Primary Care Practice Redesign–Successful Strategies


Principal Investigator: Michael K. Magill, M.D.

University of Utah, School of Medicine, Department of Family and Preventive Medicine


This study evaluated the impact of a comprehensive care management program targeting patients with multiple chronic conditions at the University of Utah Community Clinics. The program aimed to demonstrate improvements in care quality through redesign of care delivery. It featured deployment of care managers in 9 of the organization's 10 primary care clinics, along with the implementation of transitions management services delivered by the care managers and a pilot transitions navigator role at the University of Utah Hospital.


The study used a pre-post, mixed-methods design to assess the program, evaluating its impact on clinical quality, patient satisfaction and experience, total costs of care, provider and staff attitudes, and financial performance of the participating practices.


The care management program was associated with significant improvements in some clinical quality measures, such as hemoglobin A1c and low-density lipoprotein levels, and with enhancements in coordination of care and followup care, including a significant reduction in all-cause 30-day readmissions and delayed time to readmission after hospital discharge. Patient experience improved with regard to the patient-centered medical home (PCMH) domains of Comprehensive Care, Self-Management Support, and Continuity of Care. The experience of patients enrolled in our care management program improved over the 3 years of the project on 7 of 9 PCMH domains. Improvements were significant for those PCMH functions emphasized in our Care By Design (CBD) model, including asking about depression, setting personal goals, and providing after-visit summaries.

Surveys of providers and staff showed improvements in measures of team development in 2012, but declines in some clinics the following year highlighted the importance of an ongoing focus on development of team skills and roles. Clinician support for patient self-management suggests that practice staff believe that patients are capable of being effective members of their care teams. Clinic net revenues and patient visits did not change significantly after implementation of the care management program. Staffing costs increased in some clinics and decreased in others, without a consistent pattern. Levels of staff burnout varied across clinics and correlated with clinic culture.

Multivariable analyses revealed that certain characteristics of implementation of CBD in the community clinics, particularly continuity of care, had significant effects on reducing costs that extended beyond 1 year of exposure. Such effects were most evident among patients with multiple chronic conditions, the precise high-risk patient population targeted by care management.

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Page last reviewed December 2017
Page originally created December 2014
Internet Citation: Primary Care Practice Redesign–Successful Strategies. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD.