Patient-centered Medical Home Program Research Articles

Impact of the patient-centered medical home on consistently high-cost patients.

To evaluate the effect of a statewide multipayer patient-centered medical home (PCMH) demonstration on patients consistently within the highest ranks of health services expenditure across Maryland. Post hoc longitudinal analyses of administrative data on privately insured patients of medical homes that participated in the Maryland Multi-Payer PCMH Program (MMPP), matched for comparison to medical homes in a single-payer PCMH program and to non-PCMH practices. Consistently high-cost patients (CHPs) were defined as being in the top statewide quintile of payer expenditure over a 2-year baseline period. Using population-averaged generalized linear regression models, we evaluated the odds of CHPs remaining in the highest-cost quintile during the 2-year MMPP implementation period and assessed changes in their utilization patterns. Six percent of included patients were CHPs and accounted for one-third of total expenditure. For CHPs in multipayer PCMHs, estimated odds of remaining in this status after 2 years were lower by 34% (adjusted OR [AOR], 0.66; 95% CI, 0.41-0.90; P = .03) relative to CHPs in non-PCMH practices and higher by 41% (AOR, 1.41; 95% CI, 1.08-1.75; P = .004) compared with CHPs in single-payer PCMHs. Relative to CHPs in non-PCMH practices, CHPs in multipayer PCMHs had inpatient admissions decline by 40% (incidence rate ratio [IRR], 0.60; 95% CI, 0.36-1.00; P = .049) and visits to the attributed primary care provider increase by 21% (IRR, 1.21; 95% CI, 1.05-1.39; P = .01). Relative to routine primary care, the PCMH model significantly reduces the probability that CHPs remain in this expensive category and enhances continuity of care.

Reasons Primary Care Practices Chose Patient Experience Surveys During Patient-Centered Medical Home Transformation.

Patient-centered medical home takes years to attain. Fifteen-to-eighteen percent of US primary care practices in 2008-2017 sought or maintained patient-centered medical home recognition. We conducted interviews with a stratified-random sample of 105 of these practices to determine why patient experience surveys were chosen. Fifty-one were using a Consumer Assessment of Healthcare Providers and Systems survey and 53 administering another patient survey. The 3 most common reasons were (1) to compare performance against other practices, which requires systematically collected data across large numbers of practices (ie, the Consumer Assessment of Healthcare Providers and Systems survey), (2) participation in an external patient-centered medical home program, and (3) survey administration cost. Leaders invested in a second patient survey for quality improvement needs.

Impact of a Statewide Multi-Payer Patient-Centered Medical Home Program on Antihypertensive Medication Adherence.

Evidence suggests that the patient-centered medical home (PCMH) model of primary care improves management of chronic disease, but there is limited research contrasting this model's effect when financed by a single payer versus multiple payers, and among patients with different types of health insurance. This study evaluates the impact of a statewide medical home demonstration, the Maryland Multi-Payer PCMH Program (MMPP), on adherence to antihypertensive medication therapy relative to non-PCMH primary care and to the PCMH model when financed by a single payer. The authors used a difference-in-differences analytic design to analyze changes in medication possession ratio for antihypertensive medications among Medicaid-insured and privately insured non-elderly adult patients attributed to primary care practices in the MMPP ("multi-payer PCMHs"), medical homes in Maryland that participated in a regional PCMH program funded by a single private payer ("single-payer PCMHs"), and non-PCMH practices in Maryland. Comparison sites were matched to multi-payer PCMHs using propensity scores based on practice characteristics, location, and aggregated provider characteristics. Multi-payer PCMHs performed better on antihypertensive medication adherence for both Medicaid-insured and privately insured patients relative to single-payer PCMHs. Statistically significant effects were not observed consistently until the second year of the demonstration. There were negligible differences in outcome trends between multi-payer medical homes and matched non-PCMH practices. Findings indicate that health care delivery innovations may yield superior population health outcomes under multi-payer financing compared to when such initiatives are financed by a single payer.

Implementation of Patient Safety Structures and Processes in the Patient-Centered Medical Home.

Although most patient-clinician interactions occur in ambulatory care, little research has addressed measuring ambulatory patient safety or how primary care redesign such as the patient-centered medical home (PCMH) addresses patient safety. Our objectives were to identify PCMH standards relevant to patient safety, construct a measure of patient safety activity implementation, and examine differences in adoptions of these activities by practice and community characteristics. Using a consensus process, we selected elements among a widely adopted, nationally representative PCMH program representing activities that, according to a physician panel, represented patient safety overall and in four domains (diagnosis, treatment delays, medications, and communication and coordination) and generated a score for each. We then evaluated this score among 5,007 practices with the highest PCMH recognition level. Implementation of patient safety activities varied; the few military practices (2.4%) had the highest, and community clinics the lowest, patient safety score, both overall (82.0 and 72.0, respectively, p < .001) and across specific domains. Other practice and community characteristics were not associated with the patient safety score. Understanding better what factors are associated with implementation of patient safety activities may be a key step in improving ambulatory patient safety.

Did Arkansas' Medicaid Patient-Centered Medical Home Program Have Spillover Effects on Commercially Insured Enrollees?

Patient-centered medical homes are increasingly being implemented by state Medicaid programs to incentivize high-quality, coordinated care and ultimately lower health care spending. This study examined whether the Arkansas Medicaid Patient-Centered Medical Home Program’s practice-wide transformation activities had spillover effects on commercial beneficiaries. We used difference-in-differences to compare utilization and expenditures of commercially insured enrollees as their practices received Medicaid patient-centered medical home certification on a rolling basis between 2014 and 2016. We found a 5.7% increase in outpatient visits and 13% higher expenditures among early adopting practices. Even without associated reductions in costly emergency department visits or inpatient hospital admissions, decisionmakers should not lose sight of the potential value of increased engagement in and coordination of professional services for a population with high unmet health needs. Our results also emphasize that states can leverage Medicaid to spur system-wide transformation, and the investments generate spillover effects beyond those covered directly by Medicaid.

Provider Experiences with a Payer-Based PCMH Program.

The patient-centered medical home (PCMH) is an enhanced primary care model that aims to improve quality of care. Over the past several years, the PCMH model has been adopted by Medicare and private payers, which offer financial resources and technical assistance to participating practices. However, few studies have examined provider experiences and perspectives on the adoption of payer-based PCMH models in different practice settings. The goal of this qualitative study was to analyze how providers experienced specific elements of a payer-based PCMH model and identify cross-cutting themes that can be applied to other payer-based PCMH initiatives. Observational qualitative study. A total of 65 individuals (which includes 57 primary care physicians) participated in focus group sessions. Telephone interviews were conducted with an additional 14 physicians and 2 practice administrators. Interviews and focus groups were recorded after obtaining the informed consent of participants. Written transcripts from the recordings were then imported into NVivo 11 for subsequent coding and qualitative analysis of themes. We found that nurse care coordinators (NCCs) were the single most valuable and visible program element. Individual care plans served as effective tools of communication between the NCC and physician on patient care management goals and issues. The online data portal was viewed as the least valuable element. With regard to cross-cutting themes, some providers expressed a strained relationship with CareFirst due to communication challenges, a lack of trust, and differing priorities in selecting patients for care plans. Nurse care coordinators and the targeted use of individualized care plans are essential components in a payer-based PCMH program. Improving communication and trust in data reports are critical for effective implementation. Future research should examine provider experiences in other payer-based PCMH programs to see how interactions with payers affect program implementation.

Maryland Multipayor Patient-centered Medical Home Program: A 4-Year Quasiexperimental Evaluation of Quality, Utilization, Patient Satisfaction, and Provider Perceptions.

To evaluate impact of the Maryland Multipayor Patient-centered Medical Home Program (MMPP) on: (1) quality, utilization, and costs of care; (2) beneficiaries' experiences and satisfaction with care; and (3) perceptions of providers. 4-year quasiexperimental design with a difference-in-differences analytic approach to compare changes in outcomes between MMPP practices and propensity score-matched comparisons; pre-post design for patient-reported outcomes among MMPP beneficiaries. Beneficiaries (Medicaid-insured and privately insured) and providers in 52 MMPP practices and 104 matched comparisons in Maryland. Participating practices received unconditional financial support and coaching to facilitate functioning as medical homes, membership in a learning collaborative to promote education and dissemination of best practices, and performance-based payments. Sixteen quality, 20 utilization, and 13 cost measures from administrative data; patient-reported outcomes on care delivery, trust in provider, access to care, and chronic illness management; and provider perceptions of team operation, team culture, satisfaction with care provided, and patient-centered medical home transformation. The MMPP had mixed impact on site-level quality and utilization measures. Participation was significantly associated with lower inpatient and outpatient payments in the first year among privately insured beneficiaries, and for the entire duration among Medicaid beneficiaries. There was indication that MMPP practices shifted responsibility for certain administrative tasks from clinicians to medical assistants or care managers. The program had limited effect on measures of patient satisfaction (although response rates were low) and on provider perceptions. The MMPP demonstrated mixed results of its impact and indicated differential program effects for privately insured and Medicaid beneficiaries.

Dual Eligibles' Experience of Care with North Carolina's Patient-Centered Medical Home.

Although individuals enrolled in both Medicare and Medicaid (dual eligibles) are among those with the nation's greatest need, at $300 billion per year, their care is also expensive and beset by quality problems. Previous research found problems associated with inadequate coordination of benefits and services; however, these studies have largely used quantitative approaches and focused on providers-few studies have explored the perspective of dual eligible patients. In an effort to improve care and reduce costs, North Carolina (NC) developed a Patient-Centered Medical Home (PCMH) model centered on a continuous relationship with a primary care provider who is responsible for coordination of services and addressing patients' health care needs by providing direct services or arranging care with other qualified professionals. This article presents the history of the NC PCMH model and describes results of an in-depth qualitative investigation of dual eligible patients' experience of care with this model. Experience of care was captured through 11 focus groups with 61 dual eligible patients. Focus groups were audio recorded and analyzed using NVivo 9 software, which supported the categorization of data into themes based on frequency and intensity of discussions. Findings indicate that dual eligible patients were generally satisfied by the care received through the NC PCMH program. However, many patients reported continuity of care issues, problems accessing necessary prescription drugs, and difficulties navigating the health care delivery system. Findings also revealed that conflicting state and federal Medicaid drug co-pay policies confused and limited access for some patients.

Medical Home Implementation in Small Primary Care Practices: Provider Perspectives.

CareFirst BlueCross BlueShield of Maryland implemented a voluntary patient-centered medical home (PCMH) program in 2011 that did not require formal certification to participate. This study assessed attitudes and awareness of PCMH programs among participating providers in Maryland and Northern Virginia. This qualitative study used information from 13 focus groups. In addition, 39 telephone interviews were conducted. An experienced facilitator moderated the focus groups. Written transcripts were analyzed using NVivo software. Several cross-cutting themes emerged. First, the payment bump of 12% was a motivating factor to participate but did not have long-term effects on participation. Second, nurse care coordinators were perceived as the key element of the PCMH program. Third, providers had limited awareness of an external data portal. Finally, small practices were generally receptive to the externally supported program elements. Implementation of PCMH program elements can be facilitated in small primary care practices even if third-party certification is not a requirement. Participating providers viewed having an external nurse care coordinator as the key element of the PCMH program. Small practices were receptive to external supports, but a lack of trust was viewed as a barrier to implementing a payer-based medical home program.

The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years.

BackgroundEnhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time.ObjectiveTo test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, and fewer emergency room visits.DesignWe compared medical care expenditures and utilization among adults who participated in the PCMH program to adults who did not participate. We computed difference-in-difference estimates using two-part multivariate generalized linear models for expenditures and negative binomial models for utilization. Control variables included patient demographics, county, chronic condition indicators, and illness severity.ParticipantsA total of 1,433,297 adults aged 18–64 years, residing in Maryland, Virginia, and the District of Columbia, and insured by CareFirst for at least 3 consecutive months between 2010 and 2013.InterventionCareFirst implemented enhanced fee-for-service payments to the practices, offered a large retrospective bonus if annual cost and quality targets were exceeded, and provided information and care coordination support.MeasuresOutcomes were quarterly claims expenditures per member for all covered services, inpatient care, emergency care, and prescription drugs, and quarterly inpatient admissions and emergency room visits.ResultsBy the third intervention year, annual adjusted total claims payments were $109 per participating member (95 % CI: −$192, −$27), or 2.8 % lower than before the program and compared to those who did not participate. Forty-two percent of the overall decline in spending was explained by lower inpatient care, emergency care, and prescription drug spending. Much of the reduction in inpatient and emergency spending was explained by lower utilization of services.ConclusionsA PCMH model that does not require practices to make infrastructure investments and that rewards cost savings can reduce spending and utilization.Electronic supplementary materialThe online version of this article (doi:10.1007/s11606-016-3814-z) contains supplementary material, which is available to authorized users.

Oral Health in Primary Care: Creating Interprofessional Faculty Leadership and Family and Community Engagement

s / Journal of Interprofessional Education & Practice 1 (2015) 48e77 59 children.1 The patient centered medical home (PCMH) was originally developed as a system of care for CSHCN by the American Academy of Pediatrics (AAP), and is considered a significant priority in health care policy for primary care of children.2 In 2010, our community-based, federally qualified health centered, general pediatrics clinic located within a tertiary medical center established a Pediatric PCMH Program for CSHCN, to provide closely coordinated case management for CSHCN, in hopes to improve their health outcomes, reduce high cost care, and enhance patient, family and provider satisfaction. Currently, our PCMH team case manages 824 families with CSHCN, utilizing a team of pediatricians and nurse coordinators. Barriers in communication, psychosocial factors, multi-subspecialty complex care and difficulties in access are factors which create impediments to providing comprehensive, effective case management for our CSHCN population.

Health care utilization from chemotherapy-related adverse events among low-income breast cancer patients: effect of enrollment in a medical home program.

Chemotherapy-related health care utilization by breast cancer patients can be expensive for payers and patients. This study evaluated the patient-centered medical home program Community Care of North Carolina (CCNC) in terms of its potential to reduce health care utilization associated with chemotherapy-related adverse events (AEs). Early-stage breast cancer cases diagnosed during the 5-year period 2003-2007 were identified in the North Carolina Central Cancer Registry; these cases were then linked to North Carolina Medicaid claims data. We measured health care utilization associated with chemotherapy-related AEs by setting (inpatient, outpatient, or emergency department) during a 15-month postdiagnosis follow-up period. Descriptive and multivariate analyses were performed to examine associations between CCNC enrollment and health care utilization associated with chemotherapy-related AEs. A large proportion of breast cancer patients had at least 1 health care visit associated with a chemotherapy-related AE (n = 412 [72.3%]). The mean numbers of AE-related visits occurring in inpatient, outpatient, and emergency department settings were 0.30 (standard deviation [SD] = 0.83), 6.92 (SD = 10.94), and 0.46 (SD = 1.26), respectively. CCNC enrollment was associated with significantly fewer inpatient admissions (marginal effect, -0.1421; 95% confidence interval, -0.280 to -0.004). In this observational study, we were unable to draw conclusions about the causality of these associations. Patients enrolled in CCNC had fewer inpatient health care visits associated with chemotherapy-related AEs. Future research should continue to explore the extent to which patient-centered medical homes can monitor and help manage the effects of cancer treatments.

Dissemination and Adoption of the Advanced Primary Care Model in the Maryland Multi-Payer Patient Centered Medical Home Program

The Maryland Learning Collaborative together with the Maryland Multi-Payer Program transformed 52 medical practices into patient-centered medical homes (PCMH). The Maryland Learning Collaborative developed an Internet-based 14-question Likert scale survey to assess the impact of the PCMH model on practices and providers, concerning how this new method is affecting patient care and outcomes. The survey was sent to 339 practitioners and 52 care management teams at 18 months into the program. Sixty-seven survey results were received and analyzed. After 18 months of participation in the PCMH initiative, participants demonstrated a better understanding of the PCMH initiative, improved patient access to care, improved care coordination, and increased health information technology optimization (p > .001). The findings from the survey evaluation suggest that practice participation in the Maryland Multi-Payer Program has enhanced access to care, influenced patient outcomes, improved care coordination, and increased use of health information technology.

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

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

Assessment and Measurement of Patient-Centered Medical Home Implementation: The BCBSM Experience

Our goal was to describe an approach to patient-centered medical home (PCMH) measurement based on delineating the desired properties of the measurement relative to assumptions about the PCMH and the uses of the measure by Blue Cross Blue Shield of Michigan (BCBSM) and health services researchers. We developed and validated an approach to assess 13 functional domains of PCMHs and 128 capabilities within those domains. A measure of PCMH implementation was constructed using data from the validated self-assessment and then tested on a large sample of primary care practices in Michigan. Our results suggest that the measure adequately addresses the specific requirements and assumptions underlying the BCBSM PCMH program-ability to assess change in level of implementation; ability to compare across practices regardless of size, affiliation, or payer mix; and ability to assess implementation of the PCMH through different sequencing of capabilities and domains. Our experience illustrates that approaches to measuring PCMH should be driven by the measures' intended use(s) and users, and that a one-size-fits-all approach may not be appropriate. Rather than promoting the BCBSM PCMH measure as the gold standard, our study highlights the challenges, strengths, and limitations of developing a standardized approach to PCMH measurement.

Defining the Medical Home: The Oregon Experience

The patient-centered medical home (PCMH) is emerging as a key strategy to improve health outcomes, reduce total costs, and strengthen primary care, but a myriad of operational measures of the PCMH have emerged. In 2009, the state of Oregon convened a public, legislatively mandated committee charged with developing PCMH measures. We report on the process of, outcomes of, and lessons learned by this committee. The Oregon PCMH advisory committee was appointed by the director of the Oregon Department of Human Services and held 7 public meetings between October 2009 and February 2010. The committee engaged a diverse group of Oregon stakeholders, including a variety of practicing primary care physicians. The committee developed a PCMH measurement framework, including 6 core attributes, 15 standards, and 27 individual measures. Key successes of the committee's work were to describe PCMH core attributes and functions in patient-centered language and to achieve consensus among a diverse group of stakeholders. Oregon's PCMH advisory committee engaged local stakeholders in a process that resulted in a shared PCMH measurement framework and addressed stakeholders' concerns. The state of Oregon now has implemented a PCMH program using the framework developed by the PCMH advisory committee. The Oregon experience demonstrates that a brief public process can be successful in producing meaningful consensus on PCMH roles and functions and advancing PCMH policy.

The Litmus Test for Health Information Exchange Success: Will Small Practices Participate?

The Litmus Test for Health Information Exchange Success: Will Small Practices Participate?