The Colorado Multipayer Patient-Centered Medical Home Pilot, which ran from May 2009 through April 2012, was one of the first voluntary multipayer medical home pilot projects in the country. Six health plans, the state's high-risk pool carrier, and sixteen family or internal medicine practices with approximately 100,000 patients participated. Although a full analysis is currently under way, preliminary results show that the pilot significantly reduced emergency department visits and also reduced hospital admissions, particularly for patients with multiple chronic conditions. One payer reported a return on its investment of 250-400 percent in the pilot. However, participants also ran into numerous obstacles. Among them: Many practices were left providing extra services to a large fraction of patients whose employer-sponsored insurance plans declined to pay the enhanced fees necessary to cover the cost of the patient-centered medical home expansion. The experience demonstrates that creating patient-centered medical homes and enabling them to be successful will take strong commitments and collaborative efforts on multiple fronts.

An increasing proportion of the U.S. population resides in nursing homes (NHs). No surveillance system exists for infections in these facilities. To determine the incidence and types of infections in NH residents, and to identify predictors of death among residents with infections, we initiated a surveillance system at 13 NHs in California during a 6-month period from October 1989 through March 1990. The study included 1754 residents, among whom 835 infections were identified during the study period. The most common infections were urinary tract infections (UTIs; 286, 34.2%), respiratory tract infections (RTIs; 259, 31%), and skin infections (150, 17.9%). Of the 259 residents with respiratory tract infections, 69 (27%) had pneumonia. Antimicrobials were prescribed for 646 (77%) of the infectious episodes. Residents with pneumonia were more likely to die than residents with other infections (4 of 69 versus 12 of 766; P = 0.04). Symptoms of altered body temperature (fever, hypothermia, chills) and change in mental status also were associated with an increased risk of a fatal outcome (10 of 260 versus 6 of 575; P = 0.01) and (7 of 127 versus 9 of 708; P = 0.004). This study suggests that the most common infections among NH residents are UTIs, RTIs, and skin infections. Pneumonia, symptoms of fever, and mental status changes all were associated with increased mortality. The frequency of infections among NH residents and their impact on resident outcome highlights the need for infectious disease surveillance in this population.

Primary care must be reengineered to improve outcomes and affordability. To achieve those goals, WellPoint invested in ten patientcentered medical home pilots that encourage care coordination, preventive care, and shared decision making. Two of the three pilots described in this article-in Colorado and New Hampshire-layer incentive payments for care coordination and quality improvement on top of a traditional fee-for-service payment. The third-in New York-pays doctors an enhanced fee that is tied to achievement of quality levels. Preliminary evaluations show encouraging signs that the Colorado and New Hampshire pilots are meeting some cost, utilization, and quality objectives. A full evaluation in all three states is ongoing. To help enable systemwide transformation, WellPoint is now applying similar payment strategies to primary care practices that may not have the resources to become full-fledged medical homes.

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