Understanding the Transformation Experiences of Small Practices With National Committee for Quality Assurance Medical Home Recognition

Principal Investigator: Sarah Hudson Scholle, DrPH
Institution: National Committee for Quality Assurance and Health Partners Research Foundation
AHRQ Grant Number: R18 HS019162

Overview of Transformation Efforts

A nationwide sample of 249 small practices (i.e., fewer than five physicians) that obtained Level 1 or Level 3 patient-centered medical home (PCMH) recognition from the National Committee for Quality Assurance (NCQA) was surveyed to identify common elements of PCMH transformation. Approximately 85 percent of practices reported receiving some form of physician and staff training. More than half (54%) participated in PCMH demonstration or pilot projects that offered a range of assistance, including coaching, learning collaboratives, and technical assistance with information technology. Nearly 70 percent of practices received financial incentives for PCMH transformation, and 80 percent had an electronic health record (EHR) in place. Almost 70 percent of surveyed practices involved front-line staff in improvement efforts, but only 15 percent included patients on quality improvement committees or teams.

Supporting patient self-management was a key focus area for transformation efforts across practices. Strategies implemented by more than 80 percent of practices included: working with patients to develop care plans, reconcile medications, address barriers to self-care, and review progress between visits; referring patients to community programs; and providing evidence-based patient education. More than 60 percent of practices delegated some aspects of self-management support or other elements of patient care to nonclinicians.

Case studies were conducted in six practices to gain more insight into PCMH strategies used by small practices. All six practices assigned medical and nursing assistants with clinical tasks that had previously been completed by physicians (e.g., routine screenings and vaccinations). The practices also implemented population management and care coordination activities, such as maintaining a chronic care registry and reminding patients of appointments and screenings, and expanded their use of the EHR to assist with these tasks.

Results of Transformation Efforts

Thirty-three practices (13%) changed from Level 1 to Level 3 NCQA PCMH recognition during the survey period.

Practices with Level 3 recognition were more likely to have EHRs and to use measurement-based quality improvement strategies; physicians in these practices were also more likely to view the PCMH model as sustainable.

Practices that trained medical and nursing assistants and other office staff in self-management support activities conducted more self-management activities with patients.

Key Impacts of Transformation

Quality of Care

• In the case studies, physicians reported that they provided better care after becoming a PCMH. Even those who said they "were always a medical home" noted that their care processes were more comprehensive and efficient after formal transformation activities, which led to better patient care and improved health outcomes.

Provider Satisfaction

• Physicians in 77 percent of surveyed practices rated their job satisfaction as moderate to high and described their practice atmosphere as "calm" or "busy, but reasonable."

Patient Satisfaction

• Physicians in 56 percent of surveyed practices said they received positive feedback from patients about changes introduced during PCMH transformation.

Challenges to Transformation

Time and resources were the biggest barriers to PCMH transformation. The resources available to the practices varied, even for those practices that had access to demonstration funding. Practices with Level 1 recognition rated resources and challenges associated with implementing and using information systems as higher barriers than Level 3 practices. Practices that used demonstration project reimbursements to create and fund new staff positions were concerned about the sustainability of these positions.

Some physicians and staff were initially resistant to learning new processes and systems, especially EHR and registry systems. Implementing new processes was also time consuming, and the changes sometimes caused confusion and stress until the processes operated smoothly.

Lessons Learned and Implications for Others

• The path to PCMH transformation varied across practices and was strongly influenced by the practice's internal characteristics and the availability of local supports, such as demonstration and pilot projects, financial incentives, and other resources.
• The transformation process spurred many practices to expand their use of EHR and registry systems for care and population management. Physicians and staff reported that these were instrumental to PCMH transformation.

For additional information about this grant, please visit the AHRQ Transforming Primary Care Grants: Bibliography.