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Hopkins to Assist Practices in Medicare Medical Home Demonstration


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Posted: 9/11/2008

The Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public Health has received a $1.7 million grant from the John A. Hartford Foundation to help primary care practices improve the quality and outcomes of health care for older adults with chronic illnesses. 

The Lipitz Center will use the grant to help medical practices in eight statesto be selected by the Centers for Medicare & Medicaid Services (CMS)to qualify for and participate in CMSs three-year Medicare Medical Home Demonstration project. Beginning in January 2010, practices participating in the demonstration will provide a set of comprehensive, coordinated “medical home” services to Medicare beneficiaries living with chronic medical conditions. Under the direction of Charles E. Boult, MD, MPH, MBA, the Lipitz Center will offer health care providers information, education and technical support based on the Hopkins-developed Guided Care model, an innovative and successful care solution for chronically ill older adults.

“Older adults with chronic conditions are a critical and growing medical challenge in need of new solutions, said Boult. “If this demonstration is successful, the Medical Home could become the new standard for treating the chronically ill.”

Medicare beneficiaries with multiple chronic conditions account for 80 percent of Medicare spending, which totaled $425 billion in 2007. Without prompt changes, chronic care in America will soon become unsustainably expensive. The Medicare Medical Home Demonstration is an important step in responding to this crisis. Mandated by the 2006 Federal Tax Relief and Health Care Act, participating practices are required to provide patients with comprehensive, coordinated, inter-disciplinary, evidence-based care in return for care management fees and incentive payments. Practices must track patients health status, provide them with convenient access to care through the use of health information technology, and support patients’ management of their conditions.

With funding from the Hartford grant, and drawing on its Guided Care model, the Lipitz Center will develop and provide primary care practices with online courses for physicians and nurses, a practice implementation manual and technical assistance in meeting the Medicare Medical Home Demonstrations requirements. The Lipitz Center will partner with the American Academy of Family Physicians/TransforMED, the American College of Physicians (ACP), the Medical Group Management Association (MGMA), and The Institute for Johns Hopkins Nursing.

In the Guided Care model, a specially trained registered nurse is based in a primary care office and works closely with physicians and chronically ill patients to improve quality of life and reduce the need for expensive inpatient health services. The nurse assesses patient needs in their home, develops a care plan, monitors conditions, educates and empowers the patient, supports family caregivers, smoothes transitions between sites of care, and works with community agencies to ensure that the patients health care needs are met.

Led by Boult, the Guided Care model was developed in 2002 by a team of researchers at Johns Hopkins. In a pilot study, patients who received Guided Care rated their quality of care significantly higher than patients who received standard care. In addition, the average insurance costs for Guided Care patients were 23 percent lower over a six month period. The program is currently being tested at eight primary care sites in the Baltimore/Washington, D.C. area in a 30-month randomized trial involving over 900 patients, 300 caregivers, and 48 primary care physicians. Six months of data show that Guided Care improves the quality of care, reduces health care costs and improves job satisfaction. For more information, go to www.guidedcare.org.