Patient-centered Medical Home Transformation Research Articles

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.

Using CAHPS patient experience data for patient-centered medical home transformation.

To examine how primary care practices use the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and its patient-centered medical home (PCMH) items during their PCMH transition. Qualitative study of practices' use of patient experience data during PCMH transformation, based on a random sample of primary care practices engaged in PCMH transformation, stratified by region, practice size, PCMH recognition history, and use of the CAHPS PCMH survey. We interviewed 105 practice leaders from 294 sampled practices (36% response rate) and used content analysis to identify themes about uses of patient experience data for practice improvement during PCMH transformation. Patient experience data were used primarily to assess and track improvements toward PCMH goals and as quality improvement (QI) metrics. CAHPS measures were used most often to discuss best practices, share data with patient advisory councils, and improve provider performance. The CAHPS PCMH survey helped practices improve patient-centeredness, particularly in coordinating care and supporting patient self-management and communication. The CAHPS PCMH items that assisted practices most were about patient self-management and provider referrals. Most practice leaders using the CAHPS PCMH survey felt that its items were actionable for standardizing PCMH changes or making structural changes. Practices administering CAHPS surveys focused on a more diverse set of QI areas. CAHPS surveys were considered actionable for PCMH transformation and used in standardizing and coordinating care. The CAHPS PCMH items were considered integral to the continuous QI needed for moving beyond formal PCMH recognition and maximizing transformation. This supports the National Committee for Quality Assurance's recommendation to administer the CAHPS or CAHPS PCMH survey for PCMH transformation.

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.

Nationwide Qualitative Study of Practice Leader Perspectives on What It Takes to Transform into a Patient-Centered Medical Home.

Despite widespread adoption of patient-centered medical home (PCMH), little is known about why practices pursue PCMH and what is needed to undergo transformation. Examine reasons practices obtained and maintained PCMH recognition and what resources were needed. Qualitative study of practice leader perspectives on PCMH transformation, based on a random sample of primary care practices engaged in PCMH transformation, stratified by US region, practice size, PCMH recognition history, and practice use of Consumer Assessment of Healthcare Providers and Systems (CAHPS®) PCMH survey. 105 practice leaders from 294 sampled practices (36% response rate). Content analysis of interviews with practice leaders to identify themes. Most practice leaders had local control of PCMH transformation decisions, even if practices adopted quality initiatives under the direction of an organization or network. Financial incentives, being in a statewide effort, and the intrinsic desire to improve care or experiences were the most common reasons practice leaders decided to obtain PCMH recognition and pursue associated care delivery changes. Leadership support and direction were highlighted as essential throughout PCMH transformation. Practice leaders reported needing specialized staff knowledge and significant resources to meet PCMH requirements, including staff knowledgeable about how to implement PCMH changes, track and monitor improvements, and navigate implementation of simultaneous changes, and staff with specific quality improvement (QI) expertise related to evaluating changes and scaling-up programs. PCMH efforts necessitated support and assistance to frontline, on-site practice leaders leading care delivery changes. Such change efforts should include financial incentives (e.g., direct payment or additional reimbursement), leadership direction and support, and internal or external staff with experience with the PCMH application process, implementation changes, and QI expertise in monitoring process and outcome data. Policies that recognize and meet the needs of on-site practice leaders will better promote primary care practice transformation and move practices further toward their PCMH transformation goals.

Impact of health information technology optimization on clinical quality performance in health centers: A national cross-sectional study.

Delivery of preventive care and chronic disease management are key components of a high functioning primary care practice. Health Centers (HCs) funded by the Health Resources and Services Administration (HRSA) have been delivering affordable and accessible primary health care to patients in underserved communities for over fifty years. This study examines the association between health center organization's health information technology (IT) optimization and clinical quality performance. Using 2016 Uniform Data System (UDS) data, we performed bivariate and multivariate analyses to study the association of Meaningful Use (MU) attestation as a proxy for health IT optimization, patient centered medical home (PCMH) recognition status, and practice size on performance of twelve electronically specified clinical quality measures (eCQMs). Bivariate analysis demonstrated performance of eleven out of the twelve preventive and chronic care eCQMs was higher among HCs attesting to MU Stage 2 or above. Multivariate analysis demonstrated that Stage 2 MU or above, PCMH status, and larger practice size were positively associated with performance on cancer screening, smoking cessation counseling and pediatric weight assessment and counseling eCQMs. Organizational advancement in MU stages has led to improved quality of care that augments HCs patient care capacity for disease prevention, health promotion, and chronic care management. However, rapid technological advancement in health care acts as a potential source of disparity, as considerable resources needed to optimize the electronic health record (EHR) and to undertake PCMH transformation are found more commonly among larger HCs practices. Smaller practices may lack the financial, human and educational assets to implement and to maintain EHR technology. Accordingly, targeted approaches to support small HCs practices in leveraging economies of scale for health IT optimization, clinical decision support, and clinical workflow enhancements are critical for practices to thrive in the dynamic value-based payment environment.

Practice Leaders Report Targeting Several Types of Changes in Care Experienced by Patients During Patient-Centered Medical Home Transformation.

Patient-centered medical home (PCMH) has spurred primary care reform and improvements in patient care quality. Very little is known about the differences practices implement during PCMH transformation. We examined 105 primary care practice leader experiences during PCMH transformation, asking in semi-structured interviews about the changes they targeted. We used content analysis to classify these PCMH changes and examined how they aligned with what is measured on PCMH-recommended patient experience surveys. During PMCH transformation, practices most commonly targeted changes in care coordination (30%), access to care (25%), and provider communication (24%). Reported areas of PCMH transformation were measured by Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CAHPS), PCMH CAHPS, or supplemental CAHPS survey items, including team-based care (35%), providing more services on site (28%), care management (22%), patient-centered culture (18%), and chronic condition health education (13%). Many PCMH changes are captured by CAHPS patient experience items; some are not. For some uncaptured areas, patients are not the best source of information. To provide practice leaders information they need for PCMH transformation, CAHPS items need to measure care management to support medical and chronic conditions, and chronic condition health education.

Patient Centred Medical Home (PCMH) transitions in western Sydney, Australia: a qualitative study

BackgroundPatient Centred Medical Homes (PCMHs), increasingly evidenced to provide high quality primary care, are new to Australia. To learn how this promising new healthcare model works in an Australian setting we explored experiences of healthcare providers in outer urban Sydney, where a number of practices are transitioning from traditional Australian general practice models to incorporate elements of PCMH approaches.MethodsWe collected qualitative data from semi-structured interviews with healthcare providers working in a range of transitioning practices and thematically analysed the data. We interviewed 35 participants including general practitioners, practice managers and practice nurses from 25 purposively sampled general practices in western Sydney, Australia, seeking maximal variation in practice size, patient demographics and type of engagement in practice transformation.ResultsInterviewees described PCMH transformation highlighting the importance of whole of practice engagement with a shared vision; key strategies for transformation to PCMH models of care including leadership, training and supportive information technology; structures and processes required to provide team-based, data-driven care; and constraints such as lack of space and the current Australian fee-for-service general practice funding model. They also reported their perceptions of early outcomes of the PCMH model of care, describing enhanced patient and staff satisfaction and also noting fewer hospital admissions, as likely to reduce costs of care.ConclusionsOur study exploring the experience of early adopters of PCMH models of care in Australia, informs the international movement towards PCMH models of care. Our findings provide guidance for practices considering similar transitions and describe the challenges of such transitions within a fee-for-service payment system.

Impact of Patient-Centered Medical Home Transformation on Providers, Staff, and Quality.

The Patient-Centered Medical Home (PCMH) has become a widely implemented model to transform the delivery of care, but little evidence exists regarding the model's impact on providers, nurses, and staff. This study examined the impact of the PCMH model on (1) provider and staff satisfaction, (2) work-life balance, (3) teamwork, (4) professional experience, (5) patient care factors, and (6) quality outcomes. The authors confidentially surveyed physicians, advanced practice providers (APPs), nurses, care managers, and office staff in 2011 prior to implementation of the PCMH model and in 2016 after implementation at 34 primary care offices providing care to 171,045 patients. A total of 349 pre-PCMH implementation surveys (84% response rate) and 549 follow-up surveys (92% response rate) were received. Implementation of the PCMH model did not result in changes in provider, nurse, and staff responses to composite measures of satisfaction (P = 0.45), work-life balance (P = 0.68), teamwork (P = 0.26), patient care (P = 0.62), or professional experience (P = 0.14). Physicians and APPs experienced a negative, but mostly nonsignificant, change in all composite measures with implementation of the PCMH model. Quality markers improved for diabetes control HbA1c <8 (62.6% to 67.9%; P < 0.001), hypertension control (60.9% to 75.0%; P < 0.001), breast cancer screening (53.9% to 77.4%; P < 0.001), and colorectal cancer screening (43.9% to 70.3%; P < 0.001). Across a large primary care network, implementation of the PCMH model failed to improve overall satisfaction, work-life balance, teamwork, patient care, or professional experience. The model, combined with financial incentives, did result in improvements across multiple patient quality domains.

Assessing fidelity to evidence-based quality improvement as an implementation strategy for patient-centered medical home transformation in the Veterans Health Administration

BackgroundEffective implementation strategies might facilitate patient-centered medical home (PCMH) uptake and spread by targeting barriers to change. Evidence-based quality improvement (EBQI) is a multi-faceted implementation strategy that is based on a clinical-researcher partnership. It promotes organizational change by fostering innovation and the spread of those innovations that are successful. Previous studies demonstrated that EBQI accelerated PCMH adoption within Veterans Health Administration primary care practices, compared with standard PCMH implementation. Research to date has not documented fidelity to the EBQI implementation strategy, limiting usefulness of prior research findings. This paper develops and assesses clinical participants’ fidelity to three core EBQI elements for PCMH (EBQI-PCMH), explores the relationship between fidelity and successful QI project completion and spread (the outcome of EBQI-PCMH), and assesses the role of the clinical-researcher partnership in achieving EBQI-PCMH fidelity.MethodsNine primary care practice sites and seven across-sites, topic-focused workgroups participated (2010–2014). Core EBQI elements included leadership-frontlines priority-setting for QI, ongoing access to technical expertise, coaching, and mentoring in QI methods (through a QI collaborative), and data/evidence use to inform QI. We used explicit criteria to measure and assess EBQI-PCMH fidelity across clinical participants. We mapped fidelity to evaluation data on implementation and spread of successful QI projects/products. To assess the clinical-researcher partnership role in EBQI-PCMH, we analyzed 73 key stakeholder interviews using thematic analysis.ResultsSeven of 9 sites and 3 of 7 workgroups achieved high or medium fidelity to leadership-frontlines priority-setting. Fidelity was mixed for ongoing technical expertise and data/evidence use. Longer duration in EBQI-PCMH and higher fidelity to priority-setting and ongoing technical expertise appear correlated with successful QI project completion and spread. According to key stakeholders, partnership with researchers, as well as bi-directional communication between leaders and QI teams and project management/data support were critical to achieving EBQI-PCMH fidelity.ConclusionsThis study advances implementation theory and research by developing measures for and assessing fidelity to core EBQI elements in relationship to completion and spread of QI innovation projects or tools for addressing PCMH challenges. These results help close the gap between EBQI elements, their intended outcome, and the finding that EBQI-PCMH resulted in accelerated adoption of PCMH.

Using Lean Performance Improvement for Patient-Centered Medical Home Transformation at an Academic Public Hospital.

Although Lean performance improvement (PI) has been used in health care for more than 15 years, little is known about how Lean has been used in Patient-Centered Medical Home (PCMH) transformation. We describe our experience implementing Lean in our safety-net, primary care teaching clinic. To advance high value care, a culture of systematic, sustainable PI methods needed to be integrated into primary care and taught to resident physicians. Clinic leadership were trained in Lean methods, protected time was dedicated to PI for a stable, interdisciplinary team, then visual management was introduced, and resident physicians were integrated into the clinic's PI initiatives. Self-assessment using the PCMH Assessment tool demonstrated improvement in core features of the PCMH model. Process outcomes also revealed successful, sustainable integration of Lean into our primary care clinic and resident training, and early findings show improvements in clinical quality outcomes. Patient survey outcomes demonstrate improvement in patient experience. Lean can be used successfully to promote PCMH transformation and create a culture of continuous PI in an academic, safety-net primary care setting.

Colorado Residency PCMH Project: Results From a 6-Year Transformation Effort.

Our objective was to describe the results of a 6-year patient-centered medical home (PCMH) transformation program in 11 Colorado primary care residency practices. We used a parallel qualitative and quantitative evaluation including cross-sectional surveys of practice staff and clinicians, group and individual interviews, meeting notes, and longitudinal practice facilitator field notes. Survey analyses assessed change over time, adjusting for practice-level random effects. Qualitative data analysis used iterative template coding and matrix analyses to synthesize data over time and across cases. There were significant improvements in clinicians' self-reported routine delivery of patient-centered care, team-based care, self-management support, and use of information systems (P&lt;.0001). Clinicians and staff reported significant gains in practice change culture (P=.001). Self-reported practice-level assessments pointed to additional significant improvements in quality improvement (QI) processes, continuity of care, self-management support/care coordination, and the use of data and population management (P≤.0215). Practices and their practice facilitators reported important changes in how practices operated, significantly improving their QI processes, shared leadership, change culture, and achieving Level III PCMH NCQA Recognition. Important barriers to further progress remain, including inadequate payment models, inflexible staff roles, and difficult access to clinical data. The success of these 11 primary care residency practices in making significant improvements in their delivery of patient-centered care, team-based care, self-management support, and use of information systems took time, effort, and external support. Further practice redesign for advanced primary care models will take sustained sources of well-aligned support, flexibility, shared leadership, and partnerships across residency programs for collaborative learning to assist in their transformation efforts.

Provider and Staff Morale, Job Satisfaction, and Burnout over a 4-Year Medical Home Intervention.

The patient-centered medical home (PCMH) is a widely adopted primary care model. However, it is unclear whether changes in provider and staff perceptions of clinic PCMH capability are associated with changes in provider and staff morale, job satisfaction, and burnout in safety net clinics. To determine how provider and staff PCMH ratings changed under a multi-year PCMH transformation initiative and assess whether changes in provider and staff PCMH ratings were associated with changes in morale, job satisfaction, and burnout. Comparison of baseline (2010) and post-intervention (2013-2014) surveys. Sixty clinics in five states. Five hundred thirty-six (78.2%) providers and staff at baseline and 589 (78.3%) post-intervention. Collaborative learning sessions and on-site coaching to implement PCMH over 4years. Provider and staff PCMH ratings on 0 (worst) to 100 (best) scales; percent of providers and staff reporting good or better morale, job satisfaction, and freedom from burnout. Almost half of safety net clinics improved PCMH capabilities from the perspective of providers (28 out of 59, 47%) and staff (25 out of 59, 42%). Over the same period, clinics saw a decrease in the percentage of providers reporting high job satisfaction (- 12.3% points, p = .009) and freedom from burnout (- 10.4% points, p = .006). Worsened satisfaction was concentrated among clinics that had decreased PCMH rating, with those clinics seeing far fewer providers report high job satisfaction (- 38.1% points, p < 0.001). Control clinics were not used. Individual-level longitudinal survey administration was not feasible. If clinics pursue PCMH transformation and providers do not perceive improvement, they may risk significantly worsened job satisfaction. Clinics should be aware of this potential risk of PCMH transformation and ensure that providers are aware of PCMH improvements.

Multiyear Performance Trends Analysis of Primary Care Practices Demonstrating Patient-Centered Medical Home Transformation: An Observation of Quality Improvement Indicators among Outpatient Clinics.

Despite the ever-changing requirements of modern policy, payers seek interventions for care delivery improvement through value-based care models. Prior research acknowledges the Patient-Centered Medical Home (PCMH) as a tool for performance and outcomes improvement. However, these studies lack empirical evidence of performance trends across medical homes. A retrospective observational study was conducted to describe national trends in National Committee for Quality Assurance PCMH recognition for more than 23 000 primary care practices across the United States from 2008 to 2017. More than half of recognized practices scored 100% pass rates for activities related to appointment availability, patient care planning, and data for population management. The most common underperforming PCMH activities were for practice team, referral tracking and follow-up, and quality improvement implementation. Study findings indicate that patient-centered care collaboration between clinical and nonclinical team members, primary care provider coordination with specialty care providers, and practice implementation of clinical quality improvement methodologies are particularly challenging activities.

The Impact of a Health Information Technology-Focused Patient-centered Medical Neighborhood Program Among Medicare Beneficiaries in Primary Care Practices: The Effect on Patient Outcomes and Spending.

The Center for Medicare & Medicaid Innovation (CMMI) tests new models of paying for or delivering health care services and expands models that improve health outcomes while lowering medical spending. CMMI gave TransforMED, a national learning and dissemination contractor, a 3-year Health Care Innovation Award (HCIA) to integrate health information technology systems into physician practices. This paper estimates impacts of TransforMED's HCIA-funded program on patient outcomes and Medicare parts A and B spending. We compared outcomes for Medicare fee-for-service (FFS) beneficiaries served by 87 treatment practices to outcomes for Medicare FFS beneficiaries served by 286 matched comparison practices, adjusting for differences in outcomes between the 2 groups during a 1-year baseline period. We estimated impacts in 3 evaluation outcome domains: quality-of-care processes, service use, and spending. We estimated the program led to a 7.1% reduction in inpatient admissions and a 5.7% decrease in the outpatient emergency department visits. However, there was no evidence of statistically significant effects in outcomes in either the quality-of-care processes or spending domains. These results indicate that TransforMED's program reduced service use for Medicare FFS beneficiaries, but also show that the program did not have statistically significant favorable impacts in the quality-of-care processes or spending domains. These results suggest that providing practices with population health management and cost-reporting software-along with technical assistance for how to use them-can complement practices' own patient-centered medical home transformation efforts and add meaningfully to their impacts on service use.

Barriers and Facilitators to Expanding Roles of Medical Assistants in Patient-Centered Medical Homes (PCMHs).

Many primary care practices participating in patient-centered medical home (PCMH) transformation initiatives are expanding the work roles of their medical assistants (MAs). Little is known about attitudes of MAs or barriers and facilitators to these role changes. Secondary data analysis of qualitative cross-case comparison study of 15 New Jersey primary care practices participating in a PCMH project during 2012 to 2013. Observation field notes and in-depth and key informant interviews (with physicians, office managers, staff and care coordinators) were iteratively analyzed using grounded theory. MA roles and responsibilities changed from a mostly reactive role, completing tasks dependent on physician orders during the patient visit and facilitating patient flow through the office, to a more proactive one, conducting previsit planning, engaging in the overall care for patients, and assisting with population management. MAs differed in their attitudes about increased responsibilities, with some welcoming the opportunity to take on expanded roles, others resenting their increased responsibilities, and some expressing insufficient understanding regarding why new tasks and procedures were being implemented. Major barriers to MA role shifts included 1) insufficient understanding of the PCMH concept, 2) lack of time for added responsibilities, 3) additional workload without additional compensation, 4) disparate levels of medical knowledge and training, 5) reluctance of clinicians to delegate tasks, 6) uncertainty in making new workflow changes routine, 7) staff turnover, and 8) change fatigue. MAs were more positive about their role shifts when they 1) understood how their responsibilities fit within broader PCMH practice transformation goals; 2) received formal training in new tasks; 3) had detailed protocols and standing orders; 4) initiated role changes with small, achievable goals; 5) had open communication with clinicians and practice leaders; and 5) received additional compensation or paths to career advancement. Practice leaders need to be conscious of obstacles when they increase expectations of MAs, and they must be willing to invest time and resources into developing their MA workforce. An environment that allows open dialog with MAs and rewards and compensation that recognizes their increased efforts will help make expansion of MA roles occur more smoothly and efficiently.

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.

What matters in patient-centered medical home transformation: Whole system evaluation outcomes of the Brown Primary Care Transformation Initiative.

Objectives:Patient-centered medical home transformation initiatives for enhancing team-based, patient-centered primary care are widespread in the United States. However, there remain large gaps in our understanding of these efforts. This article reports findings from a contextual, whole system evaluation study of a transformation intervention at eight primary care teaching practice sites in Rhode Island. It provides a picture of system changes from the perspective of providers, staff, and patients in these practices.Methods:Quantitative/qualitative evaluation methods include patient, provider, and staff surveys and qualitative interviews; practice observations; and focus groups with the intervention facilitation team.Results:Patient satisfaction in the practices was high. Patients could describe observable elements of patient-centered medical home functioning, but they lacked explicit awareness of the patient-centered medical home model, and their activation decreased over time. Providers’ and staff’s emotional exhaustion and depersonalization increased slightly over the course of the intervention from baseline to follow-up, and personal accomplishment decreased slightly. Providers and staff expressed appreciation for the patient-centered medical home as an ideal model, variously implemented some important patient-centered medical home components, increased their understanding of patient-centered medical home as more than specific isolated parts, and recognized their evolving work roles in the medical home. However, frustration with implementation barriers and the added work burden they associated with patient-centered medical home persisted.Conclusion:Patient-centered medical home transformation is disruptive to practices, requiring enduring commitment of leadership and personnel at every level, yet the model continues to hold out promise for improved delivery of patient-centered primary care.

Practice Transformation: Using Team-Based Care Training to Improve Diabetes Outcomes

Background: One of the key factors of the patient-centered medical home (PCMH) transformation require shifting mental models at the individual level and culture change at the practice level on how clinicians and support staff work together. This culture shift requires a reeducation on the roles and communication strategies within the medical practice. The objective of this project was to implement a team-based care training program based on the AHRQ TeamSTEPPS framework in 6 primary care practices affiliated with a Primary Care Practice Based Research Network to increase communication and performance of the care teams. Methods: Clinicians and staff from these sites received external facilitation by a certified TeamSTEPPS master trainer, who is a physician specializing in diabetes care, over a 1-year period. An analysis of their established diabetes patients’ hemoglobin A1c and low-density lipoprotein cholesterol before the training program and posttraining was performed using the paired t test and verified using the Wilcoxon sign rank test. Results: There was a statistically significant decrease in the mean hemoglobin A1c levels from 7.48% to 7.32% (P < .001) and low-density lipoprotein cholesterol from 92.34 to 88.34 mg/dL (P = .002) for all the practices combined but only 3 practices saw significant improvement individually. Conclusions: Even though the practices participating in this training are PCMHs and are part of a larger primary care network, they have achieved different levels of success, partly due to leadership and buy-in by staff. Practice leaders and team members need to fully embrace team care concepts and continuously monitor teamwork experiences to support effective team-based care.

Pathways to Medical Home Recognition: A Qualitative Comparative Analysis of the PCMH Transformation Process.

To understand the process of practice transformation by identifying pathways for attaining patient-centered medical home (PCMH) recognition. The CMS Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration was designed to help FQHCs achieve NCQA Level 3 PCMH recognition and improve patient outcomes. We used a stratified random sample of 20 (out of 503) participating sites for this analysis. We developed a conceptual model of structural, cultural, and implementation factors affecting PCMH transformation based on literature and initial qualitative interview themes. We then used conventional cross-case analysis, followed by qualitative comparative analysis (QCA), a cross-case method based on Boolean logic algorithms, to systematically identify pathways (i.e., combinations of factors) associated with attaining-or not attaining-Level3 recognition. Site-level indicators were derived from semistructured interviews with site leaders at two points in time (mid- and late-implementation) and administrative data collected prior to and during the demonstration period. The QCA results identified five distinct pathways to attaining PCMH recognition and four distinct pathways to not attaining recognition by the end of the demonstration. Across these pathways, one condition (change leader capacity) was common to all pathways for attaining recognition, and another (previous improvement or recognition experience) was absent in all pathways for not attaining recognition. In general, sites could compensate for deficiencies in one factor with capacity in others, but they needed a threshold of strengths in cultural and implementation factors to attain PCMH recognition. Future efforts at primary care transformation should take into account multiple pathways sites may pursue. Sites should be assessed on key cultural and implementation factors, in addition to structural components, in order to differentiate interventions and technical assistance.