Table 2

PCMH demonstrations reporting outcomes in diabetes care

PCMH demonstrationStartSizeImprovementsKey transformation features
Community Care of North Carolina19981,200 practices; 3,000 physiciansImprovements in A1C, blood pressure, and LDL cholesterol control (29); all three measures were above the NCQA target benchmarks. Reductions in emergency room and inpatient admissions; reductions in outpatient and pharmacy utilization (29)Care coordination assisted by care managers; (Medicaid) – Single payer; PMPM fee; regular reporting of quality measures; community health networks
Geisinger Health System200625 outpatient practice sites; 110 physiciansImprovements in the diabetic bundle (9 evidence-based quality indicators of diabetes care) (19). Reduction in inpatient admissions and total medical costs (33)Care coordination assisted by care managers; single payer; monthly payments per physician; monthly infrastructure payments; performance-tied bonus payments; regular reporting of quality measures; patient registry; patient access to EHR
Pennsylvania Chronic Care Initiative2008102 practices; 518 physiciansImprovements in A1C, blood pressure, and LDL cholesterol control in the first year (35)Care coordination assisted by care managers; multipayer; infrastructure payments based on NCQA certification; regular reporting of quality measures; patient registry; practice coaches; learning collaborative
Rhode Island Chronic Care Sustainability Initiative200813 practices; 53 physiciansImprovements in A1C documentation, blood pressure control, and smoking advice documentation 6 months after begin of the initiative (36)Care coordination assisted by care managers; multipayer; PMPM fee; care management reimbursement; regular reporting of quality measures; patient registry; practice coaches; learning collaborative
Group Health Cooperative Medical Home Pilot20071 Seattle clinic serving 9,200 adult patientsImprovement in the composite quality score in the first and second year (38). Improved patient satisfaction; reductions in emergency room and inpatient admissions; return of $1.5 for every dollar invested in the PCMH after 21 months (38)Care coordination assisted by care managers; single payer; no reimbursement change; reduction of physician panel size; regular reporting of quality measures; patient registry; daily care team huddles to plan day, address problems and root cause analysis
Health Partners Medical Group, Minneapolis2002600 physicians; 50 clinicsImprovements in A1C, blood pressure, LDL cholesterol, aspirin use and tobacco cessation (40). Reductions in inpatient admissions and readmissions; clinic cost savings (40)Care coordination assisted by care managers; single payer; change from salary to productivity based physician payments; regular reporting of quality measures; patient registry; learning collaborative
Colorado PCMH Pilot200917 practicesImprovements in A1C, LDL cholesterol and blood pressure control (42); all measures above NCQA quality benchmarks including tobacco cessation and depression screening. Reductions in emergency room and inpatient admissions; improved patient satisfaction; improved healthcare worker satisfaction (42)Care coordination assisted by care managers; multiple payer; PMPM fee; pay-for-performance payments; regular reporting of quality measures; patient registries; practice coaches; learning collaborative
The PCMH National Demonstration Project200636 practicesImprovements in chronic illness care quality (44). No improvements in patient experience; practice coaches helpful in adopting more Medical Home features (44)Care coordination; regular reporting of quality measures; patient registry; improved access; practice coaches; learning collaborative
  • PMPM, per-member-per-month.