Patient-Centered Medical Home Pilot

Categories: Change Incentives to Promote Better Care

Blue Cross and Blue Shield of South Carolina has teamed up with Palmetto Primary Care Physicians in Charleston, S.C., to initiate a year-long patient-centered medical home pilot project that could become a model for South Carolina. The patient-centered medical home is a first for the Plan, a first for Palmetto Primary Care Physicians and its patients and a first in South Carolina involving an insurance company.

The pilot project will focus on diabetic patients who are members of Blue Cross and Blue Shield of South Carolina and BlueChoice HealthPlan of South Carolina. Patient-centered medical homes integrate quality improvement, coordinated care management and patient educational tools into primary care practices. The concept places the primary care doctor in charge of a team that can include social workers, pharmacists, wellness coordinators, nurses, disease managers and clinical diabetic educators, all working together to proactively reach out and develop an individual treatment plan for patients.

Case managers will help reduce gaps in care, such as missed appointments with specialists, lack of transportation and medication non-compliance. They also will perform outreach, such as registering patients for wellness clinics, scheduling appointments with specialists and monitoring medical effects. The clinical quality goals will be monitored by measuring blood sugar levels and cholesterol levels.

Electronic medical records will be a key component for delivering comprehensive care. Palmetto Primary Care Physicians uses software, at the point of care, that integrates information received from the health plan, case manager and local emergency rooms. This is information that the primary care practice has never had before. The medical record then becomes more complete and readily available to the primary care physician. Palmetto Primary Care Physicians also has created a portal on its website where pilot participants can schedule an interactive e-visit with their physicians, create their own personal health records, upload and chart their own glucose results and pay their bills.