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Exploring Variation in Transformation of Primary Care Practices to Patient-Centered Medical Homes: A Mixed Methods Approach

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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 completed a survey, which was adapted from the 2011 NCQA standards. Semistructured follow-up interviews were conducted, descriptive statistics were computed for the quantitative analysis, and a process of thematic coding was deployed for the qualitative analysis. Practices had considerable quantitative variation in their workforce composition and the PCMH-related activities they implemented. Most practices improved access and continuity through staff training and team-based care as well as expanded data collection for population management. The barriers to PCMH recognition were least burdensome for the largest practices. The heterogeneity of the small PCMH practices within the study sample underscore the need to understand the key transformation issues as efforts to disseminate the PCMH model continue.
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Original Article
Exploring Variation in Transformation of Primary Care
Practices to Patient-Centered Medical Homes:
A Mixed Methods Approach
Robert D. Lieberthal, PhD,
1,2
Tom Karagiannis, PharmD,
2
Evan Bilheimer, MD, MPH,
2,3
Manisha Verma, MD, MPH,
4
Colleen Payton, MPH,
3
Mona Sarfaty, MD, MPH,
3
and George Valko, MD
3
Abstract
The objective was to quantify the activities required for patient-centered medical home (PCMH) transfor-
mation 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 prac-
tices in Southeastern Pennsylvania completed a survey, which was adapted from the 2011 NCQA standards.
Semistructured follow-up interviews were conducted, descriptive statistics were computed for the quantitative
analysis, and a process of thematic coding was deployed for the qualitative analysis. Practices had considerable
quantitative variation in their workforce composition and the PCMH-related activities they implemented. Most
practices improved access and continuity through staff training and team-based care as well as expanded data
collection for population management. The barriers to PCMH recognition were least burdensome for the largest
practices. The heterogeneity of the small PCMH practices within the study sample underscore the need to
understand the key transformation issues as efforts to disseminate the PCMH model continue.
Keywords: patient-centered care, medical home, primary health care, practice management, cost control
Introduction
Background
The patient-centered medical home (PCMH) is an
evolving model directed toward better equipping prac-
tices to provide comprehensive and coordinated care to a
growing population with complex chronic care needs, as
well as improving care for all patients.
1,2
It has been widely
supported by purchasers, payers, physicians, and patient-
advocacy groups as a vehicle to increasing the value of care
provided in primary care.
2,3
Currently, recognition of practices as PCMHs is a for-
malized process. Under the process established by the Na-
tional Committee for Quality Assurance (NCQA), a major
PCMH recognition body, medical practices demonstrate
their patient-centeredness across 6 domains. Practices ac-
crue points for activities in each domain, and they may at-
tain recognition as a Level 1, 2, or 3 practice based on the
number of points accrued as well as the type of points (ie,
points accrued in specific domains). In addition, Level 2 or 3
recognition required the use of an electronic medical record
(EMR); this was not required for Level 1 recognition under
the 2011 standards.
4
NCQA is not the only source for
PCMH recognition—URAC and the Accreditation Asso-
ciation for Ambulatory Health Care are 2 private organi-
zations that provide PCMH recognition, while state-based
recognition exists in states such as Michigan and Oregon.
5–7
The formal application procedure for PCMH recognition
can be contrasted with the actual utilization of patient-
centered principles underlying the transformation of a pri-
mary care practice. This study explored the choices that a
group of small practices made in transforming their prac-
tices into PCMHs seeking recognition for their prac-
tices from NCQA. A mixed methods approach was used to
1
Department of Public Health, University of Tennessee, Knoxville, Knoxville, Tennessee.
2
College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania.
3
Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
4
Einstein Healthcare Network, Philadelphia, Pennsylvania.
Prior presentation: This work was previously presented at the 2014 AcademyHealth Annual Research Meeting, June 2014, San Diego,
CA, and at the 2014 North American Primary Care Research Group Practice-Based Research Network meeting, November 2014, New
York, NY.
POPULATION HEALTH MANAGEMENT
Volume 00, Number 00, 2017
ªMary Ann Liebert, Inc.
DOI: 10.1089/pop.2016.0132
1
quantitatively analyze the changes practices made to trans-
form to a PCMH and to qualitatively explore why practices
adopted, and did not adopt, specific PCMH features. The
study team concludes by commenting on the broader im-
plications of these results from a science practice transfor-
mation perspective.
Motivation
Studies of PCMH are often based on state-based pilots
designed for the purposes of health reform. For example,
‘‘The Washington State Multi-Payer Medical Home Re-
imbursement Pilot (Pilot) tested a payment method for the
patient-centered medical home PCMH model intended to
reduce avoidable emergency department (ED) and hospi-
talization rates.’’ An analysis of that pilot by Koshy et al
used qualitative analysis of semistructured interviews and
delineated a number of barriers and facilitators to PCMH
implementation, with a strong focus on barriers, but in-
cluded a heterogeneous mix of practices.
8
Prior studies have
focused on the success of the PCMH model as the founda-
tion for primary care reform by examining the determinants
of uptake by small and medium sized practices across the
United States.
9
However, the prior literature has not ade-
quately addressed how transformation takes place in such
practices.
The present study focused specifically on the transfor-
mation to PCMH in small to medium-sized practices in
order to address a gap in the literature. Small and medium-
sized practices have been found to utilize few PCMH pro-
cesses in general.
10
Small and medium-sized practices in
particular may not have the economies of scale and re-
sources required to surpass the initial barriers to adoption
of the PCMH model. The importance of small to medium-
sized practices is accounted for by the total number of
providers working in such practices. A study by Welch
et al in 2013 found that nearly half of physicians work
either in solo practices or in practices with between 2 and
10 physicians.
11
Thus, research that addresses the avenues
by which smaller practices can attain PCMH recognition
can help both the practices that transform and the patients
those practices serve.
Methods
Context
The 2007 Chronic Care Initiative (CCI), developed by the
Chronic Care Commission within Pennsylvania, was created
to provide a framework for tackling dual obstacles to better
care for people with chronic disease by changing how care is
provided based on the Chronic Care Model and rewarding
practices for helping to deliver this care with aligned fi-
nancial incentives.
12
The initial rollout of the CCI focused
on diabetes in adults and asthma in children. Additional
chronic diseases such as hypertension and coronary artery
disease were added later as conditions of interest.
13–15
Participation in the CCI included financial incentives for
practices that achieved NCQA recognition at any level,
participated in conference calls, attended CCI learning ses-
sions, and submitted monthly process and outcomes data.
Financial incentives were practice specific per full-time
equivalent (FTE) and publicly available. The original
demonstration project included 32 small and medium-sized
practices.
Survey design
The survey was adapted from the 2011 NCQA application
for PCMH recognition and constructed to elicit the activities
responsible for both gaining and sustaining practice trans-
formation. The survey questions were organized to reflect
the 6 core competencies identified by NCQA: (1) enhance
access and continuity, (2) identify and manage patient
populations, (3) plan and manage care, (4) provide self-care
support and community resources, (5) track and coordinate
care, and (6) measure and improve performance.
16
In ad-
dition, the survey also included 2 components targeting
practice culture and reimbursement of each practice. The
decision to include practice culture in the survey was based
on prior findings of the study team and of the CCI that
indicated it was a crucial element of PCMH transformation
and unaddressed by NCQA guidelines.
The study’s principle investigator and one of the co-
investigators were members of a large academic family
practice that had previously obtained PCMH recognition
from NCQA through the CCI. The survey was pilot
tested with providers and administrators responsible for the
transformation of that practice to refine the survey. That
practice was part of the CCI demonstration, but it was not
part of the sample of practices because of its size. In tandem
with the survey, in-depth interviews were conducted to
provide qualitative data to support the understanding of
PCMH transformation in each of the participating practices,
and also to explore possible reasons for preferentially im-
plementing one activity over another.
Study recruitment and data
The study team initially approached 35 small and
medium-sized NCQA-recognized PCMHs that were located
in southeastern Pennsylvania and had fewer than 10 FTE
providers, and assessed their interest in sharing their expe-
rience of transforming and sustaining their PCMH. These 35
practices included the 32 in the southeastern Pennsylvania
collaborative and 3 additional PCMH-recognized practices
that also were located in southeastern Pennsylvania but were
not part of the collaborative. After receiving initial feedback
from 12 practices, the study team chose to limit the study
sample to 11 practices that served only adults by excluding
1 individual pediatric specialty practice to enhance between-
practice comparability. Nine of the 11 practices previously
participated in the southeastern Pennsylvania collaborative.
Two practices were not part of the collaborative but were
NCQA-recognized PCMHs and also located in southeastern
Pennsylvania. Nonparticipating practices were not enrolled
in the study, and therefore data on the characteristics of
those practices is not available. This study was approved by
Thomas Jefferson University’s Institutional Review Board.
The electronic survey was administered in October
through December of 2013, and the semistructured inter-
views were administered with each practice from October
2013 through March 2014. The practices decided who
among their practitioners and staff would fill out the survey,
and they then returned the survey by e-mail or by fax. The
study research coordinator then verified that the survey
2 LIEBERTHAL ET AL.
instrument had been filled out and noted any gaps or in-
consistencies in survey responses. These gaps or incon-
sistencies became part of the semistructured interviews for
practices. Each interview was conducted face-to-face or by
telephone with members of the study team and representa-
tives of the participating practice. The interview questions
further elaborated on survey responses and were tailored to
each individual practice. Each interview lasted approxima-
tely 1 hour, and the responses were transcribed by a member
of the research study for data coding and analysis.
Analytic approach
Two researchers cataloged survey responses, including
structured and free-text data, independently from one an-
other using Microsoft Excel software (Microsoft Corpora-
tion, Redmond, WA). Differences between the 2 researchers
in classifying the data were resolved through discussion
with the study team’s principle investigator and coinvesti-
gators. In a small number of cases, practices were asked
follow-up questions in order to resolve these differences.
The individual practices were de-identified and coded to
preserve confidentiality. The entire de-identified database
was then shared with the larger research team for more in-
depth analysis, including identifying patterns in the re-
sponses between the practices.
To gain a more detailed understanding of the activities
and attitudes surrounding transformation, a qualitative
analysis was performed. Themes and concepts from the
follow-up interviews were identified and utilized to elabo-
rate on and clarify the survey responses. Initial codes were
created and then data were collapsed into labels, creating
categories that were used for analysis. Recurring ideas and
concepts were combined into overarching themes that were
present in the data set. To assure validity of the coding
scheme, a separate member of the research team indepen-
dently reviewed the raw data and compared and reconciled
any coding differences between the reviews. The results of
both the quantitative and qualitative analyses were then
combined. Of note, 3 practices (practices I, J, and K) were
part of the same umbrella organization. Although they dif-
fered in many of the descriptive statistics that were ana-
lyzed, they responded to the interview questions as if they
were 1 practice. As a result, for the qualitative analysis, all 3
of these practices were grouped together as if they were 1
practice.
Results
Quantitative results
Overall, the practices in the sample differed in the com-
position of their workforce as well as in the level of NCQA
recognition they previously achieved (Table 1). Level 1
practices achieved the ‘‘must pass’’ elements under the 2011
guidelines, Level 2 practices achieved these elements as
well as 60–84 points for NCQA recognition elements, and
Level 3 practices achieved the ‘‘must pass’’ elements as
well as 85–100 points for NCQA recognition elements.
4,16
Practices typically employed anywhere from 2 to 5 medical
assistants, and 1 practice employed 13 medical assistants.
Medical assistants were employed for all activities within a
practice, although in many cases these individuals may have
been hired specifically to achieve PCMH recognition. The
ratio of clinical staff per provider ranged from 0.80–2.67.
All practices within the sample had previously achieved
NCQA recognition as a PCMH: 5 practices had achieved
Level 3, 3 practices had achieved Level 2, and 3 practices
had achieved Level 1 (Table 1). Six practices received either
initial recognition or renewal of their PCMH designation
using the updated 2011 NCQA recognition standards. There
also was considerable variation in how the practices within
the sample were paid and with whom they were financially
affiliated (Table 2).
Based 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. Likewise, 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).
Qualitative results: themes from the interviews
A total of 11 themes emerged from the qualitative anal-
ysis: (1) Workforce Changes, (2) Outcomes Measurement,
(3) EMR Integration, (4) Patient Engagement, (5) Care
Coordination and Communication, (6) Implementation
Barriers, (7) Enhanced Access, (8) Enhanced Continuity, (9)
Medication Management, (10) Outside Resources, and (11)
No Change. Each of these themes is composed of sev-
eral key ideas, many of which were repeated frequently
throughout the discussions with the providers (Table 4).
Access was a main theme that emerged; 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.’’
Qualitative results: practice culture
Apart from changes made to meet NCQA standards, ev-
ery practice indicated that the transformation process led to
significant changes in practice culture. This idea of practice
culture revolved around the theme of workforce changes for
each of the practices. Ideas of increased staff engagement
and changing roles and responsibilities were central to the
change in practice dynamics. Practice B stated that the
‘‘staff has much more say in how things are done,’’ while
Practice E noted that the ‘‘overall accountability is in-
creased’’ and the practice has shifted to a ‘‘team-based
model with expanded roles.’’ The shifting emphasis toward
a team-based model with greater focus on prevention and
wellness led to noted improvements in patient care. As a
result, as Practice G stated, ‘‘satisfaction overall is increased
and people are confident that we are doing what is right.’’
In contrast to the binary (yes/no) question from the initial
interview, the qualitative analysis of themes gives a more
VARIATION IN TRANSFORMATION OF PRACTICES TO PCMHS3
nuanced view of changes in practice culture. These results
are presented in Table 5. Themes of Workforce Changes,
Outcomes Measurement, and EMR Integration were men-
tioned by every practice and more frequently than any other
themes (Table 5). These themes were brought up not only
when pointed questions were asked, but were referenced
frequently throughout the discussions. Workforce Changes
was the most prevalent theme. Ideas surrounding new hir-
ing, staff trainings, and changes in staff roles/responsibilities
were brought up at least 6 times by each practice, and as
often as 10 times. Every practice discussed specifically the
expansion of medical assistant roles as they adopted new
responsibilities including medical reconciliation, patient
education and counseling, cancer screening, diabetic foot
exams, and health coaching. It became clear that changing
the practice’s workforce dynamics was essential in order to
successfully transform into a PCMH. Every practice men-
tioned the need for outside resources to help support the
transformation process. However, the 3 largest practices–C,
E, and H–appeared to have the easiest time undergoing
transformation.
Patient engagement emerged as a main theme throughout
the practices. Although 8 of 9 practices (89%) indicated that
they increased patient engagement, only 5 of 9 practices
(56%) stated that patients and families were involved in
providing feedback to the practice. There was variation in
how practices engaged patients including through patient
feedback, patient surveys, shared decision making, patient
education and outreach, and self-management. However,
during the interviews, every practice mentioned on multiple
occasions that they had increased patient involvement.
Practice F, which did not indicate that they increased patient
engagement or incorporated patient feedback on the survey,
mentioned increased patient engagement 3 separate times
during the interviews, including the use of patient feedback
surveys in the practice.
Table 1. Descriptive Characteristics by Practice
Practices A B C D E F G H I J K Average
NCQA recognition level 2 23332331112
NCQA recognition
cycles, 2008–2011
222122111111.45
Year of most
recent recognition
2012 2012 2011 2010 2011 2011 2012 2010 2009 2009 2009 N/A
Providers and staff 11.25 12 34 4 29.50 11 17 43 10 12 10 17.61
Medical doctor 2 3 9 1 4.50 1.50 3 8 0 0 0 4.00
NP/PA/APN
a
0.50 01121.50 7 2 3 5 3 2.60
Clinical staff
per provider
2.38 1.00 1.22 2.00 3.11 2.67 1.00 1.00 1.33 0.80 1.33 1.62
Registered nurse 0 01011031111.29
Medical assistant 3.75 3 5 2 13 3 2 4 2 2 2 3.80
Social work 0 00000001110.50
Clerical staff 3 5 12 0 8 3 0 24 3 3 3 7.11
Practice manager 1 11011410001.43
Case manager 1 05000110002.00
Active patient
population
(within 2 years)
b
2361 3800 14,000 2000 11,000 2235 4890 13,976 2278 2149 1988 5516
Patients per provider 1181 1267 1556 2000 2444 1490 1630 1747 759 430 663 1379
a
NPs, PAs, and APNs were counted as clinical staff in medical practices, and as providers in nurse practitioner-led practices.
b
As reported by practices.
APNs, advanced practice nurses; N/A, not applicable; NCQA, National Committee for Quality Assurance; NPs, nurse practitioners; PAs,
physician assistants.
Table 2. Financial Characteristics by Practice
Practices A B C D E F G H I J K
Financial characteristics
a
11111 122333
Medicare/Managed Medicare (% of patient population) 30 65 35 30 10 60 41 60 1 10 5
Medicaid/Medicaid Managed Care (% of
patient population)
25 0 0 2 2 0 11 1 45 60 45
Private (commercial) insurance (% of patient population) 45 30 65 65 87 39 47 38 10 1 2
Uninsured (% of patient population) 0 5 5 3 1.5 1 1 2 43 29 48
Capitation (% of patient population) 50 50 20 33 47.5 10 58 63 52 30 50
FFS (% of patient population) 50 45 75 64 47.5 89 41 35 48 70 50
Self-pay (% of patient population) 0 5 5 3 1.5 1 1 2 0 0 0
a
Financial characteristics: 1, financially independent; 2, financially affiliated with an academic medical center; 3, financially affiliated
with another organization (Federally Qualified Health Center grantee).
FFS, fee for service.
4 LIEBERTHAL ET AL.
Table 3. Practice Activity Data Table
Practice
Answer by practice Proportion,
%ABCDEF G HI JK
I. Access and continuity
Did you expand access? YYYYNY Y NYYY 82
Did you improve continuity? YYYYYY Y YYYY 100
Did you increase training for
practice staff?
YYYYYY Y YYYY 100
Did you change responsibilities of
practice staff for more team-
based care?
YYYYYY Y YYYY 100
Did you add cultural/linguistic
services?
YNNYNN N NNNN 18
II. Identify and manage patient populations
Did you expand or improve health
data collected on patients?
YYYYYY Y NYYY 91
Do you use health data for new
population management activities?
YYYYYN Y YYYY 91
III. Plan and manage care
Did you create new ways of getting
evidence/guidelines to the point
of care?
YYYYYN Y NYYY 82
Did you change the process for
identifying or managing high-
risk patients?
YNYYYN Y YYYY 82
Did you make changes to the
process of medication management?
YYYYYN N YYYY 82
IV. Provide self-care support
Did you increase patient
engagement? Add/expand self-care
support?
YYYYYN Y YYYY 91
Any new approaches to involving
patient/family in shared decision
making?
YYNYYN N NYYY 64
V. Track and coordinate care
Did you add tracking/follow-up of
any tests or referrals?
YYYYYN Y YYYY 91
Did you increase coordination of
patient care with other providers
or community resources/specialists?
YYYYYN Y NYYY 82
VI. Measure and improve performance
Any change in the way practice
performance data is measured or
used?
YYYYYN Y YYYY 91
Have you expanded/changed the
way you assess patient/family
experience?
YYYNYN Y NNNN 45
Are the patients/families involved
in providing feedback to the
practice?
YYNNNN Y YYYY 64
Did you add/expand quality or
safety aspects of practice?
YYYYYY Y NYYY 91
VII. Practice culture
The way the practice is managed? YYYYYY Y YYYY 100
The culture of your practice? NYYYYY Y YYYY 91
VIII. Continuation in chronic care initiative
Are you also participating in the
CMS demo which continued from
SEPA?
YYYYYY N NYYY 82
If not, why not? Data didn’t show
enough improvement__ Other___
N/A N/A N/A N/A N/A N/A Not
invited
N/A N/A N/A N/A N/A
CMS, Centers for Medicare & Medicaid Services; N, no; N/A, not applicable; SEPA, southeastern Pennsylvania; Y, yes.
VARIATION IN TRANSFORMATION OF PRACTICES TO PCMHS5
Table 4. Descriptions of Themes and Representative Quotes
Theme Description Representative quote
Workforce changes Staff hiring, staff training, changing roles/
responsibilities
‘‘We initially hired +1 FTE chronic care
manager for the process that has since
retired but we are actively recruiting for a
new one. However, we reengineered the
practice model to accommodate for
workflow changes that happened
secondary to transformation.’’—Practice
A
Outcomes
measurement
Data collection and reporting, patient/disease
registries, quality indicators, risk
stratification/tracking
‘‘Yes, we created reports to identify target
populations. We rely on payers to send us
paper notifications about thirty-day
readmissions, patients not taking meds,
no-shows, and eligibility issues.’’—
Practice G
EMR integration EMR adoption, EMR use for data collection
and reporting, creation of patient/disease
registries, patient portals
‘‘Helps create patient registries, reminder
systems for patients, enhance reporting
and recall ability, and clinical decision-
making prompts.’’—Practice B
Patient engagement Patient feedback, patient surveys, shared
decision making, patient education/
outreach, self-management
‘‘We offer many educational materials and
self-care tools, including the health action
plan and the health progress report
mentioned above.’’—Practice C
Care coordination
and
communication
Communication and coordination with
outside hospitals/providers and patients,
referrals
‘‘Community coordinator that calls into the
nurse. Also the nurse helps coordinate
with the hospice and home care sites.’’—
Practice F
Implementation
barriers
Time constraints, financial constraints ‘‘If we had more revenue available we would
hire someone, but this has been a struggle
with bare-bones funds.’’—Practice A
Enhanced access Extended hours, open access scheduling,
increased visit numbers, patient portals
‘‘We opened evening hours for 2 days
weekly. We are now using our EMR’s
patient portal, which allows easy access
for patients. Our providers e-mail back and
forth to patients, they can access their test
results, send requests for referrals,
prescriptions, appointments, etc.’’
—Practice C
Enhanced continuity Patient stays with same primary care
provider/team, patient visit mapping,
routine follow-up
‘‘Identify the PCP in EMR real time, which
helped sorting out patients to switch
between the inpatient team and outpatient
team. For example, a call may go to a
physician-specific nurse, which helps
improve continuity and identification. We
have an automated e-mail system that e-
mails PCPs when their patients are in the
hospital or ER’’—Practice H
Medical
management
Medical reconciliation, renewal policies ‘‘Medication reconciliation occurs at each
visit and within 24 to 48 hours of a
patient’s discharge from the hospital. We
use ePrescribing and have configured
alerts within the ePrescribing module of
the EMR’’—Practice D
Outside resources Financial support, CCI, Transformed,
training resources
‘‘We are planning on continuing with CCI.
No, we needed the leverage to move
forward with our staff and practice. It gave
us the reasonable goods and resources to
force us to look at what we’ve been doing
and how we can get better.’’—Practices
I–K
No change No change after transformation, No change
to assessing patient/family experience
‘‘No we have not changed the way we assess
patient/family experience’’—Practice H
CCI, chronic care initiative; EMR, electronic medical record; ER, emergency room; PCP, primary care provider.
6 LIEBERTHAL ET AL.
Data convergence
The 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.’’ However, dur-
ing the discussions, the theme of Enhanced Access was not
emphasized as much as other themes, with practices men-
tioning it a maximum of 3 times (Table 5). The possibility
that the quantitative results and qualitative results are not
fully reconciled is one that is a fruitful area for future re-
search, especially in order to determine the real meaning of
PCMH recognition both in terms of practice activities and
patient outcomes.
Discussion
Implications of the study findings
The practices in this study were heterogeneous despite the
similarities in the PCMH transformation context. For ex-
ample, all of the practices had fewer than 10 FTE providers,
were located in similar primary care markets within south-
eastern Pennsylvania, and underwent PCMH transformation
during the same time period, with 9 of them participating in
the CCI. Achievement of NCQA recognition among the
practices in the sample was not related to similar infra-
structure and capacities. Practices delivered care to any-
where from 1988 to 14,000 patients across a 2-year period
with different combinations of staff supporting the activities
of the PCMH; 1 practice had access to as many as 24
clerical staff while another had 4 practice managers.
The variation in workforce composition suggests that
small and medium-sized practices may have different abil-
ities to conduct the activities needed to become a PCMH
depending on whether they can delegate staff members in
different categories to take on some of the more time-
intensive activities. The practices in this study employed a
range of staff and a range of managers in order to achieve
PCMH recognition and in order to run the practice. For
example, only 6 of the 11 practices employed a practice
manager—the other 5 practices achieved practice manage-
ment through the use of clerical staff or by having clinical
staff perform this crucial role. Practices also utilized a range
of different kinds of nonclinical or clinical health profes-
sionals and support staff, such as case managers and social
workers, to deliver more patient-centered care.
Despite their differences, the practices in this sample
appeared to make similar decisions as to which PCMH ac-
tivities to implement during their transformation. For ex-
ample, NCQA does not require each activity but rather a
total number of points in order to achieve recognition, and
the majority of practices in the sample chose not to add
linguistic services or activities that incorporate the patient
family’s experience within the delivery of care. It may be
that certain activities are already linked with current reim-
bursement schedules from payers and are thus of more value
to practices than other activities. Further exploration of the
return on investment from pursuing certain activities and not
others will help shed light on practice choices and how in-
centives should be constructed to encourage uniform ac-
tivity implementation. It also is important to note that there
may be other motivations for PCMH activities besides re-
turn on investment, such as perceived benefit to patients.
Limitations
One major limitation of this study is that it does not ex-
plore how a practice can overcome the barriers to trans-
formation or utilize the available resources to its advantage.
The majority of practices were in the CCI, which provided
both financial and nonfinancial resources to facilitate prac-
tice transformation. In this sense, this study likely represents
a conservative estimate of the barriers to transformation.
This study is also subject to issues of recall bias and bias
associated with the choice to allow practices to determine
who would participate in the survey and follow-up inter-
views. Another important limitation to this study is the de-
sign for the qualitative analysis. Ideally, the semistructured
interview results would have been recorded and transcribed,
but it is possible that practices were more open because they
were not being recorded. Finally, discrimination among the
responses to the semistructured interview would have been
enhanced through an increased range of answers, perhaps on
a 5-point Likert scale. This may have helped to quantify the
variability of effort across the different activities. (The au-
thors thank an anonymous reviewer for making this point
explicitly.)
Table 5. Grouped Theme Frequencies by Practice
No. of times mentioned 0 1–3 4–6 7–10
Workforce changes D,E A,B,C,F,G,H,I–K
Outcomes measurement F A,E,H B,C,D,G,I–K
EMR integration E A,F,G,H B,C,D,I–K
Patient engagement B,C,F,G,H A,D,E,I–K
Care coordination and communication A–K
Implementation barriers C,E,H B,D,F,G,I–K A
Enhanced access E A–D,F–K
Enhanced continuity E,G,I–K A–D,F,H
Medication management A–K
Outside resources A–K
No change A,D B,C,E,F,G,I–K H
EMR, electronic medical record.
VARIATION IN TRANSFORMATION OF PRACTICES TO PCMHS7
Conclusions
These findings regarding the variation in the utilization of
PCMH activities by the sample practices show the need to
further examine transformation of small to medium-sized
practices. These results can be used to improve dissemina-
tion and generalizability of the PCMH model. The practices
could be considered homogeneous in the sense that they
all had fewer than 10 FTE providers, all obtained NCQA
recognition as PCMHs, and most were part of the CCI.
Conversely, these practices could be considered quite het-
erogeneous in that the number of FTE providers and staff
ranged from 4 to nearly 30, practices had different primary
payers, and practices were mixed in terms of whether they
were led by physicians or by nurse practitioners. The study
team sees the transformation to PCMH in the absence of the
type of incentives offered by the CCI as an important area
for future study of the model. Future studies would include
both the amount of such incentives and the design (eg,
capitated [per member per month] payments, shared sav-
ings, quality bonuses).
It is clear that practices chose different routes to obtain
PCMH recognition. Practices also had different views of
that recognition, which the study team determined through
the use of 2 research tools—a survey and a semistructured
interview—in combination with a mixed methods analysis.
It is clear that practices are not adopting certain PCMH
features because they see them as costly—the barriers to
such features, especially for smaller practices, are too high.
Finding ways to further examine these barriers to PCMH
transformation in smaller practices, as well as outlining fa-
cilitators, is key to successful transformation to the PCMH
model in primary care.
Acknowledgments
We would like to thank the practices that participated in
this study. The authors received the following financial
support: This work was supported by an Agency for
Healthcare Research and Quality (AHRQ) grant titled Pa-
tient Centered Medical Home (PCMH) Cost of Sustaining
and Transforming (1-R03-HS022630-01). The content is
solely the responsibility of the authors and does not neces-
sarily represent the official views of the AHRQ. Dr. Kar-
agiannis’ time was supported by a fellowship grant from
Novartis, Inc.
Author Disclosure Statement
Drs. Lieberthal, Karagiannis, Bilheirmer, Verma, Sarfaty,
and Valko, and Ms. Payton declared the following potential
conflicts of interest with respect to the research, authorship,
and/or publication of this article: Dr. Valko reports receiv-
ing payments from the Pennsylvania Chronic Care Initiative
(CCI). However, the Jefferson practice was not enrolled in
this study, and this study was performed after the comple-
tion of the initial CCI, and during the second phase of the
initiative (CCI2).
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Address correspondence to:
Robert D. Lieberthal, PhD
Department of Public Health
University of Tennessee, Knoxville
390 HPER
1914 Andy Holt Avenue
Knoxville, TN 37996
E-mail: rliebert@utk.edu
8 LIEBERTHAL ET AL.
... 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 ...
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The “patient-centered medical home” and the “accountable care organization” are two widely discussed models for delivery-system reform. Drs. Diane Rittenhouse, Stephen Shortell, and Elliott Fisher have identified several strategies for ensuring that these models are mutually reinforcing.
E-mail: rliebert@utk
  • Lieberthal Et
E-mail: rliebert@utk.edu 8 LIEBERTHAL ET AL.
The Pennsylvania Chronic Care Initiative. Paper presented at Academy Health State Health Research and Policy Interest Group
  • P Magistro
Magistro P. The Pennsylvania Chronic Care Initiative. Paper presented at Academy Health State Health Research and Policy Interest Group, February 3, 2009, Washington, DC.