Patient-centered Medical Home Care Research Articles

Person-centered care for common mental disorders in Ontario’s primary care patient-centered medical homes: a qualitative study of provider perspectives

BackgroundFor more than a decade, the Patient-Centered Medical Home model has been a guiding vision for the modernization of primary care systems. In Canada, Ontario’s Family Health Teams (FHTs) were designed in the mid-2000s with the medical home model in mind. These primary care clinics aim to provide accessible, comprehensive, and person-centered primary care services to communities across Ontario. Their services typically include mental health care for people experiencing common mental disorders, such as depression and anxiety disorders. It remains unclear, however, whether the mental health care delivered within FHTs is consistent with person-centered care approaches. In the current study, we aimed to explore the perspectives of FHT providers on the care delivered to people with common mental disorders to determine whether, and to what extent, they believed this care was person-centered.MethodsWe conducted a qualitative grounded theory study involving interviews with 65 health professionals and administrators from 18 FHTs across Ontario. Transcripts were coded using a three-step process of initial, focused, and axial coding that mixed inductive and deductive approaches informed by sensitizing concepts on person-centeredness.ResultsPractices and challenges associated with the delivery of mental health care in a person-centered way were captured by several themes regrouped into five domains: (1) patient as unique person, (2) patient-provider relationship, (3) sharing power and responsibility, (4) connecting to family and community, and (5) creating person-centered care environments. FHT providers perceived that they delivered person-centered care by delivering mental health care that was responsive, flexible, and consistent with biopsychosocial approaches. They emphasized the importance of creating long-lasting relationships with patients grounded in empathy and trust. Their challenges included being able to ensure continuity of care, adequately prioritizing patients’ mental health issues, and meaningfully engaging patients and families as partners in care.ConclusionsOur findings suggest that FHT providers have adopted a range of person-centered practices for people with common mental disorders. However, greater attention to practices such as shared decision making, supporting self-management, and involving families in care would strengthen person-centeredness and bring teams closer to the Patient-Centered Medical Home vision.

The association between population health management tools and clinician burnout in the United States VA primary care patient-centered medical home

BackgroundTechnological burden and medical complexity are significant drivers of clinician burnout. Electronic health record(EHR)-based population health management tools can be used to identify high-risk patient populations and implement prophylactic health practices. Their impact on clinician burnout, however, is not well understood. Our objective was to assess the relationship between ratings of EHR-based population health management tools and clinician burnout.MethodsWe conducted cross-sectional analyses of 2018 national Veterans Health Administration(VA) primary care personnel survey, administered as an online survey to all VA primary care personnel (n = 4257, response rate = 17.7%), using bivariate and multivariate logistic regressions. Our analytical sample included providers (medical doctors, nurse practitioners, physicians’ assistants) and nurses (registered nurses, licensed practical nurses). The outcomes included two items measuring high burnout. Primary predictors included importance ratings of 10 population health management tools (eg. VA risk prediction algorithm, recent hospitalizations and emergency department visits, etc.).ResultsHigh ratings of 9 tools were associated with lower odds of high burnout, independent of covariates including VA tenure, team role, gender, ethnicity, staffing, and training. For example, clinicians who rated the risk prediction algorithm as important were less likely to report high burnout levels than those who did not use or did not know about the tool (OR 0.73; CI 0.61-0.87), and they were less likely to report frequent burnout (once per week or more) (OR 0.71; CI 0.60-0.84).ConclusionsBurned-out clinicians may not consider the EHR-based tools important and may not be using them to perform care management. Tools that create additional technological burden may need adaptation to become more accessible, more intuitive, and less burdensome to use. Finding ways to improve the use of tools that streamline the work of population health management and/or result in less workload due to patients with poorly managed chronic conditions may alleviate burnout. More research is needed to understand the causal directional of the association between burnout and ratings of population health management tools.

The Impact of Delivery Reform on Health Information Exchange with Behavioral Health Providers: Results from a National Representative Survey of Ambulatory Physicians.

Health information exchange (HIE) is an effective way to coordinate care, but HIE between health and behavioral health providers is limited. Recent delivery reform models, including the Accountable Care Organization (ACO) and Patient Centered Medical Home (PCMH) prioritize interprofessional collaboration, but little is known about their impact on behavioral health HIE. This study explores whether delivery reform participation affects behavioral health HIE among ambulatory health providers using pooled 2015-2019 data from the National Electronic Health Record Survey, a nationally representative survey of ambulatory physicians' technology use (n = 8,703). The independent variable in this analysis was provider participation in ACO, PCMH, Hybrid ACO-PCMH, or standard care. The dependent variable was HIE with behavioral health providers. Chi square analysis estimated unweighted rates of behavioral health HIE across reform models. Logistic regression estimated the impact of delivery reform participation on rates of behavioral health HIE. Unweighted estimates indicated that Hybrid ACO-PCMH providers had the highest rates of HIE (n = 330, 33%). In the fully adjust model, rates of HIE were higher among ACO (AOR = 2.66, p < .01), PCMH (AOR = 4.73, p < .001) and Hybrid ACO-PCMH participants (AOR = 5.55, p < .001) compared to standard care, but they did not significantly vary between delivery models. Physicians infrequently engage in HIE with behavioral health providers. Compared to standard care, higher rates of HIE were found across all models of delivery reform. More work is needed to identify common elements of delivery reform models that are most effective in supporting this behavior.

Impact of the PCMH model on post-stroke healthcare utilization

The patient-centered medical home (PCMH) model has aimed to enhance chronic care in a primary care setting where providers are expected to provide timely post-discharge follow-up and decrease potentially preventable hospital readmissions through coordinated disease management. The study examined PCMH and other (risk) factors associated with 30-day unplanned readmission as well as 7- and 28-day follow-up visit with primary care providers (PCPs). We identified 8424 New York State Medicaid patients having initial stroke discharges during 2016–2018 from the Medicaid claims database and Statewide Planning and Research Cooperative System. A patient was in the PCMH group if the attributed provider had a valid National Committee for Quality Assurance PCMH recognition upon patient’s discharge. Cox regression and competing risk analyses were used to estimate the hazard ratios of readmissions and follow-up visits between PCMH and non-PCMH groups. The PCMH group had slightly but not statistically significant lower all-cause and recurrent stroke unplanned readmission rates. While the general follow-up rates between the two groups are similar, the PCMH group had significantly higher rates of stroke-specific 7-day (HR = 1.27, P < 0.01) and 28-day follow-up visits (HR = 1.22, P < 0.01). PCPs play an essential role in post stroke care. Our findings show a significantly higher rate of stroke-specific follow-up visits and a trend towards lower readmissions among patients in the PCMH group. The intervals between stroke discharge and follow-up visit time in our study population were generally greater than the recommended timeframe. We recommend the PCMH care model to improve patients’ primary care follow-up and prevent potential readmissions.

Using medical expenditure panel survey data to explore the relationship between patient-centered medical homes and racial disparities in severe maternal morbidity outcomes.

There are persistent racial/ethnic disparities in the occurrence of severe maternal morbidity. Patient-centered medical home care has the potential to address disparities in maternal outcomes. To examine (1) the association between receiving patient-centered medical home care and severe maternal morbidity outcomes and (2) the interaction of race/ethnicity on patient-centered medical home status and severe maternal morbidity. Using 2007 to 2016 data from the Medical Expenditures Panel Survey, we conducted a cross-sectional study to estimate the association between receipt of care from a patient-centered medical home and the occurrence of severe maternal morbidity, and racial-specific (White, Black, Asian, Other) relative risks of severe maternal morbidity. Our study used race as a proxy measure for exposure racism. We identified mothers (⩾15 years) who gave birth during the study period. We identified patient-centered medical home qualities using 11 Medical Expenditures Panel Survey questions and severe maternal morbidities using medical claims, and calculated generalized estimating equation models to estimate odds ratios of severe maternal morbidity and 95% confidence intervals. Among all mothers who gave birth (N = 2801; representing 5,362,782 US lives), only 25% received some exposure patient-centered medical home care. Two percent experienced severe maternal morbidity, and this did not differ statistically (p = 0.11) by patient-centered medical home status. However, our findings suggest a 85% decrease in the risk of severe maternal morbidity among mothers who were defined as always attending a patient-centered medical home (odds ratios: 0.15; 95% confidence interval:0.01-1.87; p = 0.14) and no difference in the risk of severe maternal morbidity among mothers who were defined as sometimes attending a patient-centered medical home (odds ratios: 1.00; 95% confidence interval:0.16-6.42; p = 1.00). There was no overall interaction effect in the model between race and patient-centered medical home groups (p = 0.82), or ethnicity and patient-centered medical home groups (p = 0.62) on the severe maternal morbidity outcome. While the rate of severe maternal morbidity was similar to US rates, few mothers received care from a patient-centered medical home which may be due to underreporting. Future research should further investigate the potential for patient-centered medical home-based care to reduce odds of severe maternal morbidity across racial/ethnic groups.

The ‘Service Transformation Outline’ toolkit to assist in the design, comparison and replication of integrated care programmes

PurposeThe author is introducing a toolkit that can assist stakeholders to design, compare and replicate integrated care programmes, by making explicit their view on the transformations of care and cure services, according to a structured template. The purpose of this paper is to address this issue.Design/methodology/approachThe toolkit is made of two elements: a classification and a template. The author adopted a step-wise approach of semantic modelling to work out three layers of a classification in the domain of integration needs related to care and cure services. The third layer consists of 23 non-overlapping classes that fully cover that semantic domain. The classes are used to build a template to elicit the stakeholder's standpoint about the transformations involved in the deployment of a programme. The result is the «Outline» of the programme.FindingsSo far, in eight years the author applied the toolkit to 100+ programmes either to design, simulate or evaluate them, either to compare them to similar ones in the same or in different jurisdictions, and we refined the description of the classes according to that experience.Research limitations/implicationsThe objective of the toolkit is not to provide solutions, but to stimulate reflections on the transformations involved in a programme and their practical consequences in a precise context. In fact, the Outlines cannot be generalized: they are conceived to reflect the perspective of the stakeholders and thus are intrinsically subjective; in addition, they must be contingent, as they must depend on the local context in the particular timeframe. In case of similar initiatives in other localities, the Outlines must be filled in again by the local stakeholders; however, a subsequent comparison could help to explore similarities and motivated differences.Practical implicationsIdeally the stakeholders should use the Outline of the actual transformations in a programme as a reference to mediate between the principles and the methodologies provided by the «Models» and «Conceptual Frameworks» in the literature (e.g. Chronic Care Model, Rainbow Model, Development Model of Integrated Care Patient-Centered Medical Home and Maturity Models) and the deeper studies using the specific tools developed in their disciplines (e.g. on information modelling, process modelling, cost–benefit analysis and health technology assessment). The toolkit could have its role also in a multi-annual roadmap made of a sequence of programmes to cope with the urgent challenges on ageing, social changes and technological evolution, in synergy with regulations, budget, context maturity, critical success factors and local priorities.Originality/valueThe author argues that the approach of the structured Outline is unique, as the scoring mechanism to assess the relevance of the transformation within each class on the overall change brought by the whole programme into the health systems.

Predictors of Temporary Profile Days Among U.S. Army Active Duty Soldiers.

More than 40,000 soldiers cannot deploy every year, which undermines readiness. The medical readiness of soldiers is a critical component of the overall operational readiness of the U.S. Army. Acute musculoskeletal injuries (MSIs) are the greatest threat to medical readiness. Medical providers place soldiers on temporary profiles to facilitate treatment and recovery of acute MSIs. Poorly managed temporary profiles negatively impact a soldier's work attendance, resulting in the loss or limitation of over 25 million workdays annually. Upgrading the electronic profile system and implementing the Army Medical Home has led to improvements in managing temporary profiles over the last decade. The Army Medical Home encompasses care delivery platforms, including the Patient-Centered Medical Home (PCMH) and Soldier-Centered Medical Home (SCMH). The structure of U.S. Army PCMHs and SCMHs differ in ways that may affect care processes and patient outcomes. Temporary profile management is an important soldier health outcome that has not been studied in relation to the U.S. Army's PCMH and SCMH structures or care processes. Access to care, continuity, and communication are three care processes that have been described as essential factors in reducing lost workdays and functional limitations in workers after an acute injury. Understanding the impact of the medical home on temporary profile days is vital to medical readiness. This study aimed to (1) compare temporary profile days between the U.S. Army PCMHs and SCMHs and (2) determine the influence of medical home structures and care processes on temporary profile days among active duty U.S. Army soldiers receiving care for MSIs. This was a retrospective, cross-sectional, and correlational study guided by Donabedian's conceptual framework. We used secondary data from the Military Data Repository collected in 2018. The sample included 27,214 temporary profile records of active duty U.S. Army soldiers and 266 U.S. Army PCMH and SCMH teams. We evaluated bivariate and multivariate associations between outcomes and predictors using general and generalized linear mixed regression models. The U.S. Army Medical Department Center and School Institutional Review Board approved this study. Total temporary profile days ranged from 1 to 357, with a mean of 37 days (95% CI [36.2, 37.0]). There was a significant difference in mean temporary profile days between PCMHs (43) and SCMHs (35) (P < 0.001). Soldiers in PCMHs were more likely to have temporary profiles over 90 days (OR = 1.54, 95% CI [1.17, 2.03]). Soldiers in the heavy physical demand category had fewer temporary profile days (P < 0.001) than those in the moderate physical demand category. Age, sex, rank level, physical demand category, profile severity, medical home type, the "explain things" communication subscale, and primary care manager continuity were significant predictors of temporary profile days. Excessive temporary profile days threaten medical readiness and overall soldier health. Aspects of the medical home structure and care processes were predictors of temporary profile days for musculoskeletal conditions. This work supports continued efforts to improve MSI-related outcomes among soldiers. Knowledge gained from this study can guide future research questions and help the U.S. Army better meet soldier needs.

The Value of the Patient-Centered Medical Home in Getting Adults Suffering From Acute Conditions Back to Work: An Integrative Literature Review.

Acute conditions are the leading cause of work restrictions and missed workdays, contributing to over $27 billion in lost productivity each year and negatively impacting workers' health and quality of life. Primary care services, specifically patient-centered medical homes (PCMHs), play an essential role in supporting timely acute illness or injury recovery for working adults. The purpose of this review is to synthesize the evidence on the relationship between PCMH implementation, care processes, and outcomes. In addition, we discuss the empirical connection between this evidence and return-to-work outcomes, as well as the need for further research.

Practices and changes associated with patient-centered medical home transformation.

Knowing which patient-centered medical home (PCMH) care delivery changes and quality improvement (QI) practices further PCMH implementation isessential. We used the 2008-2017 National Committee of Quality Assurance (NCQA) PCMH directory of 15,188 primary care practices that received Level 1, 2, or 3 NCQA PCMH recognition to construct a stratified national sample of 105 practices engaged in PCMH transformation. We examined their QI practices and PCMH changes associated with PCMH transformation. We derived QI practice and PCMH change variables from semistructured interviews. Practice leaders completed the PCMH Assessment (PCMH-A) measuring the practice's degree of PCMH implementation, which is a proxy for patient-centeredness. Controlling for practice characteristics, we regressed PCMH-A scores on QI practice and PCMH change variables. Practices undergoing PCMH transformation nationwide most commonly made care delivery changes in access and continuity of care. To improve quality, practices most commonly engaged in discussing and targeting areas of patient experience improvement, trending performance, and conducting targeted QI. However, practices lower in patient-centeredness as measured by the PCMH-A were more likely to engage in efforts to improve patient experiences, such as reviewing patient experience data or engaging in 1-on-1 provider counseling related to patient interactions. Mature PCMH practices focused on changes in continuity of care. Practices undertake a wide variety of care delivery changes and QI practices simultaneously to meet PCMH requirements. The patient experience-specific QI practices and PCMH care delivery changes that practices make to improve patient-centeredness differ by years of PCMH recognition.

Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation.

Patient-centered medical homes (PCMH) are primary care delivery models that improve care access and population-level health outcomes, yet they have not been observed to narrow racial-ethnic disparities in the Veteran Health Administration (VHA) or other health systems. We aimed to identify and compare underlying drivers of persistent hypertension and diabetes control differences between non-Hispanic Black (Black) and Hispanic versus non-Hispanic White (White) patients before and after PCMH implementation in the VHA. Among Black and Hispanic versus White VHA primary care patients in 2009 (nhypertension = 26,906; ndiabetes = 21,141) and 2014 (nhypertension = 83,809; ndiabetes = 38,887), we retrospectively examined hypertension control (blood pressure<140/90) and diabetes control (hemoglobin A1c <9) obtained through random chart abstraction of patient health records nationally via VHA’s quality monitoring program. We fit linear probability regression models, adjusting for age, gender, comorbidity, and socioeconomic status (SES). Blinder-Oaxaca and Smith-Welch decomposition methods were used to parse out explained and unexplained contributors to health disparity between racial-ethnic groups pre- and post-PCMH implementation. Compared to White patients, hypertension and diabetes control remained significantly lower for Black (-6.2%[0.4%] and -3.1%[0.6%], respectively; p’s<0.001) and Hispanic (-1.4%[0.8%] and -4.0%[1.0%], respectively; p’s<0.001) patients following VHA PCMH implementation. Most racial-ethnic differences (55.7–92.3%; all p<0.05) were not attributed to age, gender, comorbidity, and SES. The contribution of explained versus unexplained factors did not significantly change over time. While many explanations for persistent racial-ethnic disparities in disease control among veterans exist, our study did not find that it was due to an influx of “sick” or “socioeconomically vulnerable” patients into the VHA following PCMH implementation. Instead, unexplained differences may be due to differential healthcare and community experiences (e.g., discrimination). Understanding underlying pathways leading to health disparities will better inform policy and clinical interventions to improve PCMH care delivery to racial-ethnic minority patients in health systems.

Patient-centered oncology care: impact on utilization, patient experiences, and quality.

To determine whether implementation of patient-centered oncology standards in 5 medical oncology practices improved patient experiences and quality and reduced emergency department (ED) and hospital use. Retrospective, pre-post study design with a concurrent nonrandomized control group. We used insurance claims to calculate all-cause hospitalizations and ED visits and primary care and specialist office visits (n = 28,826 eligible patients during baseline and 30,843 during follow-up) and identify patients for a care experiences survey (n = 715 preintervention and 437 postintervention respondents). For utilization and patient experience outcomes, we compared pilot practices' performance with 18 comparison practices using difference-in-differences (DID) regression models accounting for practice-level clustering. We assessed pilot practice performance on 31 quality measures from the American Society of Clinical Oncology Quality Oncology Practice Initiative program. There were no statistically significant differences in hospital, ED, or primary care visits between the pilot and comparison groups over time, but there was a significant increase in specialty visits for the pilot group (adjusted DID of 0.07; 95% CI, 0.01-0.13; P = .03). For care experiences, pilot practices improved more on shared decision-making (4.03 DID composite score; P = .013), whereas the comparison group improved more on access (-6.36 DID composite score; P < .001) and exchanging information (-4.25 DID composite score; P = .013). On average, pilot practices improved performance on 65% of core quality measures from baseline to follow-up. This pilot of patient-centered oncology care showed improved quality but no impact on hospitalizations/ED use and mixed results for patient experiences. Findings are consistent with early evaluations of primary care patient-centered medical homes.

Association of healthy child-rearing practices and children's receipt of care in patient-centered medical homes.

Efforts to improve the quality of care for children have focused on the patient-centered medical home (PCMH), defined by the National Committee for Quality Assurance (NCQA). Little research has focused on caregivers' role in choosing physicians for children. This study aims to determine whether healthy caregiving behaviors and specific behaviors are associated with children's receipt of PCMH care. Using data from the 2016-2017 National Survey of Children's Health, which includes information on child-rearing behaviors, we estimated logistic regressions, controlling for children's and caregivers' characteristics, to quantify possible associations. We found that each additional healthy child-rearing practice followed increased a child's chance of receiving PCMH care by 4.5% (p < 0.001). Being breastfed (children aged 0-5 years), sharing ideas with their caregiver (children aged 6-17 years), their caregiver ensuring homework is finished (children aged 6-17 years), and having TV time monitored (all ages), each increased the likelihood of PCMH use. These findings show that caregiving behavior is independently associated with locus of care. Future research is warranted as educating caregivers about healthy child-rearing may lead them to seek higher quality care for their children. Also, evaluating the effect of behaviors on health outcomes associated with PCMH would be valuable.

1173-P: Use of Patient-Centered Medical Homes (PCMH)–Related Care Management Processes to Improve Glycemic Control in Medicaid Patients and Non-Medicaid Patients

Background: Care management processes are meant to improve care quality, but there is little information about their effectiveness in socioeconomically disadvantaged individuals. This study was aimed to test if systematic care management processes are as effective in controlling diabetes among Medicaid as in non-Medicaid patients. Methods: This cross-sectional study used standardized performance measures (glycemic control, BP control, statin drug use, aspirin use, smoking cessation) matched to a 2017- clinic survey on the use of diabetes-related care management processes (62 items in Physician Practice Connections-Research Survey). A mixed effect multi-level regression model with fixed clinic- and patient-level independent variables and random clinic-level intercepts was used to test the association between clinic use of care management processes (index of 0-100%) and glycemic control of glycated hemoglobin (A1C) level while adjusting for patient covariates (age, sex, comorbid conditions, diabetes type 1 or 2, residence rurality) and clinic covariates (PCMH certification, medical group size, federally qualified health center). Results: The overall mean index of care-management processes usage was 86% (IQR of 76-97%). Every 10% increase in the use of care management processes was associated with a decrease of 0.57 in A1C (p&amp;lt;.001). Among Medicaid patients, every 10% increase in the use of care-management was associated with a decrease of 0.72 in A1C (p&amp;lt;.001), while for non-Medicaid patients the associated decrease was 0.53 (p&amp;lt;.001). The 0.2 difference between Medicaid and non-Medicaid groups was also statistically significant (p&amp;lt;.001). Conclusions: Clinic utilization of PCMH care management processes had a larger effect on diabetes control for patients on Medicaid than for other patients. Improving and implementing these processes may be an important strategy for reducing disparities in diabetes outcomes. Disclosure H.N. Fu: None. J. Wolfson: None. L. Solberg: None. M. Grey: None. K.A. Peterson: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R18DK110732)

The Patient-Centered Medical Home: Mental Health and Parenting Stress in Mothers of Children With Autism.

Objective: This study examined the correlations between receiving care in patient-centered medical home and maternal reports of their mental health and parenting stress in a national sample of mothers of children with autism spectrum disorder (ASD). Method: Participants were 1108 mothers of children with ASD (average age = 10.6 years; 81% male) from the 2011-2012 National Survey of Children’s Health. Multiple linear regression analysis and polynomial logistic regression analysis were used to evaluate if having a child with ASD cared for in a patient-centered medical home was significantly associated with maternal reports of their parenting stress and mental health. We also assessed whether 5 indicators of the American Academy of Pediatrics medical home definition were differentially associated with maternal outcomes. Results: Receiving care in a patient-centered medical home was associated with maternal reports of less parenting stress (standardized β = −0.201; P < .001) and better mental health (odds ratios range from 0.204 to 0.360; P < .001) after controlling for sociodemographic variables. Of the 5 indicators of the medical home definition, only effective care coordination was significantly associated with maternal perceptions of their parenting stress and mental health. Conclusion: Future longitudinal studies are needed to assess the temporal associations between patient-centered medical home status and maternal perceptions of their mental health and parenting stress in mothers of children with ASD.

Care Experiences of Patients with Multiple Chronic Conditions in a Payer-Based Patient-Centered Medical Home.

Individuals with multiple chronic health conditions require additional support and medical services, incur higher health care costs, and often have a higher risk of hospitalization. The goal of this study was to examine care experiences of patients with multiple chronic conditions in the CareFirst patient-centered medical home (PCMH). The study used a repeated cross-sectional research design and included 1308 adult CareFirst plan members with multiple chronic conditions. Patient care experiences were collected using a structured telephone survey in 2015 and 2017. Composite scores and individual question responses for patient-provider communication, coordination of care, access to care, and self-management support were analyzed to determine differences between survey years. Overall, patients reported positive care experiences with communication, self-management support, and care coordination. Access to care indicators received lower composite scores. Between 2015 and 2017, patients reported higher ratings for appointment reminders, communicating test results, providers listening carefully, and care plan effectiveness. Patients who completed their CareFirst PCMH care plan had higher care experience scores than patients who did not. A key finding of this study is that care plan completion is associated with positive care experiences, indicating the importance of the care plan to this PCMH model. Lower scores on access to care measures suggest a need for improved pathways for patients to obtain care during nontraditional office hours. Payer-based PCMH models that include enhanced care coordination and additional provider payments to support these activities may be beneficial to patients with multiple chronic conditions.

Economic benefits of implementing patient-centered medical home among patients with hypertension.

IntroductionDespite the strong evidence of an association between adoption of the patient-centered medical home (PCMH) and improved clinical outcomes among patients with hypertension, evidence for associations between the PCMH and health care utilization and cost reduction within the general adult population with hypertension is less developed.ObjectiveThis study was designed to examine the effect of PCMH on health service expenditures and utilization in a national sample of the US adult population who were diagnosed with hypertension.MethodsThe 2010–2015 Medical Expenditure Panel Survey data were used. The study sample was limited to adults (≥18 years) diagnosed with essential hypertension. We investigated the impact of PCMH on the direct hypertension-related total and on the costs of inpatient stays, prescription medications, outpatient visits, emergency room visits, office-based services, and other medical expenditures by using log-transformed multiple linear regression models and the propensity score method.ResultsOf the 18,630 adults identified with hypertension, 19.2% (n=3,583) of them had received PCMH care from 2010 to 2015. After matching, the no PCMH group showed greater mean in all hypertension-related health service costs and utilization. After adjusting for the remaining con-founders, the PCMH group showed a significant association with lower total costs, office-based services, number of office-based visits, and outpatient visits compared with the control group.ConclusionA significant relationship between experiencing PCMH care and a lower total health care expenditure was found in patients with hypertension.

Disparities in Self-reported Access to Patient-centered Medical Home Care for Children With Special Health Care Needs.

Efforts to transform primary care have been underway for over a decade. Yet, we lack understanding of the progress made in scaling up this care model nationwide and on whether patient-centered medical home (PCMH) has benefited every group of children with special health care needs (CSHCNs). The main objective of this study was to examine variation in caregiver service experience concordant with PCMH care over time and by child characteristics. This was a cross-sectional pooled data analysis using the 2003-2012 Medical Expenditures Panel Survey data for CSHCNs, aged 5-17 years. Logistic regressions were implemented, accounting for child and parent sociodemographic, child's health insurance, and contextual characteristics. PCMH concordant care and each component were constructed as binary variables and child functional impairment was measured with the Columbia Impairment Scale. Thirty-one percent of children reported medical home concordant care; comprehensive (83%) and compassionate (82%) care were most prevalent, and the least common were accessible care (59%) and patient-centered care (60%). PCMH concordant care significantly increased nationwide between 2003 and 2012, but disparities remained based on child needs and sociodemographic characteristics. Multivariate regressions showed variation across medical home components. Despite increased parent perception of care that is concordant with medical home care over time, disparities remain among high-need CSHCNs. Future research may focus on better understanding how clinical settings tailor this care model, particularly on providing increased access and patient-centered care, to better serve children at the highest need.

Patient-centered medical home care access among adults with chronic conditions: National Estimates from the medical expenditure panel survey

BackgroundThe Patient-Centered Medical Home (PCMH) model is a coordinated-care model that has served as a means to improve several chronic disease outcomes and reduce management costs. However, access to PCMH has not been explored among adults suffering from chronic conditions in the United States. Therefore, the aim of this study was to describe the changes in receiving PCMH among adults suffering from chronic conditions that occurred from 2010 through 2015 and to identify predisposing, enabling, and need factors associated with receiving a PCMH.MethodsA cross-sectional analysis was conducted for adults with chronic conditions, using data from the 2010–2015 Medical Expenditure Panel Surveys (MEPS). Most common chronic conditions in the United States were identified by using the most recent data published by the Agency for Healthcare Research and Quality (AHRQ). The definition established by the AHRQ was used as the basis to determine whether respondents had access to PCMH. Multivariate logistic regression analyses were conducted to detect the association between the different variables and access to PCMH care.ResultsA total of 20,403 patients with chronic conditions were identified, representing 213.7 million U.S. lives. Approximately 19.7% of the patients were categorized as the PCMH group at baseline who met all the PCMH criteria defined in this paper. Overall, the percentage of adults with chronic conditions who received a PCMH decreased from 22.3% in 2010 to 17.8% in 2015. The multivariate analyses revealed that several subgroups, including individuals aged 66 and older, separated, insured by public insurance or uninsured, from low-income families, residing in the South or the West, and with poor health, were less likely to have access to PCMH.ConclusionOur findings showed strong insufficiencies in access to a PCMH between 2010 and 2015, potentially driven by many factors. Thus, more resources and efforts need to be devoted to reducing the barriers to PCMH care which may improve the overall health of Americans with chronic conditions.

Implementing Comprehensive Primary Care Referral Tracking in a Patient-Centered Medical Home.

The Patient-Centered Medical Home care model emphasizes efficient, coordinated care distributed among interdisciplinary team members. One key function to care coordination is referral/test tracking. This study evaluated the referral practices in a nurse-managed Patient-Centered Medical Home primary care clinic. The major findings corroborate the need for a well-organized referral-tracking system that is centralized and contains safety nets to reduce the number of delayed or missed referrals.

Patient-Centered Medical Home Care for Adolescents in Need of Mental Health Treatment

PurposeThe patient-centered medical home (PCMH) has emerged as an optimal primary care model for all youth; however, little is known about the extent to which adolescents in need of mental health (MH) treatment receive care consistent with the PCMH. This study assessed (1) 10-year trends in PCMH care among U.S. adolescents according to MH need and (2) variations in PCMH care and its subcomponents among adolescents with MH need, by individual and family characteristics. MethodsThis was a secondary analysis of Medical Expenditure Panel Survey data (2004–2013). The sample included adolescents aged 12–17 years with ≥1 office-based visits in the past year (N = 18,717). Questions assessing a usual source of care and care that is accessible, comprehensive, family-centered, and compassionate were used to define PCMH care. For adolescents with MH needs, multivariable logistic regression was used to describe the association between PCMH care and sample characteristics. ResultsFifty percent of adolescents experienced PCMH care, with little change between 2004 and 2013. Adolescents with MH need (N = 3,794) had significantly lower odds of experiencing PCMH care compared with those without MH need (odds ratio, .78; 95% confidence interval, .69–.87). Among adolescents with MH needs, being uninsured and living with a parent who did not graduate high school were negatively associated with PCMH care, whereas parental usual source of care was positively associated (odds ratio, 1.69; 95% confidence interval, 1.28–2.22). ConclusionsIncreasing care accessibility, integrating MH services into primary care settings, and targeting socioeconomically disadvantaged subgroups could improve rates of PCMH care among adolescents with MH needs.