1. Using traditional research to detect a "statistically significant" decrease in insurance claims expense is notoriously difficult.

2. Theres scientific statistical proof and then there is a reasonable business assurance.  The latter may be enough for business-minded health insurers.

3. The conclusion is based on published research.  Unpublished "in house" data have convinced many insurers to include the medical home in their covered benefit.  They know something AHRQ doesnt.

4. While medical homes alone may be insufficient to save money, that doesnt mean that medical homes that are part of a package of interventions (value-based purchasing, P4P, vendor-based population health management or an ACO) are unnecessary.

5. While there is no evidence of savings, there is also no consistent evidence of increased cost. That means the quality associated with the medical home represents high value.

That being said, the U.S. Agency for Healthcare Research and Quality (AHRQ) Evidence Report Technology Assessment on the Patient Centered Medical Home says:

"Based on a combination of good- and fair-quality studies, there is a low strength of evidence that PCMH implementation may lead to lower utilization (inpatient and emergency department) for some subgroups of patients, but this effect was not uniform. Moreover, total costs were not lowered in the reviewed studies.

However, three observational studies specifically designed to test PCMH do report lower inpatient and emergency department utilization among patients in the PCMH program. However, total costs were not statistically different for PCMH and non-PCMH patients in the three studies. None of the clinical trials of functional PCMH interventions had statistically significant differences between intervention and control arms for inpatient or emergency department utilization.

No studies reported statistically significant cost savings among PCMH patients. In fact, when taking into account program costs, two studies, one good-quality trial and one fair-quality observational study, reported greater total costs among intervention patients."

 Image from Wikipedia

Months ago, the caffeine-addled Disease Management Care Blog reviewed with the spouse how to pre-set the kitchen coffee brewer for a pot of fresh coffee for the next morning. After listening politely to its earnest instructions, the DMCB spouse rarely set up the brewer.

Which is why the DMCB wasnt surprised by an Iowa Chronic Care Consortium (ICCC) study of how its newly minted medical home coach trainees were being deployed in the real world. The ICCC is a not-for profit organization that was founded in 2002 and offers a training program that prepares health professionals to be members of a medical home team.
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The Consortium surveyed 318 graduates from their program. Of that number, there were 164 responses, yielding a 54% response rate. 83% of the respondents were nurses, while the remainder were medical or office assistants, diabetes educators, dietitians, social workers, physicians, pharmacists or administrators.
 
The good news is that care-management caffeine was available. The majority of respondents reported that they were using their skills to coach patients for self management, care coordination, planning visits and supporting registry use.  The majority also found their work professionally rewarding.

The bad news is that these professionals were not being supported for maximum effect:

55% were still "building support for the position."

48% reported that "office work" was given a "higher priority," often due to physician and administrator resistance.

73% reported that their coaching duties were part time and was in addition to their more traditional roles.

Only 8% were involved in office "change management."

Only 11% enjoyed a pay differential that rewarded their coaching skills.

The Consortiums paper concludes - paralleling the DMCBs coffee-making travails - that a good idea accompanied by well-meaning training is not enough to overcome established clinic routines, business roles and local culture.  The authors recommend that provider payments "change," coaching functions be "operationalized," training programs be "advanced," outcomes be "demonstrated" and that roles be "clarified."

While the DMCB ponders coffee change, operations, advances, demonstrations and clarifications, the DMCB has a far more more fundamental concern for the medical home:

With friends like this, the fledgling medical home movement doesnt need any enemies.

If the clinics that took the time and the money to train these individuals are unable to leverage their skills, disappointing outcomes could end up snatching usual care from the jaws of primary care clinic transformation.

The DMCB has three recommendations:

History Repeats: Years ago, established "disease management" companies had to go on record and oppose start-ups that were offering "faux" telephonic patient counseling programs. The medical home and population health management community, including the PCPCC, likewise cant afford to have clinics going to market with diluted medical home programs that deliver empty process instead of hard outcomes.  All health care is local, and much of the buy-in for the medical home will ultimately be won or lost at that level.  Speak up!
 
Buyer Beware: Payers and insurers need to be wise to the possibility that having a trained health coach on staff with credentials is not the same as having a health coach on line with the patients. On site credentialing may be in necessary that includes review of policies, job descriptions, pay scales and staff interviews.

Build or buy: Primary care clinics need to know that when they buy patient counseling services from a population health management vendor, you get full time on a plug and play basis. That may be a better option for a clinic that is not prepared to both train and fully use an on-site health coach.

Vincent Scordo is the proprietor of Scordo.com, a fabulous blog about Italian American cooking. Check out his Pasta Challenge, which is more than sufficiently awesome.

As Ive said in the past, eating out/ordering in is a colossal waste of money, and beyond the occasional breakdown or special night out I tend not to reach for the Chinese take out menu or make reservations at our local restaurant. My other rationale for not eating out is that I simply will not get the same quality food at 95 percent of the restaurants in our immediate area (including New York City). Im not a trained Chef, but outside some extraordinary restaurants in New York, Ill take a simple meal prepared at home, with high quality ingredients, over a mediocre restaurant experience. Eating well at home is not rocket science, and moreover, you dont always need to purchase exotic ingredients to make tasty dishes. (The ingredients need to be high quality, but they shouldnt break the bank).

Here are 4 ingredients that can help you eat cheap and well for as long as our recession lasts:


From Flickrs Minimalist Photography


2. Tuna in Olive Oil
I always keep between 3-4 cans of Italian tuna in olive oil stocked in my kitchen. My ideal tuna sandwich consists of one can of tuna (do not discard the oil!) with salt and pepper on toasted whole wheat bread. You can also add some fresh parsley and a few slices of tomatoes if theyre in season. (Try it without the mayonnaise, I swear youll like it.)

3. Pasta and Rice
My pasta and rice arsenal includes: thin linguine, angel hair or capellini, linguine, rigatoni, penne rigate, pastine, soba noodles, arborio rice for risotto, Carolina rice, brown rice, jasmine rice, and whole wheat couscous. Having the aforementioned pasta and rice on hand at all times gives you limitless possibilities, including: linguine with olive oil, parsley, and garlic, baked rigatoni with tomato sauce, mozzarella, and Parmigiano-Reggiano, soba noodles stir fried with green peppers, chicken breast, and onion, brown rice with ginger, cilantro, and cracked black pepper, couscous with feta, red onion, cucumber, and olive oil, etc.

4. Whole Chicken
Buying a whole, free range, chicken is the equivalent to getting the deal of a lifetime. A whole chicken gets you two types of meat (dark and white) as well various parts which translate into various types of dishes. I purchase a whole, free range, chicken every other week and butcher the chicken according to my perences. If Im interested in making a whole roasted chicken, Ill simply leave the bird as is and make a rub mixture with lemon zest, salt and pepper, rosemary, and olive oil. If I have a little more time on my hands Ill butcher the bird into nine pieces and freeze the parts for various dishes throughout the week, including: braised chicken thighs with fresh mint, breaded and baked drumsticks and wings, thinly pounded chicken breast with shitake mushrooms and sherry wine, etc.

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If you like this article, check out:

• The 10 Cheapest, Healthiest Foods Money Can Buy
• 10 Ways to Eat Less Meat
• Touch of Class: 10 Thrifty, Healthy Ingredients to Improve the Quality of Your Meals

Perhaps you bent the wrong way while lifting something heavy. Or youre dealing with a degenerative condition like arthritis. Whatever the cause, once you have low back pain, it can be hard to shake. About one in four Americans say theyve had a recent bout of low back pain. And almost everyone can expect to experience back pain at some point in their lives.

Chill it. Ice is best in the first 24 to 48 hours after an injury because it reduces inflammation, says E. Anne Reicherter, PT, DPT, PhD, associate professor of Physical Therapy at the University of Maryland School of Medicine. "Even though the warmth feels good because it helps cover up the pain and it does help relax the muscles, the heat actually inflames the inflammatory processes," she says. After 48 hours, you can switch to heat if you per. Whether you use heat or ice -- take it off after about 20 minutes to give your skin a rest.
Keep moving. "Our spines are like the rest of our body -- theyre meant to move," says Reicherter. Keep doing your daily activities. Make the beds, go to work, walk the dog. Once youre feeling better, regular aerobic exercises like swimming, bicycling, and walking can keep you -- and your back -- more mobile. Just dont overdo it. Theres no need to run a marathon when your back is sore.
Stay strong. Once your low back pain has receded, you can help avert future episodes of back pain by working the muscles that support your lower back, including the back extensor muscles. "They help you maintain the proper posture and alignment of your spine," Reicherter says. Having strong hip, pelvic, and abdominal muscles also gives you more back support. Avoid abdominal crunches, because they can actually put more strain on your back.
Stretch. Dont sit slumped in your desk chair all day. Get up every 20 minutes or so and stretch the other way. "Because most of us spend a lot of time bending forward in our jobs, its important to stand up and stretch backward throughout the day," Reicherter says. Dont forget to also stretch your legs. Some people find relief from their back pain by doing a regular stretching routine, like yoga.
Think ergonomically. Design your workspace so you dont have to hunch forward to see your computer monitor or reach way out for your mouse. Use a desk chair that supports your lower back and allows you to keep your feet planted firmly on the floor.
Watch your posture. Slumping makes it harder for your back to support your weight. Be especially caul of your posture when lifting heavy objects. Never bend over from the waist. Instead, bend and straighten from the knees.
Kick the habit. Smoking can increase your risk for osteoporosis of the spine and other bone problems. Osteoporosis can lead to compression fractures of the spine. One study found that smokers are about a third more likely to have low back pain compared with nonsmokers.
Watch your weight. Use diet and exercise to keep your weight within a healthy range for your height. Being overweight puts excess stress on your spine.
Try an over-the-counter pain reliever. Anti-inflammatory drugs such as ibuprofen (Advil, Motrin), naproxen (Aleve, Naproxyn), and aspirin can help reduce back pain and swelling. Acetaminophen (Tylenol) is another over-the-counter option for pain management. Be sure to check with your doctor or pharmacist about any interactions over-the-counter pain relievers may have with other medications you are taking. People with a history of certain medical conditions (such as ulcers, kidney disease, and liver disease) should avoid some medicines

Tangzhong or roux method give a soft bread,the texture of the bread coz of the water roux aka tangzhong makes cotton like bread and stays pect for more than 2 days in room temperature. But am sure that this bread gets vanished very quickly coz of the presence of chocolate in it.To make the “tangzhong” or “water roux,” a mixture of water and bread flour is heated and stirred just until it forms a paste.  Then, this paste is removed from the heat and allowed to cool, and added to the dough ingredients.  When the water and flour first combine, the flour absorbs the liquid.  Once heat is applied, the flour particles swell many times their original size and burst, releasing starch into the liquid.  At that point, the mixture will turn like gel.This gel like flour paste can then be used as a dough enhancer to improve the moisture and texture in the final bread loaf.Breads prepared by this roux method doesn’t get stale and hard like other breads within a day of baking, it will stays soft and fluffy for several days.

Coming to this marble Asian bread, Manjula of Desi Fiesta chosed this chocolate marble bread for this months Home Bakers Challenge as the challenge of this month are breads.This eggless chocolate marble Asian bread goes for easy preparation and they can be done easily through bread machine or manually. This bread with mild sweetness suits pect for breakfast or for snacks. Enjoy this softy bread with your cup of tea or coffee for your breakfast and am sure you will have a filling breakfast.Sending to Bake fest hosted by Manjula,event by Vardhini.



Recipe Source: Simple Recipes
Water roux:
1/3 cup bread flour
1 cup water

For dough:
2+1/2 cups bread flour
2 tbsp sugar
1/2tsp salt
3tbsp Milk powder
100 ml Water + 2 tablespoons water
1+1/2tbsp Unsweetened cocoa powder
1+1/2tsp Instant yeast
2tbsp  Butter

Water roux or tangzhong:
In a small pan, mix all the ingredients of water roux, place in a low heat and stir constantly, cook until ripples form.

Set aside to cool by covering with a plastic film.

Dough:
In a bowl, add the water roux, and all the other ingredients, except for the butter, water and cocoa powder.
knead it until it forms soft dough.

Add the butter and  knead until the butter incorporates into the dough.

Divide the dough in approximately 2/3 and 1/3 portions. Remove the small portion and set aside by covering with a cling film.

Knead the bigger portion until the dough is smooth and elastic. Set aside in a bowl by covering the dough with a cling film.

Take back the small portion and knead it again and add cocoa powder and water as needed and knead until the dough is smooth and elastic.

Cover the chocolate dough and set aside in a bowl by covering with a cling film.Let both dough proof until the dough doubles to its original size.

Knock back both dough and let it rest for 5 minutes on the counter, cover both dough.


Flatten the chocolate dough into a rectangle shape of approximately 6 x 9 inches and the white dough to 12 x 6 inches.

Layer the chocolate rectangle in between the white rectangle. Flatten the rectangle and cut in 2 equal portions. Layer one piece on top of the other and flatten again.

Repeat this procedure 3-4times.

Then again cut into 3 equal strips. Gently roll the strips and place 3 together and make a braid.

Place the braided bread in the loaf tin. Cover the tin with plastic film and let them rise in a warm place until the dough has almost tripled its original size.

Meanwhile, preheat oven at 350 F.Bake the tin for approximately 20 minutes.

Remove from the oven and brush with melted butter.

Transfer the bread to a wire rack to cool.

Slice and enjoy with your favourite spread.

"Hello, Dr. Smith? This patient has a fever..."

Read this New England Journal Perspective by Drs. Ouslander and Berenson on Reducing Unnecessary Hospitalizations of Nursing Home Residents, and its easy to conclude that the enlightened application of better documentation, quality assurance, payment orm, administrative policies, decision support, guidelines, appropriate downjobbing and delegation of responsibility will keep many sick and feverish nursing home residents away from the unnecessary expense of emergency rooms and hospitals.

Were that it was so simple.  Such is the unreality of many Journal authors inhabiting the oxygen-deprived academisphere.

When residents of nursing homes get sick, they require a significant amount of nursing attention.  Since busy, salaried (and sometimes understaffed) nursing home personnel arent compensated for the additional work of documenting, monitoring and worrying about that sick patient down the hall, they have every incentive to transfer sick patients elsewhere.  No amount of macroeconomic policy making bells and whistles is likely to change that.

When physicians and other non-physician providers are alerted by the nursing home personnel that a patient is sick, they have been taught that the best approach is to evaluate the patient in person. That takes time and effort.  While they may be compensated for the additional work of a bedside evaluation, its not enough to make up for the additional work of documenting, monitoring and worrying about that sick patient down the hall.  So, they also have every incentive to agree with the nurse and transfer the patient to a setting where a bedside evaluation is available.  At 2 AM, the answer is to move that bedside to the local emergency room.

Would the bells and whistles that Ouslander and Berensen be enough to keep the nursing homes and the doctors from sending most sick patients to the emergency room?  Based on the simple realities described above, the answer is no.