Hospital-Medical Home (H-MH) Demonstration Program

Program Location: 
Albany, NY
Payer Type: 

Reported Outcomes


The Hospital Medical Home program is part of New York's 1115 Medicaid waiver and one of the Medicaid Redesign Team (MRT) initiatives. The purpose of this demonstration is to improve the coordination, continuity, and quality of care for individuals receiving primary care in hospital outpatient departments operated by teaching hospitals, as well as other primary care settings used by teaching hospitals to train resident physicians. The demonstration will be instrumental in influencing the next generation of practitioners in the important concepts of patient- centered medical homes. Training sites, in particular, due to the structural discontinuity imposed by rotating residents and attending physicians’ schedules, present a significant opportunity to improve patient experience and care through residency redesign. 

Entities that serve as clinical training sites for primary care residents will work toward transforming their delivery system consistent with the National Committee on Quality Assurance (NCQA) requirements for medical home recognition under its Physician Practice Connections® - Patient-Centered Medical Home program and the “Joint Principles” for medical home development articulated by primary care professional associations. In addition, hospitals which receive funding under this demonstration shall be required to implement a number of patient safety and systemic quality improvement projects.

According to a June 2015 article published in the Journal of Graduate Medical Education, "A key aim of HMH is to prepare physicians for the new landscape of care. Participating hospital sites and Federally Qualified Health Centers provide primary care to more than 1 million Medicaid beneficiaries and are the training sites for more than 5000 resident physicians from 118 programs in internal medicine, family medicine, pediatrics, and internal medicine–pediatrics." 

Improved Health: 

Journal of Graduate Medical Education (June 2015)

  • 82% of sites saw improvement in breast cancer screening (rates significantly improved from 47% to 60%, P 5 .01)
  • 80% of sites saw improvement in colorectal screening rates since baseline (rates improved from 48% to 59%, P # .001)
  • 75% improved rates of tobacco use screening and cessation counseling (rates improved from 70% to 86%, P # .001).
Improved Access: 

Journal of Graduate Medical Education (June 2015)

  • Improved access and coordination between primary and specialty care composite increased from 72% to 79% (P , .001)
  • Integration of physical and behavioral health care composite increased from 40% to 73% (P , .001).
Increased Preventive Services: 

Final Report (2018)

  • Breast cancer screening increased by 13%
  • Cervical cancer screening increased by 12%
  • Colorectal cancer screening increased by 11%
  • Childhood immunization increased by 14%
  • TObacco use assessment increased by 16%
Other Outcomes: 

Journal of Graduate Medical Education (June 2015)

  • 85% depression screening rate
  • 90% of patients are seeing a behavioral health provider within the time frame requested by PCP
  • All sites hired a care manager
  • 73% postdischarge follow-up call within 48 hours
  • 80% of clinics working on culturally competent care have interpreter wait time of 15 minutes or less 99% of the time.
  • The average rate of prescription labels being written in the preferred language of the patient has increased to 67% in the last year.
Last updated April 2019
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