NJ FQHC Medical Home Pilot

Region Within State: 
Hudson County
Project Category: 
Multi-Stakeholder
PROJECT STATUS
Target Start Date: 
Tuesday, February 16, 2010
Pilot/Demo Length: 
3 years

As a Federally Qualified Health Center, we are charged with providing care to those who may not be able to afford it, but who may need it the most. This particular population is at an increased risk of adverse outcomes. They also contribute to a significant number of emergency room visits in Hudson County. Our goal, in establishing a patient centered medical home is to be able to provide our constituents with all the resources they need to manage their care. Through improved coordination and communication with patients we hope to involve them more in their care. Through the use of electronic medical records and community wide data sharing we hope to be able to treat each of our patients more efficiently and more effectively. As our center services the breadth and depth of our population, we are uniquely positioned to serve the entire family unit. They can each receive services and support in a single location, and be able to receive care coordination a single team if they so choose. Our hypothesis is can we improve the quality of the care the patient receives through measurable metrics? Can we demonstrate improved communication both with patients and accross provider networks? Can we diminish the need for high cost services in Hudson County? Is this a model that can become self sufficient under these conditions and payment structures? We propose that with this combination we will be able to provide better care at a better value, significantly diminishing the need for high cost services such as emergency room visits, and we will use the pilot to demonstrate it and to transform care.

Type of Practices: 
Other
CONVENING ENTITY/PROJECT CONTACTS
Convening Organization Name: 
Horizon Health Center, Inc.
Primary Contact: 
Arlene Simon
E-mail: 
asimon@horizonhealth.org
Phone: 
201-209-2306
Participating Stakeholders: 

New Jersey Department of Health and Human Services; HRSA; Maternal and Child Health Consortium; Medicare; Medicaid; Americhoice; Amerigroup; New Jersey Health, Aetna, United Healthcare; Jersey City Medical Center, Bayonne Medical Center; Newark Beth Israel; Hoboken Hospital; Christ Hospital; University of Medicine and Dentistry in NJ.

Participating Organization Types: 
community centers, hospital, private and public payors, government and private entities
EXPECTED OR ACTUAL DEMOGRAPHICS OF PARTICIPATING PRACTICES
Number of Practices: 
3
Number of Participating Physicians: 
17
Physicians per practice: 
3-11 providers
Types of Practices: 
Internal Medicine, Family Medicine, OBGYN, Pediatrics, Dental
Health Plan Lines of Business Included: 
Private and Public Payors
Overall Number of Covered Lives: 
20000
Technology Characteristics at Start of Pilot: 

% of practices with practice management system 100% % of practices with EMR 100% % of practices with registry software 100% 100% of sites have e-prescribing, communicate with patients using email and text, have a secure patient portal.

Consumer Involvement: 

Patients will be involved in their choice of physicians. They will also participate in evaluating how well the PCMH has met its objectives.

PRACTICE TRANSFORMATION SUPPORT (INCLUDING TECHNOLOGY)
Focal areas of transformation: 

A new more robust platform is being developed to further improve patient access.

Services participating practices have added as a result of their participation: 

Sites have added a director of quality, care coordinators, patient navigator and other staff members

Technology that participating practices have added as a result of their participation: 

e-prescribing, communicating with patients using email and text, as well as through the use of a secure patient portal.

Payment Model: 

Fee for service for patient visits, plus an overall management fee, plus incentives for specific performance measures.

PROJECT EVALUATION
Types of data to be collected : 

Data collection will focus on 3 key areas; Maximization of access to care; effectiveness of rendered care, effectiveness of communication; and minimization of cost.

Which of the data types are being shared?: 

Clinical, Quality and performance Data

Are the practices involved in the demonstration participating in any data sharing arrangements? If so please describe.: 

Yes, we have recently began sharing clinical data with a partner hospital in an initial exchange pilot project that facilitates the exchange of provider, patient, and hospital information with Federal Qualified Health Centers using a shared clinical repository to its physicians, patients and facilities. Insurance providers and the state legislature are also involved in the demonstration.  We expect to leverage the.  regional HIE recently funded by the ONC to reach an additional 7 facilities with similar interoperable sharing

Results to Share: 

no data to date

Relevant links: 

http://www.horizonhealth.org