Outcomes of Embedded Care Management in a Family Medicine Residency Patient-Centered Medical Home

Fam Med. 2017 Jan;49(1):46-51.


Background and objectives: Much attention is devoted nationally to preventing hospital readmissions and emergency department (ED) use, given the high cost of this care. There is a growing body of evidence from the Patient Centered Primary Care Collaborative that a patient-centered medical home (PCMH) model successfully lowers these costs. Our study evaluates a specific intervention in a family medicine residency PCMH to decrease readmissions and ED utilization using an embedded care manager.

Methods: The Department of Family and Community Medicine at Eastern Virginia Medical School in Norfolk, VA, hired an RN care manager in May of 2013 with a well-defined job description focused on decreasing hospital readmissions and ED usage. Our primary outcomes for the study were number of monthly hospital admissions and readmissions over 23 months and monthly ED visits over 20 months.

Results: Readmission rates averaged 22.2% per month in the first year of the intervention and 18.3% in the second year, a statistically significant 3.9% decrease. ED visits averaged 176 per month in the first year and 146 per month in the second year, a statistically significant 17% reduction.

Conclusions: Our study adds to the evidence that a PCMH model of care with an embedded RN care manager can favorably lower readmission rates and ED utilization in a family medicine residency practice. Developing a viable business model to support this important work remains a challenge.

MeSH terms

  • Case Management / organization & administration*
  • Costs and Cost Analysis
  • Emergency Service, Hospital / statistics & numerical data
  • Humans
  • Internship and Residency*
  • Nurse Administrators
  • Patient Readmission / statistics & numerical data*
  • Patient-Centered Care / organization & administration*
  • Virginia