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.

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    • "CenteringPregnancy provides greater health promotion education, group peer support, a collaborative patient-provider relationship; and self-management training and activities, all of which should contribute to empowerment[12,13]. Other more recent interventions include patient navigators, patient centered medical homes, and the use of mobile technology in prenatal care14151617. Evaluating the impact of prenatal care innovations on empowerment and subsequent health outcomes requires a valid and reliable measure of pregnancy-related empowerment. However, few such measures of health-related empowerment exist[18,19]. "

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    • "no means a given. It often requires sustained leadership, extensive training and support , robust measurement and data systems, realigned incentives and human resource practices, and cultural receptivity to change (Nembhard, Alexander, Hoff, & Ramanujam, 2009; Nutting et al., 2009; Friedberg et al., 2009). Furthermore, because implementation is rarely prescribed or standardized, physician practices may implement PCMH narrowly, focusing on a particular clinical condition, or broadly by employing the PCMH model as a standard way of conducting clinical practice and patient care across all conditions and patients. "
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    ABSTRACT: There has been relatively little empirical evidence about the effects of patient-centered medical home (PCMH) implementation on patient-related outcomes and costs. Using a longitudinal design and a large study group of 2,218 Michigan adult primary care practices, our study examined the following research questions: Is the level of, and change in, implementation of PCMH associated with medical surgical cost, preventive services utilization, and quality of care in the following year? Results indicated that both level and amount of change in practice implementation of PCMH are independently and positively associated with measures of quality of care and use of preventive services, after controlling for a variety of practice, patient cohort, and practice environmental characteristics. Results also indicate that lower overall medical and surgical costs are associated with higher levels of PCMH implementation, although change in PCMH implementation did not achieve statistical significance. © The Author(s) 2015.
    No preview · Article · Apr 2015 · Medical Care Research and Review
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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.
    Full-text · Article · Apr 2014 · Journal of General Internal Medicine
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