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https://doi.org/10.1177/2050312118781936
SAGE Open Medicine
Volume 6: 1 –15
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DOI: 10.1177/2050312118781936
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Introduction
The patient-centered medical home (PCMH) model of primary
care delivery has taken hold throughout the United States,1 and
practice transformation efforts have proliferated across the
country, yet there remain significant gaps in our understanding
of the processes, roles, and outcomes. Large numbers of prac-
tices 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
What matters in patient-centered medical
home transformation: Whole system
evaluation outcomes of the Brown Primary
Care Transformation Initiative
Roberta E Goldman1,2 , Joanna Brown1, Patricia Stebbins1,
Donna R Parker1,2,3, Victoria Adewale1, Renee Shield4,
Mary B Roberts2, Charles B Eaton1,2,3 and Jeffrey M Borkan1
Abstract
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.
Keywords
Patient-centered medical home, primary care transformation, primary care, evaluation outcomes, quantitative and
qualitative evaluation, health services delivery, health-care delivery
Date received: 9 February 2018; accepted: 17 May 2018
1 Department of Family Medicine, The Warren Alpert Medical School of
Brown University, Providence, RI, USA
2 Center for Primary Care & Prevention, Brown University, Pawtucket, RI, USA
3 Department of Epidemiology, School of Public Health, Brown University,
Providence, RI, USA
4School of Public Health, Brown University, Providence, RI, USA
Corresponding author:
Roberta E Goldman, Center for Primary Care & Prevention, Brown
University, 111 Brewster Street, Pawtucket, RI 02860, USA.
Email: Roberta_Goldman@Brown.Edu
781936SMO0010.1177/2050312118781936SAGE Open MedicineGoldman et al.
research-article2018
Original Article
2 SAGE Open Medicine
that include examination of work roles and processes for
understanding how PCMHs develop and function.2–9 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 achiev-
ing the Triple Aim12 of improved outcomes, better patient
experience, and reduced costs. In recent years, this notion has
been expanded to the proposed Quadruple Aim that recognizes
provider satisfaction as an additional fundamental component
of primary care practice.13 It has become clear over time that
while PCMH core principles have evolved and there is no sin-
gle way to achieve transformation,14 substantive PCMH trans-
formation requires a values culture change, and even
modification in the words used to discuss how primary care is
delivered.15,16
Evaluation and outcomes investigations of PCMH and
other practice transformation initiatives have been problem-
atic for many reasons, including: (1) outcomes have been
largely focused on relatively simple-to-capture “micro-meas-
ures” that provide a reductionist view of PCMH transforma-
tion, such as documentation of HgA1C and blood pressure, or
provide limited understanding of what actually occurred,
such as checking off that smoking cessation counseling was
done;17,18 and (2) reported outcomes of PCMH initiatives
have demonstrated varied efforts and results, with individual
components creating successes or challenges. For example, a
study of PCMH transformation in 30 practices across the
United States documented successful work role innovations
that enhanced team-based care.9 In California, a study of
PCMH “concordant care” found that patients who experi-
enced the three PCMH-related care components of continu-
ity, coordination, and management, also received multi-faceted
high-quality care. Patients who did not experience all three
components received fewer aspects of care that constitute
high-quality primary care.19 Health centers in New Orleans
that undertook more significant PCMH transformation
received higher scores from patients on care coordination.20
Furthermore, primary care settings that serve as teaching sites
of various kinds may experience additional challenges and
opportunities regarding PCMH transformation.21–23
Provider and staff burnout are frequently discussed in
relation to increasing job satisfaction within primary care
practice. Burnout is therefore important to consider in the
context of the hard work of transformation in primary
care.13,24 Findings have varied. In a survey of safety net clinic
employees, staff and providers who perceived their site to
include more PCMH components reported higher morale,
and staff reported increased job satisfaction. However, pro-
viders reported decreased “freedom from burnout.”25 An ear-
lier study comparing a PCMH site with controls found that a
lower percentage of staff at the PCMH reported high emo-
tional exhaustion at follow-up.26 Despite contradictory find-
ings, it is clear that in addition to stress associated with the
change process itself, stress resulting from insufficient
resources to efficiently meet increasing demands for docu-
mentation, along with inadequacy of many electronic health
records to produce the required data, is a significant con-
tributor to burnout.27
The overarching research question for this article is: What
are the evaluation outcomes that provide a picture of whole
system changes from the perspective of patients, providers,
and staff in a facilitated Rhode Island PCMH transformation
intervention? This study was conducted by the Brown
Primary Care Transformation Initiative (BPCTI) in the
Department of Family Medicine at the Warren Alpert
Medical School of Brown University. Our transformation
facilitation team delivered in-depth, on-site facilitation,
working closely with each practice to develop its unique
PCMH transformation plan targeted to the conditions, needs,
and goals of each practice.
New contribution
In an era where change initiatives for delivery of primary
care are widespread, and evaluation is often limited to the
measurement of micro markers of change, this study pro-
vides an example of an effort to obtain a more contextual
understanding of whole system change. With increasing
attention to PCMH as an expected primary care delivery
model, findings from our evaluation study will expand our
understanding of how practices transform and, further, how
stakeholders respond to the change process. Our approach
used quantitative and qualitative methods for the evaluation
of varied primary care practice types. This approach is trans-
ferable to diverse practice settings, with potential for tailor-
ing to address the particular needs of each transformation
initiative.5,28
Methods
Study background
Overview. The BPCTI was a 5-year Health Resources and
Services Administration (HRSA) grant (2010–2015), devel-
oped to facilitate PCMH transformation and training initia-
tives in the state of Rhode Island.28 Our aim was to facilitate
and evaluate change at eight differing types of RI primary
care teaching practices. Data collection for evaluation began
1 year into the study, with most of the first year having been
dedicated to the development of the methodology, staff
recruitment and training, and recruitment of the first prac-
tices. Our philosophy for the facilitation intervention was to
prioritize the voice and experiences of patients in practice
transformation, foster widespread practice engagement and
identification of each practice’s most pressing transforma-
tion needs, and promote culture change within the practice.16
Given the design of this study, which did not offer monetary
performance incentives to the practices, it was essential that
Goldman et al. 3
participating practices express high interest at the outset in
engaging with the hard work required to make changes in
care delivery. Practices recruited into our study chose to par-
ticipate due to their leadership’s interest in how the PCMH
model could enhance the efficacy and efficiency of patient-
centered care. We developed a project description and made
it known across the state through various communication
mechanisms that we were seeking interested practices with
the following inclusion criteria: (1) being a primary care
teaching site for residents and/or medical students; (2) hav-
ing an electronic medical record (or being in the process of
obtaining one); (3) identifying a physician champion for the
PCMH transformation process; and (4) demonstrating moti-
vation to engage providers and staff in transformation. Addi-
tional considerations for overall practice recruitment
included selecting a diversity of primary care practice sizes,
types, and locations in the state. Our project directors met
with leadership of interested practices to gage their eligibil-
ity and commitment prior to inviting them to participate.
PCMH facilitation. The practice facilitation team lead was a
family physician (co-author J.B.), and facilitation staff came
to the project with varying educational and professional
backgrounds, creating a dynamic team environment. To
enhance PCMH transformation facilitation expertise among
our team, a PCMH practice transformation expert was
engaged as a consultant to train staff and guide development
of the facilitation strategies. The BPCTI facilitation team
met weekly throughout the project period to discuss progress
in the practices, review literature and share PCMH tools,
techniques, and innovations, and engage in ongoing training
in a collaborative learning environment. While the approach
to each practice was individualized, these team meetings fos-
tered communication among facilitators and project leader-
ship and standardized our project’s overall approach across
practices. In addition, twice-yearly focus groups with the
entire facilitation team (moderated by the project’s evalua-
tion lead, co-author R.E.G.) added to our ability to explore
how facilitation was progressing over time, and what changes
needed to be made to our practice facilitation and project
staff training plans.
Facilitation began at each practice site with a kickoff
event to which all practice personnel and patient representa-
tives were invited. The kickoff was designed and led in part-
nership with each practice’s PCMH champions. The event
included explanation of the concepts associated in the litera-
ture with the PCMH model, practice leadership articulating
their vision and goals for PCMH transformation, and invita-
tion to the entire practice to brainstorm on further goals and
collaborate on coordinated change initiatives. We encour-
aged patient involvement, and patients often were active par-
ticipants right from the start at the kickoffs.
Facilitators visited the practices regularly throughout the
study period, attended monthly PCMH practice meetings
and were available by email and phone to provide support
services, including assistance with operational innovations
(e.g. instituting open-access scheduling where patients book
same-day appointments), health information technology,
PCMH recognition applications (i.e. National Committee for
Quality Assurance—NCQA),29 communication processes,
team-based care, patient engagement, workflow modifica-
tion, and maintaining motivation for practice transformation.
During particularly intensive periods, a facilitator may have
been in contact with a practice daily, and at other times
would communicate primarily at monthly meetings and
when needed also by email or phone.
Data collection to foster transformation facilitation. Data were
collected that served both to inform facilitation strategies
and to evaluate the practices’ experiences with PCMH
change processes. After the kickoff, extensive observation
was conducted in each practice to develop iterative strategies
to facilitate transformation and promote establishment of
PCMH components in the practices. A baseline PCMH needs
assessment using quantitative and qualitative methods was
conducted, and findings were presented to each practice in a
detailed report addressing the following categories: access to
care, provider continuity, team-based care, adaptive reserve,
care coordination, care management, patient centeredness,
physical plant layout, health information technology, popu-
lation management and workflow. Readiness to change was
assessed with a survey designed by the BPCTI team and
results of this formative, working survey were included in
practice reports. Facilitators met with each practice to review
the findings and assist practices in designing specific, staged
action plans to address outstanding issues and devise pro-
jected timelines. Our facilitation team worked closely with
each practice through observations, consultation and collab-
oration to determine strengths and needs and to engage lead-
ership and staff in developing transformation plans suited to
their unique circumstances.16
Conceptual framework
The assumptions underlying study design, data collection and
analysis, and development of our final interpretation of the
findings stem from insights gleaned from PCMH Evaluation
and Transformation Think Tanks we convened at Brown
University.5,28 The purpose of the Think Tanks was to bring
together international experts on PCMH evaluation and trans-
formation to identify the critical methods, tools, and concepts
for understanding and implementing PCMH transformation
from a holistic perspective. We convened the Evaluation
Think Tank first in order to benefit from the findings prior to
beginning our baseline evaluation work for the study, and to
formulate the conceptual framework that would underlie the
project. The resulting framework5 draws from the Think Tank
discussions and literature on PCMH published at the time.30–
34 The framework holds that in PCMH evaluation it is essen-
tial to obtain a conceptual understanding of not only what
4 SAGE Open Medicine
occurs through PCMH transformation, but also how it occurs
and why, and a study design using both qualitative and quan-
titative methods must be implemented with multiple stake-
holders to explore the transformation environment. Figure 1
illustrates the multiple components identified in the Think
Tanks as underlying a comprehensive approach to transfor-
mation, including the need to consider inputs from the envi-
ronment and prepare components of the “soil” to reap
successful production of the “fruits” of PCMH. This article
discusses a selection of the components that stood out as
especially impactful in this project.
Evaluation methods overview
A baseline and follow-up evaluation study of the eight prac-
tices was conducted to understand how practice providers,
staff and patients understood and experienced the transforma-
tion process, endeavoring to explore, as Crabtree et al.31 rec-
ommend, the “whole system changes.” Evaluation methods
included practice observations; patient, provider, and practice
staff qualitative interviews; surveys for patients, providers,
and practice staff, and periodic focus groups with the facilita-
tion team to discuss progress, barriers, and solutions. Patient
instruments were in English and Spanish. Our evaluation
team met weekly throughout the project period to develop the
evaluation plan, choose methods and instruments, train data
collection staff, monitor data collection, work through prob-
lems, and analyze the quantitative and qualitative data.
Complete details of the evaluation design are described else-
where.5,28 This article reports findings from one provider/staff
survey, two patient surveys, qualitative interviews with pro-
viders, staff, and patients, and the facilitation team focus
groups. Practice observation field notes were used to inform
selection of surveys, development of interview guides, and
practice facilitation plans. Observation data are not reported
in this article. The Memorial Hospital of RI Institutional
Review Board approved the study (#11-24), and informed
consent was obtained for surveys and interviews.
Quantitative surveys
Samples, recruitment, data collection and measures. We
included quantitative measurement tools that were feasible to
implement, validated when possible, and that addressed mul-
tiple areas of practice functioning. Data were collected from
providers, staff, and patients at each practice at baseline, aim-
ing for a range of participant characteristics and then again at
around one and a half years into the transformation process.
Providers included family medicine and internal medicine
residents, independently practicing MDs and DOs, nurse
practitioners, and physician assistants. Practice provider/staff
sample sizes for the total of the two assessment time points
Figure 1. Contextual model of PCMH evaluation components.
Goldman et al. 5
were calculated based on practice employee size. Only the
smallest practices had universal samples, and so the N over
the two time points ranged from 4 to 83. Practice employees
were recruited for surveys in person and through email and
completed the surveys either on paper or through an online
platform. Patient survey sample sizes also ranged based on
practice size, with a total of 58 to 220 for the two assessment
time points. For several weeks over various times of the day
and week, evaluation staff handed paper surveys directly to
patients in practice waiting rooms. Also, practices made
paper copies available to patients who deposited completed
surveys in a locked collection box. All surveys for providers,
staff and patients were completed and returned anonymously.
We used the following survey instruments:
Practice clinician survey. The Maslach Burnout Inventory
(MBI)35 is a 22-item instrument designed to assess three
aspects of burnout: emotional exhaustion, depersonalization
and decreased personal accomplishment. Questions are
answered on a 7-point scale regarding how often respondents
experience symptoms, from 0 = never to 6 = every day.
Patient surveys. The Patient Activation Measure (PAM)36
consists of 13 items that include statements regarding confi-
dence, beliefs, knowledge and skills related to managing
one’s health and healthcare. For each question, there are five
possible responses on the PAM with four that range from
strongly disagree to strongly agree and a fifth response—not
applicable.37 The total score ranges from 13 to 52. Using
Hibbard’s methodology,37,38 the raw scores are transformed
into an activation score ranging between 0 and 100. A higher
score corresponds to a higher level of patient activation.
The Patient Satisfaction Survey5 was developed by the
U.S Department of Health and Human Services Health
Resources and Services Administration and has 25 items
with closed responses and three additional open-ended ques-
tions. For the first 23 questions, patients rate their care in
multiple categories on a scale from 1 = poor to 5 = great; the
final two questions have a yes/no response. Open-ended
questions were included about what patients like best and
least about the practice, and about their suggestions for
improvements.
Statistical analysis. Simple frequencies and percentages were
generated for practice level data. Data collected from
respondents within each practice are often correlated with
each other. To address this potential for correlation, these
data collected from patients, staff and providers were ana-
lyzed using generalized linear mixed models (GLMMs)
adjusting for practice. Since all surveys were collected anon-
ymously, matching of data collected at baseline and follow-
up assessments was not possible. Although this may
introduce some bias in the analysis, the length of time
between assessments (1.5 years) is long enough such that
repeated testing bias is minimal, and respondent turnover
would provide relatively independent samples at baseline
and follow-up. To examine changes between baseline and
follow-up responses, an assessment variable was included in
the GLMM models in addition to adjusting for practice. No
adjustments were made for missing data, since all values
reported had <5% missing items, and most values had <2%
missingness. All analyses were conducted using IBM SPSS
Statistics for Windows v23.
Qualitative interviews and focus groups
Instruments, samples, recruitment and data collection. Qualita-
tive in-depth, semi-structured individual interviews of
approximately 30 min were conducted with PCMH champi-
ons, practice administrators, providers and staff who were
involved in the PCMH process at each site, as well as with
patients. Development of two open-ended question guides
for practice employees and for patients was informed by the
PCMH Evaluation Think Tank discussions, published litera-
ture, and observations in the medical practices. For practice
employees, interviews focused on initial plans for becoming
a PCMH; PCMH attitudes, knowledge and engagement; job
roles; workflow communication; vision for practice transfor-
mation; and perceived barriers and facilitators to change.
Patient interviews addressed patients’ perspectives on the
nature and processes of care they received at the practice. All
questions were pilot tested and modified as necessary.
Practice employees were purposively sampled39 to engage
individuals in all practice roles and those who were involved
in different aspects of the transformation endeavor.
Employees were informed about the study at the initial kick-
off event, through the facilitators’ presence at meetings and
during observation, and through practice-wide emails to
invite participation in interviews. Patients were purposively
sampled in the clinic waiting rooms to include women and
men of all adult ages, and parents of pediatric patients. Data
collection staff approached patients/parents in waiting rooms
at varying times of the day over several weeks to invite them
to participate in an interview in English or Spanish. Patients
who agreed signed the consent form, and an arrangement
was made to meet the patient following conclusion of the
medical visit to conduct the interview in a private room.
Documentation monitored fulfillment of recruitment goals
for participant characteristics. Interviews were audio-
recorded, and interviewers listened to the recordings and
wrote a detailed summary of each session.
Focus groups with the entire facilitation staff were con-
ducted and recorded by the evaluation lead approximately
every 6 months. An open-ended question guide was created
to explore how the staff perceived their changing facilitation
role over time, barriers they encountered at the practices, and
solutions they devised.
Qualitative analysis. For qualitative data analysis, we used
immersion/crystallization40 processes with our conceptual
6 SAGE Open Medicine
framework for understanding the multiple dimensions of
PCMH transformation from the perspectives of different
stakeholders. This involved: (1) two co-authors listening to
the interview and focus group recordings and reading the sum-
maries while taking further analytic notes to extract data and
specific quotes relevant to discerning elements of the practice
culture and other factors that might impact the transformation
process; and (2) periodic larger project team group discussions
of the data to discuss patterns that emerged from the individual
analyses, identify variations in interpretation possibilities, and
to arrive at final interpretation and selection of illustrative
quotes for presentation of the findings. Insights from the inter-
view analyses were included in the reports provided to each
practice. Furthermore, findings from the focus groups with
facilitation staff were used to adjust facilitation and on-going
staff training strategies as we moved through the project.
Results
Provider and practice characteristics
The eight recruited practices were family medicine and internal
medicine outpatient residency training sites at a Brown
University-affiliated hospital, and six community-based RI pri-
mary care teaching practices that precepted medical students
and/or residents for time-limited rotations: two community
health centers, one micro-practice with two part-time family
physicians, one single physician practice with a nurse, one
multiple family physician practice with nursing and other staff,
and one college health service. Table 1 presents characteristics
of the providers and practices. The majority of providers (83%)
were under 50 years of age and were female (73%). Of the prac-
tices, 25% were solo practices, 25% were residency training
practices and the other practices included community health
centers, multiple physician/staff, and collegiate health services.
Quantitative surveys
Patient demographics. Table 2 presents a summary of patient
participant (n = 415) characteristics at baseline and follow-up.
Mean age was 37 years, and about 77% of the independent
samples of patients were female at both surveys. About 15%
of the baseline population and 18% of the follow-up group
were Hispanic. Whites comprised about 70% at both time
points.
Patient satisfaction survey. The Patient Satisfaction Survey
questions were grouped in categories, and results are pre-
sented as composites in each category5 (Table 3). Overall,
patient satisfaction scores were high at baseline and follow-
up. The survey categories with the lowest mean scores were
“Waiting” and “Payment,” while the categories with the
highest mean scores were “Confidentiality” and “Nurse and
Medical Assistants.” Total satisfaction (composite score) on
this survey increased (p = 0.04) and one of the nine subscales,
“Satisfaction in the Facility”, demonstrated a statistically
significant improvement (p = 0.03) from baseline to follow-
up. Improvement in the subscale “Ease of Care” trended
toward significance (p = 0.06).
PAM. Table 3, final row, shows an overall, statistically sig-
nificant decrease from baseline to follow-up in patient acti-
vation (p = 0.01).36 When stratifying by type and size of
practice, this change was statistically significant only for the
college health service (p = 0.01).
MBI. Primary care providers, nurses and other clinical staff
completed the MBI.35 Table 4 shows that in the three sub-
scales of emotional exhaustion, depersonalization,
Table 1. Characteristics of providers and practices.
Provider characteristics (n = 56) Frequency (%)
Age (years)
<50 46 (82.1)
>51 10 (17.9)
Gender
Female 41 (73.2)
Race/ethnicity
White 33 (58.9)
Other 23 (41.1)
Practice information (n = 8) Frequency (%)
Type of practice
Solo or micro-practice 2 (25.0)
Community health center or
multiple physician/staff
3 (37.5)
Residency training 2 (25.0)
Collegiate health services 1 (12.5)
Registries in use (diabetes,
COPD, cancer)
3 (37.5)
NCQA certified 4 (50.0)
Open access 5 (62.5)
Precept medical students/
residents in the practice
8 (100.0)
COPD: chronic obstructive pulmonary disease; NCQA: National
Committee for Quality Assurance.
Table 2. Patient survey respondent demographics*.
Baseline (n = 415) Follow-up (n = 415)
Age (mean (SE);
range = 18–92 years)
37.3 (4.5) 36.8 (4.6)
Female (n, %) 320 (77.1) 318 (76.6)
Race (n, %)
Asian 18 (4.3) 21 (5.1)
Black 28 (6.7) 31 (7.5)
White 293 (70.6) 274 (66.0)
Other 76 (18.3) 89 (21.4)
Hispanic (%) 58 (14.0) 73 (17.6)
*Values presented are adjusted for within practice correlation.
Goldman et al. 7
and personal accomplishment, emotional exhaustion and
depersonalization increased slightly and personal accom-
plishment decreased slightly, although it was not statisti-
cally significant. Clinical staff had slightly higher levels of
emotional exhaustion than the national mean, lower levels
of depersonalization, and higher levels of personal accom-
plishment. Stratifying by role, emotional exhaustion, and
depersonalization were considerably higher at baseline and
follow-up for providers compared to nurses and other clini-
cal staff, and these differences between roles regardless of
time point were statistically significant (p < 0.01). Personal
accomplishment did not exhibit the same extent of
difference by role. Compared to nurses and other clinical
staff, providers had somewhat higher levels of personal
accomplishment at both baseline and follow-up, but this dif-
ference was not statistically significant (p = 0.36).
Qualitative interviews
In total, 95 interviews were conducted with patients; 78 with
practice staff (including nurses, medical assistants, and
administration and pharmacy staff); 42 with physicians
(including residents at the family medicine and internal med-
icine residency practices); and 4 with nurse practitioners and
Table 3. Patient survey results—total scores and subscales.
HRSA Patient Satisfaction
Survey
Baseline (n = 415) Follow-up (n = 415) p value
Mean** SE** Mean** SE**
Total satisfaction*
(range = 7–49)
33.21 0.40 34.03 0.51 0.04‡
Ease of care 4.14 0.09 4.24 0.08 0.06§
Waiting 3.81 0.11 3.87 0.14 0.49
Provider 4.45 0.07 4.48 0.08 0.67
Nurse & medical assistants 4.53 0.05 4.51 0.07 0.78
Staff 4.40 0.09 4.47 0.07 0.20
Payment 3.93 0.11 4.11 0.12 0.19
Facility 4.46 0.06 4.51 0.05 0.03‡
Confidentiality 4.60 0.05 4.64 0.05 0.29
Patient Activation Measure
(PAM)
(range = 0–100; median = 63)
65.68 1.35 63.12 1.74 0.01‡
HRSA: Health Resources and Services Administration.
*Higher scores indicate greater satisfaction.
**Values presented are adjusted for within practice correlation.
‡p ≤ 0.05.
§p > 0.05 but less than 0.10.
Table 4. Provider and staff burnout—Maslach Burnout Inventory (MBI) results*.
MBI Scale Personnel Baseline (n = 161) Follow-up (n = 104) National
Mean (SE)*** Mean (SE)*** Mean
Emotional
exhaustion
All clinical staff 21.10 (1.79) 21.58 (1.30) 20.54
By role**
Nurse/staff 18.97 (1.92) 18.45 (0.75)
Provider 24.41 (1.10) 25.09 (1.22)
Depersonalization All clinical staff 5.74 (1.31) 6.03 (0.97) 7.18
By role**
Nurse/staff 4.25 (0.56) 3.79 (0.48)
Provider 8.02 (1.24) 8.54 (0.57)
Personal
accomplishment
All clinical staff 39.12 (0.56) 38.45 (0.56) 36.42
By role**
Nurse/staff 38.87 (0.85) 37.87 (0.70)
Provider 39.50 (0.78) 39.09 (0.98)
*MBI scales were not statistically different between assessments (baseline vs follow-up).
** There were no differential changes over time by role (interaction between role and assessment). There is an overall significant difference by role for
the emotional exhaustion (p < 0.01) and depersonalization scales (p < 0.01).
***Values presented are adjusted for within practice correlation.
8 SAGE Open Medicine
2 with physician assistants at the one practice that employed
these types of clinicians.
Patient perceptions of their primary care practice
Satisfaction. Across the eight healthcare sites, patients
expressed high satisfaction with their care and said they
would recommend their primary care practice to others. As a
patient commented, “I can switch at any time, but I’m com-
fortable here. The doctors here know about me. It’s nice.” A
patient in another practice asserted, “This is the way health-
care should be, and you don’t find that everywhere.”
Recognition of PCMH components. While patients were
not explicitly aware that their primary care practice was
a PCMH, they described aspects of practice functioning
that align with the PCMH model. Patients across practices
expressed recognition of and appreciation for staff team-
work, for example: “They’re my own little team, they’re
on the same page.” Another patient said she “saw the front
desk working together” to make her appointment. Patients
of the smaller practices in particular noticed team-based
care: “It seems that work is seamless … I have put in vol-
unteer time [at the practice] and seen them work together
very well.”
Coordination of care with outside providers was variable
across practices and appeared to function better in smaller
practices:
I see [my primary care physician] less frequently than I see my
[specialist] and I walk in here today, and she’s like, “I already
have everything.” So I don’t have to track down blood lab
results and tests. Everyone communicates really well.
In contrast, a patient from a larger practice expressed
frustration about the communication between her psychia-
trist and her primary care physician: “I think that would be a
good idea if they were more in sync with each other … espe-
cially with what I went through with lost paperwork and
stuff. It should all go into the computer.” Some patients were
concerned about patient flow and communication with non-
clinical staff. Long wait-time was a frequently mentioned
source of frustration, except for patients at the micro-prac-
tice. Receptionists, often harried by the multiple tasks they
simultaneously perform, were at times seen as unaccommo-
dating and “not too friendly.” As one patient explained, “[I
wish they were] showing a little more compassion, being in
the medical fields. Just because you’re a receptionist doesn’t
mean you’re just a receptionist.”
Continuity with providers is a PCMH component that
patients appeared to value highly, though only some of the
practices prioritized continuity. A patient who wished she
had a doctor “assigned to her” felt that since her doctor
changed “every six months,” her care was not as good as if
she had one doctor who “knows all of your case because they
are there with you all the time.” Another patient explained, “I
don’t like being told that we’ll continue talking about an
issue next time, only to have it be a different doctor next
time.”
Communication with providers. Patients felt that they were
able to communicate well with their primary care providers,
and that their providers involved them in health-care deci-
sion-making. This was particularly so in the small practices
where they felt they received high-level personalized care:
It’s great because the doctors here are very responsive. You
never get a sense that they’re rushing or not spending enough
time with you. [My doctor] is happy to answer all of my
daughter’s questions and explain everything as she is going
along.
I’m always involved in the decisions … They’re very receptive
to that and I know I can always put forth how I feel about what
I like to do care-wise.
I am treated as a person and not a number. I’ve been to other
practices where it is like an assembly line and I don’t like that.
[Here] I am not rushed.
Patients throughout the practices felt well-informed about
the various implications of treatment options and were espe-
cially appreciative when they thought that the decisions were
left up to them. One asserted, “[My doctor] asks me to do a
lot of things, and I say “No.” She accepts it and tells me the
pros and cons.” Another explained, “The doctor will tell you
what they recommend, but will not demand it.”
Provider and practice staff perceptions of PCMH
Impact of participating in the PCMH initiative and receiving
in-person transformation facilitation. Practice employees noted
that as a result of the facilitation process, they have a “new
mind-set,” and “it reinvigorated everyone.” The practices
became “aware and awake” to issues that were long plaguing
daily workflow, but that had not previously been adequately
recognized, discussed and addressed. Some claimed that the
facilitation process enabled the development of improved
communication strategies, which in turn resulted in the for-
mation of better relationships through all levels of the prac-
tice, as a medical assistant explained: “More communication
on an even basis—not ‘Oh, you’re the doctor’.” In addition,
practice employees claimed that through the transforma-
tion facilitation, more staff beyond the PCMH champions
became “on board” with the PCMH initiative, new programs
and policies were established, and a heightened focus was
placed on establishing strategies for patient-centeredness. In
contrast, some providers and staff were dismissive about the
special nature of PCMH, for example: “This is a place that is
always changing. If it’s not PCMH, it’s always something.”
Knowledge and recognition of PCMH transformation. Many
providers and staff were familiar with the jargon and catch-
phrases associated with the PCMH model but did not grasp
Goldman et al. 9
the gestalt of what it means to be a PCMH. Even among
those who valued PCMH, many still had doubts at the fol-
low-up point about the overarching goals of the model:
PCMH feels sometimes so nebulous. Impossible to grasp or
achieve. But I think the important thing is that you generally try
to bring things up to speed in terms of meaningful use and using
your [electronic] medical record. And take little pieces of
[PCMH] and try to attack it … But when we rolled out the new
health center we were able to brandish PCMH as something that
we wanted to embody. And it’s not just idle words to be able to
offer something to people and say, “We’re really current, and
this is what we do.” (Physician)
Most providers and staff initially reduced the PCMH
model to specific elements, such as hiring a nurse care man-
ager, struggling to apply for and achieve NCQA recognition,
and the on-going burden of documentation and outcomes
reporting. In the follow-up interviews, many still associated
PCMH with particular components, but at this later point
these were process-oriented elements, such as having regu-
larly scheduled PCMH meetings, creating mechanisms for
team-based care, establishing the norm of morning team
huddles, routinizing medication reconciliation, establishing
an open-access appointment system, figuring out how to best
integrate a nurse care manager in the practice, and using
patient satisfaction data to drive practice improvements.
At some sites where implementation of PCMH features
became routine over the course of the study period, providers
and staff no longer identified these practice elements as
PCMH innovations. This indicates that at least some compo-
nents of PCMH were becoming institutionalized within the
practices:
PCMH is rolled in. So when we had operations meetings today,
many things on the agenda, I mentioned pods. I think that’s the
way it should be. Because if you isolate it and say, “This is
PCMH and this is the time we’re going to talk about it,” that’s
okay when you’re starting, but now it has to encompass
everything you’re doing. And I think it’s demonstrated very well
in all of our meetings. (Practice manager)
I feel really lame that I don’t know precisely how PCMH is
proceeding. My sense is that it’s almost been folded into PI
[practice improvement]. And it’s now just a part of that
bi-weekly PI and health leadership operations amalgam that
we’re sort of doing, which I think maybe is good. Maybe that’s
something PCMH is. Rather than being a specific meeting, it’s
being sort of absorbed. (Nurse)
Leadership and staff involvement in PCMH transforma-
tion. Each practice differed in regard to how, in actuality,
the transformation initiative went forward. Variations among
practices included which roles in the practice the champion(s)
held (e.g. physician owner/partner, physician employee,
nurse, and office manager); how the champion(s) initially
engaged and sustained engagement of other providers and
staff; and to what extent and in what ways staff embraced the
PCMH goals, were involved in the early stages of the trans-
formation process, and remained involved. This was evident
in the baseline interviews and persisted in follow-up inter-
views with little consistency within practices, as employees
and even champions in the same practice expressed dispa-
rate views of which aspects of PCMH transformation were
needed and had been accomplished.
Attitudes toward PCMH. Across sites, most of the provid-
ers and staff had at least partially positive attitudes toward
PCMH, although most also harbored reservations about the
model, and frustration with the extra work implementation
involves. Concerns included the perception that a fully suc-
cessful PCMH requires a tremendous amount of change that
is impossible to achieve and conversely, that PCMH is a
new name for what good primary care has always been. For
some, confusion lingered, as they continued to view PCMH
not as a transformative process, but as a concrete entity—the
monthly meeting, or specific people associated with PCMH.
For example, a nurse referring to the changes in member-
ship on our facilitation team over the course of the project
explained that her practice had difficulty keeping track of
“who PCMH is.” Others equated PCMH with NCQA rec-
ognition and the accompanying burden of data reporting
and establishing NCQA-required protocols. When providers
reduced PCMH to specific, disjointed components and did
not view them as contributing to a broader whole leading to
an environment of enhanced patient care, they were discour-
aged. A physician wearily commented, “They tell us ‘This
is the requirement: PCMH wants us to do this and this’.”
Another expressed that PCMH is “jumping through the
hoops” of NCQA. A physician who had recently completed
the NCQA application and its required practice modifica-
tions asserted, “PCMH has been a distraction to the things
we really would like to implement.”
Despite these many concerns, providers and staff in all of
the practices felt that at least ideally, the PCMH model has
positive potential.
Moving into [the PCMH] model is absolutely the way to go for
patient satisfaction and efficiency. It makes sense for the same
group of people to work with the same clientele. You get to
know them and their needs more intimately. You’re able to
huddle as a care team and look at what is coming up for the day
and have everything ready to make the process as efficient as
possible. (Physician)
Persisting challenges to PCMH implementation. Practice
providers and staff described a variety of challenges that
they grappled with throughout the study period and that
persisted, at least to some extent, at the time of follow-up
interviews. Even though all providers and staff were invited
to the kickoff and subsequent regularly scheduled PCMH
meetings, they did not equally internalize the PCMH model
nor understand how it related to needed changes in their
10 SAGE Open Medicine
practice. Therefore, embracing the transformation goals and
taking the time to work with their colleagues and our facili-
tators to develop strategies for transformation implementa-
tion and maintenance was uneven both across and within
practices. At one large practice, multiple staff explained
that some changes that were established by protocol modi-
fications were not sufficiently communicated throughout
the practice, and other changes that were tried simply fell
by the wayside over time. In small practices, the PCMH
principle of physician leadership6 was given, as there were
few or no employees. In larger practices, PCMH leadership
varied and was sometimes shared to include practice manag-
ers, an executive director, a quality improvement nurse, or
a physician medical director. At a university health service,
PCMH champions were designated from each clinical role
at the site. Practice employees considered shared leadership
to be beneficial, though it took concerted effort within the
practices to maintain.
Despite efforts and intentions for inclusion, in the larger
sites, it was more difficult for staff to understand and estab-
lish their roles in PCMH transformation. Reconfiguring
long-held job roles was difficult at some sites where staff
may have been excited by the new opportunities, yet con-
cerned about taking on new responsibilities themselves or
allowing others to do so. One nurse explained this difficulty,
stating, “Nurses needed to find their niche in the PCMH.” A
nurse who had encountered resistance noted, “People don’t
want to change.” A physician champion stated that while
leadership support is essential, he believed that it is easier to
bring the non-physician staff into the change process first,
and physicians will follow more agreeably once the change
is somewhat established.
When practices instituted mechanisms to encourage all
staff to “work to the top of their license,” as the frequently-
heard PCMH concept for leveraging the potential of every
member of the team is phrased, it meant, according to medi-
cal assistants, that they had to take on “extra work.” Chronic
understaffing in larger sites complicated this process and
also limited the time and energy that staff had to devote to
PCMH activities. On the positive side, the PCMH model
improved communication and promoted inclusiveness, as a
medical assistant explained: “Instead of throwing directives,
[the practice is] making [medical assistants] a part of the
team and saying ‘Listen, this is what happens to a diabetic’s
eye’.”
Incorporating patient engagement, another vital compo-
nent of the PCMH model, was a challenge for all practices.
One practice had a patient advisory board that periodically
met through the year, all practices solicited patient satisfac-
tion feedback through surveys (as is required by NCQA), but
none felt that they were adequately engaging patients in their
PCMH efforts. A nurse practitioner commented in the fol-
low-up interview that she still hoped to enhance patient
engagement in the future “to creatively address some things
we haven’t thought about yet.”
Finally, structural and process components of transforma-
tion constituted persisting barriers to full implementation of
desired innovations, such as finding ways to make the open-
access system function well for both patients and practice
workflow. Open access was considered one of the hallmark
modifications associated with the PCMH model and some of
the practices put in great effort to convert to this system.
However, it was difficult to handle the volume of patient calls
flooding the receptionists’ telephone lines first thing in the
morning, and the available slots quickly filled up each day
without accommodating all patients needing appointments.
In addition, for those patients who needed language interpre-
tation, the open-access system precluded the necessary pre-
booking of interpreters who are external to the practices. One
of the larger practices worked through the kinks in their open-
access system over time and deemed it successful.
Practice achievements in PCMH transformation. Despite the
barriers and difficulties encountered by practices in imple-
menting practice changes consistent with the PCMH model,
providers and staff described many areas of success. As one
provider said of her practice after working on PCMH trans-
formation, “We are prepared not only to meet the provider
needs but also the patient needs.” The successful change
components were not uniform across the eight study sites
because the objective of our project was to facilitate the
practices in identifying and implementing needed changes
specific to their own practice conditions. Table 5 provides
the types of PCMH-related changes achieved among the
practices as a whole. Each practice accomplished a selection
of these components.
Facilitation staff perceptions of their role and their work. Over
the course of periodic focus group discussions with the facil-
itation staff, they explained that their job required flexible
role identities as they shifted between being participant
observers of interactions within the practices, data collectors
to understand how the practice functioned, and advisors. As
one facilitator noted, “We’re kind of a reflector and also a
resource.”
Facilitators saw themselves as variously information,
resource, technology and conflict resolution specialists.
They were teachers, problem solvers, organizational counse-
lors and motivational coaches. Irrespective of background,
age and amount or type of facilitation training received, all
staff felt their confidence increased through on-the-job expo-
sure and being initially paired with more experienced
facilitators:
When I started as a facilitator … I had to meditate, or I had to
really, really work on my own presence because I felt like I was
jumping into this milieu where there was all this tension, and
conflicts and background … As sort of a coaching figure I had
to be together and supportive, no matter what. And it drew a lot
[from me]. And then, as I got more comfortable, I don’t have to
do that as much anymore. (Facilitator)
Goldman et al. 11
They cited persistence, patience, appreciation of site
uniqueness, and the need to curb their tendency to prescribe
an agenda as essential for gaining trust and meaningfully
engaging busy practice providers and staff in the transforma-
tion effort:
What is my role? Am I taking the lead enough in the meetings
that I have at [the practice]? Am I standing back too much? Am
I letting them drive it? I should be, but I still feel like they’re not
very straight drivers … (Facilitator)
Each facilitator worked with more than one practice, and
because the practices had different goals and approached
their change initiatives differently, varied facilitation tech-
niques were used. Facilitators asserted that transparent com-
munication, maintenance of relationships, and in-person
interactions with PCMH champions from every practice role
were critical for promoting progress and fostering movement
of providers’ and staff’s focus away from the burdens of
PCMH and toward embracing the potential of PCMH for
enhancing patient care. As one facilitator explained later in
the project period:
I can see sites thinking about how they can make their patient
experience better, not just focusing on if their NCQA is up
to date. There’s a patient at the other end of that measure, and
I think a lot of our [practices] get that more and more.
(Facilitator)
Discussion
Facilitation and transformation
While best practices for PCMH implementation have been
promoted, it has also been recognized that a single facilitation
design or PCMH content list will not suit all PCMH
endeavors.41–45 Our evaluation of eight varying types and sizes
of primary care practices, using both quantitative and qualita-
tive methods, attempted to identify elements of PCMH trans-
formation processes that were important to providers and staff
and that may influence patients’ experiences. Providers and
staff in our study described the effect of the on-site PCMH
transformation facilitation process as both adding to and
detracting from the essence of how they perceive their practice.
For some staff, PCMH had such a concrete presence that it was
associated with particular facilitation staff from our team or
meetings those facilitators convened. For others, PCMH dis-
cussions and processes had become less tangible, as these
became more integrated into normal practice functioning, and
practice staff even wondered if enough explicit attention was
still paid to PCMH. While a goal in PCMH is for change efforts
to eventually become routinely implemented, transformation
in thinking and transformation in action are necessarily itera-
tive processes that must be re-evaluated as practice needs and
the healthcare environment evolve. Consequently, a risk asso-
ciated with complete routinization is that the on-going iterative
process of PCMH transformation at the practice may stall, as
special attention to PCMH is no longer considered necessary.
Transformation goals gradually drop off the radar during eve-
ryday workflow and meetings, and providers and staff may not
recognize that this has occurred.
Patients’ attitudes toward PCMH
Shifts in attitudes about PCMH were less dramatic among
patients than among practice employees, possibly because
the PCMH model promotes changes in care and operations
that are less visible to patients46,47 and occur in the back-
ground of the care experience. A prime example is our find-
ing that the two patient satisfaction survey subscales with
significant increase regarded the more identifiable elements
of “satisfaction in the facility” and “ease of care.” Patient
satisfaction was high overall, which is similar to findings
from a study by Hochman et al.48 who reported that a PCMH
intervention model emphasizing continuity, coordination,
and quality of care at a teaching clinic had favorable effects
on patient satisfaction. Patient activation was found to
decrease from baseline to follow-up in our study, although
surveys were completed by different patients and this
requires further investigation.
Provider and staff attitudes toward PCMH
Regarding providers and practice staff, our survey analyses
identified changes in attitudes and perceptions about PCMH
Table 5. Types of PCMH transformation components achieved
among the practices*.
Enhanced team-based care
Establishment of daily morning huddles to discuss the day’s
scheduled patients
Nurse follow-up of doctor visits
Nurse provision of patient education
“Boot camp” sessions to train medical assistants to take on
more responsibilities and work to the top of their license
Restructure of a large practice into a pod system: proximity
of all levels of clinicians improved both provider/staff
communication and care
Deliberate empanelment which facilitated improved continuity
of care and enhanced patient–physician relationships
Systematized, routinized medication reconciliation review
More effective use of the electronic health record, including
for population health management
Creation of an electronic patient portal
Institution of online patient self-scheduling within an existing
patient portal
Instituting an open access, same-day appointment system
Establishing and expanding behavioral health services within
the practice
Redesign of waiting room to improve confidentiality
Redecoration of waiting room to improve inclusion of diverse
ages, genders, races/ethnicities
*Each practice achieved some, but not all, of these PCMH components.
12 SAGE Open Medicine
similar to findings from Solimeo et al.,49 where primary care
providers were enthusiastic but still noted challenges in align-
ing PCMH ideals with clinical practice. Our participant pro-
viders and staff valued the PCMH concept in principle but
were concerned about persistent barriers to implementation
and the burden of PCMH recognition (i.e. NCQA) require-
ments. Our facilitation team worked closely with practice
providers and staff to identify, think through, and formulate
solutions to barriers, but for some barriers such as understaff-
ing, successful solutions were not forthcoming. All of the
practices in our study exhibited progress in some of the tenets
associated with successful PCMHs, although each according
to its particular circumstances had developed different sub-
sets of these PCMH elements for their innovations.
A study in the Veterans’ Health Administration system
found that while survey respondents had an overall positive
attitude toward the PCMH, researchers identified multiple
barriers including understaffing, low team efficacy, and
stressful work environment contributing to higher feelings of
burnout.50,51 Stress and burnout are commonplace among
providers in the United States, with more than half of those
surveyed in 2014 claiming burnout.52 While the PCMH aims
to improve practice functioning, our MBI results and other
studies demonstrate that the change process itself can wear
on providers and staff, and perhaps more so on providers
than staff. 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 par-
ticipation 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.53–55 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. During
the course of our study, several of these practices joined
Rhode Island’s all-payer PCMH initiative that provided pay-
ments for intensive documentation and reporting for specific
patient outcome benchmarks. Other factors outside the scope
of our intervention were staffing and workflow challenges
which can diminish the positive benefits of implementing
particular PCMH components, such as effective teamwork
and morning huddles.56–58
The presence of engaged PCMH leaders within the prac-
tice is a basic necessity for achieving transformation,59 and
as others have found,60 provider and staff engagement
beyond the designated PCMH champions was a challenge to
achieve and sustain in our larger practices. Some PCMH fea-
tures such as routinized medication reconciliation or
morning huddles were deemed by providers and staff in our
study to enhance quality; while some requirements such as
the process of NCQA application were seen as consuming
time that could be better spent doing direct patient care. As
Wagner et al.59 assert, PCMH transformation is necessarily
disruptive to the work of providing patient care. Wagner’s
study of three practices that successfully underwent transfor-
mation found that the primary motivator for engagement
with the process was their desire to improve quality of care
and patient or provider experience, rather than the financial
incentive. Similarly, as the practices in our study received
only a small, one-time payment, we sought to recruit prac-
tices inherently interested in enhancing patient-centered care
to improve the experiences of receiving and delivering qual-
ity care.
PCMH in varying types of teaching practices
The practices in our study were teaching practices of several
different types. Our transformation time-frame occurred rel-
atively early on in PCMH adoption in the United States, and
as Clay et al.61 note, teaching about PCMH while providers
and staff are still learning about the concepts has substantial
challenges. It is also essential to consider the impact of resi-
dency or medical student training on PCMH transforma-
tion62 and how hosting students and trainees in private
teaching practices may impact the practices’ ability to engage
in the labor and resource intensive process of PCMH imple-
mentation. What has become clear over time is that new edu-
cational models are required to adequately equip faculty and
learners to practice effectively in medical homes, including
the use of panel management and other population health
strategies.63–69
Limitations
This study has several limitations. Evaluation of patient clini-
cal outcomes was beyond the scope of this project. We did not
document the specific doses of each aspect of the facilitation
that individual practices received. Many of the providers and
staff were the same at baseline and follow-up but not all were
the same due to staff changeover. Patients who participated at
baseline were not the same patients at the follow-up time
point. Each practice underwent a unique transformation pro-
cess, and the study design did not include providing recruited
practices with per-member/per-month payment for achieve-
ment of clinical benchmarks. While provision of such pay-
ment is typical of many PCMH transformation efforts, a
strength of our approach is that our study was not tied to an a
priori set of outcomes. Each practice underwent a unique
change process driven by its own needs and so progress
among practices was not comparable; however, this strategy
allowed our facilitation team to tailor their work with prac-
tices and focus on the PCMH components that each practice
deemed to be critical. Finally, our quantitative findings are
Goldman et al. 13
based on results obtained from eight practices; to increase the
power of our findings will require a larger number of prac-
tices for further evaluation.
Conclusion
PCMH transformation in our participating practices took dif-
ferent routes and focused on different types of changes.
Despite these differences, themes indicating both the on-
going challenges and potential rewards of PCMH transforma-
tion endeavors emerged. Strong, practice-wide communication
about on-going transformation plans and newly implemented
protocols, as well as maintaining provider and staff engage-
ment can be problematic but are essential for fostering sus-
tained PCMH efforts. At the same time, when chronic
understaffing occurs in primary care practices, the ability and
interest of staff to “work to the top of their license” is impeded.
Internalization of exactly what PCMH is remains difficult, as
varying conceptualizations about the concept and its pro-
cesses persist. In addition, patient engagement is an acknowl-
edged component of importance that is challenging to
implement adequately. At this time, PCMH initiatives and
evaluation studies are widespread, yet objectives for the
PCMH continue to evolve.7 With continuing development of
PCMH facilitation, implementation and whole systems eval-
uation approaches, the benefits of PCMH may eventually
come to outweigh the tribulations of transformation processes
that have led to provider and staff burnout and persisting frus-
tration with the concept of PCMH as a whole.
Acknowledgements
The authors would like to thank all of the providers, staff, and
patients in the participating primary care practices who collabo-
rated with them on this project, and who gave them access to the
inner workings of their practices to understand their PCMHs in the
context of change. They would also like to thank the attendees of
the Brown Evaluation and Transformation Think Tanks for their
contributions to the creative discussions that the authors considered
as they designed this project.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Ethical approval
Ethical approval for this study was obtained from Memorial
Hospital of Rhode Island Institutional Review Board, approval
#11-24.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
work was supported by the Health Resources and Services
Administration (HRSA), grant no. 1D54HP20675-01-00.
Informed consent
Written informed consent was obtained from all patients, providers,
and staff prior to the qualitative interviews. The authors initially
prepared written consents for the surveys as well, and submitted
them to the IRB committee for review. The Memorial Hospital of
Rhode Island, in its full board review, then deemed the de-identi-
fied surveys that also did not collect any protected health informa-
tion, to not require written consent.
ORCID iD
Roberta E Goldman https://orcid.org/0000-0001-7801-0530
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