Patient-centered Primary Care Research Articles

Diabetes self-care in primary health facilities in India - challenges and the way forward.

India has approximately 73 million people living with diabetes and another 37 million with prediabetes while nearly 47% of the diabetes cases are undiagnosed. The high burden of poor glycemic control and early onset of complications with associated economic costs indicates a high prevalence of poor self-management practices. It is well-established that achieving patient-centered primary care consistent with a chronic care model ensures optimum diabetes self-management support and improves long-term clinical and health outcomes in diabetes patients. The public sector primary care system in India provides services free of cost to beneficiaries but lacks patient-centered care that undermines diabetes self-management education and support. Furthermore, factors like poor patient knowledge of diabetes, suboptimal medication adherence, persistent clinical inertia, lack of data for monitoring and evaluation through clinical audit worsens the standards of diabetes care in primary care settings of India. There is a need for government initiatives to be directed towards the provision of comprehensive outpatient care that is inclusive of uninterrupted supply of drugs, provision of essential laboratory investigators, training and availability of qualified diabetes educators and availability of specialist support when required. Furthermore, the integration of depression screening and smoking cessation services at the primary care level is warranted.

Defining High Value Elements for Reducing Cost and Utilization in Patient-Centered Medical Homes for the TOPMED Trial.

Introduction:Like most patient-centered medical home (PCMH) models, Oregon’s program, the Patient-Centered Primary Care Home (PCPCH), aims to improve care while reducing costs; however, previous work shows that PCMH models do not uniformly achieve desired outcomes. Our objective was to describe a process for refining PCMH models to identify high value elements (HVEs) that reduce cost and utilization.Methods:We performed a targeted literature review of each PCPCH core attribute. Value-related concepts and their metrics were abstracted, and studies were assessed for relevance and strength of evidence. Focus groups were held with stakeholders and patients, and themes related to each attribute were identified; calculation of HVE attainment versus PCPCH criteria were completed on eight primary care clinics. Analyses consisted of descriptive statistics and criterion validity with stakeholder input.Results:2,126 abstracts were reviewed; 22 met inclusion criteria. From these articles and focus groups of stakeholders/experts (n = 49; 4 groups) and patients (n = 7; 1 group), 12 HVEs were identified that may reduce cost and utilization. At baseline, clinics achieved, on average, 31.3 percent HVE levels compared to an average of 87.9 percent of the 35 PCMH measures.Discussion:A subset of measures from the PCPCH model were identified as “high value” in reducing cost and utilization. HVE performance was significantly lower than standard measures, and may better calibrate clinic ability to reduce costs.Conclusion:Through literature review and stakeholder engagement, we created a novel set of high value elements for advanced primary care likely to be more related to cost and utilization than other models.

Balancing patient priorities for technical and interactional aspects of care in a measure of primary care quality.

This study attempts to strike a balance to measure primary care quality in a way that considers what is important to patients, providers and the healthcare system, all at the same time. The interest in delivering patient-centered primary care implies a need for patient-centered performance measurement. However, the distinction between measures of patient experience and technical aspects of care raises an unanswerable question: if a provider has good performance on technical measures but not on patient experience measures (or vice versa), what can be said about the quality of care? We surveyed patients to determine the relative priorities of each of a series of primary care measures in the patients' relationship with their primary care provider. The on-line survey was co-designed with patient co-investigators. The items consisted of 14 primary care quality measures used in pre-existing performance report, 41 additional indicators including a novel set of patient-generated Key Performance Indicators and 17 questions about patients' demographics, health and socioeconomic status as well as open-ended questions. Despite challenges, the study suggests that this is feasible. We argue that it is necessary to get better at measuring and finding ever-better ways to put patients at the center of primary care.

The effectiveness of patient-centred medical home model versus standard primary care in chronic disease management: protocol for a systematic review and meta-analysis of randomised and non-randomised controlled trials

BackgroundStudies suggest that the Patient-Centred Medical Home (PCMH) model of primary care is more effective than standard care for improving clinical outcomes in patients with chronic diseases (non-communicable diseases), but the strength of the evidence base is unclear. The aim of the proposed systematic review is to generate a current synthesis of relevant studies on the effectiveness of PCMH model of primary care versus standard care in chronic disease management.MethodsElectronic databases such as MEDLINE, CINAHL, Embase, Cochrane Library, and Scopus will be searched using predefined search terms for PCMH, primary care, and chronic diseases for articles published up to November 2018. Reference lists of included articles and relevant reviews will also be hand searched. This review will consider eligible randomised controlled trials and controlled trials against predetermined criteria including two or more principles of PCMH model endorsed by Australian Medical Association. Data extraction will be performed independently by two reviewers, and retrieved papers will be assessed for quality using JBI Critical Appraisal Tools. Where possible, quantitative data will be pooled in statistical meta-analysis using the R packages ‘Meta’ and ‘metafor’. Effect sizes will be expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for meta-analysis; robustness will be explored using sensitivity analysis. Heterogeneity will be assessed narratively and statistically using the Q statistics and visualised using Baujat plots including subgroup or sensitivity analyses techniques where possible. Where statistical pooling is not possible, the findings will be presented narratively.DiscussionThe findings of the proposed systematic review will provide the highest level of evidence to date on the effectiveness of the PCMH model versus standard primary care in chronic disease management. We believe that our findings will inform patients, primary care providers, and public health administrators and policy-makers on the benefits and risks of PCMH model of care.Systematic review registrationPROSPERO CRD42018085378

Creating Partnerships to Achieve Health Care Reform: Moving Beyond a Politics of Scale?

This article critically exams efforts to achieve primary health care reform using a consultative and relationship-building approach. The study is set in a predominantly rural region of British Columbia, Canada, and concerns the efforts of a regional health authority to engage actively with community members to develop more integrated and patient-centered primary health care delivery. We examine points of tension between providers and administrators engaged in the reform process and show how these are often expressed discursively as a binary opposition involving central and local interests. We offer a critical examination of this politics of scale and seek to unpack claims of hierarchy and power as a means to offer insight into health care reform processes more generally.

Patient-centered primary care and self-rated health in 6 Latin American and Caribbean countries: Analysis of a public opinion cross-sectional survey.

BackgroundDespite the substantial attention to primary care (PC), few studies have addressed the relationship between patients’ experience with PC and their health status in low-and middle-income countries. This study aimed to (1) test the association between overall patient-centered PC experience (OPCE) and self-rated health (SRH) and (2) identify specific features of patient-centered PC associated with better SRH (i.e., excellent or very good SRH) in 6 Latin American and Caribbean countries.Methods and findingsWe conducted a secondary analysis of a 2013 public opinion cross-sectional survey on perceptions and experiences with healthcare systems in Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama; the data were nationally representative for urban populations. We analyzed 9 features of patient-centered PC. We calculated OPCE score as the arithmetic mean of the PC features. OPCE score ranged from 0 to 1, where 0 meant that the participant did not have any of the 9 patient-centered PC experiences, while 1 meant that he/she reported having all these experiences. After testing for interaction on the additive scale, we analyzed countries pooled for aim 1, with an interaction term for Mexico, and each country separately for aim 2. We used multiple Poisson regression models double-weighted by survey and inverse probability weights to deal with the survey design and missing data. The study included 6,100 participants. The percentage of participants with excellent or very good SRH ranged from 29.5% in Mexico to 52.4% in Jamaica. OPCE was associated with reporting excellent or very good SRH in all countries: adjusting for socio-demographic and health covariates, patients with an OPCE score of 1 in Brazil, Colombia, El Salvador, Jamaica, and Panama were more likely to report excellent or very good SRH than those with a score of 0 (adjusted prevalence ratio [aPR] 1.61, 95% CI 1.37–1.90, p < 0.001); in Mexico, this association was even stronger (aPR 4.27, 95% CI 2.34–7.81, p < 0.001). The specific features of patient-centered PC associated with better SRH differed by country. The perception that PC providers solve most health problems was associated with excellent or very good SRH in Colombia (aPR 1.38, 95% CI 1.01–1.91, p = 0.046) and Jamaica (aPR 1.21, 95% CI 1.02–1.43, p = 0.030). Having a provider who knows relevant medical history was positively associated with better SRH in Mexico (aPR 1.47, 95% CI 1.03–2.12, p = 0.036) but was negatively associated with better SRH in Brazil (aPR 0.71, 95% CI 0.56–0.89, p = 0.003). Finally, easy contact with PC facility (Mexico: aPR 1.35, 95% CI 1.04–1.74, p = 0.023), coordination of care (Mexico: aPR 1.53, 95% CI 1.19–1.98, p = 0.001), and opportunity to ask questions (Brazil: aPR 1.42, 95% CI 1.11–1.83, p = 0.006) were each associated with better SRH. The main study limitation consists in the analysis being of cross-sectional data, which does not allow making causal inferences or identifying the direction of the association between the variables.ConclusionsOverall, a higher OPCE score was associated with better SRH in these 6 Latin American and Caribbean countries; associations between specific characteristics of patient-centered PC and SRH differed by country. The findings underscore the importance of high-quality, patient-centered PC as a path to improved population health.

The different perspectives of patients, informal caregivers and professionals on patient involvement in primary care teams. A qualitative study

BackgroundPatient involvement in the decision‐making process, especially for chronically ill elderly patients, has become an important element of patient‐centred primary care in many countries, including the Netherlands. This study openly explores different perspectives of patients, informal caregivers and primary care professionals on patient involvement in primary care team interactions.MethodsSixty‐four qualitative semi‐structured interviews with chronically ill elderly patients, informal caregivers and primary care professionals from various disciplines. Underpinned by a phenomenology approach, this study used conventional content analysis for data analysis.ResultsParticipants have different views of the roles of patients and informal caregivers in the primary care team and thus different expectations of the extent and level of patient involvement. Three challenges impact patient involvement in the team: (a) patients feel misunderstood and less involved that they would like when professionals take control, (b) patients have to balance the conflicting opinions of different professionals and (c) informal caregivers act undesirably as team leaders due to their own view of the level of patient involvement.Discussion and conclusionPatient involvement is formed in complex interactions between patients, informal caregivers and multiple professionals whose perspectives and expectations can be misaligned. Recognizing the value of patients and informal caregivers on the team could help professionals to understand them better and thus limit the likelihood of challenges arising in team interactions.

Validation of an instrument for the assessment of patient-centred care among patients with multimorbidity in the primary care setting: the 36-item patient-centred primary care instrument

BackgroundValidated instruments are needed to assess the delivery of patient-centred care (PCC) to patients with multimorbidity in the primary care setting. Eight dimensions of PCC have been identified: respect for patients’ preferences, access to care, emotional support, information and education, involvement of family and friends, continuity and secure transition between health care settings, physical comfort, and coordination of care. The main objective of this study was to validate an instrument for the assessment of PCC among patients with multimorbidity in the primary care setting: the 36-item patient-centred primary care (PCPC) instrument.MethodsWe included patients with multimorbidity from seven health care practices in the region of Tilburg, the Netherlands. All patients enrolled in at least two chronic care programmes (involving diagnosis of and treatment for combinations of diabetes, asthma and/or chronic obstructive pulmonary disease, cardiovascular diseases and conditions, and age-related frailty) were selected from the practices’ data registries and included as eligible participants. A total of 216 patients with multimorbidity filled in the study questionnaire (55% response rate). We tested the instrument using structural equation modelling, and examined its validity and reliability.ResultsConfirmatory factor analyses revealed good indices of fit and overall internal consistency, as represented by Cronbach’s alpha values. All eight dimensions of PCC were related positively to satisfaction with care (all p ≤ 0.001). Patients with multimorbidity who experienced joint decision making and responsibility taking in the primary care setting also had significantly higher scores for all eight PCC dimensions, indicating the instrument’s construct validity.ConclusionsWe conclude that the psychometric properties of the 36-item PCPC instrument are good. Based on these results the PCPC instrument seems a promising tool for the assessment of PCC among patients with multimorbidity in the primary care setting.

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.

Rethinking the shortage of primary care physicians.

For decades, public concerns about a shortage of physicians led federal and state policy makers to pursue policies to increase the number of medical graduates. In response, the number of medical schools increased dramatically over the past decade. By 2016, the United States produced more new physicians than ever before. Expanding medical school enrollments, however, were not matched by a corresponding increase in the number of physicians choosing primary care. To date, few policy makers questioned the conventional wisdom that more is better when it comes to the supply of primary care physicians. Instead, policy makers should consider alternative approaches to increase access to patient-centered primary care.

Answering patient-centred questions efficiently: response-adaptive platform trials in primary care.

As currently designed and conducted, randomised controlled trials rarely address the complexity of patient characteristics that need to be taken into account when making clinical decisions in primary care. We introduce the concept of a response-adaptive platform trial design, as this approach may be better suited to answering patient-centred primary care research questions. The primary question addressed by a traditional clinical trial is whether a treatment is beneficial in the average patient. However, the question that trials should ideally provide would instead answer the question: ‘What is the best treatment for each individual patient, given all of their characteristics that could influence the effectiveness, or otherwise, of the treatment?’ Although sub-group analyses are often performed in traditional trials to determine if the treatment effect is associated with certain patient or disease characteristics (for example, comorbidities, age, or illness severity), these analyses are typically post-hoc, underpowered, and usually consider only one patient characteristic at a time. Thus we might learn something about the influence of age in general on the outcome of treatment from sub-group analysis of a traditional trial, but not about the influence of age, illness severity, and symptom duration combined. Furthermore, participants in traditional clinical trials are often selected to be homogeneous in terms of their illness and to be free of comorbid conditions and any concomitant medications that might complicate the assessment of the effect of a treatment. This leads to a lack of applicability of trial findings to many complex primary care patients. Most registration trials (those intended to support regulatory approvals of new medications) also fail to address important comparative effectiveness questions such as which therapy or combination of therapies may be the most or least effective, or which therapy, out of all of the available therapies, has the best compliance or tolerability. The traditional …

Strategies for Addressing the Challenges of Patient-Centered Medical Home Implementation: Lessons from Oregon.

Patient-centered medical homes (PCMHs) are at the forefront of the transformation of primary care as part of health systems reform. Despite robust literature describing implementation challenges, few studies describe strategies being used to overcome these challenges. This article addresses this gap through observations of exemplary PCMHs in Oregon, where the Oregon Health Authority supports and recognizes Patient-Centered Primary Care Homes (PCPCH). Twenty exemplary PCPCHs were selected using program scores, with considerations for diversity in clinic characteristics. Between 2015 and 2016, semistructured interviews and focus groups were completed with 85 key informants. Clinics reported similar challenges implementing the PCPCH model, including shifting patterns of care use, fidelity to the PCPCH model, and refining care processes. The following ten implementation strategies emerged: expanding access through care teams, preventing unnecessary emergency department visits through patient outreach, improved communication and referral tracking with outside providers, prioritization of selected program metrics, implementing patient-centered practices, developing continuous improvement capacity through committees and "champions," incorporating preventive services and chronic disease management, standardization of workflows, customizing electronic health records, and integration of mental health. Clinic leaders benefited from understanding the local context in which they were operating. Despite differences in size, ownership, geography, and population, all clinic leaders were observed to be proponents of strategies commonly associated with a "learning organization": systems thinking, personal mastery, mental models, shared vision, and team. Clinics can draw on their own characteristics, use state resources, and look to established PCMHs to build the evidence base for implementation in primary care.

Implementation of the Geriatric Patient-Aligned Care Team Model in the Veterans Health Administration (VA).

Here, we describe the implementation of a specialty primary care medical home (PCMH) model called Geriatric Patient-Aligned Care Teams (GeriPACT) in the Veterans' Health Administration (VA) that is focused on serving older complex patients. In particular, our aims in this article are to describe how the GeriPACT model was developed and implemented in VA sites, provide a closer look at how GeriPACT functions by presenting a case study, and highlight data showing national variation in the implementation of GeriPACT staffing models and PCMH practices. Stakeholder feedback regarding the GeriPACT model was obtained from a GeriPACT team and the director of GeriPACT in VA. Here, we present national data regarding variations in GeriPACT staffing and PCMH practices. Following the adoption and implementation of the GeriPACT model and release of the GeriPACT handbook, sites were able to adopt the model's principles. The VA's adoption of PCMH reinforced the mission of patient-centered primary care by integrating psychosocial and environmental determinants of health. This was accomplished with enhancements to staff support through new full-time employment equivalents, but also by optimizing staff productivity through improved team function and interpersonal care. The GeriPACT model was implemented in a bottom-up fashion that has led to variation in how GeriPACTs are structured and staffed, as well as how they conform to various PCMH principles. GeriPACT is one approach for bringing an interdisciplinary, patient-centric perspective to primary care in a manner that can likely support the higher staffing costs with economies realized from diminished reliance on institutional placement and highly technologic health care. It is a model which can provide training for the next generation of providers and clinicians.

Home Visit-Based Community Paramedicine and Its Potential Role in Improving Patient-Centered Primary Care: A Grounded Theory Study and Framework.

Community paramedicine (CP) is a model of community-based health care being used around the world. Our objective was to study the patient perspective and valuation of this type of program to understand its potential value for primary care innovation in the future. The EPIC community paramedicine program is a partnership between primary care physicians and specially trained community paramedics, designed to provide in-home support for complex chronic disease patients in Ontario, Canada. As part of an ongoing clinical trial we designed an embedded qualitative evaluation using constructionist grounded theory methodology. Data collection included in-depth interviews with 30 patients and/or family members and 60hours of observation. The health care needs of this complex population are largely attributes that impact a patient's quality of life-including recognition of their vulnerability, providing a safety-net in times of exacerbation and health education and accountability. This seems to be facilitated by a relationship with a dedicated provider that increases continuity of care. Home-based community paramedicine programs like EPIC appear to be able to create a patient-centered, safe, responsive therapeutic relationship that is often not possible within the standard primary health care system.

A Multidisciplinary, Team-Based Teleconsultation Approach to Enhance Child Mental Health Services in Rural Pediatrics

ABSTRACTMental health services for rural youth are extremely limited, especially given the national shortage of child and adolescent psychiatrists (CAPs). Patient-centered primary care medical homes (PCMHs) are often their only available portal of care, yet high-quality PCMH integrated models of behavioral health that include a CAP are rare. This manuscript presents a unique multidisciplinary teleconsultation model wherein integrated behavioral systems consultation was employed to increase access to integrated behavioral health services. Common referrals included complex presentations outside of provider comfort range or medication and diagnostic clarification. Primary concerns were symptoms of ADHD, autism spectrum disorder, anxiety, and depression. Recommendations included referral to outpatient therapy, further coordination with the medical team, and follow-up with the CAP. Providers noted access to care, specialized quality of care, provider support, and enhancing principles of the PCMH as strengths of the teleconsultation. Challenges included patient engagement, scheduling/availability, challenges with the teleconsultation process, and provider-level barriers.

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.

Virtual care policy recommendations for patient-centred primary care: findings of a consensus policy dialogue using a nominal group technique

Background The development of new virtual care technologies (including telehealth and telemedicine) is growing rapidly, leading to a number of challenges related to health policy and planning for health systems around the world. Methods We brought together a diverse group of health system stakeholders, including patient representatives, to engage in policy dialogue to set health system priorities for the application of virtual care in the primary care sector in the Province of Ontario, Canada. We applied a nominal group technique (NGT) process to determine key priorities, and synthesized these priorities with group discussion to develop recommendations for virtual care policy. Methods included a structured priority ranking process, open-ended note-taking, and thematic analysis to identify priorities. Results Recommendations were summarized under the following themes: (a) identify clear health system leadership to embed virtual care strategies into all aspects of primary and community care; (b) make patients the focal point of health system decision-making; (c) leverage incentives to achieve meaningful health system improvements; and (d) building virtual care into streamlined workflows. Two key implications of our policy dialogue are especially relevant for an international audience. First, shifting the dialogue away from technology toward more meaningful patient engagement will enable policy planning for applications of technology that better meet patients’ needs. Second, a strong conceptual framework on guiding the meaningful use of technology in health care settings is essential for intelligent planning of virtual care policy. Conclusions Policy planning for virtual care needs to shift toward a stronger focus on patient engagement to understand patients’ needs.

Digital health in primary care

Digital technologies are increasingly being used in healthcare, by both patients and health professionals. Such use is often referred to as ‘digital health’. Digital technologies comprise a range of services that have the potential to improve treatment outcomes and patient experiences, and to lower the costs of healthcare. Digital health can be used to capture longitudinal outcome and experience data. Patient-reported data is increasingly required for health systems payments (an example being payments under the Commissioning for Quality and Innovation system) and outcomes-based contracting in the NHS. In this article, we focus on digital health technologies used in England to support patient-centred primary care. The article will consider an overview of policies leading to the adoption of digital technologies in primary care, current trends in digital health in primary care, case studies, key concerns and possible future developments.

Family Health Teams in Ontario – Vorstellung eines kanadischen Primärversorgungsmodells und Anregungen für Deutschland

The German healthcare system is struggling with fragmentation of care in the face of an increasing shortage of general practitioners and allied health professionals, and the time-demanding healthcare needs of an aging, multimorbid patient population. Innovative interprofessional, intersectoral models of care are required to ensure adequate access to primary care across a variety of rural and urban settings into the foreseeable future. A team approach to care of the complex multimorbid patient population appears particularly suitable in attracting and retaining the next generation of healthcare professionals, including general practitioners. In 2014, the German Advisory Council on the Assessment of Developments in the Health Care System highlighted the importance of regional, integrated care with community-based primary care centres at its core, providing comprehensive, population-based, patient-centred primary care with adequate access to general practitioners for a given geographical area. Such centres exist already in Ontario, Canada; within Family Health Teams (FHT), family physicians work hand-in-hand with pharmacists, nurses, nurse practitioners, social workers, and other allied health professionals. In this article, the Canadian model of FHT will be introduced and we will discuss which components could be adapted to suit the German primary care system.

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

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