Patient-centered Medical Home Teams Research Articles

Delegation of Work Within a Patient-Centered Medical Home.

The aim of this study was to analyze the perceptions of core team members implementing patient-centered medical home (PCMH) within the Veterans Health Administration regarding delegation of work. Significant overlap exists in the performance of work tasks among PCMH team members (primary care providers, RNs, clinical associates, clerks), and scant literature exists on appropriate delegation within PCMH teams. This study conducted used a quantitative and qualitative analysis of 4254 respondents to a 2018 survey. Primary care providers rely heavily on team members, and nurses report being relied upon at high levels. Lack of role clarity and a perceived need for a team leader were concerns voiced by participants. Findings indicated a need for clear guidance on roles and responsibilities within the team. Patient-centered medical home team members need information about the scope of practice of each professional group to allow providers to function at the top of their scope of practice and ensure effective delegation.

Primary Care Physician Perspectives on the Influence of Patient Values, Health Priorities, and Preferences on Clinical Decision-Making for Complex Patients with Multimorbidity: A Qualitative Study.

The prevalence of patients with multimorbidity (ie, multiple chronic conditions) is increasing. Clinical decision-making guided by patients' values, health priorities and goals, and treatment preferences is particularly important in the context of interacting diseases and psychosocial needs. Physicians face challenges incorporating patient perspectives into care plans. We examined primary care physician (PCP) views on the influence of patients' values, health priorities and goals, and preferences on clinical decisions for patients with multimorbidity and increased psychosocial complexity. We conducted semi-structured telephone interviews with 23 PCPs within patient-centered medical home teams in a nationally integrated health system in the United States between May and July 2020. Data were analyzed via thematic analysis with deductive and inductive coding. Three major themes emerged: 1. Patient personal values were rarely explicitly discussed in routine clinical encounters but informed more commonly discussed concepts of patient priorities, goals, and preferences; 2. Patient values, health priorities and goals, and preferences were sources of divergent views about care plans between healthcare teams, patients, and families; 3. Physicians used explicit strategies to communicate and negotiate about patient values, health priorities and goals, and preferences when developing care plans, including trust-building; devoting extra effort to individualizing care; connecting patient values to healthcare recommendations; deliberate elicitation and acknowledgement of patient concerns; providing "space" for patient perspectives; incorporating family into care planning; pairing physician to patient priorities; and collaborative teamwork. Primary care physicians perceive patient values, health priorities and goals, and preferences as influential during clinical decision-making for complex patients with multimorbidity. Participants used concrete strategies to negotiate alignment of these aspects when physician-patient divergence occurred. While rarely discussed directly in clinical encounters, personal values affected patient health priorities, goals, and preferences during care planning, suggesting a clinical role for more deliberate elicitation and discussion of patient values for this population.

Factors Associated With Patient-Centered Medical Home Teams' Use of Resources for Identifying and Approaches for Managing Patients With Complex Needs.

Using data from a Veterans Health Administration national primary care survey, this study identified the most highly rated tools and care approaches for patients with complex needs and how preferences varied by professional role, staffing, and training. Nurses were significantly more likely to rate most tools as very important as compared with primary care providers. Having a fully staffed team was also significantly associated with a very important rating on all tools. Nurses and fully staffed teams reported a greater likeliness to use most care approaches, and those with perceived need for training reporting a lower likeliness to use.

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.

What Do Patient-Centered Medical Home (PCMH) Teams Need to Improve Care for Primary Care Patients with Complex Needs?

Intensive primary care (IPC) programs for patients with complex needs do not generate cost savings in most settings. Strengthening existing patient-centered medical homes (PCMH) to address the needs of these patients in primary care is a potential high-value alternative. Explore PCMH team functioning and characteristics that may impact their ability to perform IPC tasks; identify the IPC components that could be incorporated into PCMH teams' workflow; and identify additional resources, trainings, and staff needed to better manage patients with complex needs in primary care. We interviewed 44 primary care leaders, PCMH team members (providers, nurses, social workers), and IPC program leaders at 5 VA IPC sites and analyzed a priori themes using a matrix analysis approach. Higher-functioning PCMH teams were described as already performing most IPC tasks, including panel management and care coordination. All sites reported that PCMH teams had the knowledge and skills to perform IPC tasks, but not with the same intensity as specialized IPC teams. Home visits/assessments and co-attending appointments were perceived as not feasible to perform. Key stakeholders identified 6 categories of supports and capabilities that PCMH teams would need to better manage complex patients, with care coordination/management and fully staffed teams as the most frequently mentioned. Many thought that PCMH teams could make better use of existing VA and non-VA resources, but might need training in identifying and using those resources. PCMH teams can potentially offer certain clinic-based services associated with IPC programs, but tasks that are time intensive or require physical absence from clinic might require collaboration with community service providers and better use of internal and external healthcare system resources. Future studies should explore the feasibility of PCMH adoption of IPC tasks and the impact on patient outcomes.

STAKEHOLDER PERSPECTIVES ON DESIGN, IMPLEMENTATION, AND SUSTAINMENT OF SERVICES FOR OLDER VETERANS

A majority of United States Veterans are older adults, compelling healthcare systems such as Veterans Health Administration to attend to their unique needs when designing and implementing programs for workforce development and service delivery. In this symposium authors will present findings from four studies examining how older Veterans’ needs and preferences affect implementation and sustainment in a variety of settings. Presenters demonstrate how: 1) understanding Veterans’ perspectives and preferences for measuring functional status may inform the improvement of care coordination in the primary care setting; 2) the role of population characteristics in implementation of geriatric patient centered medical home teams (i.e., GeriPACTs); 3) the interaction of patient, provider, and delivery system information needs in limiting sustainment of diverse initiatives to improve osteoporosis screening and management for Veterans; and 4) the factors affecting transferability and sustainment of rural and geriatrics-focused quality improvement initiatives beyond local settings. Beyond their focus on how older adults’ needs are reflected or shape implementation, the studies illustrate the application of qualitative data to clinical practice and workforce development.

Protocol for a cluster-randomized controlled trial of a technology-assisted health coaching intervention for weight management in primary care: The GEM (goals for eating and moving) study

IntroductionOver one-third of American adults have obesity with increased risk of chronic disease. Primary care providers often do not counsel patients about weight management due to barriers such as lack of time and training. To address this problem, we developed a technology-assisted health coaching intervention called Goals for Eating and Moving (GEM) to facilitate obesity counseling within the patient-centered medical home (PCMH) model of primary care. The objective of this paper is to describe the rationale and design of a cluster-randomized controlled trial to test the GEM intervention when compared to Enhanced Usual Care (EUC). MethodWe have randomized 19 PCMH teams from two NYC healthcare systems (VA New York Harbor Healthcare System and Montefiore Medical Group practices) to either the GEM intervention or EUC. Eligible participants are English and Spanish-speaking primary care patients (ages 18–69 years) with obesity or who are overweight with comorbidity (e.g., arthritis, sleep apnea, hypertension). The GEM intervention consists of a tablet-delivered goal setting tool, a health coaching visit and twelve telephone calls for patients, and provider counseling training. Patients in the EUC arm receive health education materials. The primary outcome is mean weight loss at 1 year. Secondary outcomes include changes in waist circumference, diet, and physical activity. We will also examine the impact of GEM on obesity-related provider counseling competency and attitudes. ConclusionIf GEM is found to be efficacious, it could provide a structured approach for improving weight management for diverse primary care patient populations with elevated cardiovascular disease risk.

Pharmacist-Delivered Comprehensive Medication Management Within Family Medicine Practices An Evaluation of the SCRIPT Project.

Pharmacist inclusion in patient-centered medical home (PCMH) teams has been shown to benefit both patients and practices. However, pharmacists' inclusion on these teams is not widespread, partly because the work they do is not well known. The Successful Collaborative Relationships to Improve PatienT care (SCRIPT) project was started in August 2009 to understand the clinical and economic impact of pharmacists providing direct patient care. The objective of this study was to describe the work of pharmacists practicing as integrated members of the patient care team within PCMHs through retrospective analysis of their patient care documentation over a 4-year time frame. Two pharmacists were placed into four suburban medical home practices in Pittsburgh, Pennsylvania to perform comprehensive medication management (CMM). These pharmacists documented their CMM encounters in an electronic health record and a database for reporting purposes. This study is a retrospective, descriptive analysis of pharmacist-documented CMM encounters from February 2010 through February 2014. Pharmacists' work-including patient demographics, disease states, and medication therapy problems-was recorded in a Microsoft Access database and tabulated. The pharmacists conducted 11,206 CMM encounters with 3,777 unique patients during the study period. The pharmacists identified 9,375 medication therapy problems (MTPs) and performed 14,092 interventions. Pharmacists most commonly worked with patients with diabetes, hypertension, pain, and hyperlipidemia. Physician and patient acceptance of the pharmacists' work was high. Pharmacists working in family medicine offices contribute to patient care through identification and resolution of MTPs and also by collaborating with PCMH teams.

Team functioning as a predictor of patient outcomes in early medical home implementation

New models of patient-centered primary care such as the patient-centered medical home (PCMH) depend on high levels of interdisciplinary primary care team functioning to achieve improved outcomes. A few studies have qualitatively assessed barriers and facilitators to optimal team functioning; however, we know of no prior study that assesses PCMH team functioning in relationship to patient health outcomes. The aim of the study was to assess the relationships between primary care team functioning, patients' use of acute care, and mortality. Retrospective longitudinal cohort analysis of patient outcomes measured at two time points (2012 and 2013) after PCMH implementation began in Veterans Health Administration practices. Multilevel models examined practice-level measures of team functioning in relationship to patient outcomes (all-cause and ambulatory care-sensitive condition-related hospitalizations, emergency department visits, and mortality). We controlled for practice-level factors likely to affect team functioning, including leadership support, provider and staff burnout, and staffing sufficiency, as well as for individual patient characteristics. We also tested the model among a subgroup of vulnerable patients (homeless, mentally ill, or with dementia). In adjusted analyses, higher team functioning was associated with lower mortality (OR = 0.92, p = .04) among all patients and with fewer all-cause admissions (incidence rate ratio [IRR] = 0.90, p < 0.01), ambulatory care-sensitive condition-related admissions (IRR = 0.91, p = .04), and emergency department visits (IRR = 0.91, p = .03) in the vulnerable patient subgroup. These early findings give support for the importance of team functioning within PCMH models for achieving improved patient outcomes. A focus on team functioning is important especially in the early implementation of team-based primary care models.

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.

Nurses and Psychologists Advancing the Patient-Centered Medical Home Model.

As America experiences the largest health care revolution of the past 50 years, clinicians and administrators are refocusing their attention on the goals of the Quadruple Aim. Motivation and capabilities among stakeholders vary as practical tools and an adequate workforce remain elusive. At the same time, the patient-centered medical home (PCMH) model is spreading rapidly but demonstrating variable results. Positive PCMH outcomes seem to reflect high-quality teamwork. A primary care physician shortage is looming, and increasing numbers of health professionals are being pushed into the PCMH, mandated to provide "integrated" care. Even now, the majority of our Graduate Medical Education programs do not train clinicians in team-based workflow models and interaction skills. Consequently, PCMH teams will only optimize and realize the model's true potential if they learn to coordinate, communicate, and collaborate effectively. This means all PCMH staff members achieve solid teamwork skills and work at the top of their license. The authors discuss resources for improving coordination, communication, and collaboration among members of PCMH teams, and strategies for including other professionals.

The experience of Patient Aligned Care Team (PACT) members.

In April 2010, the Veterans Health Administration (VHA) launched the Patient Aligned Care Team (PACT) initiative to implement a patient-centered medical home (PCMH) model. Few evaluations have addressed the effects of PCMH on health care professionals' experiences. The aim of this study was to contribute to evaluation of the PACT initiative and the broader literature on PCMH by assessing respondents' experiences of implementing a PCMH model and becoming a teamlet. A retrospective qualitative analysis of open-text responses in a survey fielded to all VHA Primary Care personnel (VHA Primary Care physicians, nurse practitioners, physician assistants, nurse care managers, clinical associates, and administrative clerks) in May and June 2012 (approximately 2 years into the 5-year planned implementation of PACT) using deductive and inductive content analysis. The main measures were two open-response fields: "Is there anything else you would like us to relay to the VA leadership in Central Office?" and "Do you have any other comments or feedback on PACT?" The data consisted of free text responses of 3,868 survey participants who provided text for one or both of the open-response fields. Although respondents viewed PACT positively as a model and reported it improved relationships with patients and increased patient satisfaction, they described multiple barriers to achieving functioning teamlets and unintended consequences, including reduced time with patients, increased participant burnout, and decreased team efficacy because of low-performing team members. A central theme related to staffing being insufficient for the new model. Insufficient staffing of PCMH teams is a critical barrier to realizing the benefits of the new model. Frontline staff have concrete recommendations for other problems, such as using back-up teams to cover during absences, but that will require providing more opportunities for feedback from staff to be heard.

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.

An analytics approach to designing patient centered medical homes.

Recently the patient centered medical home (PCMH) model has become a popular team based approach focused on delivering more streamlined care to patients. In current practices of medical homes, a clinical based prediction frame is recommended because it can help match the portfolio capacity of PCMH teams with the actual load generated by a set of patients. Without such balances in clinical supply and demand, issues such as excessive under and over utilization of physicians, long waiting time for receiving the appropriate treatment, and non-continuity of care will eliminate many advantages of the medical home strategy. In this paper, by using the hierarchical generalized linear model with multivariate responses, we develop a clinical workload prediction model for care portfolio demands in a Bayesian framework. The model allows for heterogeneous variances and unstructured covariance matrices for nested random effects that arise through complex hierarchical care systems. We show that using a multivariate approach substantially enhances the precision of workload predictions at both primary and non primary care levels. We also demonstrate that care demands depend not only on patient demographics but also on other utilization factors, such as length of stay. Our analyses of a recent data from Veteran Health Administration further indicate that risk adjustment for patient health conditions can considerably improve the prediction power of the model.

Perceptions of pharmacists' integration into patient-centered medical home teams.

Patient-centered medical homes (PCMHs) are a newer paradigm of health care service delivery. Team-based care that includes pharmacists has been implemented in several countries. Subsequently studies have successfully identified challenges and barriers with team-based care. Research on pharmacists' integration into PCMH is warranted to help bridge knowledge from earlier studies exploring team-based care. In 2010, the Department of Veteran Affairs (VA) began a national PCMH implementation, operationalized as "Patient-Aligned Care Teams" (PACTs). The VA's national PACT implementation presents an opportunity to describe other persistent barriers to effective coordination between primary care and pharmacy providers. To identify perceived barriers and facilitators to pharmacist integration into VA PACTs from the perspective of non-pharmacist team members. Semi-structured interviews were conducted as part of a formative evaluation of PCMH implementation. Participants were from VA medical centers and community-based outpatient clinics in the Midwestern United States and included physicians, nurses, associated health care professionals, and health system administrators. In working toward pharmacy service integration, role clarity and work activities were influenced by team member attitudes toward and previous experiences with pharmacists. Interviewees reported that coordination with pharmacists was hindered if communication placed extra burdens on other team members. Interviewees reported collaboration was easier when pharmacists were onsite, but that technology helped facilitate off-site access to pharmacy services. Finally, some team members characterized pharmacist integration as essential while others failed to integrate pharmacists at all. Non-pharmacist members of PACT teams reported some reluctance in pharmacists' integration. They attributed this reluctance to knowledge deficits, limited participation in PACT training by pharmacists, an imbalance in effort expended for pharmacists' integration, and coordination or communication challenges. While there may be unique opportunities for pharmacists to improve patient care through participation in PCMHs, work remains to improve other health professionals' knowledge of and attitudes toward pharmacists' roles on health care teams.

A new era of collaboration for primary care and psychiatry.

A new era of collaboration for primary care and psychiatry.

Evaluation of pharmacy faculty knowledge and perceptions of the patient-centered medical home within pharmacy education

PurposeTo assess pharmacy faculty knowledge about key patient-centered medical home (PCMH) principles and evaluate pharmacy faculty perception of inclusion of PCMH information in didactic and/or experiential pharmacy education. MethodsE-mail addresses of 6433 pharmacy faculty members were obtained from the 2011–2012 American Association of Colleges of Pharmacy (AACP) roster. In an online survey, faculty rated their familiarity with key PCMH principles, indicated whether PCMH concepts are currently included and/or should be included in pharmacy education, and where and how this information should be taught. ResultsResponses are included from 781 faculty members (12.1%). Among them, 641 (82%) respondents reported being aware of PCMH. A total of 207 (27%) respondents report PCMH is taught didactically and 203 (28%) report inclusion in experiential education. Faculty members were most likely to indicate that PCMH should be incorporated into required lectures and workshops in the first, second, and third professional didactic years, and into experiential education in the third and fourth years. ConclusionMany faculty members agree that it is important to teach about the PCMH health care model, but there is a low level of faculty familiarity with the standards and principles that guide this health care paradigm. Future pharmacists have an important opportunity to advance practice by participating in PCMH team care, and pharmacy education has a central responsibility in incorporating these concepts into the didactic and experiential curriculum in order to prepare pharmacists to effectively contribute in this setting.

The Patient-Centered Medical Home and Community Pharmacists' Perceptions

Background: As new models of health care delivery are being discussed, it is important to determine the pharmacist's role within each care model to assist in the provision of clinical services. Recent literature suggests that pharmacists are integral members of the patient-centered medical home (PCMH) and should be included as members of the health care team. As the most accessible health care professionals, community pharmacists are uniquely positioned to play a prominent role within the PCMH, as enhanced access is one of the joint principles of the PCMH care model. To date, no studies have described the barriers to community pharmacists' participation in the PCMH model or their acceptance as members of the PCMH team. Objective: To evaluate community pharmacists' perceptions of barriers to participation and acceptance within the PCMH in a community pharmacy chain. Methods: Online surveys were made available to 244 community pharmacists working for a supermarket pharmacy chain in Ohio. Pharmacists completed the survey anonymously and indicated their opinions on preparedness to participate in the PCMH, their relationship with other health care providers, their relationship with patients, and their perceived barriers to participation in a PCMH. Results: Of the 244 pharmacists contacted, 129 completed the survey (52.9%). In total, 32.6% of responding pharmacists were familiar with the PCMH before the survey. A majority of respondents agreed that pharmacists are sufficiently trained and have the skills required to participate within the PCMH (79.8%, 93.8%, respectively). Only 36.4% of pharmacists agreed that physicians are willing to work closely with community pharmacists. Pharmacists also indicated that they do not have adequate opportunities to meet with other members of their patients' health care team (68.5%). Conclusions: Most community pharmacists are still unfamiliar with the concept of the PCMH. Once they were made aware of what a PCMH is, the pharmacists surveyed indicated that they want to be members of a PCMH. Before pharmacists participate in this model of care within the community setting, it is important that they first understand and address the barriers identified from this survey in order to facilitate a smooth transition of pharmacy services into the PCMH.