Trends in Quality During Medical Home Transformation

HealthPartners Research Foundation, Minneapolis, Minnesota 55440-1524, USA.
The Annals of Family Medicine (Impact Factor: 5.43). 11/2011; 9(6):515-21. DOI: 10.1370/afm.1296
Source: PubMed


PURPOSE We describe changes over time in performance on measures of technical quality and patient experience as a group of primary care clinics transformed themselves into level III patient-centered medical homes. METHODS A group of 21 Minnesota primary care clinics achieving level III recognition as medical homes by the National Committee for Quality Assurance has been tracking a variety of quality and patient satisfaction measures for years. We analyzed trends in these measures and compared them with those of other medical groups in the community to estimate what we might expect as other primary care sites gear up to achieve medical home status. RESULTS The clinics in this group achieved a 1% to 3% increase per year in patient satisfaction and a 2% to 7% increase per year in performance on quality measures for diabetes, coronary artery disease, preventive services, and generic medication use. When compared with the average for other medical groups in the region, the rates of increase were greater for satisfaction, but similar for the quality measures. CONCLUSIONS Achieving medical home recognition was associated with improvements in quality and patient satisfaction for these clinics, but the rate of improvement is slow and does not always exceed levels in the surrounding community in Minnesota (which are also improving). Expectations for large and rapid change are probably unrealistic.

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Available from: Thomas J Flottemesch
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    • "PF occurs when a trained facilitator provides support services to a primary care practice for an improvement initiative. The PF approach enables teams to overcome challenges encountered when implementing changes in the office setting by building their internal capacity to engage in redesign or improvement efforts [4]. Facilitators assist teams within the practice as they identify and prioritize areas of change as well as help them develop tailored action plans for improvement. "
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    ABSTRACT: Practice facilitation (PF) is an implementation strategy now commonly used in primary care settings for improvement initiatives. PF occurs when a trained external facilitator engages and supports the practice in its change efforts. The purpose of this group-randomized trial is to assess PF as an intervention to improve the delivery of chronic illness care in primary care. A randomized trial of 40 small primary care practices who were randomized to an initial or a delayed intervention (control) group. Trained practice facilitators worked with each practice for one year to implement tailored changes to improve delivery of diabetes care within the Chronic Care Model framework. The Assessment of Chronic Illness Care (ACIC) survey was administered at baseline and at one-year intervals to clinicians and staff in both groups of practices. Repeated-measures analyses of variance were used to assess the main effects (mean differences between groups) and the within-group change over time. There was significant improvement in ACIC scores (p < 0.05) within initial intervention practices, from 5.58 (SD 1.89) to 6.33 (SD 1.50), compared to the delayed intervention (control) practices where there was a small decline, from 5.56 (SD 1.54) to 5.27 (SD 1.62). The increase in ACIC scores was sustained one year after withdrawal of the PF intervention in the initial intervention group, from 6.33 (SD 1.50) to 6.60 (SD 1.94), and improved in the delayed intervention (control) practices during their one year of PF intervention, from 5.27 (SD 1.62) to 5.99 (SD 1.75). Practice facilitation resulted in a significant and sustained improvement in delivery of care consistent with the CCM as reported by those involved in direct patient care in small primary care practices. The impact of the observed change on clinical outcomes remains uncertain. Trial registration This protocol followed the CONSORT guidelines and is registered per ICMJE guidelines: Clinical Trial Registration Number: NCT00482768.
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    • "It includes the chronic care model of proactively organizing care, and emphasizes supportive payment mechanisms (American Academy of Family Physicians, 2007). Early evidence suggests that a successful PCMH implementation lowers costs through reduced use of emergency department and inpatient services (Gilfillan et al., 2010; Reid et al., 2009, 2010), prompting health care leaders and policymakers to explore the PCMH model as a way to control costs, improve quality, and create more positive patient and provider primary care experiences (Berenson et al., 2008; Bodenheimer et al., 2002; Grumbach & Bodenheimer, 2002; Rosenthal et al., 2010; Solberg et al., 2011). For the PCMH to fulfill its promise in addressing cost and quality challenges, (Grumbach & Bodenheimer, 2002; Institute of Medicine, Committee on the Future of "
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    ABSTRACT: Health care leaders and policymakers are turning to the patient-centered medical home (PCMH) model to contain costs, improve the quality of care, and create a more positive primary care work environment. We describe how Group Health, an integrated delivery system, developed and implemented a PCMH intervention that included standardized structural and practice level changes. This intervention was spread to a diverse set of 26 primary care practices in 14 months using Lean Management principles. Group Health's experience provides valuable insights that can be used to improve the design and implementation of future PCMH models.
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    ABSTRACT: Purpose: The patient-centered medical home is often discussed as though there exist either traditional practices or medical homes, with marked differences between them. We analyzed data from an evaluation of certified medical homes in Minnesota to study this topic. Methods: We obtained publicly reported composite measures for quality of care outcomes pertaining to diabetes and vascular disease for all clinics in Minnesota from 2008 to 2010. The extent of and change in practice systems over that same time period for the first 120 clinics serving adults certified as health care homes (HCHs) was measured by the Physician Practice Connections Research Survey (PPC-RS), a self-report tool similar to the National Committee for Quality Assurance standards for patient-centered medical homes. Measures were compared between these clinics and 518 non-HCH clinics in the state. Results: Among the 102 clinics for which we had precertification and postcertification scores for both the PPC-RS and either diabetes or vascular disease measures, the mean increase in systems score over 3 years was an absolute 29.1% (SD = 16.7%) from a baseline score of 38.8% (SD = 16.5%, P ≤.001). The proportion of clinics in which all patients had optimal diabetes measures improved by an absolute 2.1% (SD = 5.5%, P ≤.001) and the proportion in which all had optimal cardiovascular disease measures by 4.4% (SD = 7.5%, P ≤.001), but all measures varied widely among clinics. Mean performance rates of HCH clinics were higher than those of non-HCH clinics, but there was extensive overlap, and neither group changed much over this time period. Conclusions: The extensive variation among HCH clinics, their overlap with non-HCH clinics, and the small change in performance over time suggest that medical homes are not similar, that change in outcomes is slow, and that there is a continuum of transformation.
    No preview · Article · May 2013 · The Annals of Family Medicine
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