Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home

University of Colorado Health Sciences Center and Director of Research, Center for Research Strategies, 225 E. 16th Ave, Suite 1150, Denver, Colorado, USA.
The Annals of Family Medicine (Impact Factor: 5.43). 05/2009; 7(3):254-60. DOI: 10.1370/afm.1002
Source: PubMed


The patient-centered medical home (PCMH) is emerging as a potential catalyst for multiple health care reform efforts. Demonstration projects are beginning in nearly every state, with a broad base of support from employers, insurers, state and federal agencies, and professional organizations. A sense of urgency to show the feasibility of the PCMH, along with a 3-tiered recognition process of the National Committee on Quality Assurance, are influencing the design and implementation of many demonstrations. In June 2006, the American Academy of Family Physicians launched the first National Demonstration Project (NDP) to test a model of the PCMH in a diverse national sample of 36 family practices. The authors make up an independent evaluation team for the NDP that used a multimethod evaluation strategy, including direct observation, in-depth interviews, chart audit, and patient and practice surveys. Early lessons from the real-time qualitative analysis of the NDP raise some serious concerns about the current direction of many of the proposed PCMH demonstration projects and point to some positive opportunities. We describe 6 early lessons from the NDP that address these concerns and then offer 4 recommendations for those assisting the transformation of primary care practices and 4 recommendations for individual practices attempting transformation.


Available from: Carlos Roberto Jaén
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    • "Achieving mandated PACT goals such as interdisciplinary continuity of care for patient panels, new scheduling methods, and improved care transitions requires substantial local redesign.8 Prior literature on non-VA PCMH shows that model implementation is transformative, requiring multi-dimensional changes9 that continuously adapt to local context.10 We thus expected that implementation of PACT would necessitate an ongoing local quality improvement (QI) process, in addition to top-down mandates and education.11 "
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    ABSTRACT: Healthcare systems and their primary care practices are redesigning to achieve goals identified in Patient-Centered Medical Home (PCMH) models such as Veterans Affairs (VA)'s Patient Aligned Care Teams (PACT). Implementation of these models, however, requires major transformation. Evidence-Based Quality Improvement (EBQI) is a multi-level approach for supporting organizational change and innovation spread. To describe EBQI as an approach for promoting VA's PACT and to assess initial implementation of planned EBQI elements. Descriptive. Regional and local interdisciplinary clinical leaders, patient representatives, Quality Council Coordinators, practicing primary care clinicians and staff, and researchers from six demonstration site practices in three local healthcare systems in one VA region. EBQI promotes bottom-up local innovation and spread within top-down organizational priorities. EBQI innovations are supported by a research-clinical partnership, use continuous quality improvement methods, and are developed in regional demonstration sites. We developed a logic model for EBQI for PACT (EBQI-PACT) with inputs, outputs, and expected outcomes. We describe implementation of logic model outputs over 18 months, using qualitative data from 84 key stakeholders (104 interviews from two waves) and review of study documents. Nearly all implementation elements of the EBQI-PACT logic model were fully or partially implemented. Elements not fully achieved included patient engagement in Quality Councils (4/6) and consistent local primary care practice interdisciplinary leadership (4/6). Fourteen of 15 regionally approved innovation projects have been completed, three have undergone initial spread, five are prepared to spread, and two have completed toolkits that have been pretested in two to three sites and are now ready for external spread. EBQI-PACT has been feasible to implement in three participating healthcare systems in one VA region. Further development of methods for engaging patients in care design and for promoting interdisciplinary leadership is needed.
    Journal of General Internal Medicine 04/2014; 29(S2). DOI:10.1007/s11606-013-2703-y · 3.42 Impact Factor
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    • "In this study we collected outpatient data from a random sample of 888 different facilities (which corresponds to 130 VAMCs of all 23 VISNs) during FY11 quarter 3 to FY12 quarter 2. To achieve a better picture of the data environment, we tentatively arranged all independent attributes into five groups as summarized in Table 1[14] [15]. It should be noted that these variables remain the same for a patient during the fiscal year. "
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    ABSTRACT: Recently the patient centered medical home (PCMH) model has become a popular approach to deliver better care to patients. Current research shows that the most important key for succession of this method is to make balance between healthcare supply and demand. Without such balance in clinical supply and demand, issues such as excessive under and over utilization of physicians, long waiting time for receiving the appropriate treatment, and non continuity of care will eliminate many advantages of the medical home strategy. To reach this end we need to have information about both supply and demand in healthcare system. Healthcare supply can be calculated easily based on head counts and available hours which is offered by professionals for a specific time period while healthcare demand is not easy to calculate, and it is affected by some healthcare, diagnostic and demographic attributes. In this paper, by extending the hierarchical generalized linear model to include multivariate responses, we develop a clinical workload prediction model for care portfolio demands in a Bayesian framework. Our analyses of a recent data from Veteran Health Administration indicate that our prediction model works for clinical data with high performance.
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    • "Health planners can use this extended model to explore changes to enhance continuity. For example, by centering primary care services in patients’ medical homes [39], the nature of the circle changes and may well improve continuity of care. Provider connectedness increases through increased contact between providers who share more patients. "
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    ABSTRACT: Continuity is an important aspect of quality of care, especially for complex patients in the community. We explored provider perceptions of continuity through a system's lens. The circle of care was used as the system. Soft systems methodology was used to understand and improve continuity for end of life patients in two communities. Participants: Physicians, nurses, pharmacists in two communities in British Columbia, involved in end of life care. Two debates/discussion groups were completed after the interviews and initial analysis to confirm findings. Interview recordings were qualitatively analyzed to extract components and enablers of continuity. 32 provider interviews were completed. Findings from this study support the three types of continuity described by Haggerty and Reid (information, management, and relationship continuity). This work extends their model by adding features of the circle of care that influence and enable continuity: Provider Connectedness the sense of knowing and trust between providers who share care of a patient; a set of ten communication patterns that are used to support continuity across the circle of care; and environmental factors outside the circle that can indirectly influence continuity. We present an extended model of continuity of care. The components in the model can support health planners consider how health care is organized to promote continuity and by researchers when considering future continuity research.
    BMC Health Services Research 08/2013; 13(1):309. DOI:10.1186/1472-6963-13-309 · 1.71 Impact Factor
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