Medical Home's Payoff Comes From Effort and Technology

Robust tech-powered tracking mechanisms keep tabs on everything from referrals to scheduled tests, and in collaboration with Hopkins' payer arm, Kravet's team assesses risks for each patient. "The highest-risk folks got an RN case manager, and the medium-risk folks got health coaches."

Over the past three years, Kravet says, those clinics where patient-centered medical home practices have been implemented have seen a decrease in emergency room visits, admissions, and readmissions have significantly decreased, and because of this, costs to the related Hopkins payers have declined significantly.

Using Microsoft's Sharepoint, JHCP shares a dashboard that lets all providers, on a secured link, see metrics on quality, workflow, and productivity, and see how they compare to their colleagues. "Once we began sharing this information transparently, we obviously began to see a transformation in our outcomes," Kravet says. "I think that's just because of the inherent competitive spirits of providers, who are all trying to do the right thing."

Overlaid on top of JHCP's electronic medical record are registries, views of data by provider or group that can manage populations. "Again, it's a big part of how we are able to help drive success, because our chiefs and our regional directors can work with practices that are lagging, and help them brainstorm on how to improve their processes," Kravet says.

A large banner hangs in Water's Edge, inhabiting nearly an entire wall. "What good choices can you make today that will affect your health tomorrow?" it asks patients.

Clearly, what Kravet's team has already accomplished has begun generating the shared savings that can fund even more effective patient engagement. His efforts represent the kind of virtuous cycle that healthcare needs to get out of its fee-for-service sand trap.