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Susquehanna Health and Blue Cross of Northeastern Pennsylvania Launch Patient Centered Medical Home Pilot

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December 19, 2013
Pictured left to right are members of the Patient Centered Medical Home pilot project team: Margie Andrews, RN, Manager, Health Improvement, BCNEPA; Lisa Baskin, RN, Nurse Navigator, Susequehanna Health; Belinda Gregory, RN, Nurse Navigator, Susquehanna Health; Nina M. Taggart, Vice President of Clinical Operations and Chief Medical Officer, BCNEPA; David Lopatofsky, MD, Associate Vice President, Susquehanna Health Medical Group; Susan Heilmann, RN, Nurse Navigator, Susquehanna Health; and Stuart Gitomer, Senior Director, Health Care Informatics, BCNEPA

In an effort to enhance quality and better manage health care costs, Susquehanna Health (SH) and Blue Cross of Northeastern Pennsylvania (BCNEPA) have joined together to launch a Patient Centered Medical Home (PCMH) pilot program with Susquehanna Health Medical Group’s (SHMG) primary care physician practices in Lycoming and Clinton Counties.

The PCMH model is part of the evolution of the health care industry toward accountable care and the transformation of regional health delivery to meet the Institute for Healthcare Improvement (IHI) Triple Aim goals:

  • improving the health of the population (quality and safety)
  • improving the patient experience (satisfaction with care provided)
  • reducing the cost of health care (better value for the community)

The BCNEPA/SHMG pilot program will seek to meet these goals by ensuring that the care patients are receiving meets national quality measures in areas such as childhood immunizations, cancer screenings, diabetes testing and cholesterol management.

As part of the pilot program, BCNEPA will support SHMG primary care physicians in making necessary office and technology improvements, and will help facilitate the integration of care coordinators into the practice.  The care coordinators will work with all of SHMG’s 45,617 patients, regardless of insurance coverage, making this program unique to other PCMH programs.

“The care coordinators are a key component of this program,” said Nina M. Taggart, MD, Vice President of Clinical Operations and Chief Medical Officer for BCNEPA.  “They will be in the physician offices working with patients every day to make sure they are getting the right care at the right time for the best outcomes.”

BCNEPA’s Blue Health Solutions?Care Managers will also have access to the same tools and reports as on-site SHMG staff, meaning they can work together to manage the patient’s care needs.  This coordination will allow for better care management of all patients, regardless of health status, including those patients with chronic diseases such as diabetes, asthma and heart disease.

“In a patient-centered medical home, each patient has an ongoing relationship with a personal physician who leads a team of healthcare professionals who are accountable for all the patient’s healthcare needs,” says Dr. William McCauley, President of Susquehanna Health Medical Group.  “Care for the patient is coordinated and based on evidence-based medicine and clinical decision-support tools.  Just as importantly, it includes shared decision-making with patients and families.”

The pilot program launched on November 1, 2013 and will continue through December 31, 2015.  It is expected to produce best practices and methodologies that can be implemented by other practices across the region.

This PCMH pilot program is the first within BCNEPA’s 13 county service area in which BCNEPA is the principle sponsor.   


Tracie Witter: 570-321-2137
Susquehanna Health  

Anthony Matrisciano: 570-200-6310
Blue Cross of Northeastern Pennsylvania