Patient-centered Medical Home Clinics Research Articles

Neighborhood Socioeconomic Deprivation and Health Care Utilization of Medically Complex Children.

To assess the association between neighborhood socioeconomic deprivation and health care utilization in a cohort of children with medical complexity (CMC). Cross-sectional study of children aged <18 years receiving care in our institution's patient-centered medical home (PCMH) for CMC in 2016 to 2017. Home addresses were assigned to census tracts and a tract-level measure of socioeconomic deprivation (Deprivation Index with range 0-1, higher numbers represent greater deprivation). Health care utilization outcomes included emergency department visits, hospitalizations, inpatient bed days, and missed PCMH clinic appointments. To evaluate the independent association between area-level socioeconomic deprivation and utilization outcomes, multivariable Poisson and linear regression models were used to control for demographic and clinical covariates. The 512 included CMC lived in neighborhoods with varying degrees of socioeconomic deprivation (median 0.32, interquartile range 0.26-0.42, full range 0.12-0.82). There was no association between area-level deprivation and emergency department visits (adjusted risk ratio [aRR] 0.98; 95% confidence interval [CI]: 0.93 to 1.04), hospitalizations (aRR 0.97; 95% CI: 0.92 to 1.01), or inpatient bed-days (aRR 1.00, 95% CI: 0.80 to 1.27). However, there was a 13% relative increase in the missed clinic visit rate for every 0.1 unit increase in Deprivation Index (95% CI: 8%-18%). A child's socioeconomic context is associated with their adherence to PCMH visits. Our PCMH for CMC includes children living in neighborhoods with a range of socioeconomic deprivation and may blunt effects from harmful social determinants. Incorporating knowledge of the socioeconomic context of where CMC and their families live is crucial to ensure equitable health outcomes.

Primary care provider perceptions of an integrated community pharmacy hypertension management program

BackgroundTrained community pharmacists provided hypertension (HTN) management services in collaboration with a patient-centered medical home (PCMH). ObjectiveTo explore primary care provider (PCP) perceptions of a HTN management program in which patients at the PCMH with elevated blood pressure could choose to receive follow-up care with a trained community pharmacist at a chain community pharmacy. MethodsWe conducted informal interviews with 8 PCPs with a range of level of involvement with the collaborative HTN management program to inform the development of a 13-question online survey that was distributed to PCPs at 10 participating Michigan Medicine PCMH clinics. The primary outcome was the percent of PCPs who reported that the program improved their patient’s blood pressure. Secondary outcomes included awareness of the program, alternative follow-up strategies, PCP satisfaction, and barriers to using the program. ResultsA total of 39 PCPs (30.0%) responded to the survey. More than one-half (n = 21 of 39, 53.9%) of respondents reported that at least 1 of their patients had seen a trained community pharmacist for HTN management services. Almost all of these PCPs (n = 19 of 21, 90.5%) reported being satisfied with the program, and 80.9% (n = 17 of 21) agreed that it helped patients improve their blood pressure control. The most common barriers identified were patients preferring to follow up directly with their PCP (n = 18 of 39, 46.2%), PCPs being more comfortable with patients having a visit with an embedded ambulatory care pharmacist (n = 16 of 39, 41.0%), and a lack of written materials to share with patients about the program (n = 15 of 39, 38.5%). ConclusionPCPs who used the integrated community pharmacy HTN management program were satisfied with the program and thought that it resulted in improved blood pressure control. PCPs may benefit from written information to share with their patients as well as education to increase their awareness of the program and its beneficial effect on patient blood pressure.

Association of High-Cost Health Care Utilization With Longitudinal Changes in Patient-Centered Medical Home Implementation

In 2010, the US Veterans Health Administration (VHA) implemented one of the largest patient-centered medical home (PCMH) models in the United States, the Patient Aligned Care Team initiative. Early evaluations demonstrated promising associations with improved patient outcomes, but limited evidence exists on the longitudinal association of PCMH implementation with changes in health care utilization. To determine whether a change in PCMH implementation is associated with changes in emergency department (ED) visits, hospitalizations for ambulatory care-sensitive conditions (ACSCs), or all-cause hospitalizations. This cohort study used national patient-level data from the VHA and Centers for Medicare & Medicaid Services between October 1, 2012, and September 30, 2015. A total of 1 650 976 patients from 897 included clinics were divided into 2 cohorts: patients younger than 65 years who received primary care at VHA sites affiliated with a VHA ED and patients 65 years or older who were enrolled in both VHA and Medicare services. Clinics were categorized on improvement or decline in PCMH implementation based on their Patient Aligned Care Team implementation progress index (Pi2) score. Change in the number of ED visits, ACSC hospitalizations, and all-cause hospitalizations among patients at each clinic site. The study included a total of 1 650 976 patients, of whom 581 167 (35.20%) were younger than 65 years (mean [SD] age, 49.03 [10.28] years; 495 247 [85.22%] men) and 1 069 809 (64.80%) were 65 years or older (mean [SD] age, 74.64 [7.41] years; 1 050 110 [98.16%] men). Among patients younger than 65 years, there were fewer ED visits among patients seen at clinics that had improved PCMH implementation (110.8 fewer visits per 1000 patients; P < .001) and clinics that had somewhat worse implementation (69.0 fewer visits per 1000 patients; P < .001) compared with clinics that had no change in Pi2 score. There were no associations of change in Pi2 scores with all-cause hospitalizations or ACSC hospitalizations among patients younger than 65 years. In patients 65 years or older, those seen at clinics that had somewhat worse PCMH implementation experienced fewer ED visits (20.1 fewer visits per 1000 patients; P = .002) and all-cause hospitalizations (12.4 fewer hospitalizations per 1000 patients; P = .007) compared with clinics with no change in Pi2 score. There was no association between change in Pi2 score with ACSC hospitalizations among patients 65 years or older. There were no consistent associations of change in Pi2 score with high-cost health care utilization. This finding highlights the key differences in measuring PCMH implementation longitudinally compared with cross-sectional study designs.

Integrating Personalized Care Planning into Primary Care: a Multiple-Case Study of Early Adopting Patient-Centered Medical Homes.

Personalized care planning is a patient-centered, whole-person approach to treatment planning. Personalized care plans improve patient outcomes and are now mandated for chronic care management reimbursement. Yet guidance on how to best implement personalized care planning in practice is limited. We examined the adoption of personalized care planning in patient-centered medical home (PCMH) clinics to identify processes and organizational characteristics that facilitated or hindered use in routine practice. Qualitative multiple-case study design. We conducted site visits at PCMH clinics in four US Veterans Health Administration (VHA) medical centers. Data included 10 general clinic observations, 34 direct observations of patient-provider clinical encounters, 60 key informant interviews, and a document review. Data were analyzed via qualitative content analysis using a priori and emergent coding. Employees and patients participating in clinical encounters in PCMH clinics at four VHA medical centers. Each clinic used a distinct approach to personalized care planning: (1) distributed tasks approach; (2) two-tiered approach; (3) health coaching approach; and (4) leveraging a village approach. Each varied in workflow, healthcare team utilization, and degree of integration into clinical care. Across sites, critical components for implementation included expanding planning beyond initial assessment of patient priorities; framing the initiative for patients; using a team-based approach to care plan development and updates; using communication mechanisms beyond the electronic health record; and engaging stakeholders in implementation planning. Personalized care planning is a novel patient-centered practice, but complicated to implement. We found variation in effective implementation and identified critical components to structuring this practice in a manner that engages patients in treatment aligned with personal priorities. Primary care practices seeking to implement personalized care planning must go beyond simply asking patients a series of questions to establish a plan. They must also engage team members in plan development, communication, and dissemination.

Linking the patient-centered medical home to community pharmacy via an innovative pharmacist care model

ObjectivesTo develop and pilot test a model that extends pharmacists’ direct patient care from the patient-centered medical home (PCMH) to the community pharmacy. SettingTwo Michigan Medicine PCMH clinics and 2 CVS Pharmacy sites in Ann Arbor, MI. Practice descriptionIn the PCMH clinics, pharmacists have provided patient care using collaborative practice agreements for diabetes, hypertension, and hyperlipidemia for more than 5 years. Practice innovationLegal agreements were developed for sharing data and for accessing the Michigan Medicine Electronic Medical Record (EMR) in the CVS pharmacies. An immersion training model was used to train 2 community pharmacists to provide direct patient care and change medications to improve disease control. Then these community pharmacists provided disease management and comprehensive medication reviews (CMRs) in either the PCMH clinic or in CVS pharmacies. Main outcome measuresGlycosylated hemoglobin (A1C ≤ 9% and < 7%) and blood pressure (BP < 140/90) were compared for patients seen by PCMH pharmacists, patients seen by community pharmacists, and a propensity score–generated control group. Surveys were used to assess patient satisfaction. ResultsOf 503 shared patients, 200 received disease management and 113 received a CMR from the community pharmacists. Lack of efficacy was the most common reason for medication changes in diabetes (n = 136) and hypertension (n = 188). For CMR, optimizing the dosage regimen was the most common intervention. For the community pharmacist group, the odds of patients having an A1C ≤ 9% increased by 8% in each time period, whereas the odds decreased by 16% for the control group (odds ratio 1.29; P = 0.0028). No statistically significant differences were seen in the outcomes for patients seen by PCMH versus community pharmacists. Most patients (90%) rated the care as excellent. ConclusionDirect patient care provided by community pharmacists, either in PCMH clinics or CVS pharmacies, was consistent with care provided by PCMH pharmacists. Patients were highly satisfied with the services provided.

Patient-Centered Medical Home Implementation and Improved Chronic Disease Quality: A Longitudinal Observational Study.

To examine associations between clinics' extent of patient-centered medical home (PCMH) implementation and improvements in chronic illness care quality. Data from 808 Veterans Health Administration (VHA) primary care clinics nationwide implementing the Patient Aligned Care Teams (PACT) PCMH initiative, begun in 2010. Clinic-level longitudinal observational study of clinics that received training and resources to implement PACT. Clinics varied in the extent they had PACT components in place by 2012. Clinical care quality measures reflecting intermediate outcomes and care processes related to coronary artery disease (CAD), diabetes, and hypertension care were collected by manual chart review at each VHA facility from 2009 to 2013. In adjusted models containing 808 clinics, the 77 clinics with the most PACT components in place had significantly larger improvements in five of seven chronic disease intermediate outcome measures (e.g., BP<160/100 in diabetes), ranging from 1.3 percent to 5.2 percent of the patient population meeting measures, and two of eight process measures (HbA1c measurement, LDL measurement in CAD) than the 69 clinics with the least PACT components. Clinics with moderate levels of PACT components showed few significantly larger improvements than the lowest PACT clinics. Veterans Health Administration primary care clinics with the most PCMH components in place in 2012 had greater improvements in several chronic disease quality measures in 2009-2013 than the lowest PCMH clinics.

Reduced acute inpatient care was largest savings component of Geisinger Health System's patient-centered medical home.

Early evidence suggests that the patient-centered medical home has the potential to improve patient outcomes while reducing the cost of care. However, it is unclear how this care model achieves such desirable results, particularly its impact on cost. We estimated cost savings associated with Geisinger Health System's patient-centered medical home clinics by examining longitudinal clinic-level claims data from elderly Medicare patients attending the clinics over a ninety-month period (2006 through the first half of 2013). We also used these data to deconstruct savings into its main components (inpatient, outpatient, professional, and prescription drugs). During this period, total costs associated with patient-centered medical home exposure declined by approximately 7.9 percent; the largest source of this savings was acute inpatient care ($34, or 19 percent savings per member per month), which accounts for about 64 percent of the total estimated savings. This finding is further supported by the fact that longer exposure was also associated with lower acute inpatient admission rates. The results of this study suggest that patient-centered medical homes can lead to sustainable, long-term improvements in patient health outcomes and the cost of care.

Associations between medical home characteristics and support for patient activation in the safety net: understanding differences by race, ethnicity, and health status.

Few studies have evaluated whether the patient-centered medical home (PCMH) supports patient activation and none have evaluated whether support for patient activation differs among racial and ethnic groups or by health status. This is critical because activation is lower on average among minority patients and those in poorer health. To assess the association between clinic PCMH characteristics and patient perception of clinic support for patient activation, and whether that association varies by patients' self-reported race/ethnicity or health status. A total of 214 providers/staff and 735 patients in 24 safety net clinics across 5 states. Provider/staff surveys produced a 0-100 score for PCMH characteristics. Patient surveys used the patient activation subscale of the Patient Assessment of Chronic Illness Care to produce a 0-100 score for patient perception of clinic support for patient activation. Across all patients, we did not find a statistically significant association between PCMH score and clinic support for patient activation. However, among the subgroup of minority patients in fair or poor health, a 10-point higher PCMH score was associated with a 14.5-point (CI, 4.4, 24.5) higher activation score. In a population of safety net patients, higher-rated PCMH characteristics were not associated with patients' perception of clinic support for activation among the full study population; however, we found a strong association between PCMH characteristics and clinic support for activation among minority patients in poor/fair health status. The PCMH may be promising for reducing disparities in patient activation for ill minority patients.

Spreading a Medical Home Redesign: Effects on Emergency Department Use and Hospital Admissions

The patient-centered medical home (PCMH) is being rapidly deployed in many settings to strengthen US primary care, improve quality, and control costs; however, evidence supporting this transformation is still lacking. We describe the Group Health experience in attempting to replicate the effects on health care use seen in a PCMH prototype clinic via a systemwide spread using Lean as the change strategy. We used an interrupted time series analysis with a patient-month unit of analysis over a 4-year period that included baseline, implementation, and stabilization periods for 412,943 patients. To account for secular trends across these periods, we compared changes in use of face-to-face primary care visits, emergency department visits, and inpatient admissions with those of a nonequivalent comparison group of patients served by community network practices. After accounting for secular trends among network patients, patients empaneled to the PCMH clinics had 5.1% and 6.7% declines in primary care office visits in early and later stabilization years, respectively, after the implementation year. This trend was accompanied by a 123% increase in the use of secure electronic message threads and a 20% increase in telephone encounters. Declines were also seen in emergency department visits at 1 and 2 years (13.7% and 18.5%) compared with what would be expected based on secular trends in network practices. No statistically significant changes were found for hospital admissions. The Group Health experience shows it is possible to reduce emergency department use with PCMH transformation across a diverse set of clinics using a clear change strategy (Lean) and sufficient resources and supports.

CA8-03: Evaluating Primary Care Renewal in Oregon's Safety Net Clinics: Preliminary Quantitative Findings from CareOregon's Adult Medicaid Population

Background/AimsThe patient-centered medical home (PCMH) holds great promise for improving care delivery. Primary Care Renewal (PCR) is an initiative, launched in early 2007, to transform Oregon safety-net clinics to the PCMH model of care. It is sponsored by CareOregon (CO), a Medicaid/Medicare managed care organization. The primary objective of this study was to conduct a quantitative assessment to identify utilization and cost metrics relevant to PCR practices and to evaluate PCR’s degree of success in improving these metrics.MethodsThe study population includes CO adult Medicaid enrollees assigned to 17 PCMH clinics (n=11,639) and 280 usual care clinics (n=64,686) over two time periods:18-month pre- implementation period (1/1/2006-6/30/2007) and33-month post-implementation period (1/1/2008-9/30/2010).A six-month break (7/1/2007-12/31/2007) was included as the PCR rollout period. Outcome measures include:hospital days, ED visits, and primary care visits per 1,000 members per year andper member per month (PMPM) medical costs (paid by CO).Utilization and cost information were obtained via claims data. Segmented regression models were used to compare post and pre-implementation periods for each outcome measure. Models were stratified by:adult population (entire population) andExpanded Diagnosis Clusters (EDCs, proxy measure for disease burden).Interactions of level change (post vs. pre-implementation) and clinic type (PCMH vs. non- PCMH) were assessed using segmented regression analysis.ResultsWe found a significant interaction of level change (post vs. pre-implementation) by clinic type for inpatient utilization (beta coefficient = −2.09, p-value = p < .001). Inpatient utilization was significantly lower immediately following implementation than just prior to the implementation. The level change by clinic type interactions were not significant for primary care visits, ED visits and PMPM medical costs. Stratification by EDC for each outcome measure will be completed by the start of the HMORN conference.DiscussionPreliminary results suggest PCMH was successful in reducing inpatient utilization after implementation, but no differences were found in other utilization metrics or medical costs. Study results were limited because no clinical quality information was available for analysis. Future research should analyze changes in clinical quality metrics (e.g. HbA1c value) after PCMH interventions are implemented.

Impact on Seniors of the Patient-Centered Medical Home: Evidence From a Pilot Study

To assess the impact on health care cost and quality among seniors of a patient-centered medical home (PCMH) pilot at Group Health Cooperative, an integrated health care system in Washington State. A prospective before-and-after evaluation of the experience of seniors receiving primary care services at 1 pilot clinic compared with seniors enrolled at the remaining 19 primary care clinics owned and operated by Group Health. Analyses of secondary data on quality and cost were conducted for 1,947 seniors in the PCMH clinic and 39,396 seniors in the 19 control clinics. Patient experience with care was based on survey data collected from 487 seniors in the PCMH clinic and of 668 in 2 specific control clinics that were selected for their similarities in organization and patient composition to the pilot clinic. After adjusting for baseline, seniors in the PCMH clinic reported higher ratings than controls on 3 of 7 patient experience scales. Seniors in the PCMH clinic had significantly greater quality outcomes over time, but this difference was not significant relative to control. PCMH patients used more e-mail, phone, and specialist visits but fewer emergency services and inpatient admissions for ambulatory care sensitive conditions. At 1 and 2 years, the PCMH and control clinics did not differ significantly in overall costs. A PCMH redesign can be associated with improvements in patient experience and quality without increasing overall cost.

Operational and clinical components for integrated-collaborative behavioral healthcare in the patient-centered medical home.

Behavioral healthcare will be an essential piece of meeting the patient-centered medical home (PCMH) principles of easy access and whole person, coordinated, and integrated care as primary care clinics transform themselves into PCMHs. As this transformation occurs, PCMH clinic staff and behavioral health providers must carefully consider how to adapt their operations to include the provision of integrated-collaborative behavioral health services within the PCMH. Without this careful consideration, integrated-collaborative behavioral healthcare will likely fail to reach its full potential. We discuss the operational and clinical components that appear to be important for success when integrating behavioral healthcare into the PCMH.