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South Carolina medical home pilot for diabetes enrolls 1,110

A patient-centered medical home pilot project that could become a model for South Carolina has completed its first quarter with 1,110 patients enrolled.

It's also attracting the attention of South Carolina physicians not involved in the program, and businesses in the state are interested in it as a means of managing their healthcare costs.

The project, a year-long collaboration started in April, focuses on diabetic patients who are members of Blue Cross Blue Shield of South Carolina, BlueChoice HealthPlan of South Carolina and the State Health Plan and who are patients of Palmetto Primary Care Physicians in the Charleston area.

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Patient-centered medical homes are designed to integrate quality improvement, coordinated care management and patient educational services into primary care practices. The concept places the primary care doctor in charge of a team that can include social workers, pharmacists, wellness coordinators, nurses, disease managers, certified educators, dieticians and pharmacists, all working together to develop an individual treatment plan for patients.

In the first three months of the South Carolina program, case managers hired for the project have contacted 60 percent of the eligible patients to explain the concept, gather baseline health data and encourage them to use an online portal that contains tools that help manage their disease and enable them to have "e-visits" with a physician.

The case managers aim to reduce gaps in care, such as missed appointments with specialists, and lifestyle issues such as medication adherence. They also perform outreach, such as registering patients for diabetic education, scheduling appointments with specialists, providing discount vouchers for medications, offering discounted memberships to local gyms and monitoring quality processes and outcomes measures to help increase patient compliance.

"Our case managers have been calling patients who are eligible for the pilot project, and the patients absolutely love it," said Jennifer O'Donnell, director of quality improvement for Palmetto Primary Care Physicians. "We've been able to provide patients with additional resources and education. Furthermore, we are able to encourage patients to make diet and exercise changes as well as schedule appointments for their concerns before the problem gets worse,"

There is no copayment or extra charge to the patients for participation in the pilot.

Laura Long, Blue Cross' vice president of clinical quality and health management, and Kirt Caton, from Palmetto Primary Care Physicians, addressed the South Carolina Academy of Family Physicians at a meeting in Litchfield Beach, S.C., on Saturday.

"As the debate continues nationally about healthcare reform, we're already on the cutting edge with this new look at delivering healthcare," Long said. "We've been invited to address a number of meetings of business and medical societies."

"The goal is to reduce the disconnects in healthcare, improve quality of life for the patient, create tighter relationships and better communications and add for the first time a focus on measurement of quality and continuous improvement of clinical outcomes," said David L. Castellone, MD, president of the Palmetto Primary Care Physicians board of directors. "We're pleased to work with Blue Cross, BlueChoice HealthPlan and the State Health Plan and their diabetic members in this pilot and believe this could be a state model,"