AHRQ Transforming Primary Care Grants

Bibliography

This bibliography includes citations for and short summaries of the more than 50 peer-reviewed articles resulting from the AHRQ Transforming Primary Care grants as of January 1, 2015. The evidence generated from this initiative has formed a solid foundation that can be used to assist with future primary care improvement, and this bibliography provides an overview of that evidence. The bibliography is organized in alphabetical order by the Principal Investigator’s last name, with two joint publications at the beginning.

Contents

Joint/Overview Publications

McNellis RJ, Genevro JL, Meyers DS. Lessons learned from the study of primary care transformation. Ann Fam Med. 2013;11(Suppl 1):S1-5. PMID: 23690378

The authors summarized the overarching lessons learned from 14 research studies funded by AHRQ to better understand the processes and determinants of patient-centered medical home (PCMH) transformation. Five lessons learned were identified across studies: 1) a strong foundation (including structural capacity, financial stability, and organizational support) is necessary for successful redesign; 2) the transformation process can be long and difficult; 3) approaches to transformation vary across groups; 4) visionary leadership and a supportive culture facilitate change; and 5) contextual factors are inextricably linked to the success of transformation. The authors acknowledged the challenges of measuring the financial impact of transformation and the difference between true transformation and externally recognized transformation. The authors concluded that these studies demonstrate that although PCMH transformation is challenging, it is both possible and desirable.

Tomoaia-Cotisel A, Scammon DL, Waitzman NJ, et al. Context matters: the experience of 14 research teams in systematically reporting contextual factors important for practice change. Ann Fam Med. 2013;11(Suppl 1):S115-23. PMID: 23690380

The authors examined contextual factors identified as important for interpreting and replicating the findings from 14 research studies on primary care practice transformation. Five thematic domains were identified for contextual factors: 1) the practice setting, 2) the larger organization, 3) the external environment, 4) the implementation pathway, and 5) motivation for implementation. Investigators recommended steps to better understand context, including: a) engaging diverse perspectives and data sources, b) considering multiple levels (i.e., practice level, organizational level, external/community level), c) evaluating history and evolution of contextual factors over time, d) looking at formal and informal systems and culture, and e) assessing the (often nonlinear) interactions between contextual factors and both the process and outcomes of studies. The authors concluded that this work demonstrates the potential utility of identifying and reporting contextual factors to improve the impact of health care research.

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Health Care Transformation Among Small Urban Practices Serving the Underserved
Principal Investigator: Carolyn A. Berry, PhD, MA

Berry CA, Mijanovich T, Albert S, et al. Patient-centered medical home among small urban practices serving low-income and disadvantaged patients. Ann Fam Med. 2013;11(Suppl 1):S82-9. PMID: 23690391

The authors analyzed the practice characteristics, prior experiences, and dimensions of the PCMH model among 94 very small primary care practices that serve disadvantaged patient populations and participated in the Primary Care Information Project of the New York City Department of Mental Health and Hygiene. Based on descriptive data focused on PCMH redesign, the authors determined that these small practices were able to achieve substantial implementation even though they faced numerous potential challenges. The small practices tended to use informal team-based care and care coordination, which suggests that flexible and less formal strategies can be valuable for PCMH implementation in small practices.

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A Study of the PCMH: Lessons From a New York State Community Health Center
Principal Investigator: Neil S. Calman, MD, MA

Calman NS, Hauser D, Weiss L, et al. Becoming a patient-centered medical home: a 9-year transition for a network of Federally Qualified Health Centers. Ann Fam Med. 2013;11(Suppl 1):S68-73. PMID: 23690389

The authors examined changes in patterns of health care utilization and outcomes in patients with diabetes served by a network of Federally Qualified Health Centers over a 9-year period of practice transformation. The number of encounters with educators, outreach personnel, and psychosocial services increased, while visits with a primary care clinician decreased. Among a subgroup of patients, mean annual levels of glycated hemoglobin decreased steadily, with reductions largely driven by those with high baseline levels. These findings suggest that PCMH implementation has the potential to alter processes of care (such as shifting resource use by patients with diabetes) and to improve health outcomes, particularly among those with higher disease burden.

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Medical Home Transformation in Pediatric Primary Care—What Drives Change?
Principal Investigator: William C. Cooley, MD

McAllister JW, Cooley WC, Van Cleave J, et al. Medical home transformation in pediatric primary care—what drives change? Ann Fam Med. 2013;11(Suppl 1):S90-8. PMID: 23690392

The authors identified the essential attributes of medical home transformation in 12 high-performing pediatric primary care practices 6 to 7 years after participation in a national medical home learning collaborative. Four attributes were determined to be essential drivers of transformation: 1) a culture of quality improvement; 2) family-centered care, with parents as improvement partners; 3) team-based care; and 4) care coordination. Other attributes of high-performing practices included flexible access options, population approaches, shared care plans, and employment of care coordinators. The authors concluded that participation in the learning collaborative stimulated, but did not complete, medical home changes in the pediatric practices, and that transformation requires continuous development and quality improvement in addition to family partnership skills, teamwork, and strong care coordination.

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Transforming Primary Care Practice in North Carolina
Principal Investigator: Katrina E. Donahue, MD, MPH

Reiter KL, Halladay JR, Mitchell CM, et al. Costs and benefits of transforming primary care practices: a qualitative study of North Carolina’s Improving Performance in Practice. J Healthc Manag. 2014;59(2):95-108. PMID: 24783367

The authors assessed the practice-level costs and benefits of practice transformation for 12 primary care practices participating in North Carolina’s Improving Performance in Practice program. This was a statewide quality improvement initiative that provided primary care practices with onsite improvement coaches, tools, and resources to assist with transformation efforts and improve clinical care. Annual opportunity costs of $21,550 ($6,659 per full-time equivalent provider, or 50% of a full-time registered nurse or licensed practical nurse) were required to maintain core transformation activities (e.g., data management, form development and maintenance, meeting attendance). These transformation costs were a burden for practices, despite the use of cost-saving efforts such as scheduling meetings during slower patient care periods and leveraging existing resources. The benefits of transformation included opportunities to increase revenue through reimbursement incentives and practice growth, improved efficiency and care quality, and maintenance of certification. The authors recommended that policymakers consider reimbursement and other strategies to help practices manage the costs of primary care transformation.

Halladay JR, DeWalt D, Wise A, et al. More extensive implementation of the chronic care model is associated with better lipid control in diabetes. J Am Board Fam Med. 2014;27(1):34-41. PMID: 24390884

The authors examined whether higher implementation scores after the first year of primary care transformation were associated with improved diabetes outcomes during the second year in 42 practices participating in the North Carolina Improving Performance in Practice program. Implementation scores from the Key Drivers Implementation Scale, which measures four key areas of practice change (disease registries, planned care templates, care protocols, and self-management support) were used. Practices with higher implementation scores in patient registries and protocols had statistically significant improvements in the proportion of patients with diabetes who met the cholesterol target (low-density lipoprotein <100 mg/dL). Hemoglobin A1c and blood pressure values in patients with diabetes were not significantly different between practices with high and low implementation scores. The authors concluded that implementing the use of registries and protocols can help practices improve low-density lipoprotein cholesterol control in patients with diabetes.

Donahue KE, Halladay JR, Wise A, et al. Facilitators of transforming primary care: a look under the hood at practice leadership. Ann Fam Med. 2013;11(Suppl 1):S27-33. PMID: 23690383

The authors examined how characteristics of practice leadership affected the change process in a statewide initiative to improve the quality of diabetes and asthma care. Existing quality improvement data from 76 practices was analyzed (including monthly diabetes and asthma clinical measures), as well as practice implementation, leadership, and engagement scores as rated by an external practice coach. In addition, focus groups were conducted with clinicians and staff from a subsample of 12 practices. Between 50 and 78 percent of the practices showed improvement on each of the clinical measures within the first year. Practices with higher leadership scores were significantly more likely to make practice changes. Focus groups revealed the importance of a midlevel operational leader to help create and sustain practice changes. This midlevel leader was found to be necessary in addition to a visionary leader (usually a physician) who believed in and supported the transformation work.

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Transforming Primary Care Practice
Principal Investigator: David L. Driscoll, PhD, MPH, MA

Smith JJ, Johnston JM, Hiratsuka VY, et al. Medical home implementation and trends in diabetes quality measures for AN/AI primary care patients. Prim Care Diabetes. 2015;9(2):120-6. PMID: 25095763

The authors examined how the implementation of a PCMH at Southcentral Foundation, a tribal health organization in Alaska, changed trends for type 2 diabetes quality indicators. Electronic health records (EHRs) were used to calculate monthly rates of new type 2 diabetes diagnoses, hemoglobin A1c measurements, and utilization of health care services. Changes in trends were estimated using interrupted time series analysis. Rates of new diagnoses for type 2 diabetes were stable prior to implementation and increased after implementation. Rates of hemoglobin A1c screening were stable after implementation, with nonsignificant increases prior to implementation. The number of emergency visits increased before and decreased after implementation, and the number of inpatient days decreased in both periods, although not significantly. The authors concluded that PCMH implementation prompted positive changes in diabetes quality trends, although these changes varied in strength, onset, and sustainability.

Johnston JM, Smith JJ, Hiratsuka VY, et al. Tribal implementation of a patient-centered medical home model in Alaska accompanied by decreased hospital use. Int J Circumpolar Health. 2013;72. PMID: 23984283

The authors evaluated hospitalization trends of Southcentral Foundation customer-owners receiving health care at the Alaska Native Medical Center before, during, and after PCMH implementation. The percentage of Southcentral Foundation customer-owners hospitalized per month declined steadily immediately following implementation and then stabilized at a lower level compared with before or during PCMH implementation. The number of hospitalizations for unintentional injury and asthma also decreased after implementation. The authors concluded that increased accessibility to primary care likely contributed to the decrease in hospitalizations.

Driscoll DL, Hiratsuka V, Johnston JM, et al. Process and outcomes of patient-centered medical care with Alaska Native people at Southcentral Foundation. Ann Fam Med. 2013;11(Suppl 1):S41-9. PMID: 23690385

The authors compared emergency care usage for any reason, asthma, and unintentional injury (as a comparison variable) during and after PCMH implementation at a tribally owned and managed primary care system. A time series analysis from medical records showed that emergency care use for all causes had been increasing before PCMH implementation and decreased during and immediately after implementation, while emergency care use for adult asthma decreased before, during, and immediately after implementation. As a comparison, emergency care use for unintentional injury had been increasing before and during implementation, but also decreased after implementation. Qualitative findings from in-depth interviews with patients, primary care clinicians, health system employees, and tribal leaders indicated that the decreases in emergency room use resulted from improved access to primary care services resulting from PCMH implementation.

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Multimethod Evaluation of Physician Group Incentive Programs for PCMH Transition
Principal Investigator: Michael D. Fetters, MD

Paustian ML, Alexander JA, El Reda DK, et al. Partial and incremental PCMH practice transformation: implications for quality and costs. Health Serv Res. 2014;49(1):52-74. PMID: 23829322

The authors examined associations between partial implementation of the PCMH and cost and quality of care outcomes, using self-reported PCMH capabilities and administrative claims data for a sample of 2,432 primary care practices in Michigan, andsupplemented by contextual data from the Area Resource File. The medical home capabilities in place as of June 2009 were measured along with changes in capabilities between July 2009 and June 2010. Generalized estimating equations were used to estimate the mean effect of PCMH measures on total medical costs and the quality of care delivered during this period, controlling for potential confounders related to practice, patient cohort, physician organization, and practice environment. Based on the observed partial implementation, full implementation of the PCMH model was estimated to be associated with a 3.5 percent higher quality composite score, a 5.1 percent higher preventive composite score, and a $26.37 less medical cost per adult member per month. Full PCMH implementation was also associated with a 12.2 percent higher preventive composite score for pediatric populations, but no reductions in costs. Incremental improvements in PCMH model implementation yielded positive effects on quality of care for both adult and pediatric populations but were not associated with cost savings for either population. The authors concluded that the quality and cost of care appear to improve as the level of PCMH implementation increases.

Alexander JA, Paustian M, Wise CG, et al. Assessment and measurement of patient-centered medical home implementation: the BCBSM experience. Ann Fam Med. 2013;11(Suppl 1):574-81. PMID: 23690390

The authors developed and validated an approach to assessing the PCMH implementation. To measure PCMH implementation at Blue Cross Blue Shield of Michigan, the authors constructed 13 functional domains and 128 capabilities within those domains. Based on testing this measure on a large sample of primary care practices in Michigan, the measure adequately addressed the specific requirements and assumptions of the Blue Cross Blue Shield of Michigan PCMH program, which included assessing the level of implementation, comparing across practices, and differing implementation strategies. The authors concluded that measures of PCMH implementation should be based on the intended use of the measure and the users, and that attempts to develop a one-size-fits-all approach may not be successful.

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A Multipayer PCMH Initiative in Pennsylvania
Principal Investigator: Robert A. Gabbay, MD, PhD

Bleser WK, Miller-Day M, Naughton D, et al. Strategies for achieving whole-practice engagement and buy-in to the patient-centered medical home. Ann Fam Med. 2014;12(1):37-45. PMID: 24445102

The authors identified and examined strategies for obtaining organizational buy-in to, and staff engagement in, PCMH transformation. Semi-structured interviews and focus groups were conducted across 20 small- to mid-sized medical practices involved in a statewide PCMH initiative in Pennsylvania. The authors identified 13 strategies used to obtain practice buy-in, reflecting three overarching lessons: 1) effective internal communication and PCMH campaigns, 2) efficient utilization of resources, and 3) development of a team environment. This article extends Solberg’s conceptual framework for practice improvement to include buy-in as a necessary condition for the change process, and provides strategies that others can use for facilitating successful PCMH transformation.

Taliani CA, Bricker PL, Adelman AM, et al. Implementing effective care management in the patient-centered medical home. Am J Manag Care. 2013;19(12):957-64. PMID: 24512033

The authors used a positive deviance approach to compare the approaches to care management in practices with the greatest and least improvement on three clinical measures of diabetes after 18 months of involvement in a regional learning collaborative. Semi-structured interviews were conducted with 136 individuals from 21 of the 25 participating practices. Participants included clinicians, practice managers, care managers, and other practice staff. Compared with practices with the least improvement in diabetes care, those with the most improvement reported: 1) more involvement of the patient-centered care manager, 2) greater integration of the care manager into the overall care team, and 3) improved messaging and patient tracking using the electronic medical record (EMR). The authors concluded that care managers should meet with patients, support self-management, leverage the EMR for managing care, and integrate with the care team through office huddles and other ongoing communications.

Cronholm PF, Shea JA, Werner RM, et al. The patient centered medical home: mental models and practice culture driving the transformation process. J Gen Intern Med. 2013;28(9):1195-201. PMID: 23539283

The authors described factors that shape mental models and practice culture that drive the PCMH transformation process. Interviews were conducted with 118 clinicians, nurses, medical assistants, care managers, patient educators, social workers, office administrators, front office staff, and other stakeholders at 17 primary care practices in southeastern Pennsylvania, where a large multipayor PCMH demonstration project took place. Three central themes were identified as necessary changes in practice culture and mental models for successful transformation to PCMH: 1) shifting practices toward proactive population-based care, based in the practice-patient relationship; 2) creating a culture of self-examination (i.e., routine review of clinical and quality improvement data at both the individual and practice level); and 3) redistributing responsibilities and adopting a team-based care approach. The greatest amount of tension from shifts in mental models was found between clinicians and medical assistants, suggesting significant barriers to moving away from clinician-centered care. The findings suggested that PCMH transformation and sustainability requires a dramatic shift in mental models (including perceptions of population health, self-assessment, and development of shared decisionmaking) at the individual level, and culture change, including staff buy-in to new roles and responsibilities, at the practice level.

Kraschnewski JL, Gabbay RA. Role of health information technologies in the patient-centered medical home. J Diabetes Sci Technol. 2013;7(5):1376-85. PMID: 24124967

The authors examined how health information technology (IT) has been used to accomplish key PCMH objectives. The authors examined the role of health IT, including EHRs, patient portals, patient registries, and telemedicine, with a focus on diabetes care. Despite the numerous advantages conferred by health IT, many practices still did not use EHRs because of multiple barriers to adoption. These barriers included issues with information exchange and interoperability between systems, challenges with technical implementation, low acceptance rates by physicians and patients, and issues of patient access. In addition, implementing health IT requires a large upfront expense that represents a financial risk for practices. Successful implementation requires a series of steps, including the selection of an appropriate system, collaboration with the vendor, and proper physician preparation and training. The authors concluded that determining how to successfully integrate health IT is critical to a practice’s transformation into a PCMH.

Gabbay RA, Friedberg MW, Miller-Day M, et al. A positive deviance approach to understanding key features to improving diabetes care in the medical home. Ann Fam Med. 2013;11(Suppl 1):S99-107. PMID: 23690393

The authors identified and compared factors driving the practice care models of 25 practices that underwent primary care transformation in southeast Pennsylvania. Practices were ranked into highest and lowest for improvement on the following measures of diabetes care performance: glycated hemoglobin concentration, blood pressure, and low-density lipoprotein cholesterol level. The most improved/higher-performing practices had greater structural capabilities, such as EHRs, compared with the lower-performing practices. Important differences between the groups included leadership style and shared vision, use and development of care teams, processes for monitoring progress feedback, and technological and financial distractions. The authors concluded that baseline structural capabilities and existing processes to buffer the stresses of change are key factors for successful PCMH transformation.

Naughton D, Adelman AM, Bricker P, et al. Envisioning new roles for medical assistants: strategies from patient-centered medical homes. Fam Pract Manag. 2013;20(2):7-12. PMID: 23547608

The authors examined the adapting role of medical assistants in 25 practices in Pennsylvania that participated in a regional learning collaborative and were recognized as PCMHs by the National Committee on Quality Assurance (NCQA). In-depth qualitative interviews were conducted with providers, administrators, and practice staff to understand how the role of medical assistants helped the practices achieve PCMH standards and quality improvement. These interviews revealed that medical assistants can be used to augment the capacity of physicians and nurses; can move into new practice roles, such as health coaches; and can assume a greater role in population management. The barriers related to changing the roles of medical assistants included issues of human resources, training, buy-in, and sustainability. However, the authors found that expanding the role of medical assistants can help facilitate quality improvement, enhance teamwork, improve workflow, increase patient satisfaction, improve patient safety, and increase the productivity of office visits. The authors concluded that envisioning new roles for medical assistants in family medicine is a critical element in the evolution of a practice to a PCMH.

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Transformed Primary Care: Care by Design™
Principal Investigator: Michael K. Magill, MD

Scammon DL, Tabler J, Brunisholz K, et al. Organizational culture associated with provider satisfaction. J Am Board Fam Med. 2014;27(2):219-28. PMID: 24610184

The authors examined the relationship between provider satisfaction and organizational culture in practices that have transformed to a PCMH model. The authors analyzed results from the Organizational Culture Assessment Instrument and the American Medical Group Association provider satisfaction survey in 10 primary clinics that had implemented Care by Design, a version of the PCMH. Providers were most satisfied with “quality of care” and “interactions with patients” and least satisfied with “time spent working,” “paperwork,” and “compensation.” Cultures differed across clinics, with “family/clan” and “hierarchical” being the most common culture types. Provider satisfaction was signficantly correlated with certain clinic culture archetypes, suggesting that practice redesign efforts can be informed by identification of clinic culture archetypes.

Scammon DL, Tomoaia-Cotisel A, Day RL, et al. Connecting the dots and merging meaning: using mixed methods to study primary care delivery transformation. Health Serv Res. 2013;48(6 Pt 2):2181-207. PMID: 24279836

The authors discussed the importance of using a mixed methods design when studying primary care transformation. A retrospective study of practice redesign in an integrated network of university-owned primary care practices used a mixed methods design that included analyses of data collected from archival documents, operational reports, claims, chart audits, surveys, clinic observations, semi-structured interviews, and focus groups. Data from each source helped the researchers build their understanding of the change process and why some changes were more difficult overall and for certain clinics in particular. Both qualitative and quantitative data helped generate and test hypotheses and led to a more comprehensive understanding of practice change. The authors concluded that while using mixed methods can be challenging, it is necessary for understanding the complex phenomena involved in practice transformation.

Day J, Scammon DL, Kim J, et al. Quality, satisfaction, and financial efficiency associated with elements of primary care practice transformation: preliminary findings. Ann Fam Med. 2013;11(Suppl 1):S50-9. PMID: 23690386

The authors examined the relationships between individual elements of Care by Design (the University of Utah’s version of the PCMH) and four types of outcomes: quality of care, patient and clinician satisfaction, financial performance, and productivity. Using a combination of observation, chart audit, and collection of data from operational reports, correlations between the level of implementation of each Care by Design element and the outcome measures were assessed. Elements related to team-based care were associated with improvements in quality outcomes as well as patient and clinician satisfaction. Continuity with the clinician and the team were found to be important to patients and for providing better, safer care. In addition, some potential unintended consequences and trade-offs of primary care transformation were identified.

Magill MK, Baxley E. Virtuous cycles: patient care, education, and scholarship in the patient-centered medical home. Fam Med. 2013;45(4):235-9. PMID: 23553085

The authors discussed the concept of “virtuous cycles” within family medicine, in which clinical care, research, and education each enhance and support one another. Examples of virtuous cycles emerging from the University of Utah and the University of South Carolina were described. The authors found that there is value in initially focusing on primary care transformation, followed by a focus on the education of medical students and residents in these new delivery models, and a subsequent focus on scholarship to further develop the clinical practice model and curricula. The authors concluded that the idea that patient care, research, and education are separate and possibly even competing priorities is out of date, and the model of virtuous cycles should replace this thinking.

Egger MJ, Day J, Scammon DL, et al. Correlation of the Care by Design primary care practice redesign model and the principles of the patient-centered medical home. J Am Board Fam Med. 2012;25(2):216-23. PMID: 22403203

The authors compared metrics of Care by Design (a primary care model emphasizing access, care teams, and planned care) with PCMH metrics, both conceptually and statistically. Self-evaluations, including the Care by Design Extent of Use Survey and self-estimated PCMH values, were examined for 10 urban and rural primary care clinics. Both primary care tranformation models share common themes, such as appropriate access to care, team-based care, use of an augmented electronic record, planned care, and self-management support. The two models focus on complementary aspects of redesign; Care by Design focuses more on the process of transformation, while PCMH focuses more on the structure, including policy, capacity, and populated EMR fields.

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Transformation to the PCMH in CareOregon Clinics
Principal Investigator: Richard T. Meenan, PhD, MPH, MBA

McMullen CK, Schneider J, Firemark A, et al. Cultivating engaged leadership through a learning collaborative: lessons from primary care renewal in Oregon safety net clinics. Ann Fam Med. 2013;11(Suppl 1):S34-40. PMID: 23690384

The authors explored how learning collaboratives cultivate essential leadership skills for PCMH implementation. The authors conducted an ethnographic evaluation of payor-incentivized PCMH implementation in Oregon safety net clinics, known as Primary Care Renewal. Interviews with organizational leaders revealed that practice change consisted of two phases: inspiration and implementation. Leaders learned essential and different leadership skills in each phase. Collaborative learning opportunities were found to be critical for developing engaged leadership skills during the inspiration phase and adaptive leadership skills (i.e., specific operational and management skills) were found to be critical during the implementation phase.

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Transforming Primary Care: Evaluating the Spread of Group Health’s Medical Home
Principal Investigator: Robert J. Reid, MD, PhD, MPH

Cromp D, Hsu C, Coleman K, et al. Barriers and facilitators to team-based care in the context of primary care transformation. J Ambul Care Manage. 2015;38(2):125-33. PMID: 25748261.

The authors examined the barriers and facilitators to establishing high-functioning teams during PCMH transformation at Group Health Cooperative. Qualitative data were collected from site visits and interviews with 49 staff from nine diverse clinics. Site visits and interviews were conducted 6 months after a year of rapid PCMH implementation. The following key facilitators for team-based care were identified: 1) strong leadership and change management; 2) co-location or shared workspace; 3) daily clinic/team huddles; 4) daily “teamlet” huddles (between physician and medical assistant pairs); 5) monthly chronic disease management huddles; and 6) standardized roles and job expectations. Key barriers were identified as: 1) lack of intentional focus on team-building; 2) standardized workflows (which were seen as removing clinical judgment from nursing duties); and 3) implementation change measures (which staff felt were not clinically meaningful). The authors concluded that organizations undergoing large-scale PCMH transformation can use Group Health’s experiences to implement changes that facilitate the creation of strong care teams while avoiding other changes that can stifle team dynamics, even in the absence of specific interventions focused on implementing team-based care.

Liss DT, Reid RJ, Grembowski D, et al. Changes in office visit use associated with electronic messaging and telephone encounters among patients with diabetes in the PCMH. Ann Fam Med. 2014;12(4)338-43. PMID: 25024242

The authors assessed whether use of copay-free secure messaging and telephone visits affected demand for office visits in a patient population with diabetes. Using an interrupted time series design, changes in the use of primary care office visits associated with the use of secure messaging and telephone encounters were estimated before, during, and after PCMH redesign. Between the pre-PCMH baseline and the post-implementation periods, the mean quarterly number of primary care contacts increased by 28 percent, largely driven by an increase in secure messages, and quarterly office visit use declined by 8 percent. Results of regression analyses showed that a 10 percent increase in secure message threads and telephone encounters was associated with increases of 1.25 and 2.74 percent in office visits, respectively. An interaction model showed that office visit use increased proportionally with secure messaging and telephone encounters for all study periods and patient subpopulations. The authors concluded that new forms of patient-clinician communication associated with PCMH redesign can affect demand for office visits.

Liss DT, Fishman PA, Rutter CM, et al. Specialty use among patients with treated hypertension in a patient-centered medical home. J Gen Intern Med. 2014;29(5):732-40. PMID: 24493321

The authors examined changes in outpatient specialty use among patients with treated hypertension during and after a systemwide PCMH redesign. The authors used a one-group, 48-month interrupted time series design to measure annual differences in total specialty care visits as well as any use of medical and surgical specialties among adult patients with treated hypertension at baseline, during PCMH implementation, and after PCMH implementation. Adjusted results showed that the study population averaged 7 percent fewer specialty visits and 12 percent fewer cardiology visits during implementation compared with baseline, and 4 percent fewer specialty and 13 percent fewer cardiology visits in the first year post-implementation. Interaction analysis results showed that low-morbidity patients had a considerable decline in the number of specialty visits during each of the three years following baseline, and medium-morbidity patients had a comparatively smaller decline. High-morbidity patients, however, exhibited higher specialty use during the first and second years post-implementation. The authors posited that PCMH redesign enabled primary care teams to deliver more hypertension care, which was able to meet the needs of low-morbidity patients within the primary care setting. The authors recommended prioritizing high-morbidity, clinically complex patients when determining new approaches to care coordination between primary care teams and specialists as part of PCMH transformation.

Liss DT, Fishman PA, Rutter CM, et al. Outcomes among chronically ill adults in a medical home prototype. Am J Manag Care. 2013;19(10):e348-58. PMID: 24304182

The authors compared health care quality, utilization, and costs for patients with diabetes, hypertension, and/or coronary heart disease at a PCMH prototype site and 19 non-PCMH sites. Over the 2-year study period, PCMH clinic patients experienced improved clinical outcomes for coronary heart disease (2.20 mg/dL lower mean low-density lipoprotein cholesterol). Patients in the PCMH also showed changes in primary care utilization, as shown by 6 percent fewer in-person primary care visits, 86 percent more use of secure electronic messaging, 10 percent more telephone contacts, 21 percent fewer ambulatory care sensitive hospitalizations, and 7 percent fewer total inpatient admissions. Health care costs among PCMH patients were also significantly lower compared with non-PCMH patients, with 17 percent lower inpatient costs and 7 percent lower total costs. The authors concluded that PCMH redesign can significantly reduce both health care utilization and costs for patients with chronic illnesses.

Reid RJ, Johnson EA, Hsu C, et al. Spreading a medical home redesign: effects on emergency department use and hospital admissions. Ann Fam Med. 2013;11(Suppl 1):S19-26. PMID: 23690382

The authors described Group Health’s experience in redesigning primary care, using the Lean Management System as the change strategy, and the attempt to replicate systemwide the changes seen in a PCMH prototype clinic. Changes in use of face-to-face primary care visits, emergency department visits, and inpatient admissions for patients receiving care at PCMH clinics were analyzed, using rates from patients served by community network practices to adjust for secular trends. After adjustment, primary care office visits for patients at PCMH clinics declined by 5.1 and 6.7 percent in early and later stabilization years after implementation, respectively. These decreases were accompanied by a 123 percent increase in secure electronic message threads and a 20 percent increase in telephone encounters. Emergency department visits declined by 13.7 and 18.5 percent in the first and second year following implementation, respectively. No significant changes in hospital admissions were found. The authors concluded that PCMH transformation can successfully reduce emergency admissions across a diverse set of clinics when there is a clear change strategy and sufficient resources and supports are in place.

Liss D. Patients with chronic illness in the patient-centered medical home: costs, use, quality and morbidity-based variation [dissertation]. Seattle, WA: University of Washington; 2012.

The author investigated the effect of the PCMH model on health care costs, quality, and utilization in chronically ill patients through three analyses. The first analysis compared outcomes of patients with chronic illnesses receiving care through a PCMH prototype clinic and 19 non-PCMH clinics. Patients at the PCMH clinic experienced a modestly improved quality of care and a 7 percent reduction in total health care costs, largely due to reduced utilization of inpatient and emergency/urgent care. The second analysis examined whether secure electronic messaging and telephone encounters affected the number of primary care office visits among patients with diabetes during the systemwide PCMH redesign. Findings suggest that telephone encounters and, to a lesser extent, secure electronic message threads complemented rather than substituted for office visits for these patients. The third analysis examined variation in use of outpatient specialty care services among patients with hypertension treated at PCMH clinics after systemwide PCMH redesign. Overall, patients with hypertension experienced small reductions in the number of specialty visits following PCMH implementation, and the reduction was rapid and sustained for low-morbidity patients. The authors concluded that these findings can be applied to the design, implementation, and evaluation of future PCMH transformation efforts.

Fishman PA, Johnson EA, Coleman K, et al. Impact on seniors of the patient-centered medical home: evidence from a pilot study. Gerontologist. 2012;52(5):703-11. PMID: 22421916

The authors assessed the impact of a PCMH pilot on health care costs and quality among seniors (age 65 years or older) at Group Health Cooperative, an integrated health care system in Washington. Secondary data on quality and cost and survey data on patient experience were analyzed for seniors in a PCMH clinic and non-PCMH control clinics. Seniors in the PCMH clinic reported higher ratings on three out of seven patient experience scales compared with controls, after adjustment for baseline scores. Though seniors in the PCMH clinic had significantly greater quality outcomes after implementation than before, the difference was not significantly greater than that in controls. Seniors at the PCMH clinic used less emergency services and had fewer inpatient admissions for ambulatory care sensitive conditions than controls, but used more email, phone, and specialist visits. The PCMH clinic did not differ significantly in overall costs from the control clinics, demonstrating that PCMH redesign can lead to improvements in patient experience and quality without higher overall cost.

Reid RJ, Larson EB. Financial implications of the patient-centered medical home [editorial]. JAMA. 2012;308(1):83-4. PMID: 22729555

The authors discussed the importance of an article by Nocon et al, “Association between patient-centered medical home rating and operating cost at Federally Funded Health Centers,” which examined aspects of PCMH financing in a large set of Federally Funded Community Health Centers. Nocon et al found that overall, a 10-point higher score on the total PCMH rating scale was associated with a $2.26 (4.6%) greater monthly operating cost per patient, although these costs varied substantially across practices. The Nocon study highlights the cost implications of improving primary care for underserved and vulnerable populations. This population stands to benefit the most from the PCMH because it is most likely to have uncoordinated and episodic care and use emergency departments for routine care. While PCMH implementation at Community Health Centers can potentially lead to efficiencies and eventual cost savings, these often do not benefit practices directly. The authors concluded that for PCMHs to thrive in the new post-Affordable Care Act environment, Accountable Care Organizations must support the costs of added infrastructure and staffing that are needed to create and maintain medical homes.

Reid RJ, Larson EB. Improvement happens: doctors talk about the medical home. An interview with Charles Mayer, MD, MPH and Eric Seaver, MD. J Gen Intern Med. 2012;27(7):871-5. PMID: 22484772

The authors provided a detailed interview with two primary care physicians involved in the PCMH transformation of Group Health, a nonprofit health care and coverage system in Washington and Idaho. The two physicians described their experiences and shared patient stories to help inform other providers about what to expect when implementing PCMHs.

Hsu C, Coleman K, Ross TR, et al. Spreading a patient-centered medical home redesign: a case study. J Ambul Care Manage. 2012;35(2):99-108. PMID: 22415283

The authors presented a descriptive case study of the implementation of a systemwide transformation to a PCMH at Group Health, an integrated health care delivery system. Group Health’s design and approach for spreading the PCMH model from a pilot clinic to 26 diverse clinics is described, including the specific operational changes that were implemented and the data that was used to monitor the transformation. The authors also discussed how the Lean Management System was used to systematically implement systemwide changes. The authors concluded that the experience of Group Health’s transformation to a PCMH may provide useful insights for other organizations working to improve primary care.

Coleman K, Reid RJ, Johnson E, et al. Implications of reassigning patients for the medical home: a case study. Ann Fam Med. 2010;8(6):493-8. PMID: 21060118

The authors examined the effect that reassigning patients to new physicians has on patient experience and utilization of primary care services at an urban practice owned and operated by an integrated health care system. Information about primary care, emergency department, secure messaging, and telephone utilization was collected, and patient experience was measured before and after implementation. Reassigned patients were younger, less sick, and had shorter pre-existing patient-doctor relationships than those who were retained by their existing physicians. Reassigned patients were less likely to use primary care services but equally likely to use the emergency department and equally satisfied with their care. The authors suggested that more active measures are needed to help attach reassigned patients to the medical home and improve relational continuity for younger, healthier patients.

Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835-43. PMID: 20439869

The authors examined patient experiences, quality, clinician burnout, and total costs following implementation of a medical home prototype at Group Health Cooperative. Through the first 2 years, patient experience, quality, and clinician burnout improved in the medical home compared with other Group Health clinics. Furthermore, patients in the medical home experienced fewer emergency visits and hospitalizations, as well as total cost savings of $10.30 per patient per month 21 months after implementation. In addition to presenting these findings, the authors shared an operational blueprint and policy recommendations to help translate their findings to other health care settings.

Larson EB, Reid RJ. The patient-centered medical home movement: why now? [editorial]. JAMA. 2010;306(16):1644-5. PMID: 20424256

The authors discussed the medical home movement as an opportunity for the American health care system to provide greater access to care and to stem rapid cost growth through developing a strong and effective primary care system. The authors described the difficulties primary care practices faced during the 1990s due to failed health reform efforts, a backlash against managed care, and lower pay for primary care physicians compared with specialists—all while an aging population with more complex chronic conditions increased the demand for primary care. The first attempt at primary care redesign in 2002 at Group Health, an integrated health care system in Seattle, was described. The authors discussed the successes of that initiative, including improved access to care and increased physician productivity, as well as the failures, including unrealistic demands on clinicians and lack of improvements in clinical quality. The authors described the introduction of the PCMH at a Group Health prototype clinic in 2006, which resulted in improved clinician and patient experiences in addition to improved clinical quality of care. The authors concluded that the PCMH is an effective model for primary care, but only if health care systems commit to investing the necessary resources, addressing reimbursement issues, and redesigning care teams to provide comprehensive care for complex older patients.

Ross TR, Reid RJ, Fishman P, et al. C-B2-03: patient and clinician experience in a patient-centered medical home demonstration. Clin Med Res. 2010;8(1):44. PMCID: PMC2842415

The authors compared patient experience and clinician burnout between a PCMH clinic and control clinics to evaluate PCMH implementation in a real-world setting. Patient experience and clinician burnout was evaluated via survey results prior to PCMH deployment and then again 12 months following PCMH adoption. After adjusting for baseline patient differences, patients at the PCMH clinic reported significantly improved experiences on six of seven subscales compared with patients at the control clinics 12 months after PCMH implementation. At the 12-month followup, clinicians at the PCMH clinic reported significantly lower burnout compared with clinicians at the control clinics. The authors concluded that PCMH implementation can have beneficial effects on both patient experience and clinician burnout.

Tufano JT, Ralston JD, Tarczy-Hornoch P, Reid RJ. Participatory (re)design of a sociotechnical healthcare delivery system: the Group Health patient-centered medical home. Stud Health Technol Inform. 2010;157:59-65. PMID: 20543368

The authors provided a detailed description of the PCMH pilot intervention at Group Health to help contextualize the evaluation findings of this effort. The researchers conducted 10 individual semi-structured interviews with key informants to understand which traits, components, and intended effects of the redesign initiative yielded significant improvements in care and in providers’ attitudes toward increased use of health care information and communication technologies. The authors described how theories and evidence on PCMH, the chronic care model, and effective primary care were interpreted using a facilitated group process and then translated into a set of five system design principles which guided all subsequent system transformation activities.

Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009;15(9):e71-87. PMID: 19728768

The authors reported changes in patient experience, staff burnout, quality, utilization, and costs due to the PCMH demonstration project at Group Health. Outcomes were compared between a PCMH prototype clinic and control clinics at baseline and then again a year later using multivariate regressions to adjust for case-mix differences at baseline. After adjusting for baseline, PCMH patients reported higher ratings on six of seven patient experience scales compared with patients at control clinics, and 10 percent of PCMH staff reported high emotional exhaustion at 12 months compared with 30 percent of staff at control clinics. PCMH patients also had higher gains in a composite quality score and used more email, phone, and specialist visits but fewer emergency services than patients at control clinics. These differences came at no significant changes to overall costs at 12 months, indicating that improvements in patient experience, clinician burnout, and quality can occur without increasing overall costs.

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Transforming Primary Care Practice: Lessons From the New Orleans Safety Net
Principal Investigator: Diane R. Rittenhouse, MD, MPH

Rittenhouse DR, Schmidt LA, Wu KJ, Wiley J. Incentivizing primary care providers to innovate: building medical homes in the post-Katrina New Orleans safety net. Health Serv Res. 2014;49(1):75-92. PMID: 23800148

The authors studied 50 primary care safety-net clinics between June 2008 and June 2010 to evaluate their response to a communitywide PCMH financial incentive program in post-Katrina New Orleans. This longitudinal observational study examined clinic-level data collected via a semiannual survey of clinic leaders, augmented with administrative records. Sixty-two percent of clinics receiving federal funding to expand services and improve care delivery achieved PCMH recognition from the NCQA. Predictors of achieving NCQA recognition included higher patient volume, higher baseline PCMH scores, and ownership type. Use of PCMH processes stabilized or increased in 88.9 percent of clinics that received recognition. However, some specific PCMH processes had low overall adoption. The authors concluded that widespread PCMH implementation is possible in a safety-net environment if financial incentives are appropriately aligned with the goals of practice transformation.

Rittenhouse DR, Schmidt L, Wu K, Wiley J. Contrasting trajectories of change in primary care clinics: lessons from New Orleans safety net. Ann Fam Med. 2013;11(Suppl 1):S60-7. PMID: 23690388

The authors compared patterns of change in five primary care safety-net clinics in New Orleans to better understand differences in, and impediments to, transformation to PCMHs. Interviews with clinic leadership, clinicians, and staff and administrative data were used to compare the clinics over 2.5 years. Although all five practices showed improved PCMH index scores over the study period, they varied in their initial level of PCMH implementation and their rates of change. Possible reasons for differential success in PCMH transformation across these clinics included: differences in timing of practice change initiation; access to supplemental grant funding; degree of competing demands; quality of clinic leadership; and extent and quality of the relationship to the community. Barriers to practice transformation included high demand for services, insufficient linkages between hospital and specialty care, and resource limitations. The authors concluded that the PCMH model can effectively meet the needs of safety-net populations and that PCMH transformation is most successful in the presence of dedicated leadership and strong community connections.

Schmidt LA, Rittenhouse DR, Wu KJ, Wiley JA. Transforming primary care in the New Orleans safety-net: the patient experience. Med Care. 2013;51(2):158-64. PMID: 23222529

The authors tested the hypothesis that primary care PCMH improvements are associated with an improved patient experience. A multilevel, cross-sectional analysis of patients in primary care safety-net clinics in New Orleans was conducted, using patient ratings of accessibility, coordination, and confidence in the quality/safety of care, along with a clinic-level score measuring PCMH structural and process improvements. Almost two thirds of patients gave positive ratings on clinic access and quality/safety, while only one third gave a positive rating for care coordination. However, patient experience of care coordination was positively associated with the clinic’s implementation of PCMH structural and process changes in all but the largest clinics. The association between patient rating of access and quality/safety and PCMH implementation was mixed. The authors suggested that future efforts to implement PCMH should consider how transformation efforts affect different aspects of the patient experience.

Rittenhouse DR, Schmidt LA, Wu KJ, Wiley J. The post-Katrina conversion of clinics in New Orleans to medical homes shows change is possible, but hard to sustain. Health Aff (Millwood). 2012;31(8):1729-38. PMID: 22869651

The authors described a natural experiment that occurred after Hurricane Katrina in which New Orleans’ safety-net clinics were transformed into medical homes. Data from surveys with clinic leaders and administrative records revealed that overall, these clinics made significant progress in improving access, clinical quality and safety, and care coordination and integration. However, the authors also found wide variation across the clinics, with some making only minimal advances. Transformation efforts were found to be closely tied to the receipt of federal grant dollars, and declines in performance were observed toward the end of the study when clinics faced diminished funding. The authors concluded that medical home transformation funding needs to be robust and stable to achieve and maintain the goals of improved access and quality of care.

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Understanding the Transformation Experiences of Small Practices With NCQA Medical Home Recognition
Principal Investigator: Sarah H. Scholle, DrPH, MPH

Cohen MJ, Morton S, Scholle SH, et al. Self-management support activities in patient-centered medical home practices. J Ambul Care Manage. 2014;37(4):349-58. PMID: 25180650

The authors surveyed small practices (i.e., <5 physicians) with NCQA recognition (response rate, 59.1%). Main measures included the number and delegation of self-management support activities. Nearly all participating practices performed some self-management support activities, with 98 percent conducting medical reconciliation and 94 percent developing care plans with patients. Almost 60 percent of practices performed at least eight of the nine activities. Only peer-based learning was not widely used, with only 35 percent reporting this activity. Independent practices and practices with physicians and staff trained in self-management support were more likely to engage in at least eight self-management activities. Physicians, nurse practitioners, and physician assistants were primarily responsible for providing almost half of these self-management activities, but clinical support staff (registered nurses, licensed practical nurses, medical assistants) had a more substantial role in the practices that performed peer-based learning. The authors concluded that training other clinical team members in self-management activities could help increase patient involvement in care.

Scholle SH, Asche SE, Morton S, et al. Support and strategies for change among small patient-centered medical home practices. Ann Fam Med. 2013;11(Suppl 1):S6-13. PMID: 23690387

The authors surveyed lead physicians at 249 very small clinics (i.e., <5 physicians) across the country to understand their motivation to adopt the PCMH model and barriers encountered as part of this process. The authors also assessed the types of assistance these practices sought to help with practice transformation and the strategies they used to address barriers. Physicians reported that improving quality and patient experience were key motivations for PCMH implementation. The biggest barriers to implementation were time and resources; however, most practices received some kind of financial compensation and training or other assistance for PCMH transformation. The most common practice transformation strategies included staff training, systematizing processes of care, and quality measurement/goal setting. Involving patients in quality improvement was the least commonly endorsed strategy. Use of EHRs, reporting of barriers, and use of measurement-based quality improvement strategies were all associated with higher levels of PCMH recognition. The authors concluded that financial assistance, practical training, and additional support will continue to be necessary for the successful adoption of the PCMH model in small practices. They also identified the need for further assessment of the impact of greater patient involvement in PCMH transformation.

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HealthPartners Institute for Education and Research
Principal Investigator: Leif I. Solberg, MD

Fontaine P, Whitebird R, Solberg LI. Minnesota’s early experience with medical home implementation: viewpoints from the front lines. J Gen Int Med. 2014 Dec 13. [Epub ahead of print]. PMID: 25500785

The authors identified facilitators and barriers to practice transformation from nine of the first 80 primary care practices to become PCMHs in Minnesota. Semi-structured interviews were conducted with 31 administrative and clinical leaders (including physician champions, medical directors, nursing supervisors, clinic managers, and care coordinators) from across these nine practices. Key facilitators that were identified included having leadership committed to transformation at both the practice and system levels; having prior experience with and ongoing support for quality improvement initiatives; and having adequate financial and IT resources. Key barriers included reimbursement not being adequate to cover the costs of PCMH-related activities (due to the perceived inadequacy and inconsistent participation by health plans) and limitations of existing EMRs to meet PCMH documentation requirements. The majority of interviewees felt that becoming a PCMH was the right thing for patients and was also worthwhile for them personally, although they acknowledged that it required considerable effort.

Solberg LI, Stuck L, Crain AL, et al. Patient experience and physician/staff satisfaction in transforming medical homes. Am J Account Care. 2014;2(3).

The authors examined the association between the amount of change brought about by PCMH transformation and the satisfaction of patients, physicians, and staff. The lead physicians from 108 of the first PCMHs certified in Minnesota completed surveys about changes brought about by medical home–related practice systems as well as job satisfaction for physicians and staff in their practices. Patients from 54 of these PCMHs were also surveyed about their experiences using the Clinician-Group Consumer Assessment of Healthcare Providers and Systems. The degree of change in systems was positively correlated with improvements in physician and staff job satisfaction but not with the number of systems introduced. System change was negatively correlated with patient-reported access to care but not with patient experience with physicians and staff. The authors concluded that PCMH system changes can improve physician and staff job satisfaction and warned about the effects of these system changes on patient access.

Solberg LI, Crain AL, Tillema JO, et al. Challenges of medical home transformation reported by 118 patient-centered medical home (PCMH) leaders. J Am Board Fam Med. 2014;27(4):449-57. PMID: 25001999

The authors examined newly certified PCMHs in Minnesota to determine the most important organizational factors and strategies for transformation. Data from the following sources were analyzed: a 44-item survey about PCMH transformation strategies; a 105-item survey on the presence and function of practice systems (conducted twice, once for current systems and once for systems in place 3 years prior); and composite performance measures for diabetes and cardiovascular disease. The survey on PCMH transformation strategies was derived from qualitative interviews with 31 leaders from nine clinics about barriers, facilitators, and change strategies important for transformation. Almost all of the items identified through the qualitative interviews were strongly endorsed as important in the transformation survey. Eighteen items were correlated with change in practice systems over the previous 3 years. However, few factors or strategies were correlated with clinic performance measures or the presence of practice systems important for patient-centered care. The authors concluded that while every clinic needs to find their own path for transformation, the items identified in this survey should be considered when engaging in that process.

Solberg LI, Stuck LH, Crain AL, et al. Organizational factors and change strategies associated with medical home transformation. Am J Med Qual. 2014 May 1. [Epub ahead of print]. PMID: 24788251

The authors examined survey data collected from the leaders of 132 primary care practices that became the first medical homes in Minnesota. The surveys included the Change Process Capability Questionnaire and the Physician Practice Connections Survey, which measured the level of priority for transformation to a medical home, the presence of medical home practice systems, and the existence of other organizational factors and change strategies. Results from these surveys showed that at least 80 percent of the clinics reported having 15 of the 18 organizational factors for improving care processes, and at least 60 percent had successfully used each of the 16 improvement strategies. An increase in system changes was associated with a score of 5 or more on a 10-point scale for a clinic’s priority level for medical home changes and use of more than 60 percent of the surveyed strategies for implementing those changes. The authors concluded that clinics considering transformation to a medical home should first determine if transformation is a priority, and then consider the factors and systems identified in these surveys as important for transformation efforts.

Solberg LI, Crain LA, Tillema J, et al. Medical home transformation: a gradual process and a continuum of attainment. Ann Fam Med. 2013;11(Suppl 1):S108-14. PMID: 23690379

The authors analyzed clinical quality data to understand the difference in performance between certified health care homes (HCHs) and non-HCHs. Clinics included 120 adult-serving HCHs and 518 non-HCHs across Minnesota. The proportion of HCH clinics where all patients had optimal diabetes measures improved by an absolute 2.1 percent, and the proportion where all patients had optimal cardiovascular disease measures increased by 4.4 percent. While the mean performance rates of HCH clinics were higher than those of non-HCH clinics, there was wide variation in performance across HCH clinics and considerable overlap between the two groups. The authors concluded that the performance of medical homes can vary greatly, clinical outcomes change slowly, and transformation occurs on a continuum.

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Primary Care Transformation in an NCQA-Certified PCMH
Principal Investigator: Ming Tai-Seale, PhD, MPH

Panattoni L, Stone A, Chung S, Tai-Seale M. Patients report better satisfaction with part-time primary care physicians, despite less continuity of care and access. J Gen Intern Med. 2015;30(3):327-33. PMID: 25416600

The authors examined the relationship between a physician’s full-time equivalent status (FTE) and continuity of care, access to care, and patient satisfaction with their physician. Physician level of FTE, continuity of care received by patients, continuity of care provided by physicians, patient satisfaction with their physician (as measured by the Press Ganey Patient Satisfaction survey), and the number of days to the third-next-available appointment were collected for 205 primary care physicians in a multispecialty group practice. Physician FTE was directly associated with better continuity of care, both received and provided, and better access to care, but also with worse patient satisfaction. While the continuity of care provided was a significant mediator of the relationship between FTE and patient satisfaction, overall, reduced clinical work hours were associated with better patient satisfaction. The authors concluded that part-time clinicians may provide less continuity and access but a better overall patient experience. They suggested that the role of part-time clinicians should be considered in practice redesign efforts when trying to meet the demand for primary care physicians and services.

Chung S, Panattoni L, Hung D, et al. Why do we observe a limited impact of primary care access measures on clinical quality indicators? J Ambul Care Manage. 2014;37(2):155-63. PMID: 24594563

The authors reviewed the effects of enhanced access to primary care services and improved continuity of care on clinical outcomes. Findings indicated that patient access to one’s own primary care provider was predictive of improved clinical quality, although the effect was small and may not have affected clinical outcomes. Shorter wait times to see one’s own primary care provider and increased use of personal EHRs were associated with chronic disease management processes and increased preventive screening, but not consistently associated with improved clinical outcomes. The authors discussed challenges in establishing a relationship between access to care and clinical outcomes.

McCuistion MH, Stults CD, Dohan D, et al. Overcoming challenges to adoption of shared medical appointments. Popul Health Manag. 2014;17(2):100-5. PMID: 24156662

The authors conducted key informant interviews with medical and administrative staff to assess the barriers and facilitators to implementing shared medical appointments across three divisions of a large medical group. Each division differed in terms of motivations, facilitators, and barriers related to implementation of shared medical appointments. Two divisions allocated necessary resources, including management support, a physician champion, expert consults, and support staff, and were able to overcome the challenges of physician reluctance and financial sustainability. Despite early interest, attempts at implementation faltered and were abandoned in the third division, which did not devote the necessary time or resources to overcome initial physician resistance. The primary facilitators to successful implementation of shared medical appointments were identified as: a physician champion, management support, and financial sustainability. Authors concluded that implementing shared medical appointments without these facilitators in place would be difficult.

Tai-Seale M, Wilson CJ, Panattoni L, et al. Leveraging electronic health records to develop measurements for processes of care. Health Serv Res. 2014;49(2):628-44. PMID: 24236994

The authors used EHR data from a single group practice serving four counties in northern California to determine its reliability to measure care processes among primary care physicians and how these processes correspond to clinical health outcomes. The authors reviewed data from 15,370 patients with diabetes and 49,561 patients with hypertension and found the volume of electronic messages, number of days to the third-next-available appointment, and team communication to be reliable indicators of primary care physician processes of care. Among patients with diabetes, volume of electronic messages was positively correlated with low-density lipoprotein control (≤100 mg/dL), and frequent in-person visits were associated with better blood pressure and low-density lipoprotein control. Among patients with hypertension, frequent in-person visits were associated with better blood pressure control. The authors concluded that an EHR offers process of care measures that can be used to examine the level of patient-centeredness within a practice, some of which were found to be significantly correlated with clinical health outcomes.

Dohan D, McCuistion M, Frosch D, et al. Recognition as a patient-centered medical home: fundamental or incidental? Ann Fam Med. 2013;11(Suppl 1):S14-8. PMID: 23690381

The authors assessed why a medical group (Palo Alto Medical Foundation) pursued PCMH recognition and subsequently allowed this status to lapse. The authors conducted key informant interviews with medical group executives, clinicians, and front-line staff. Participants cited consistency with the organizational mission as motivation for seeking PCMH recognition. Reasons for implementing specific components of the PCMH model varied from alignment with the organization’s patient-centered culture to gaining a competitive advantage over other local medical groups. Seeking NCQA recognition was specifically motivated by a one-time financial incentive. The authors concluded that becoming a PCMH and seeking recognition were parallel but separate activities at Palo Alto Medical Foundation.

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Page last reviewed May 2015
Page originally created April 2015
Internet Citation: AHRQ Transforming Primary Care Grants. Content last reviewed May 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/primary-care/tpc/tpcbib.html