TransforMED and Collaborative Partners VHA and Phytel Begin Implementation of Patient-Centered Medical Neighborhood Demonstration Project

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Collaborative effort aims to improve care at lower costs for approximately 157,000 patients in up to 15 health systems and provider organizations nationwide

We are going to create the ideal situation for our nation’s health care system through this award, by building these medical neighborhoods on a strong foundation of transformed PCMH primary care practices.

About 157,000 Medicare and Medicaid beneficiaries in up to 15 health systems and provider organizations across the nation will begin participating in a Patient-Centered Medical Neighborhood (PCMN) demonstration project as part of a collaboration among TransforMED, Phytel and VHA Inc.

Funded by a three-year, $20.75 million cooperative agreement awarded by the Center for Medicare and Medicaid Innovation (Innovation Center), the PCMN project is scheduled to begin implementation this month.

This award is part of the Health Care Innovation Awards program, a Department of Health and Human Services initiative investing up to $1 billion to test promising new approaches that aim to improve health care and lower program costs for recipients of Medicare, Medicaid and the Children’s Health Insurance Program (CHIP).

TransforMED, VHA and Phytel will support up to six primary care practice transformation efforts within each participating community to create or continue development of Patient-Centered Medical Homes (PCMHs) into Patient Centered Medical Neighborhoods (PCMN). PCMHs connect primary care with other community-based health care providers to develop the “Patient-Centered Medical Neighborhood” concept. Designed to improve and strengthen collaborative relationships among primary care practices and other providers such as hospitals and specialists, the PCMN builds on proven methodologies and solutions to create more efficient, coordinated health care delivery networks that improve care at a lower cost.

The collaborative PCMN project plans to achieve the following goals by year three of the demonstration:
•Decrease overall health care costs by $49.5 million within the 15 communities
•Improve the health of the eligible patient population by a 15 percent average in selected quality measures
•Achieve a 25 percent improvement in the patient experience
•Extend Patient-Centered Medical Home and Patient-Centered Medical Neighborhood learning within each of the 15 communities

Health care organizations currently participating in the PCMN demonstration project are:
•Avera St. Anthony’s Hospital, O’Neill, Neb.
•Charleston Area Medical Center, Charleston, W.Va.
•Columbus Regional, Columbus, Ind.
•Greater Baltimore Medical Center, Baltimore, Md.
•Huntsville Hospital, Huntsville, Ala.
•INTEGRIS Health, Oklahoma City, Okla.
•Marquette General Health, Marquette, Mich.
•Northeast Georgia Health System, Gainesville, Ga.
•North Mississippi Health Services, Tupelo, Miss.
•North Shore Physicians Group, Salem, Mass.
•Novant Health, Winston-Salem, N.C.
•Orlando Health, Orlando, Fla.
•Owensboro Medical Health System, Owensboro, Ky.
•Via Christi Health, Wichita, Kan.
•Western Connecticut Health Network, Danbury, Conn.

The collaboration will leverage TransforMED’s PCMH primary care expertise with Phytel’s population health management solution to identify and automate care gaps, patient outreach, care management, patient engagement, and performance evaluation. VHA will bring expertise in clinical quality improvement and knowledge transfer strategies. This potent combination is expected to yield significant improvements in clinical integration and clinical outcomes at lower costs.

TransforMED CEO Terry McGeeney, MD, MBA, FAAFP, who will serve as the project's executive sponsor, said: “It’s a great time to be a primary care physician, and we are eager to get started on this exciting project. We are going to create the ideal situation for our nation’s health care system through this award, by building these medical neighborhoods on a strong foundation of transformed PCMH primary care practices that will align with the health systems and specialists to ensure that care is comprehensive, coordinated and managed throughout the communities.”

“The concept of the Patient-Centered Medical Neighborhood has enormous potential to provide a template for effective care delivery that health care providers nationwide can replicate in their communities as they progress in their journey to achieve efficient population health management,” said Peggy Naas, MD, MBA, VHA vice president for physician services.

Steve Schelhammer, CEO of Phytel, commented, "We are eager to demonstrate for health care organizations in communities across the U.S. that population health management, when done right, can ensure all of their patients receive appropriate care and are fully engaged in disease and illness prevention.”

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About TransforMED
The Leawood, Kan.-based TransforMED is a wholly-owned subsidiary of the American Academy of Family Physicians. Established in 2005, TransforMED provides ongoing consultation and support to physicians looking to transform their practices to a new model of care that is based on the concept of a Patient-Centered Medical Home. TransforMED is an active member of primary care communities and recognizes and supports the unique value that primary care offers to patients and the health care system. TransforMED shares and supports the idealism and altruism of primary care physicians and the strong commitment to their communities and patients through continuing patient relationships and independent decision making. TransforMED offers practices both products and services, including consultation and advice on implementing the patient centered medical home model. To learn more about TransforMED, visit Follow us on Twitter and find us on Facebook.

About VHA Inc.
Founded in 1977 and based in Irving, Texas, VHA Inc. is a national network of not-for-profit health care organizations that work together to drive maximum savings in the supply chain arena, set new levels of clinical performance, and identify and implement best practices to improve operational efficiency and clinical outcomes. VHA leverages its expertise in analytics, contracting, consulting and networks to help its members achieve their operational, clinical and financial objectives. In 2011, VHA delivered record savings and value of $1.9 billion to members. VHA serves more than 1,350 hospitals and more than 72,000 non-acute care providers nationwide, coordinating delivery of its programs and services through its 14 regional offices. VHA has been ranked as one of the best places to work in healthcare by Modern Healthcare since the publication introduced this list in 2008. For more information, visit and follow us on Twitter.

About Phytel
The premier company empowering physician-led population health improvement, Phytel provides physicians with proven technology to deliver timely, coordinated care to their patients. Phytel's state-of-the-art registry, which now encompasses more than 20 million patients nationwide, uses evidence-based chronic and preventive care protocols to identify and notify patients due for service, while tracking compliance and measuring quality and financial results. For more information, please visit Follow us on Twitter and find us on Facebook.

The project described is supported by Funding Opportunity Number CMS-1C1-12-0001 (the “FON”) from the Department of Health and Human Services (“HHS”), Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation (“CMS”). Pursuant to said FON, TransforMED and CMS have entered into a cooperative agreement to explore the development of new models for the delivery of better health, better health care and lower costs through improved quality for Medicare, Medicaid and Children’s Health Insurance Program (“CHIP”) enrollees. The project executed pursuant to the cooperative agreement shall not restrict the freedom of choice of providers/services for Medicare, Medicaid and/or CHIP patients in fee-for-service (“FFS”) plans. The project contents are solely the responsibility of TransforMED and its project affiliates, Phytel and VHA Inc., and do not necessarily represent the official views of HHS or any of its agencies.

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