (PCMH) shows promise in addressing provision of high-quality care, but achieving a PCMH practice model often requires comprehensive organizational change. Guided by Solberg's conceptual framework for practice improvement, which argues for shared prioritization of improvement and change, we describe strategies for obtaining organizational buy-in to and whole-staff engagement of PCMH transformation and practice improvement.

The Patient-Centered Medical Neighborhood: Transformation of Specialty Care.

The growing need for coordinated care of those with medically complex diseases is becoming more important in today's health care system, wherein reimbursement changes are driving methods to improve quality and cost. This article discusses the 6 key processes that, according to the American College of Physicians, define an effective medical neighborhood; the evidence supporting the need for this coordinated system; and pilot medical neighborhood strategies being implemented.

Collaboration in Pennsylvania: rapidly spreading improved chronic care for patients to practices.

Introduction: Pennsylvania's Improving Performance in Practice (IPIP) program is administered by the Pennsylvania (PA) chapters of the American Academy of Family Physicians, American College of Physicians, and American Academy of Pediatrics. The project has provided coaching, monthly measurement, and patient registry support for 155 primary-care practices that participate in the 3-year Pennsylvania Chronic Care Initiative led by the PA Governor's Office of Health Care Reform.

Methods: Practices participating in this case study are attending regional Breakthrough Series collaboratives and submitting monthly narrative and clinical outcomes reports.