Patient-centered Medical Home Capabilities Research Articles

Model Homes: Evaluating Approaches to Patient-centered Medical Home Implementation.

The patient-centered medical home (PCMH) model has been widely adopted, but the evidence on its effectiveness remains mixed. One potential explanation for these mixed findings is variation in how the model is implemented by practices. To identify the impact of different approaches to PCMH adoption on health care utilization in a long-term, geographically diverse sample of patients. Difference-in-differences evaluation of PCMH impact on cost and utilization. A total of 5,314,284 patient-year observations from the HealthCore Integrated Research Database, and 5943 practices which adopted the PCMH model in 14 states between 2011 and 2015. PCMH adoption, as defined by the National Committee for Quality Assurance. Six claims-based utilization measures, plus total health care expenditures. We employ hierarchical clustering to organize practices into groups based on their PCMH capabilities, then use generalized difference-in-differences models with practice or patient fixed effects to estimate the effect of PCMH recognition (overall and separately by the groups identified by the clustering algorithm) on utilization. PCMH adoption was associated with a >8% reduction in total expenditures. We find significant reductions in emergency department utilization and outpatient care, and both lab and imaging services. In our by-group results we find that while the reduction in outpatient care is significant across all 3 groups, the reduction in emergency department utilization is driven entirely by 1 group with enhanced electronic communications. The PCMH model has significant impact on patterns of health care utilization, especially when heterogeneity in implementation is accounted for in program evaluation.

Provider and Staff Morale, Job Satisfaction, and Burnout over a 4-Year Medical Home Intervention.

The patient-centered medical home (PCMH) is a widely adopted primary care model. However, it is unclear whether changes in provider and staff perceptions of clinic PCMH capability are associated with changes in provider and staff morale, job satisfaction, and burnout in safety net clinics. To determine how provider and staff PCMH ratings changed under a multi-year PCMH transformation initiative and assess whether changes in provider and staff PCMH ratings were associated with changes in morale, job satisfaction, and burnout. Comparison of baseline (2010) and post-intervention (2013-2014) surveys. Sixty clinics in five states. Five hundred thirty-six (78.2%) providers and staff at baseline and 589 (78.3%) post-intervention. Collaborative learning sessions and on-site coaching to implement PCMH over 4years. Provider and staff PCMH ratings on 0 (worst) to 100 (best) scales; percent of providers and staff reporting good or better morale, job satisfaction, and freedom from burnout. Almost half of safety net clinics improved PCMH capabilities from the perspective of providers (28 out of 59, 47%) and staff (25 out of 59, 42%). Over the same period, clinics saw a decrease in the percentage of providers reporting high job satisfaction (- 12.3% points, p = .009) and freedom from burnout (- 10.4% points, p = .006). Worsened satisfaction was concentrated among clinics that had decreased PCMH rating, with those clinics seeing far fewer providers report high job satisfaction (- 38.1% points, p < 0.001). Control clinics were not used. Individual-level longitudinal survey administration was not feasible. If clinics pursue PCMH transformation and providers do not perceive improvement, they may risk significantly worsened job satisfaction. Clinics should be aware of this potential risk of PCMH transformation and ensure that providers are aware of PCMH improvements.

The impact of patient-centered medical homes on medication adherence?

Accreditation of providers helps resolve the pervasive information asymmetries in health care markets. However, meeting accreditation standards typically involves flexibility in implementation, leading to heterogeneity in performance. For example, the patient-centered medical home (PCMH) is a leading model for recognizing high-performing primary care practices. Flexibility in PCMH implementation allows for varying degrees of emphasis on processes designed to enhance medication adherence. To assess the impact of the PCMH on adherence, we combine 6years of detailed patient claims data with a novel dataset containing detailed practice-level PCMH attributes. We study the effects of the number and configuration of adherence-relevant capabilities, using variation in the timing of PCMH adoption to estimate its impact. While PCMH adoption improved overall medication adherence, when combining claims data with the unique recognition data detailing what PCMH capabilities were adopted, we find that these gains are concentrated among patients in practices that adopted more adherence-relevant capabilities. Despite mixed evidence in the literature concerning costs and utilization, our results indicate that PCMH recognition improves medication adherence.

Development and Validation of a Short-Form Safety Net Medical Home Scale.

To develop a short-form Safety Net Medical Home Scale (SNMHS) for assessing patient-centered medical home (PCMH) capability in safety net clinics. National surveys of federally qualified health centers (FQHCs). Interviews with FQHC directors. We constructed three short-form SNMHS versions and examined correlations with full SNMHS and related primary care assessments. We tested usability with FQHC directors and reviewed scale development with an advisory group. Federally qualified health center surveys were administered in 2009 and 2013, by mail and online. Usability testing was conducted through telephone interviews with FQHC directors in 2013. Six-, 12-, and 18-question short-form SNMHS versions had Pearson correlations with full scale of 0.84, 0.92, and 0.96, respectively. All versions showed a level of convergent validity with other primary care assessment scales comparable to the full SNMHS. User testers found short forms to be low-burden, though missing some PCMH concepts. Advisory group members expressed caution over missing concepts and appropriate use of short-form self-assessments. Short-form versions of SNMHS showed strong correlations with full scale and may be useful for brief assessment of safety net PCMH capability. Each short-form SNMHS version may be appropriate for different research, quality improvement, and assessment purposes.

Capsule Commentary on Timbie et al., Association Between Patient-Centered Medical Home Capabilities and Outcomes for Medicare Beneficiaries Seeking Care from Federally Qualified Health Centers.

Capsule Commentary on Timbie et al., Association Between Patient-Centered Medical Home Capabilities and Outcomes for Medicare Beneficiaries Seeking Care from Federally Qualified Health Centers.

Patient Experience of Chronic Illness Care and Medical Home Transformation in Safety Net Clinics.

To examine the relationship between medical home transformation and patient experience of chronic illness care. Thirteen safety net clinics located in five states enrolled in the Safety Net Medical Home Initiative. Repeated cross-sectional surveys of randomly selected adult patients were completed at baseline (n=303) and postintervention (n=271). Questions from the Patient Assessment of Chronic Illness Care (PACIC) (100-point scale) were used to capture patient experience of chronic illness care. Generalized estimating equationmethods were used to (i) estimate how differential improvement in patient-centered medical home (PCMH) capability affected differences in modified PACIC scores between baseline and postintervention, and (ii) to examine cross-sectional associations between PCMH capability and modified PACIC scores for patients at completion of the intervention. In adjusted analyses, high PCMH improvement (above median) was only marginally associated with a larger increase in total modified PACIC score (adjusted β=7.7, 95 percent confidence interval [CI]: -1.1 to 16.5). At completion of the intervention, a 10-point higher PCMH capability score was associated with an 8.9-point higher total modified PACIC score (95 percent CI: 3.1-14.7) and higher scores in four of five subdomains (patient activation, delivery system design, contextual care, and follow-up/coordination). We report that sustained, 5-year medical home transformation may be associated with modest improvement in patient experience of chronic illness care for vulnerable populations in safety net clinics.

Association Between Patient-Centered Medical Home Capabilities and Outcomes for Medicare Beneficiaries Seeking Care from Federally Qualified Health Centers.

Patient-centered medical home (PCMH) models of primary care have the potential to expand access, improve population health, and lower costs. Federally qualified health centers (FQHCs) were early adopters of PCMH models. We measured PCMH capabilities in a diverse nationwide sample of FQHCs and assessed the relationship between PCMH capabilities and Medicare beneficiary outcomes. Cross-sectional, propensity score-weighted, multivariable regression analysis. A convenience sample of 804 FQHC sites that applied to a nationwide FQHC PCMH initiative and 231,163 Medicare fee-for-service beneficiaries who received a plurality of their primary care services from these sites. PCMH capabilities were self-reported using the National Committee for Quality Assurance's (NCQA's) 2011 application for PCMH recognition. Measures of utilization, continuity of care, quality, and Medicare expenditures were derived from Medicare claims covering a 1-year period ending October 2011. Nearly 88% of sites were classified as having PCMH capabilities equivalent to NCQA Level 1, 2, or 3 PCMH recognition. These more advanced sites were associated with 228 additional FQHC visits per 1000 Medicare beneficiaries (95% CI: 176, 278), compared with less advanced sites; 0.02 points higher practice-level continuity of care (95% CI: 0.01, 0.03); and a greater likelihood of administering two of four recommended diabetes tests. However, more advanced sites were also associated with 181 additional visits to specialists per 1000 beneficiaries (95% CI: 124, 232) and 64 additional visits to emergency departments (95% CI: 35, 89)-but with no differences in inpatient utilization. More advanced sites had higher Part B expenditures ($111 per beneficiary [95% CI: $61, $158]) and total Medicare expenditures of $353 [95% CI: $65, $614]). Implementation of PCMH models in FQHCs may be associated with improved primary care for Medicare beneficiaries. Expanded access to care, in combination with slower development of key PCMH capabilities, may explain higher Medicare expenditures and other types of utilization.

Improving Quality of Care through Primary Care Research

Journal of General and Family MedicineVolume 17, Issue 4 p. 267-269 EditorialsOpen Access Improving Quality of Care through Primary Care Research Machiko Inoue MD, MPH, PhD, Machiko Inoue MD, MPH, PhD Associate Editor, JGFMSearch for more papers by this author Machiko Inoue MD, MPH, PhD, Machiko Inoue MD, MPH, PhD Associate Editor, JGFMSearch for more papers by this author First published: 27 December 2016 https://doi.org/10.14442/jgfm.17.4_267Citations: 1 Corresponding author: Machiko Inoue, MD, MPH, PhDBeth Israel Deaconess Medical Center, Harvard Medical School AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat References 1Crossing the Quality Chasm: A New Health System for the 21st Century. In. Washington (DC): Institute of Medicine (US) Committee on Quality of Health Care in America. 2001. 2Quality Improvement in Primary Care - External supports for practices [http://www.ahrq.gov/research/findings/factsheets/quality/qipc/index.html]. 3Markovitz AR, Alexander JA, Lantz PM, Paustian ML: Patient-centered medical home implementation and use of preventive services: the role of practice socioeconomic context. JAMA Intern Med. 2015; 175: 598– 606. 4Shi L, Lock DC, Lee DC, et al: Patient-centered medical home capability and clinical performance in HRSA-supported health centers. Med Care. 2015; 53: 389– 395. 5Kern LM, Edwards A, Kaushal R: The patient-centered medical home and associations with health care quality and utilization: a 5-year cohort study. Ann Intern Med. 2016; 164: 395– 405. 6CAHPS Surveys and Tools to Advance Patient-Centered Care [http://www.ahrq.gov/cahps/index.html]. 7Aoki T, Inoue M, Nakayama T: Development and validation of the Japanese version of Primary Care Assessment Tool. Fam Pract. 2016; 33: 112– 117. Citing Literature Volume17, Issue4December 2016Pages 267-269 ReferencesRelatedInformation

Capsule Commentary on Gao, et al., Characteristics Associated with Patient-Centered Medical Home Capability in Health Centers: A Cross-Sectional Analysis.

T his study by Gao et al. examined characteristics of federally qualified health centers (FQHCs) to determine factors that were predictive of patient-centered medical home (PCMH) capability. The authors abstracted FQHC data from several sources and identified variables likely to be associated with PCMH capability. They then identified correlations between these HC characteristics and PCMH capability. Their results showed that the presence of an electronic health record (EHR), the number of types of financial performance incentives, and the number of types of hospital–health center affiliations were predictive of PCMH capability. The authors rated PCMH capability using the Safety Net Medical Home Scale (SNMHS) which was created by this research team using data from the 2009 Commonwealth Fund National Survey of Federally Qualified Health Centers. The data source for the three predictive characteristics identified in the study was the same survey used to create their capability assessment tool, the SNMHS. As the Commonwealth Fund Survey specifically assessed the presence and use of EHRs, it is not surprising that having an EHR in place was found to be predictive of greater PCMH capability based on the SNMHS. In addition, as the authors point out, identifying the EHR as a factor in predicting PCMH capability is less important given that, by 2014, 97 % of FQHCs had adopted an EHR. More interesting, however, are the findings that PCMH capability was associated with provider financial incentives and network affiliations. These data support the ongoing incorporation of PCMH and National Committee for Quality Assurance (NCQA) standards in both FQHC designation requirements and provider incentives. What remains unclear is how to properly align financial incentives to support increased PCMH capability. It is important to note that these authors evaluated PCMH capability, as assessed by their survey instrument, and did not include any patient-level outcomes. Assessment of PCMH achievement via outcomes rather than structural or process elements remains an essential yet elusive goal. Outcomes data related to FQHC PCMH implementation, including ongoing demonstration projects, will likely contribute substantially to the growing base of evidence related to the PCMH.

The Use of Enhanced Appointment Access Strategies by Medical Practices.

Strategies to enhance appointment access are being adopted by medical practices as part of patient-centered medical home (PCMH) implementation, but little is known about the use of these strategies nationally. We examine practice use of open access scheduling and after-hours care. Data were analyzed from the Third National Study of Physician Organizations (NSPO3) to examine which enhanced appointment access strategies are more likely to be used by practices with more robust PCMH capabilities and with greater external incentives. Logistic regression estimated the effect of PCMH capabilities and external incentives on practice use of open access scheduling and after-hours care. Physician organizations with >20% primary care physicians (n=1106). PCMH capabilities included team-based care, health information technology capabilities, quality improvement orientation, and patient experience orientation. External incentives included public reporting, pay-for-performance (P4P), and accountable care organization participation. A low percentage of practices (19.8%) used same-day open access scheduling, while after-hours care (56.1%) was more common. In adjusted analyses, system-owned practices and practices with greater use of team-based care, health information technology capabilities, and public reporting were more likely to use open access scheduling. Accountable care organization-affiliated practices and practices with greater use of public reporting and P4P were more likely to provide after-hours care. Open access scheduling may be most effectively implemented by practices with robust PCMH capabilities. External incentives appear to influence practice adoption of after-hours care. Expanding open access scheduling and after-hours care will require distinct policies and supports.

Characteristics Associated with Patient-Centered Medical Home Capability in Health Centers: A Cross-Sectional Analysis.

The patient-centered medical home (PCMH) model is being implemented in health centers (HCs) that provide comprehensive primary care to vulnerable populations. To identify characteristics associated with HCs' PCMH capability. Cross-sectional analysis of a national dataset of Federally Qualified Health Centers (FQHCs) in 2009. Data for PCMH capability, HC, patient, neighborhood, and regional characteristics were combined from multiple sources. A total of 706 (70%) of 1014 FQHCs from the Health Resources and Services Administration Community Health Center Program, representing all 50 states and the District of Columbia. PCMH capability was scored via the Commonwealth Fund National Survey of FQHCs through the Safety Net Medical Home Scale (0 [worst] to 100 [best]). HC, patient, neighborhood, and regional characteristics (all analyzed at the HC level) were measured from the Commonwealth survey, Uniform Data System, American Community Survey, American Medical Association physician data, and National Academy for State Health Policy data. Independent correlates of high PCMH capability included having an electronic health record (EHR) (11.7-point [95% confidence interval, CI 10.2-13.3]), more types of financial performance incentives (0.7-point [95% CI 0.2-1.1] higher total score per one additional type, maximum possible = 10), more types of hospital-HC affiliations (1.6-point [95% CI 1.1-2.1] higher total score per one additional type, maximum possible = 6), and location in certain US census divisions. Among HCs with an EHR, location in a state with state-supported PCMH initiatives and PCMH payments was associated with high PCMH capability (2.8-point, 95% CI 0.2-5.5). Other characteristics had small effect size based on the measure unit (e.g. 0.04-point [95% CI 0-0.08] lower total score per one percentage point more minority patients), but the effects could be practically large at the extremes. EHR adoption likely played a role in HCs' improvement in PCMH capability. Factors that appear to hold promise for supporting PCMH capability include a greater number of types of financial performance incentives, more types of hospital-HC affiliations, and state-level support and payment for PCMH activities.

Patient-centered Medical Home capability and clinical performance in HRSA-supported health centers.

To evaluate the relationship between Patient-centered Medical Home (PCMH) model adoption in health centers (HCs) and clinical performance measures and to determine if adoption of PCMH characteristics is associated with better clinical performance. Data came from the Health Resources and Services Administration's 2009 Uniform Data System and the 2009 Commonwealth Fund National Survey of Federally Qualified Health Centers. Clinical performance measures included 2 process measures (childhood immunization and cervical cancer screening) and 2 outcome measures (hypertension control and diabetes control). Total and subscale PCMH scores were regressed on the clinical performance measures, adjusting for patient, provider, financial, and institutional characteristics. The findings showed different directional relationships, with some PCMH domains (care management, test/referral tracking, quality improvement, and external coordination) showing little or no effect on outcome measures of interest, 1 domain (access/communication) associated with improved outcomes, and 1 domain (patient tracking/registry) associated with worse outcomes. This study is among the first to examine the association between PCMH transformation and clinical performance in HCs, providing an understanding of the impact of PCMH adoption within safety-net settings. The mixed results highlight the importance of examining relationships between specific PCMH domains and specific clinical quality measures, in addition to analyzing overall PCMH scores which could yield distorted findings.

Accountable Care Organizations: A Challenging Opportunity for Primary Care to Demonstrate its Value

Accountable Care Organizations: A Challenging Opportunity for Primary Care to Demonstrate its Value

Four-Year Evolution of a Large, State-wide Patient-Centered Medical Home Designation Program in Michigan

The patient-centered medical home (PCMH) has been recognized as a strategy to redesign and improve the delivery of primary health care. Collaboration between Blue Cross Blue Shield of Michigan (BCBSM) and 39 Physician Organizations in Michigan laid the foundation for a state-wide medical home program. The objective of the study was to describe a unique methodology developed and implemented by BCBSM to designate primary care physician practices as medical homes. Since 2009, practices were designated annually as medical homes on the basis of (1) implementation of PCMH-related capabilities, and (2) performance on quality-of-care and health resource utilization measures. An overall score for each practice was calculated. Practices were ranked relative to each other, with the top portion of the continuum representing an achievable level of performance. The number of practices designated as medical homes more than tripled since the program's inception: 302 (1283 physicians) in 2009, 513 (1876 physicians) in 2010, 772 (2547 physicians) in 2011, and 994 (3028 physicians) in 2012. Designated practices reported implementing more than double the PCMH capabilities of nondesignated practices, yet all practices increased their number of implemented capabilities during the 4 years. This program represents the largest state-based PCMH program in the United States. Over the 4-year period, 1130 unique practices have received designation, representing 3469 unique physicians. An estimated 1.4 million BCBSM members in Michigan received care from these practices. This program will continue to develop, drawing on changes in the health system landscape, collaboration with the physician community, and knowledge gained from PCMH evaluations.

Partial and Incremental PCMH Practice Transformation: Implications for Quality and Costs

To examine the associations between partial and incremental implementation of the Patient Centered Medical Home (PCMH) model and measures of cost and quality of care. We combined validated, self-reported PCMH capabilities data with administrative claims data for a diverse statewide population of 2,432 primary care practices in Michigan. These data were supplemented with contextual data from the Area Resource File. We measured medical home capabilities in place as of June 2009 and change in medical home capabilities implemented between July 2009 and June 2010. Generalized estimating equations were used to estimate the mean effect of these PCMH measures on total medical costs and quality of care delivered in physician practices between July 2009 and June 2010, while controlling for potential practice, patient cohort, physician organization, and practice environment confounders. Based on the observed relationships for partial implementation, full implementation of the PCMH model is associated with a 3.5 percent higher quality composite score, a 5.1 percent higher preventive composite score, and $26.37 lower per member per month medical costs for adults. Full PCMH implementation is also associated with a 12.2 percent higher preventive composite score, but no reductions in costs for pediatric populations. Incremental improvements in PCMH model implementation yielded similar positive effects on quality of care for both adult and pediatric populations but were not associated with cost savings for either population. Estimated effects of the PCMH model on quality and cost of care appear to improve with the degree of PCMH implementation achieved and with incremental improvements in implementation.

Michigan’s Physician Group Incentive Program Offers A Regional Model For Incremental ‘Fee For Value’ Payment Reform

Blue Cross Blue Shield of Michigan partnered with providers across the state to create an innovative, "fee for value" physician incentive program that would deliver high-quality, efficient care. The Physician Group Incentive Program rewards physician organizations-formal groups of physicians and practices that can accept incentive payments on behalf of their members-based on the number of quality and utilization measures they adopt, such as generic drug dispensing rates, and on their performance on these measures across their patient populations. Physicians also receive payments for implementing a range of patient-centered medical home capabilities, such as patient registries, and they receive higher fees for office visits for incorporating these capabilities into routine practice while also improving performance. Taken together, the incentive dollars, fee increases, and care management payments amount to a potential increase in reimbursement of 40 percent or more from Blue Cross Blue Shield of Michigan for practices designated as high-performing patient-centered medical homes. At the same time, we estimate that implementing the patient-centered medical home capabilities was associated with $155 million in lower medical costs in program year 2011 for Blue Cross Blue Shield of Michigan members. We intend to devote a higher percentage of reimbursement over time to communities of caregivers that offer high-value, system-based care, and a lower percentage of reimbursement to individual physicians on a service-specific basis.

Using Fuzzy Set Qualitative Comparative Analysis (fs/QCA) to Explore the Relationship between Medical “Homeness” and Quality

Determine, using fuzzy set qualitative comparative analysis (fs/QCA), the relationship between patient-centered medical home (PCMH) systems and quality in 21 NCQA recognized medical homes. Primary data collected in 2009, including measures of optimal diabetes care (ODC), preventive services up-to-date (PSUTD), patient experience (PEX), survey data assessing PCMH capabilities (PPC-RS), and other clinic characteristics. Cross-sectional study identifying associations between PPC-RS domains, demographic, socioeconomic, and co-morbidity measures, and quality outcomes. PPC-RS scores were obtained by surveying clinic leaders. PSUTD and ODC scores were obtained from provider performance data. PEX data were obtained from patient surveys. Demographic, socioeconomic, and co-morbidity data were obtained from EMR and census data. fs/QCA identified associations between all three outcomes and PCMH capabilities: ODC and team-based care; PSUTD and preventive services systems; and all three outcomes and provider performance reporting systems. Previous statistical analysis of this data had failed to identify these relationships. fs/QCA identified important associations that were overlooked using conventional statistics in a small-N health services data set. PCMH capabilities are associated with quality outcomes.