The Veterans Health Administration: Implementing Patient-Centered Medical Homes in the Nation's Largest Integrated Delivery System

Describes the implementation of a model that organizes care around an interdisciplinary team of providers who work to identify and remove barriers to access and clinical effectiveness in primary care clinics. Outlines two case studies and lessons learned

Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement

Examines four healthcare systems' expansion of patient safety interventions over five years through the development of practical training methods, effective tools for minimizing errors, an emphasis on goal setting and accountability, and other approaches

The Triple Aim Journey: Improving Population Health and Patients' Experience of Care, While Reducing Costs

Provides an overview of the Institute for Healthcare Improvement's initiative designed to help improve population health, enhance patients' experience of care, and slow the growth of per capita costs. Outlines early results from three case study sites

Gundersen Lutheran Health System: Performance Improvement Through Partnership

Highlights Fund-defined attributes of an ideal system and best practices such as using data for benchmarking, increasing transparency, and driving improvement; investing in primary care and disease management; and hiring engineers to improve operations

CareOregon: Transforming the Role of a Medicaid Health Plan From Payer to Partner

Details Triple Aim pilot programs designed to offer patient-centered medical homes and multidisciplinary case management in an effort to improve population health, enhance patients' experience, and slow cost growth

Genesee Health Plan: Improving Access to Care and the Health of Uninsured Residents Through a County Health Plan

Describes how expanding access to services and helping patients adopt healthy behaviors and manage chronic diseases cut emergency room visits and costs. Emphasizes collaboration among local government, hospitals, community groups, and other stakeholders

North Carolina's ABCD Program: Using Community Care Networks to Improve the Delivery of Childhood Developmental Screening and Referral to Early Intervention Services

Profiles community care networks' approaches to implementing the Assuring Better Child Health and Development (ABCD) program. Examines activities to increase screening for and interventions in developmental disabilities and delays, impact, and insights

Genesys HealthWorks: Pursuing the Triple Aim Through a Primary Care-Based Delivery System, Integrated Self-Management Support, and Community Partnerships

Details Triple Aim pilot programs to engage primary care doctors in care coordination, prevention, and efficient use of specialty care through a physician-hospital organization; promote healthy behaviors; and extend access for the poor and uninsured

The Hospital at Home Model: Bringing Hospital-Level Care to the Patient

Presbyterian's Hospital at Home program, launched in 2008, is based on a model developed in the mid-1990s by Bruce Leff, M.D., a geriatrician and health services researcher at Johns Hopkins University, who noticed that many of his patients suffered poor outcomes after hospital stays.1 At Johns Hopkins, teams of physicians, nurses, and other clinical staff make house calls to treat elderly patients, many of whom either refuse to go to the hospital or are at such high risk for adverse events that physicians prefer not to admit them. For select patients, this approach produces superior outcomes at a lower cost than hospital care (see Results).The Hospital at Home model has struggled to gain traction elsewhere in the United States, however, in part because Medicare's fee-for-service program will not pay for its services. Presbyterian is able to secure reimbursement from its health plan, which covers 470,000 Medicare Advantage, Medicaid, and commercially insured members throughout the state and has incentives to reduce costs and improve care.Presbyterian's program fits within a suite of services designed to deliver care in the home. These include home-based primary care, home health, hospice, and Complete Care, a care management program designed to improve coordination of services for patients with advanced illness and, when desired, avoid unwanted aggressive care at the end of life

Bringing Primary Care Home: The Medical House Call Program at MedStar Washington Hospital Center

MedStar's program offers round-the-clock access to a care team comprising a geriatrician, nurse practitioner, and social worker. The house calls reveal and address problems that are missed when care is poorly coordinated, enabling team members to identify social supports for patients that can improve quality of life, reduce the burden on caregivers, and head off problems that can lead to high-cost institutional care.Based on the cost savings it achieved, the program became one of the models for the federal Center for Medicare and Medicaid Innovation's Independence at Home Demonstration, which is testing whether providing primary care at home to frail elderly patients with multiple chronic conditions or advanced illnesses improves outcomes and lowers health care spending. MedStar participates in the demonstration as part of a consortium that includes Virginia Commonwealth University and University of Pennsylvania Health System, both of which are implementing an approach similar to MedStar's. The consortium is one of nine participating groups to earn a share of the savings they produced for Medicare