Challenges to Meeting Access and Continuity Performance Measures in a Large Hospital-Based Primary Care Clinic Implementing the Patient-Centered Medical Home: A Qualitative Study

Abstract

Article-at-a-Glance Purpose Patient-centered medical home (PCMH) performance measures are used to gauge progress towards improving timely access to care and patient-provider continuity. Starting in 2010, the Veterans Health Administration (VHA) PCMH initiative focused on clinics' performance in accommodating urgent access requests from established patients to their usual primary care providers (PCPs). Factors were examined that affected the efforts of a large hospital-based VHA primary care clinic to meet an urgent access PCMH performance measure while implementing other aspects of PCMH. Method Early in PCMH implementation (2012–2013), 20 semistructured interviews were conducted with primary care staff (physicians, residents, nurses, and administrative clerks), and 19 coaching sessions designed to help primary care teams improve access and continuity were observed. Descriptive codes were applied, and findings were developed via consensus. Results This large primary care clinic was challenged in meeting the urgent access performance measure by part-time availability of many PCPs, conflicting with performance measure structure; PCMH-encouragement of processes to increase urgent access that were not recognized by performance measures; high patient volume, overwhelming efforts to increase access; numerous and varied schedulers hindering coordination of scheduling algorithms; and multiple simultaneous access improvement goals that non-hospital-based clinics may not experience. Conclusions Early in VHA PCMH implementation, a performance measure that incentivized same-day access to the usual PCP created unanticipated challenges at a large hospital-based primary care clinic.