Patient-centered Medical Home Practices Research Articles

Transforming Primary Care in New York Through Patient-Centered Medical Homes: Findings From Qualitative Research.

Background:The patient-centered medical home (PCMH) model, an important component of healthcare transformation in the United States, is an approach to primary care delivery with the goal of improving population health and the patient care experience while reducing costs. PCMH research most often focuses on system level indicators including healthcare use and cost; descriptions of patient and provider experience with PCMH are relatively sparse and commonly limited in scope. This study, part of a mixed-methods evaluation of a multi-year New York State initiative to refine and expand the PCMH model, describes patient and provider experience with New York State PCMH and its key components.Methods:The qualitative component of the evaluation included focus groups with patients of PCMH practices in 5 New York State counties (n = 9 groups and 67 participants) and interviews with providers and practice administrators at New York State PCMH practices (n = 9 interviews with 10 participants). Through these focus groups and interviews, we elicited first-person descriptions of experiences with, as well as perspectives on, key components of the New York State PCMH model, including accessibility, expanded use of electronic health records, integration of behavioral health care, and care coordination.Results:There was evident progress and some satisfaction with the PCMH model, particularly regarding integrated behavioral health and, to some extent, expanded use of electronic health records. There was less evident progress with respect to improved access and reasonable wait times, which caused patients to continue to use urgent care or the emergency department as substitutes for primary care.Conclusions:It is critical to understand the strengths and limitations of the PCMH model, so as to continue to improve upon and promote it. Strengths of the model were evident to participants in this study; however, challenges were also described. It is important to note that these challenges are difficult to separate from wider healthcare system issues, including inadequate incentives for value-based care, and carry implications for PCMH and other models of healthcare delivery.

Association of a housing based individual socioeconomic status measure with diabetic control in primary care practices

AimsSocioeconomic status (SES) is an important variable that impacts healthcare outcomes. However, grouped SES data is not always representative of all members and it is difficult to obtain individual level data. A validated individual housing-based measure termed HOUSES is available, but has not been studied in diabetes. We hypothesize that patients in the lowest HOUSES quartile are associated with worse diabetic control as measured by the D5. MethodsA retrospective cohort study of 5463 patients with diabetes in 5 patient centered medical home practices in southeast Minnesota was conducted. HOUSES is a validated, standardized housing-based SES measure constructed from publicly available county assessor’s office data. Diabetic control was assessed by the D5 (HgbA1c < 8, BP < 140/90, statin use, nonsmoking status, and antiplatelet therapy). ResultsIn the lowest HOUSES quartile, more patients had an uncontrolled D5 (56.4%) than any of the other quartiles (49.2%, 49.8%, 49.6% respectively, p < 0.001). A multivariate analysis shows the adjusted odds of D5 control for patients in the 2nd, 3rd or 4th HOUSES quartiles as opposed to the 1st quartile are 1.28, 1.21, and 1.20, respectively. ConclusionLower SES as represented by the first quartile of HOUSES index, is associated with lower odds of D5 control and thus worse diabetic outcomes. Using the HOUSES index to identify these individuals in a patient centered medical home might prove useful in deciding where to focus diabetic control efforts.

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.

Some Aspects of Patient Experience Assessed by Practices Undergoing Patient-Centered Medical Home Transformation Are Measured by CAHPS, Others Are Not.

Delivering care as a patient-centered medical home (PCMH) is being widely adopted across the United States by primary care practices to better meet patient needs. A key PCMH element is measuring patient experience for practice improvement. The National Committee for Quality Assurance (NCQA) PCMH recognition program requires practices to both measure patient experience and engage in continuous practice/quality improvement to attain PCMH recognition and then throughout full PCMH transformation. The NCQA recommends but does not require that practices administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) clinician and group patient experience survey (CG-CAHPS) plus 14 CAHPS PCMH items, known as the CAHPS PCMH survey. We examine aspects of patient experience measured by practices with a varying number of years on their journey of PCMH transformation. We randomly selected practices from the 2008-2017 NCQA directory of practices that had applied for PCMH recognition based on region, physician count, number of years and level of PCMH recognition, and use of the CG-CAHPS PCMH survey. We collected characteristics of the practices from practice leader(s) knowledgeable about the practice's PCMH history and patient experience data. We confirmed the patient experience surveys used during their PCMH history and requested copies of their non-CAHPS survey(s). For practices not administering the recommended CG-CAHPS survey (53/105 practices), we obtained and coded the content of their non-CAHPS surveys (68%; 36/53). We mapped the patient experience domains and specific measures to the CG-CAHPS survey (versions 2.0 and 3.0), CAHPS PCMH item set (versions 2.0 and 3.0), and the available CG-CAHPS supplemental items. Whether or not practices administered the CG-CAHPS items, most of them addressed topics contained in the CG-CAHPS survey such as Access to care, Provider communication, Office staff helpfulness/courteousness, Care coordination, and Shared decision-making. The most common CAHPS measures included were Office staff helpfulness/courteousness and Provider communication. Common non-CAHPS measures included were Ease of scheduling, Being informed about delays, and Provider helpfulness/courteousness. NCQA PCMH practices included CAHPS items on their patient experience surveys even if they did not administer the full CG-CAHPS survey or the recommended CAHPS PCMH survey. To enhance the usefulness of patient experience surveys for practices undergoing PCMH changes, additional CAHPS measures could be developed related to key areas of PCMH change, including expanded access to care (ie, after-hours and weekend visits, ease of scheduling, being informed about delays), use of shared decision-making, and improvements in provider communication (ie, the provider is courteous, communication by other clinical staff members with the patient). These additional measures would assist practice leaders in capturing the breadth and depth of their PCMH transformation and its influence on providing more patient-centered care. Developing such items would help standardize the measurement of changes related to patient experience during PCMH transformation. Research is needed to determine whether a CAHPS survey is the best source of this information.

Patients’ and Caregivers’ Experiences with the Multi-Payer Advanced Primary Care Practice Demonstration

BackgroundThe patient-centered medical home (PCMH) model aims to improve primary health care using a patient-centered approach. Little qualitative research has investigated how the PCMH model affects patient experience with care.ObjectiveTo understand Medicaid and Medicare patient and caregiver experiences with PCMHs participating in the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration.DesignQualitative study.ParticipantsMedicare, Medicaid, and dually eligible patients who were patients in primary care practices participating in the MAPCP Demonstration and caregivers of such patients (N = 490).ApproachFrom July through November 2014, a trained facilitator conducted 81 focus groups in the eight states participating in the MAPCP Demonstration. Separate groups were held for Medicare high-risk, Medicare low-risk, Medicaid, and dually eligible beneficiaries, their caregivers, and caregivers of Medicaid children (or, in Vermont, with patients participating in the Support and Services at Home program), in two different geographical areas in each state. Focus group discussions were recorded, transcribed, and analyzed using NVivo qualitative data analysis software.ResultsParticipants’ experiences with care were generally consistent with the expectations of a PCMH, although some exceptions were noted. Medicaid only and dually eligible beneficiaries generally had less-positive experiences than Medicare beneficiaries. Most participants said their practices had not solicited feedback from them about their experiences with care. Few participants knew what the term “medical home” meant or were aware that their practices were working to become PCMHs, but many had noticed changes in recent years, primarily related to the conversion to electronic health records.ConclusionsMost participants had positive experiences with their care. Opportunities exist, however, to improve care for Medicaid and dually eligible beneficiaries, and enhance patient awareness of and involvement in PCMH practice transformation.

Chronic Disease Management: How IT and Analytics Create Healthcare Value Through the Temporal Displacement of Care

The treatment of chronic diseases consumes 86% of U.S. healthcare costs. While healthcare organizations have traditionally focused on treating the complications of chronic diseases, advances in information technology (IT) and analytics can help clinicians and patients manage and slow the progression of chronic diseases to result in higher quality of life for patients and lower healthcare costs. We build on prior research to introduce the notion of temporal displacement of care (TDC), in which IT and analytics create healthcare value by displacing the time at which providers and patients make interventions to improve healthcare outcomes and reduce costs. We propose that healthcare value is created by strategic actions taken at specific points-in-time during the treatment process. Our theoretical development identifies TDC mechanisms through which IT and analytics displace later high cost interventions in favor of earlier preventative procedures. We test our hypotheses using four years of data on 45,000 cardio-metabolic patients from the U.S. state of Vermont, which implemented a Patient-Centered Medical Home (PCMH) program. Our study includes four cohorts with increasing levels of IT and analytics use: (1) non-PCMH practices, (2) PCMH practices with basic IT systems installed, (3) practices that completed data quality sprints (DQS) to increase use of IT systems, and (4) practices that use analytics through the Vermont Healthcare Information Exchange (VHIE). Our results provide insights into how TDC effects develop over time. In Year 1 after implementation, the DQS cohort demonstrates a marked increase in the use of preventative procedures such as eye exams and neuropathy screenings, the increase becomes more pronounced in Years 2 and 3, and the increase is even greater for the VHIE cohort. As the use of preventative procedures increases, emergency department utilization decreases, with a more pronounced decrease for the VHIE cohort than the DQS cohort. By Year 2, the DQS and VHIE cohorts experience a decrease in total healthcare costs, with a greater decrease for the VHIE cohort than the DQS cohort. By Year 3, the healthcare outcomes indicator of Hemoglobin A1c (HbA1c) level is statistically significantly lower, with a greater decrease for the VHIE cohort than the DQS cohort. The increased use of low-intervention healthcare treatments earlier in the process leads to a decrease in overall healthcare costs, which then leads to an improvement in healthcare indicators.

The Impact of the Patient-Centered Medical Home on Asthma-Related Visits to the Emergency Room: A Fixed Effects Regression Approach.

Objective To estimate the effect of a patient-centered medical home (PCMH) intervention on asthma-related emergency room (ER) visits of pediatric patients. Methods Patients receiving care at pediatric primary care practices participating in the Florida Pediatric Medical Home Demonstration Project as well as pediatric patients treated at non-participating clinics were identified from 4 years of claims and enrollment data. We estimate several fixed effects logistic regression models using one pre-treatment year and three post-treatment years to investigate whether asthma-related ER visits decreased because of the PCMH intervention. Results The estimation suggests that the intervention did have a negative effect on asthma-related ER visits in the earlier part of the intervention (OR 0.34; 95% CI 0.16-0.73). However, this effect was not detected in the later years. Because fixed effects models require repeated observations on the same individual, we believe our estimations of the PCMH model's impact is more accurate than previous studies. Conclusion for Practice Reducing asthma ER visits is a task that might be immediately actionable for PCMH practices, or those undergoing transformation. Our results adds to the others suggesting positive impacts of the PCMH.

Communication Among Team Members Within the Patient-centered Medical Home and Patient Satisfaction With Providers: The Mediating Role of Patient-Provider Communication.

The Patient-centered Medical Home (PCMH) uses team-based care to improve patient outcomes, including satisfaction. The quality of patients' communication with their primary care providers (PCPs) is a key determinant of patient satisfaction. A shift to team-based care could disrupt the therapeutic relationship between patients and their PCPs and reduce patient satisfaction if communication and coordination among primary care team members is poor. Little is known about the relationship between intrateam communication within a PCMH and patient satisfaction with PCPs, and whether patient-provider communication might mediate this relationship. To examine the relationship between intrateam communication in a PCMH and patients' satisfaction with assigned PCPs, and whether patient-provider communication mediates this relationship. Cross-sectional surveys of Veterans Health Administration PCPs (2011-2012, n=149) matched with their assigned patients' surveys (n=3329). Mediation analyses using a nested data structure, controlling for patient and provider characteristics. Patient satisfaction with PCPs, patient-reported patient-provider communication, and PCP-reported intrateam communication within the PCMH. Intrateam communication and patient-provider communication were independently associated with patients' satisfaction with their PCPs. Patient-provider communication mediated 56% of the association between intrateam communication and patient satisfaction. Better intrateam communication combined with better patient-provider communication predicted high satisfaction (81%), compared with poor intrateam communication and poor patient-provider communication (22%). PCMH environments with better communication among team members are likely to experience better patient-provider communication and high patient satisfaction. PCMH practices with low ratings of patient satisfaction may need to look beyond individual PCPs to communication within and across teams.

A Patient-Centered Medical Home (PCMH) Rotation Prepares Residentsfor Practicing in Today’s Culture of Quality and Teamwork

Residency programs today face new challenges in training physicians for the rapidly changing culture of quality and teamwork in medical practice. New curricular initiatives must address accreditation standards for resident education in quality improvement (QI), teamwork, and patient data review. The objective of this study was to evaluate a new curriculum for internal medicine residents which introduced the concept of a patient-centered medical home (PCMH). We piloted a rotation for residents to experience PCMH practices in the community. The curriculum utilized experiential, didactic, and reflective sessions training residents in the PCMH tenets, QI, and interdisciplinary teamwork. We evaluated resident knowledge, attitudes, and behaviors using a single retrospective pre-post survey. Post rotation, residents felt better able to identify PCMH initiatives (47% before vs. 93% after, p < 0.01), PCMH team members in their primary care clinics (30% before vs. 83% after, p < 0.01), and expressed enhanced understanding of PCMH team members’ roles (30% before vs. 87% after, p < 0.01). Residents reported being more likely to utilize PCMH resources (52% before vs. 93% after, p < 0.01) and use patient data to improve their practice (37% before vs. 80% after, p < 0.01) after this intervention. This curricular model increased resident self-reported knowledge and identification of PCMH team members in their own continuity practice. This model, which embeds trainees in an experienced PCMH practice, can be used by residency programs to prepare residents for participation in team-based, quality-driven care in other PCMH sites in which they are likely to practice in their future careers.

Community pharmacist collaboration with a patient-centered medical home: Establishment of a patient-centered medical neighborhood and payment model

ObjectivesTo determine the feasibility of a partnership between a community pharmacy and a patient-centered medical home (PCMH) by measuring the impact on office- and patient-level clinical outcomes. SettingKroger Pharmacy and a PCMH practice in Cincinnati, OH. Practice descriptionThe Kroger Co. is a large grocery store chain that operates 102 pharmacies in the Cincinnati-Dayton marketing area. The PCMH practice is an accredited PCMH office serving more than 9000 patients in the Cincinnati area. Practice innovationIn a medical neighborhood, a PCMH coordinates care with other local specialty practices or partners. A partnership between the community pharmacy chain and the PCMH was established to create a medical neighborhood. The pharmacist spent 2 half-days per week at the PCMH. The pharmacist provided initial medication therapy management appointments in the PCMH and offered follow-up services in the office, the pharmacy, or both, depending on patient preference. The pharmacy received a capitated payment per patient per month for a predetermined number of 1000 high-risk patients. Main outcome measuresOffice-level changes in clinical outcomes such as A1C, blood pressure, and lipid measures were collected and compared with those of a similar control office. In addition, patient-level outcomes such as change in A1C, blood pressure, lipids, and weight were measured. ResultsOne hundred five patients were seen by the pharmacist during the study period, with 1.5% of the total managed at the office. There was a statistically significant increase in influenza vaccinations received. On a patient level, A1C and systolic blood pressure significantly improved. ConclusionThis project represents an exciting opportunity for community pharmacists to expand their scope of services through direct partnership with PCMHs and maintain a sustainable reimbursement structure.

Patient Experience with the Patient-Centered Medical Home in Michigan's Statewide Multi-Payer Demonstration: A Cross-Sectional Study.

The literature on patient-centered medical homes (PCMHs) and patient experience is somewhat mixed. Government and private payers are promoting multi-payer PCMH initiatives to align requirements and resources and to enhance practice transformation outcomes. To this end, the multipayer Michigan Primary Care Transformation (MiPCT) demonstration project was carried out. To examine whether the PCMH is associated with a better patient experience, and whether a mature, multi-payer PCMH demonstration is associated with even further improvement in the patient experience. This is a cross-sectional comparison of adults attributed to MiPCT PCMH, non-participating PCMH, and non-PCMH practices, statistically controlling for potential confounders, and conducted among both general and high-risk patient samples. Responses came from 3893 patients in the general population and 4605 in the high-risk population (response rates of 31.8% and 34.1%, respectively). The Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey, with PCMH supplemental questions, was administered in January and February 2015. MiPCT general and high-risk patients reported a significantly better experience than non-PCMH patients in most domains. Adjusted mean differences were as follows: access (0.35**, 0.36***), communication (0.19*, 0.18*), and coordination (0.33**, 0.35***), respectively (on a 10-point scale, with significance indicated by: *= p<0.05, **= p<0.01, and ***= p<0.001). Adjusted mean differences in overall provider ratings were not significant. Global odds ratios were significant for the domains of self-management support (1.38**, 1.41***) and comprehensiveness (1.67***, 1.61***). Non-participating PCMH ratings fell between MiPCT and non-PCMH across all domains and populations, sometimes attaining statistical significance. PCMH practices have more positive patient experiences across domains characteristic of advanced primary care. A mature multi-payer model has the strongest, most consistent association with a better patient experience, pointing to the need to provide consistent expectations, resources, and time for practice transformation. Our results held for a general population and a high-risk population which has much more contact with the healthcare system.

Colorectal cancer screening at US community health centers: Examination of sociodemographic disparities and association with patient‐provider communication

Colorectal cancer (CRC) screening rates are low among underserved populations. High-quality patient-physician communication potentially influences patients' willingness to undergo CRC screening. Community health centers (HCs) provide comprehensive primary health care to underserved populations. This study's objectives were to ascertain national CRC screening rates and to explore the relations between sociodemographic characteristics and patient-provider communication on the receipt of CRC screening among HC patients. Using 2014 Health Center Patient Survey data, bivariate and multivariate analyses examined the association of sociodemographic variables (sex, race/ethnicity, age, geography, preferred language, household income, insurance, and employment status) and patient-provider communication with the receipt of CRC screening. Patients between the ages of 65 and 75 years (adjusted odds ratio [aOR], 2.49; 95% confidence interval [CI], 1.33-4.64) and patients not in the labor force (aOR, 2.32; 95% CI, 1.37-3.94) had higher odds of receiving CRC screening, whereas patients who were uninsured (aOR, 0.33; 95% CI, 0.18-0.61) and patients who were non-English-speaking (aOR, 0.42; 95% CI, 0.18-0.99) had lower odds. Patient-provider communication was not associated with the receipt of CRC screening. The CRC screening rate for HC patients was 57.9%, whereas the rate was 65.1% according to the 2012 Behavioral Risk Factor Surveillance System and 58.2% according to the 2013 National Health Interview Survey. The high ratings of patient-provider communication, regardless of the screening status, suggest strides toward a patient-centered medical home practice transformation that will assist in a positive patient experience. Addressing the lack of insurance, making culturally and linguistically appropriate patient education materials available, and training clinicians and care teams in cultural competency are critical for increasing future CRC screening rates. Cancer 2017;123:4185-4192. © 2017 American Cancer Society.

The Patient-Centered Medical Home (PCMH) Framing Typology for Understanding the Structure, Function, and Outcomes of PCMHs.

Patient-centered medical homes (PCHMs) aspire to transform today's challenged primary care services. However, it is unclear which PCMH characteristics produce specific outcomes of interest for care delivery. This study tested a novel typology of PCMH practice transformation, the PCMH framing typology, and evaluated measurable outcomes by each type. Using the Patient-Centered Primary Care Collaborative 2012 to 2013 Annual Review, this secondary analysis of the published PCMH literature extracted data from publications of 59 PCMHs. Each of the 59 sites was categorized as 1 of 4 PCMH types: add-on, renovated, hybrid, or integrated. Six outcome measures (cost reductions, decreased emergency department/hospital utilization, improved quality, improved access, increased preventive services, and improved patient satisfaction) were independently coded for each site. Practices were combined based on type, and mean outcomes scores for each measure were displayed on radar graphs for comparison. While each type showed a characteristic pattern of success, only the integrated type improved in all 6 outcomes. No type achieved high success in all measures. There seem to be 4 types of PCMH, each of which shows a distinctive outcomes profile. Within the PCMH framing typology, direction is emerging for how best to transform primary care to achieve the greatest success.

Implementation of Practice Transformation: Patient Experience According to Practice Leaders.

Examine practice leaders' perceptions and experiences of how patient-centered medical home (PCMH) transformation improves patient experience. Thirty-six interviews with lead physicians (n = 13), site clinic administrators (n = 13), and nurse supervisors (n = 10). Semi-structured interviews at 14 primary care practices within a large urban Federally Qualified Health Center (FQHC) delivery system to identify critical patient experience domains and mechanisms of change. Identified patient experience domains were compared with Consumer Assessment of Healthcare Providers and Systems (CAHPS) items. We identified 28 patient experience domains improved by PCMH transformation, of which 22 are measured by CAHPS, and identified 24 mechanisms of change commonly reported by practice leaders during PCMH transformation. PCMH practice transformation can improve patient experience. Most patient experience domains reported as improved during PCMH efforts are measured by CAHPS items. Practices would benefit from collecting specific information on staff behaviors related to teamwork, team-based communication, scheduling, emergency and inpatient follow-up, and referrals. All 3 types of practice leaders reported 4 main mechanisms of PCMH change that improved patient experience. Our findings provide guidance for practice leaders on which strategies of PCMH practice transformation lead to specific improvements in patient experience measures. Further research is needed on the relationship between PCMH changes and changes in CAHPS patient experience scores.

The Reduction in ED and Hospital Admissions in Medical Home Practices Is Specific to Primary Care-Sensitive Chronic Conditions.

To determine whether the Patient-Centered Medical Home (PCMH) transformation reduces hospital and ED utilization, and whether the effect is specific to chronic conditions targeted for management by the PCMH in our setting. All patients aged 18years and older in 2,218 primary care practices participating in a statewide PCMH incentive program sponsored by Blue Cross Blue Shield of Michigan (BCBSM) in 2009-2012. Quantitative observational study, jointly modeling PCMH-targeted versus other hospital admissions and ED visits on PCMH score, patient, and practice characteristics in a hierarchical multivariate model using the generalized gamma distribution. Claims data and PCMH scores held by BCBSM. Both hospital and ED utilization were reduced proportionately to PCMH score. Hospital utilization was reduced by 13.9 percent for PCMH-targeted conditions versus only 3.8 percent for other conditions (p=.003), and ED utilization by 11.2 percent versus 3.7 percent (p=.010). Hospital PMPM cost was reduced by 17.2 percent for PCMH-targeted conditions versus only 3.1 percent for other conditions (p<.001), and ED PMPM cost by 9.4 percent versus 3.6 percent (p<.001). PCMH transformation reduces hospital and ED use, and the majority of the effect is specific to PCMH-targeted conditions.

Transitioning to Patient-Centered Medical Homes: Associations With Appointment Availability.

Recent implementation of the Patient-Centered Medical Home (PCMH) in military primary care has gained significant traction and attention from leadership and policy makers. The study objective was to measure the rate of change in appointment availability before and after primary care clinics were certified as a medical home. Access to care is one core tenet of the medical home and appointment availability is an important indicator of access. This was a retrospective, longitudinal observational study involving 21 U.S. Navy primary care clinics from 2011 to 2014. Appointment availability, as measured by third next available appointment, was constructed for 21 primary care clinics over a 29-month time period (14 months precertification, certification month, 14 months postcertification). A mixed-effects model with linear splines was applied where third next available appointment was the dependent variable. Main interest independent variables include time (precertification and postcertification). Remaining independent variables include categories pertaining to clinic characteristics, ancillary services, and nonemergent primary care treatable emergency department visits. Appointment availability improved slightly postcertification. Although there were statistically significant differences in appointment availability pre- and postcertification, the differences were so small that patients may not actually experience noticeable improvements. Although slight improvements in appointment availability following medical home certification exist, adoption of the medical home model in the military setting may not have all the potential outcomes expected on the basis of prior findings in civilian settings. This study demonstrated that improvements in appointment availability following medical home certification exist, but are quite small. Patients, as a result, are unlikely to notice any improvements. Additional research should test other expected benefits of PCMH in military settings. At that point, military policy makers can decide which aspects of PCMH practices merit sustaining.

Exploring Variation in Transformation of Primary Care Practices to Patient-Centered Medical Homes: A Mixed Methods Approach.

The objective was to quantify the activities required for patient-centered medical home (PCMH) transformation in a sample of small to medium-sized National Committee for Quality Assurance (NCQA) recognized practices, and explore barriers and facilitators to transformation. Eleven small to medium-sized PCMH practices in Southeastern Pennsylvania completed a survey, which was adapted from the 2011 NCQA standards. Semistructured follow-up interviews were conducted, descriptive statistics were computed for the quantitative analysis, and a process of thematic coding was deployed for the qualitative analysis. Practices had considerable quantitative variation in their workforce composition and the PCMH-related activities they implemented. Most practices improved access and continuity through staff training and team-based care as well as expanded data collection for population management. The barriers to PCMH recognition were least burdensome for the largest practices. The heterogeneity of the small PCMH practices within the study sample underscore the need to understand the key transformation issues as efforts to disseminate the PCMH model continue.

Evaluation of a Curriculum in an Internal Medicine Residency and Patient- Centered Medical Home Rotation

Introduction: The Patient-Centered Medical Home (PCMH) model aims to transform primary care by delivering high-quality, safe, comprehensive, patient-centered, and accessible care. Few evaluations of PCMH curricula for internal medicine residency programs have been published. The objective of this study was to develop and implement a PCMH curriculum, a new PCMH rotation, and to redesign the resident ambulatory care clinic and private primary care practices of the residency program. Effects were evaluated by examining: 1) residents’ attitudes towards primary care and PCMH, 2) residents’ skills in communicating and managing care and 3) patients’ assessments of practice accessibility. Methods: From 2010-2015, we implemented a multi-modal program combining practice redesign, a lecture series, a one-month PCMH rotation, clinical activities, a quality improvement project, and self-reflection at an academic community hospital, a Federally Qualified Health Center (FQHC) and faculty practice offices to internal medic ne residents. Evaluations were conducted through resident self-assessment, patient assessment of practice accessibility, and objective structured clinical examinations. Results: Twelve residents [41% (12/29)] completed all components of the curriculum. After the rotation, residents thought their PCMH skills improved in 13 components of PCMH (all domains: p<0.02). Residents’ attitudes towards primary care and PCMH did not improve from 2010 to 2012 [response rate: 38% (11/29) and 44% (13/29), respectively]. Patient ratings improved, mostly in practice accessibility (p<0.001) and test notification (p=0.01). Conclusion: By engaging in the PCMH curriculum and practice redesign, residents showed improvement in PCMH skills across all domains, and patients demonstrated increased satisfaction with the practice. This curriculum in PCMH can be utilized as a useful model for other internal medicine programs.

Effects of adding a new PCMH block rotation and resident team to existing longitudinal training within a certified PCMH: primary care residents' attitudes, knowledge, and experience.

BackgroundAlthough the patient-centered medical home (PCMH) model is considered important for the future of primary care in the USA, it remains unclear how best to prepare trainees for PCMH practice and leadership. Following a baseline study, the authors added a new required PCMH block rotation and resident team to an existing longitudinal PCMH immersion and didactic curriculum within a Level 3-certified PCMH, aiming for “enhanced situated learning”. All 39 residents enrolled in a USA family medicine residency program during the first year of curricular implementation completed this new 4-week rotation. This study examines the effects of this rotation after 1 year.MethodsA total of 39 intervention and 13 comparison residents were eligible participants. This multimethod study included: 1) individual interviews of postgraduate year (PGY) 3 intervention vs PGY3 comparison residents, assessing residents’ PCMH attitudes, knowledge, and clinical experience, and 2) routine rotation evaluations. Interviews were audiorecorded, transcribed, and analyzed using immersion/crystallization. Rotation evaluations were analyzed using descriptive statistics and qualitative analysis of free text responses.ResultsAuthors analyzed 23 interviews (88%) and 26 rotation evaluations (67%). Intervention PGY3s’ interviews revealed more nuanced understanding of PCMH concepts and more experience with system-level PCMH tasks than those of comparison PGY3s. More intervention PGY3s rated themselves “extremely prepared” to implement PCMH than comparison PGY3s; however, most self-rated “somewhat prepared”. Their reflections demonstrated deeper understanding of PCMH implementation and challenges than comparison PGY3s but inadequate experience to directly see the results of successful solutions. Rotation evaluations from PGY1, PGY2, and PGY3s revealed strengths and several areas for improvement.ConclusionAdding one 4-week block rotation to existing longitudinal training appears to improve residents’ PCMH knowledge, skills, and experience from “basic” to “intermediate”. However, this training level appears inadequate for PCMH leadership or for teaching junior learners. Further study is needed to determine the optimum training for different settings.

Impact of Medical Home Implementation Through Evidence-based Quality Improvement on Utilization and Costs.

Evidence-based quality improvement (EBQI) methods may facilitate practice redesign for more effective implementation of the patient-centered medical home (PCMH). We assessed changes in health care utilization and costs for patients receiving care from practices using an EBQI approach to implement PCMH and comparison practices over a 5-year period. We used longitudinal, electronic data from patients in 6 practices using EBQI and 28 comparison practices implementing standard PCMH for 1 year before and 4 years after PCMH implementation. We analyzed trends in utilization and costs using bivariate analyses and independent effects of EBQI status on outcomes using multivariate regressions adjusting for year, patient and clinic factors, and patient random effects for repeated measures. A total of 136,856 patients using Veterans Affairs primary care. Veterans Affairs ambulatory care encounters, emergency department visits, admissions, and total health care costs per patient. After PCMH implementation, overall utilization for primary care, specialty care, and mental health/substance abuse care decreased, whereas utilization for telephone care increased among all practices. Patients also had fewer hospitalizations and lower costs per patient. In adjusted analyses, EBQI practice was independently associated with fewer primary care (IRR=0.85), specialty care (IRR=0.83), and mental health care encounters (IRR=0.69); these effects attenuated over time (all P<0.01). There was no independent effect of EBQI on prescription drug use, acute care, health care costs, or mortality rate relative to comparison practices. EBQI methods enhanced the effects of PCMH implementation by reducing ambulatory care while increasing non-face-to-face care.