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Practice Activity Data Table
Source publication
The objective was to quantify the activities required for patient-centered medical home (PCMH) transformation in a sample of small to medium-sized National Committee for Quality Assurance (NCQA) recognized practices, and explore barriers and facilitators to transformation. Eleven small to medium-sized PCMH practices in Southeastern Pennsylvania com...
Contexts in source publication
Context 1
... on the responses from the survey, it was found that practices changed or implemented many similar activities during their transformation to a PCMH (Table 3). Nearly all practices indicated they made changes in order to fulfill the NCQA Access & Continuity standard by improving access, continuity of care, training for staff, and responsibilities that constitute team-based care. ...
Context 2
... 10 of 11 practices expanded the data collected on patients as well as the use of the data for facilitating population management activities to satisfy the NCQA standard called Identify and Manage Patient Populations. However, in addition to the similarity in improvements made to transform in accordance with NCQA standards, these practices also shared similarities in im- plementing some PCMH-related activities (Table 3). ...
Context 3
... results of both the quantitative and qualitative ana- lyses provide a more detailed understanding of the system changes identified in PCMH transformation. Looking at the NCQA standard, Access & Continuity, found in Table 3, 7 of the 9 practices indicated that they had expanded access. This was done in a variety of ways, including offering open access scheduling, increasing visit duration, and extending hours by ''open[ing] evening hours for two days weekly'' or ''add[ing] two half-day Saturday sessions.'' ...
Similar publications
Background. Primary care practices are poorly understood complex systems. As we collaborates with them on their transformation to value-based patient-centered care, understanding these complexities is essential for implementing any changes.
Aim. To develop a complexity-aware assessment framework for primary care practice optimization.
Methodolo...
Citations
... lthough the need to improve diabetes outcomes in primary care is evident, exactly how a practice successfully manages change in care delivery in the midst of a busy clinical environment is much less clear. 1,2 Conceptual models for improving care delivery often identify foundational principles and highlight thematic and strategic approaches based on those principles. [3][4][5] The National Demonstration Project organizes change around core principles of primary care, whereas the National Committee for Quality Assurance structures strategic guidelines around 6 transformational themes supporting team-based care. ...
Purpose:
To learn how the highest-performing primary care practices manage change when implementing improvements to diabetes care delivery.
Methods:
We ranked a total of 330 primary care practices submitting practice management assessments and diabetes reports to the Understanding Infrastructure Transformation Effects on Diabetes study in 2017 and 2019 by Optimal Diabetes Care performance. We ranked practices from the top quartile by greatest annual improvement to capture dynamic change. Starting with the top performers, we interviewed practice leaders to identify their most effective strategies for managing change. Interview transcripts were qualitatively analyzed to identify change management strategies. Saturation occurred when no new strategies were identified over 2 consecutive interviews.
Results:
Ten of the top 13 practices agreed to interviews. We identified 199 key comments representing 48 key care management concepts. We also categorized concepts into 6 care management themes and 37 strategic approaches. We categorized strategic approaches into 13 distinct change management strategies. The most common strategies identified were (1) standardizing the care process, (2) performance awareness, (3) enhancing care teams, (4) health care organization participation, (5) improving reporting systems, (6) engaging staff and clinicians, (7) accountability for tasks, (8) engaging leadership, and (9) tracking change. Care management themes identified by most practices included proactive care, improving patient relationships, and previsit planning.
Conclusions:
Top-performing primary care practices identify a similar group of strategies as important for managing change during quality improvement activities. Practices involved in diabetes improvement activities, and perhaps other chronic conditions, should consider adopting these change management strategies.
... Despite international agreement on the fundamental concepts of primary care, the specific care delivery activities implemented by primary care practices can vary widely. Evidence for clinical outcome improvement resulting from many quality improvement efforts is inconsistent (8)(9)(10)(11)(12)(13). A care management process (CMP) is a specific activity performed in a clinical practice with the goal of improving or facilitating coordinated, effective clinical care. ...
Objective:
Identify the improvement in diabetes performance measures and population-based clinical outcomes resulting from changes in care management processes (CMP) in primary care practices over 3 years.
Research design and methods:
This repeated cross-sectional study tracked clinical performance measures for all diabetes patients seen in a cohort of 330 primary care practices in 2017 and 2019. Unit of analysis was patient-year with practice-level CMP exposures. Causal inference is based on dynamic changes in individual CMPs between years by practice. We used the Bayesian method to simultaneously estimate a five-outcome model: A1c, systolic and diastolic blood pressure, guideline-based statin use, and Optimal Diabetes Care (ODC). We control for unobserved time-invariant practice characteristics and secular change. We modeled correlation of errors across outcomes. Statistical significance was identified using 99% Bayesian credible intervals (analogous to P < 0.01).
Results:
Implementation of 18 of 62 CMPs was associated with statistically significant improvements in patient outcomes. Together, these resulted in 12.1% more patients meeting ODC performance measures. Different CMPs affected different outcomes. Three CMPs accounted for 47% of the total ODC improvement, 68% of A1c decrease, 21% of SBP reduction, and 55% of statin use increase: 1) systems for identifying and reminding patients due for testing, 2) after-visit follow-up by a nonclinician, and 3) guideline-based clinician reminders for preventive services during a clinic visit.
Conclusions:
Effective quality improvement in primary care focuses on practice redesign that clearly improves diabetes outcomes. Tailoring CMP adoption in primary care provides effective improvement in ODC performance through focused changes in diabetes outcomes.
... [8][9][10][11][12] Due in part to variations in the amount and types of practices implemented, PCMH implementation varies significantly by site with practices undergoing many changes. 13 While there is no single way to achieve PCMH transformation, there is concordance in the main implementation steps. 9,14 PCMH-recognition and certification requires satisfying core criteria and also provides various optional criteria. ...
Objectives:
Knowing which patient-centered medical home (PCMH) care delivery changes and quality improvement (QI) practices further PCMH implementation is essential.
Study design:
We used the 2008-2017 National Committee of Quality Assurance (NCQA) PCMH directory of 15,188 primary care practices that received Level 1, 2, or 3 NCQA PCMH recognition to construct a stratified national sample of 105 practices engaged in PCMH transformation. We examined their QI practices and PCMH changes associated with PCMH transformation.
Methods:
We derived QI practice and PCMH change variables from semistructured interviews. Practice leaders completed the PCMH Assessment (PCMH-A) measuring the practice's degree of PCMH implementation, which is a proxy for patient-centeredness. Controlling for practice characteristics, we regressed PCMH-A scores on QI practice and PCMH change variables.
Results:
Practices undergoing PCMH transformation nationwide most commonly made care delivery changes in access and continuity of care. To improve quality, practices most commonly engaged in discussing and targeting areas of patient experience improvement, trending performance, and conducting targeted QI. However, practices lower in patient-centeredness as measured by the PCMH-A were more likely to engage in efforts to improve patient experiences, such as reviewing patient experience data or engaging in 1-on-1 provider counseling related to patient interactions. Mature PCMH practices focused on changes in continuity of care.
Conclusions:
Practices undertake a wide variety of care delivery changes and QI practices simultaneously to meet PCMH requirements. The patient experience-specific QI practices and PCMH care delivery changes that practices make to improve patient-centeredness differ by years of PCMH recognition.
... Large numbers of practices have striven to transform their care delivery to implement efficient and effective team-based, patient-centered care, and it is essential that we have contextually based evaluation studies that include examination of work roles and processes for understanding how PCMHs develop and function. [2][3][4][5][6][7][8][9] Some studies have found significant variability in how PCMH has been implemented, 10 and others see concordance in steps toward increasing establishment of PCMH processes. 11 For many who are concerned about the future of primary care, the PCMH model holds out the hope of aiding practices in achieving the Triple Aim 12 of improved outcomes, better patient experience, and reduced costs. ...
... Designing and implementing PCMH components is hard work, involving modifications in practice culture as well as the mindsets and behaviors of those working in the practice. 10,43,46 Using an electronic health record is a prerequisite for participation in PCMH initiatives to facilitate reporting and population health initiatives, and the clerical burden that technology has been shown to impose escalates provider burnout in the outpatient setting. [53][54][55] It is unclear, therefore, if the increase in burnout in our study was less due to the transformation efforts associated with our PCMH initiative (which encouraged practices to identify their needs and choose their own areas for transformation work), than it was to the demands of electronic health records, other operational challenges, and several of the practices' affiliating with more structurally demanding state-wide PCMH projects. ...
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.
... 141 A study of small to medium-sized PCMH providers in South-eastern Pennsylvania examining transformation amongst these practices found a great deal of variation in workforce composition. 142 Typically, the practices employed two to five medical assistants, with one practice employing 13. The number of active patients over a two-year period ranged from 1,988 to 14,000 patients per practice (average of 5,516), and between 430 and 2,444 patients per provider (average of 1,379). ...
... The small to medium-sized PCMHs in South-eastern Pennsylvania described in an earlier-mentioned study (p. 55) had between zero and nine medical doctors on their staff and typically employed two to five medical assistants, with one practice employing 13. 142 The medical doctor to medical assistant ratio was 1:1.4 ...
A systematic review of evidence on barriers and enablers of implementing a patient centred medical home (PCMH) model of care
Creating a clinical model to promote health equity demands a modern philosophy of care, which requires a different mindset that is distinct from the prevailing healthcare model. Using evidence-based components and guided by best practices in the delivery of care, this chapter outlines critical components that should be considered when designing healthcare programming with adolescents and young adults from non-dominant cultures or backgrounds or with any youth at risk of discrimination or vulnerable to multiple social determinants of health. These components are (1) work on internal bias; (2) cultural tailoring or appropriateness; (3) patient activation; (4) welcoming empathy; (5) navigation skills; (6) cross-sector, integrated care; (7) systems of care; (8) family-centered care; (9) foster identity development (ethnic identity in particular); (10) coach around discrimination and biases; (11) two-level advocacy; and (12) sustainability. Combining these components provides a practical framework for clinicians to promote health equity in clinical practice settings.
To explore the cost for individual practices to become more patient-centered, we inventoried and calculated the cost of costly activities involved in implementing the Patient-Centered Medical Home (PCMH) as defined by the National Committee for Quality Assurance. There were 3 key findings. The cost of each PCMH-related clinical activity can be classified in 1 of 3 major categories. Cost offsets can be used to defray part of the cost recognition. The cost of PCMH transformation varied by practice with no clear level or pattern of costs. Our study suggests that small- and medium-sized practices may experience difficulty with the financial burden of PCMH recognition.
