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Medical Home Digest

The Medical Home Digest is the Initiative's electronic newsletter. It highlights PCMH transformation stories from Initiative participants and provides commentary on PCMH topics from a wide variety of experts.

Lessons Learned (Summer 2013)
In our final issue of the Medical Home Digest, we reflect on some of what we have learned during the SNMHI. Medical Home Facilitators from our five Regional Coordinating Centers share lessons they and their practices learned about setting the stage for successful transformation. Medical Home Facilitators also describe what is coming next for their organizations and how they plan to spread and sustain PCMH. Also included in this issue is a reflection on the value of learning communities—a key component of collaboratives including the SNMHI. Specific examples of tailoring showcase the many ways organizations can harness the power of peer interaction to inspire and teach. Finally, we describe recent revisions to the SNMHI Implementation Guide Series, a comprehensive library of resources and tools intended to assist practices in understanding and implementing the SNMHI Change Concepts for Practice Transformation.

Gathering Evidence (Spring 2013)
This issue of Medical Home Digest begins with an article highlighting recent recommendations from the PCMH Evaluator’s Collaborative. The following article describes recent research on PCMH cost and quality outcomes and offers thoughts on what is needed to build the PCMH evidence base. The Digest continues with an article that outlines essential leadership roles and behaviors for effective transformational change. It concludes with an announcement about a new public domain online resource for practice facilitators built on the SNMHI framework.

Integrated Healthcare (December 2012)
This issue of the Digest presents effective ways of integrating previously separate services into primary care delivery in the safety net. We begin by summarizing several models for integrating behavioral health into primary care. Next, we discuss the creation of a strong partnership between primary medical and dental care practices, beyond simple co-location of oral health services. We also discuss successful techniques for ensuring that individual care plans address the needs of patients and families and that patient experience is incorporated into quality improvement activities. This issue of the Digest concludes with a reminder about the capacity of health information technology to support integration of medical home components and allow practices to more easily provide, track and evaluate patient-centered care.

Vulnerable Populations (November 2012)
In this issue of the Digest, we focus on experience with three vulnerable groups served by safety net practices: homeless patients, immigrants to the United States and people living in rural America. Articles and interviews highlight the unique needs and challenges of these populations, and explore how patient-centered medical home transformation can increase access, improve quality of care and improve patient experience even in challenging environments. This issue also features an article on the relationship between medical home transformation and NCQA PCMH Recognition.

Building Transformation Capacity (August 2012)
This information-packed issue of the Digest features a broad array of topics related to medical home transformation and quality improvement. It contains articles on engaging staff in measurement and quality improvement, the role of the RN in direct patient care, and balancing supply and demand in a practice. Also included are two interviews, one reflecting on how to keep the patient voice at the center of care and another on Group Health's patient-centered approach to managing phone calls.

Organized, Evidence-Based Care (March 2012)
This issue of the Digest features articles on Organized, Evidence-Based Care, including risk-stratifying patients to enable targeted care. It also provides reflections on transformation from participants in the Safety Net Medical Home Initiative, and a case study on reducing avoidable ED visits among newly-diagnosed diabetic patients (East Boston Neighborhood Health Center, Massachusetts).

Care Coordination (August 2011)
This issue of the Digest features articles on Care Coordination, care management and the new NCQA 2011 PCMH standards. It also presents case studies from Community Health Centers of Lane County (Oregon) and Denver Health (Colorado).

Quality Improvement/Enhanced Access (January-April 2011)
This double issue is dedicated to Quality Improvement Strategy and Enhanced Access. This newsletter includes articles from Jonathan Sugarman, MD, Ed Wagner, MD, Tom Bodenheimer, MD and Larry Mauksch, MEd. The Digest also highlights SNMHI successes and tools, including a case study from the Yuma Rural Health Clinic (Colorado); resources available from the SNMHI Summit; and more information on the Patient-Centered Medical Home Assessment (PCMH-A) tool.

Patient-Centered Interactions (December 2010)
This issue of the Digest is dedicated to Patient-Centered Interactions, and includes articles from Jonathan Sugarman, MD, Ed Wagner, MD, Laurie Francis, Rob Reid, MD, Bob Berenson, MD and many more. It also highlights the transformative work of Safety Net Medical Home Initiative practices in Pittsburgh.

Continuous and Team-Based Healing Relationships (August 2010)
This issue of the Digest focuses on, Continuous and Team-Based Healing Relationships, and includes articles from Jonathan Sugarman, MD, Ed Wagner, MD, L. Gordon Moore, MD and Jeff Hummel, MD. The Digest includes suggestions for accommodating part-time providers in the medical home, a special supplement on making sense of Meaningful EHR Use and an interview with Cambridge Health Alliance team members on the value of teamwork.

Empanelment (March 2010)
This issue of the Digest focuses on Empanelment, and includes articles from Jonathan Sugarman, MD, Ed Wagner, MD, L. Gordon Moore, MD, Amit Shah, MD and Jeff Hummel, MD. This issue includes articles on the importance of relationships in Empanelment and the challenges of implementing Empanelment in the safety net; two special supplements on the Health Information Technology (HIT) Information Tools to Support PCMH Workflows; and one supplement focused on HIT and patient attribution and Empanelment.

Engaged Leadership (October/November 2009)
This issue of Digest focuses on Engaged Leadership, and includes articles from Jonathan Sugarman, MD and Ed Wagner, MD. Also included are an article on Group Health's initial medical home pilot site and an article introducing the importance of registries.