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Policy Innovation Profile

Plan-Supported Medical Home Model Helps Clinics Enhance Access, Improve Quality, and Reduce Admissions for Medicaid Managed Care Enrollees

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A Medicaid managed care plan works with primary care practices to implement a medical home model. Known as the Primary Care Renewal project, this program provides additional reimbursement and other support designed to encourage practices to provide multidisciplinary, coordinated, comprehensive care to patients. Participating practices agree to implement team-based and customer-driven care, barrier-free access, proactive panel health improvement, and integrated behavioral health. Early evidence suggests that the program has helped participating sites enhance access to care, improve performance on process and outcomes measures, and reduce inpatient admissions for ambulatory care–sensitive conditions.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics at participating clinics, including waiting times for appointments, missed appointments, blood glucose testing, blood glucose levels, and ambulatory-sensitive admissions.
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Developing Organizations

Portland, ORend do

Use By Other Organizations

CareOregon was recently named one of five organizations participating in a Commonwealth Fund regional demonstration project (called the Safety Net Medical Home Initiative) designed to spread use of this model; the program, which will bring together 15 practices in Oregon, was launched in July 2009.

Date First Implemented

The program began in five practices and has since expanded to 12 sites with 50 teams.begin pp

Patient Population

Insurance Status > Medicaidend pp

Problem Addressed

Medicaid beneficiaries and other traditionally underserved populations often have difficulties accessing comprehensive, culturally competent, coordinated primary care services that proactively address chronic health conditions. Current fee-for-service payment systems provide little or no additional reimbursement for such services, leaving overworked, primary care physicians little incentive or ability to offer them. The net result is poor outcomes and high costs—including preventable hospital admissions and emergency department (ED) visits—for these populations.
  • Little time or incentive to provide coordinated care: According to 2008 data from the American Academy of Family Physicians, primary care doctors conduct an average of 84.9 office visits and 8 hospital visits each week, the equivalent of more than 16 office visits and 1.5 hospital visits every work day.1 Current fee-for-service payment systems encourage higher patient loads, particularly for physicians serving Medicaid beneficiaries and other underserved populations, for whom per-visit payment rates are low. Some physicians, moreover, have responded to financial pressures by limiting their availability outside of normal business hours, including by telephone (which is generally not a billable service.)2
  • Leading to poor access, care coordination, and outcomes and high costs: Capacity constraints and an excess focus on productivity have created access problems, especially for low-income, minority, and uninsured populations, who are much more likely than their White, higher-income counterparts to have to wait to see a doctor; to encounter delays and poorly coordinated care; and to have untreated dental caries, uncontrolled chronic disease, avoidable hospitalizations, and poor outcomes.3 As a result, costs are higher than necessary—for example, CareOregon found that 12 percent of enrollees (primarily those with the highest medical and social comorbidities) accounted for nearly two-thirds of total costs.4

What They Did

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Description of the Innovative Activity

CareOregon, a nonprofit Medicaid managed care plan, works with primary care practices that serve plan enrollees to implement a "medical home" model. Known as the Primary Care Renewal project, this program provides additional reimbursement and other support designed to encourage practices to provide multidisciplinary, coordinated, comprehensive care to patients. Participating practices must agree to implement team-based and customer-driven care, barrier-free access, proactive panel health improvement, and onsite or otherwise integrated behavioral health. Key elements of the program include the following:
  • Mandatory adoption of elements of medical home model: Participating sites agree to implement the following aspects of the medical home model, with the goal of providing comprehensive, coordinated care:
    • Team-based, customer-driven care: Providers organize into teams that typically consist of four individuals—a clinician (often a doctor, but in some cases a nurse practitioner or physician assistant), medical assistant, care manager (usually a nurse but in some cases a medical assistant), and a behaviorist. Each team cares for a set panel of patients, with relevant team members seeing patients at every visit. Each morning, the team meets to review the day's schedule to determine whether all scheduled appointments are necessary and to discuss any care gaps that need to be addressed. (See next two bullets for more information.) During visits, team members perform services appropriate for their skills and training. For example, medical assistants and care managers provide basic medical services and other support, thus freeing up clinicians to focus on more complex clinical issues.
    • Barrier-free access through same-day appointments, telephone: Participating clinics agree to offer same-day appointments and telephone contact with patients, thus reducing the incentive to use more expensive sites such as the ED for primary care. Previously, patients routinely waited days or even weeks for an appointment. Each participating practice decides how best to offer same-day access. Most have adopted some or all aspects of an "open-access" model, such as changing the scheduling template so as not to schedule patients far in advance, systematically reviewing the schedule during morning huddles to eliminate unnecessary visits (e.g., by handling a medication refill over the phone rather than in person) and limiting panel size so that teams do not become overwhelmed. Clinics that have adopted the model for the entire organization (as opposed to having just one pilot team) have also made more fundamental reforms to their systems related to scheduling, handling phone calls and prescription refills, and the like.
    • Proactive panel health improvement: Participating practices have adopted the Institute for Healthcare Improvement (IHI) concept of "max-packing" each visit. The goal is to use every encounter as an opportunity to bring the patient up to date on his or her preventive service and screening needs and to review and reconcile all medications being taken to boost compliance with an appropriate regimen. To make this happen, the medical assistant reviews the patient's medical records before each visit to identify needed services. When necessary, the assistant also proactively reaches out to patients to make sure they come in for care (e.g., through reminder calls). During the visit, the assistant queries the patient on his or her medications and other relevant issues to ensure that all care gaps can be addressed. Some practices have electronic medical records and/or electronic registries to assist with this task, although others still use paper-based registries. Teams also conduct outreach between visits as necessary to support patient self-management, medication compliance, etc.
    • Integrated behavioral health: Participating practices offer integrated behavioral health services, with most larger practices having an onsite behaviorist (although smaller practices might set up a collaborative relationship with an offsite provider). The onsite behaviorist works as part of the core team, seeing patients during visits as necessary to address common problems such as anxiety, depression (including postpartum depression), tobacco use, and chronic pain.
  • Additional reimbursement beyond fee-for-service payments: In addition to paying practices on a fee-for-service basis for visits, CareOregon provides up to 20 percent additional reimbursement to participating practices based on their performance in three distinct tiers of measures (see bullets below). Specific weightings and formulas within each tier help to determine the precise amount of the payout. These additional payments are made on a monthly basis based on how the practice performed on the metrics within the tiers during the previous quarter. Payments are on a per-member, per-month basis, with adjustments based on the risk of the population being served.
    • Payment for capacity to do work (tier one): Practices receive additional payment for ongoing participation in the collaborative project, which requires investments of time and money for training, data collection and reporting, and other areas, including having leaders commit to participating in a steering committee. This component is intended to encourage the creation of the capacity and will to do population health management on an ongoing basis.
    • Payment for improvement (tier two): CareOregon tracks roughly six to eight metrics, gauging how participating practices improve over time. In the first year, metrics focused on diabetes (e.g., the percent of patients with a hemoglobin A1c level below 8 percent), hypertension, preventive care, and continuity of care. Payment levels are based on the degree of improvement within a practice, without regard to absolute performance or national benchmarks.
    • Payment for outcomes (tier three): Any participating practice that hits the 90th percentile among Medicaid plans for any of the metrics in tier two receives an additional payment. This tier also includes incentives for reducing ambulatory-sensitive inpatient admissions and ED visits (i.e., admissions or ED visits that could likely have been avoided through the provision of more proactive, coordinated outpatient care).
  • Ongoing performance feedback, learning, sharing of best practices: The plan provides additional support to participating practices by sharing performance data on the metrics outlined above and by sponsoring an ongoing learning collaborative in which participants share ideas and best practices. A formal learning center set up at CareOregon headquarters serves as a venue where experienced practice leaders conduct periodic learning sessions (usually every 6 weeks) in which participants learn about and share "best practices" and other lessons. On some days, more than 100 people attend these sessions. Process improvement coaches meet on a regular basis to go over plan-do-study-act (PDSA) cycles; they originally met on a biweekly basis with a consultant and now meet monthly on their own as part of an ongoing working group. CareOregon staff also continually research and share best practices with participating sites. For example, the plan's chief executive officer, a strong supporter of the initiative, traveled to Sweden on his own time and with his own resources to investigate how Swedish practices have adopted the medical home model.

Context of the Innovation

CareOregon, a nonprofit Medicaid managed care plan in Portland, serves 140,000 members. Operating since 1994, CareOregon serves enrollees in 16 counties, although 85 percent live in the Portland metropolitan area. One of 13 managed care organizations to administer the Oregon Health Plan (the state-mandated benefit plan for Medicaid beneficiaries), CareOregon receives a risk-adjusted per-member, per-month payment from the state to provide all medical needs (including pharmacy and durable medical equipment) for Medicaid beneficiaries, along with mental health services for dual eligibles. CareOregon's provider network is roughly evenly divided between commercial practices and safety net clinics, including Federally Qualified Health Centers and hospital-based clinics. CareOregon represents the largest payer for these safety net clinics but is a relatively small payer for the commercial clinics.

The impetus for this program began during the 2001 to 2002 recession, as CareOregon faced extreme budget pressure due to cutbacks in state Medicaid funding. At the same time, CareOregon's primary care provider network faced severe financial and time pressures due to low reimbursement levels, leaving them with few resources to provide coordinated, comprehensive care. To address this issue, CareOregon began an internal program in which plan staff identified members with the highest social and medical comorbidities and assigned teams of nurses, social workers, and health coaches to work with these individuals over the phone. The program proved successful, but CareOregon faced limits in terms of what they could do with internal staff over the phone. As a result, plan leaders became interested in developing a medical home model that could help the primary care system build the internal capacity to take on these tasks. In 2006, a delegation of 30 CareOregon leaders (including some board members) traveled to Anchorage, AK, to visit Southcentral Foundation's Alaska Native Primary Care Clinic, a clinic serving 46,000 Native Americans that had adopted the medical home model. After seeing the model in action—including stellar results such as a 50-percent reduction in per capita ED use, a 35-percent drop in hospital days, and a 65-percent decline in use of specialty services—these leaders returned believing it was the organization's moral obligation to adopt this model.1 In January 2007, implementation began with network physicians in five practices, including one serving a predominantly homeless population.

Did It Work?

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Early evidence suggests that the Primary Care Renewal program has helped participating sites to enhance access to care, improve performance on process and outcomes measures, and reduce inpatient admissions for ambulatory-sensitive conditions.
  • Enhanced access to care: Participating sites have reduced waiting times for an appointment. For example, the Old Town Clinic, which serves many homeless patients, reduced the average wait time for an appointment from 17 days to 3 days. Another clinic reduced missed appointments by 20 percent after calling chronic "no-shows" twice to remind them about upcoming appointments.4
  • Improved performance on process and outcomes measures: Overall, participating clinics have qualified for approximately 61 percent of payments related to metrics in tier two (improvement) and 9 percent for tier three (outcomes versus 90th percentile benchmark). Significant improvement has occurred in diabetes care, as outlined below:
    • Improved diabetes outcomes: The percentage of patients with diabetes who have blood glucose levels below 8 percent (indicative of reasonably good control of the disease) rose from 45 to 65 percent at the Multnomah County Health Department's Mid County Clinic (which used a phased-in adoption of the program).1 Information provided in November 2011 indicates that the percentage of diabetes patients in participating sites who have had their blood glucose tested within the past 6 months has risen from 64 percent in fourth quarter 2008 to 78 percent in second quarter 2010, and the percentage of diabetes patients with blood glucose levels below 8 percent has risen from 50 percent to 55 percent during this time period.
    • Driven by improved processes: The gains in diabetes outcomes have been driven by better adherence to evidence-based processes, such as regular blood glucose testing. For example, since implementing the program, Mid County Clinic has increased the percentage of patients with diabetes who were up to date on blood glucose testing to 91 percent. (Precise figures from before implementation are not available, although clinic leaders believe they were much lower.) Legacy Emanuel's internal medicine clinic has reduced the number of patients with diabetes who miss scheduled blood sugar tests by 26 percent since program implementation.4
  • Fewer hospitalizations for ambulatory-sensitive conditions: Between October 2006 and November 2008, inpatient admissions for ambulatory-sensitive conditions per 100,000 member months fell from roughly 160 to 140 in clinics participating in the program. By contrast, rates remained relatively flat during this time period for CareOregon overall and for clinics not participating in the program. The decline occurred in both acute and chronic ambulatory-sensitive conditions, although the decline was much steeper for acute conditions.
  • Reduction in total adult hospitalizations: Information provided in November 2011 indicates that, between January 2008 and October 2010, average inpatient hospitalization rates for adult Medicaid patients decreased by approximately 16 percent in the original implementing clinics and 18 percent in the clinics that later adopted the program; in contrast, clinics that did not adopt the program experienced no change in hospitalization rates.
  • Stable emergency department utilization: Information provided in November 2011 indicates that, between January 2008 and October 2010, emergency department utilization remained static for members in the clinics that adopted the program, compared to an 11 percent increase for members in non-adopting clinics.
  • Reduction in cost differential due to high-risk members: CareOregon Medicaid total cost per capita has increased over time for both the adopting and nonadopting clinics. However, historically, the costs for the higher risk members in the adopting clinics were significantly greater than for those in the nonadopting clinics. With the implementation of the program, the total cost for the higher risk members in the adopting clinics has decreased to the levels of the nonadopting clinic members.
  • High patient satisfaction: Information provided in November 2011 indicates that 61 percent of participating clinic patients surveyed would rate their patient care experience as a 9 or a 10 on a 1 to 10 scale.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics at participating clinics, including waiting times for appointments, missed appointments, blood glucose testing, blood glucose levels, and ambulatory-sensitive admissions.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Initial pilot site selection: CareOregon sent out a relatively simple request for proposal to network clinics to gauge their interest in adopting the essential features of the medical home model on a pilot basis (with at least one team). For those who expressed interest, CareOregon indicated a willingness to help fund the transition, including supporting training on process improvement.
  • Training for pilot sites: The five practices that expressed interest designated a care team that received training on process improvement using techniques that included the IHI PDSA improvement cycle and other models for improvement. Two staff members from each clinic received additional training, so that they could serve as internal quality improvement consultants within their respective practices.
  • Development of financial incentives: Initially, the program did not include any changes in the payment system, with CareOregon's support limited to providing practices with training and other process improvement assistance. However, program leaders soon realized that a different form of payment was needed to further encourage practices to add care managers and engage in important activities that traditionally have not been reimbursed, such as morning huddles to review the schedule, proactive outreach, etc. To that end, CareOregon brought together clinic leaders to develop a payment system to encourage ongoing management and improvement of population health. These sessions resulted in the development of the incentive system described earlier.
  • Site expansion: Since the program began, it has expanded to include 12 practices that collectively have put in place 50 teams. All sites that initially piloted the program with one team have expanded it throughout clinic operations, including for use beyond the Medicaid population.

Resources Used and Skills Needed

  • Staffing: Most participating sites have used a combination of existing staff and new hires to create the teams. The typical site has needed to hire one additional full-time equivalent staff, often a medical assistant or a behavioral specialist (although some sites provide training to existing social work staff to fill this latter role). Each team can handle a panel of 1,000 to 2,000 patients, depending on the acuity and needs of the population being served; the homeless, for example, have more needs, and thus panel sizes will be smaller for teams that serve them.
  • Costs: The costs of implementing the program for the sponsoring plan and the participating practices are not available. CareOregon leaders believe that any financial support and increased payments to participating sites will be more than made up for by cost savings due to reductions in inpatient admissions and ED visits.
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Funding Sources

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Tools and Other Resources

A video created by CareOregon describing this innovation can be viewed at

A Commonwealth Fund–supported report from the National Academy for State Health Policy summarizes the work of more than 30 states that have developed policies to promote use of medical homes for Medicaid and Children's Health Insurance Program enrollees and also provides examples of promising practices and lessons learned. The report is available at
. This page also provides links to other related reports and articles on medical homes.

Adoption Considerations

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Getting Started with This Innovation

  • Engage leaders: Transforming primary care practices can be quite difficult, with success requiring committed leaders who are willing to think about primary care in a new way. At the plan level, a similar rethinking is also required by leaders, as this model fundamentally changes the traditional role of paying claims and managing population health to a new role that focuses on supporting the delivery system in increasing its capacity to provide better care and manage population health.
  • Empower staff within practices: The sponsoring plan cannot prescribe specific changes but rather should lay out broad principles or a framework for the medical home model. Individual practices need to be empowered to figure out what works best in their communities for their populations. When given the opportunity, professional staff within clinics demonstrate amazing creativity in coming up with effective ways to serve their customers. CareOregon's leaders believe that this type of empowerment has been critical to the program's success, which has exceeded everyone's expectations

Sustaining This Innovation

  • Conduct ongoing research and refine model accordingly: Medical homes are a work-in-process. Those implementing them should stay abreast of the latest evidence and refine the model accordingly as new "best practices" and other lessons emerge.
  • Adapt to new populations: The core principles of the medical home model will be applicable outside of the Medicaid managed care population, but the specific aspects of the medical home might look different and thus should be adjusted accordingly based on the needs of the target population (e.g., the commercially insured).

Use By Other Organizations

CareOregon was recently named one of five organizations participating in a Commonwealth Fund regional demonstration project (called the Safety Net Medical Home Initiative) designed to spread use of this model; the program, which will bring together 15 practices in Oregon, was launched in July 2009.

More Information

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Contact the Innovator

David Labby, MD
Chief Medical Officer
Health Share of Oregon
208 SW Fifth Avenue, Suite 400
Portland, OR 97204
(503) 416-4965

Mindy Stadtlander, MPH
Program Manager
315 SW Fifth Avenue, Suite 900
Portland, OR 97204
(503) 416-1463

Innovator Disclosures

Dr. Labby and Ms. Stadtlander have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Miller J. Unlocking primary care: CareOregon's Medical Home Model. Managed Healthcare Executive. May 1, 2009. Available at:

Davis J. House calls. Available at: Jan 2009.


1 Miller J. Unlocking primary care: Care Oregon's Medical Home Model. Managed Healthcare Executive. May 1, 2009. Available at:
2 Pham HH, Ginsburg PB. Unhealthy trends: the future of physician services. Health Aff (Millwood). 2007 Nov/Dec;26(6):1586-98. [PubMed]
3 Mahon M. Second national scorecard on U.S. Health Care System finds no overall improvement; steep decline in access, scores on efficiency especially low. The Commonwealth Fund. July 17, 2008. Available at:
4 Davis J. House calls. 2009 Jan.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 18, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: December 18, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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