A Model for Sustaining Health at the Primary Care Level

As the healthcare industry in USA is changing from a fee-for-service to a value-based system, the need for a shift in how patients are treated is evident. Healthcare organizations are reimbursed based on value and quality of service. The system shift recognizes that each patient possesses differing medical needs moving care from generalized medical treatments to individualistic care. To deal with this change and attempt to increase quality and value, many healthcare organizations are adopting a team care approach through the development of Patient-Centered Medical Homes (PCMH). In many examples of the team approach, the Primary Care Practitioner (PCP) is viewed as the main coordinator of care. Having this responsibility can create added stress for practitioners, which can lead to a decrease in the quality of care. The proposed model, in this article, outlines an example of how individualistic care can be achieved and assembled in the PCMH with the PCP as the main coordinator of care to sustain patient health.     

Effects of Patient-Centered Medical Home Attributes on Patients’ Perceptions of Quality in Federally Supported Health Centers

PURPOSE

We sought to assess patients’ ratings of patient-centered medical home (PCMH) attributes and overall quality of care within federally supported health centers.

METHODS

Data were collected through the 2009 Health Center Patient Survey (n = 4,562), which consisted of in-person interviews and included a nationally representative sample of patients seen in health centers. Quality measures included patients’ perceptions of overall quality of services, perceptions of quality of clinician advice/treatment, and likelihood of referring friends and relatives to the health center. PCMH attributes included (1) access to care getting to health center, (2) access to care during visit, (3) patient-centered communication with health care clinicians, (4) patient-centered communication with support staff, (5) self-management support for chronic conditions, (6) self-management support for behavioral risks, and (7) comprehensive preventive care. Bivariate analysis and logistic regressions were used to examine associations between patients’ perceptions of PCMH attributes and patient-reported quality of care.

RESULTS

Eighty-four percent of patients reported excellent/very good overall quality of services, 81% reported excellent/very good quality of clinician care, and 84% were very likely to refer friends and relatives. Higher patient ratings on the access to care and patient-centered communication attributes were associated with higher odds of patient-reported high quality of care on the 3 outcome measures.

CONCLUSIONS

More than 80% of patients perceived high quality of care in health centers. PCMH attributes related to access to care and communication were associated with greater likelihood of patients reporting high-quality care.     

Achieving Value in Primary Care: The Primary Care Value Model

The patient-centered medical home (PCMH) model provides a compelling vision for primary care transformation, but studies of its impact have used insufficiently patient-centered metrics with inconsistent results. We propose a framework for defining patient-centered value and a new model for value-based primary care transformation: the primary care value model (PCVM). We advocate for use of patient-centered value when measuring the impact of primary care transformation, recognition, and performance-based payment; for financial support and research and development to better define primary care value-creating activities and their implementation; and for use of the model to support primary care organizations in transformation.     

Elements of the Patient-Centered Medical Home in Family Practices in Virginia

PURPOSE The patient-centered medical home (PCMH) is a widely accepted theory of a practice model to improve quality of care, patient satisfaction, and access to primary care services. This study explores existing elements of the PCMH and characteristics of family practices in Virginia.METHOD We developed and administered a survey questionnaire to capture information on practice characteristics and PCMH elements. We randomly sampled 700 family medicine offices in Virginia from a population of practices derived from the Virginia Board of Medicine Practitioner Information Database. We used a mixed-mode survey, allowing practices in the sample to respond by mail or Internet or at a regional family medicine conference.RESULTS The survey resulted in a response rate of 56%, with 342 office locations participating in the study. Most practices reported continuity-of-care processes (87%) and clinical guidelines (77%). Fewer reported use of patient surveys (48%), electronic medical record for internal coordination (38%), community linkages for care (31%), and clinical performance measurement (28%). A small number reported patient registries for multiple diseases (19%). Very few practices exhibited all elements outlined in the PCMH model (1%). Practice size (number of physicians) is significantly related to PCMH model alignment.CONCLUSIONS Most family practices in Virginia exhibit some elements of the PCMH model. Full implementation of the PCMH model is low. Baseline information on practice characteristics, prevalence of PCMH, and challenges of small practices should be considered in guiding efforts, evaluating progress, and developing policies for care model reform.     

Measuring Physician Quality and Efficiency in an Era of Practice Transformation: PCMH as a Case Study

Practicing physicians face myriad challenges as health care undergoes considerable transformation, including advancing efforts to measure and report on physician quality and efficiency, as well as the growth of new care models such as Accountable Care Organizations and patient-centered medical homes (PCMHs). How do these transformational forces relate to one another? How should practicing physicians focus and prioritize their improvement efforts? This Special Report examines how physicians’ performance on quality and efficiency measures may interact with delivery reforms, focusing on the PCMH. We note that although the PCMH is a promising model, published evidence is mixed. Using data and experience from a large commercial insurer’s performance transparency and PCMH programs, we further report that longitudinal analysis of UnitedHealthcare’s PCMH program experience has shown favorable changes; however, cross-sectional analysis indicates that National Committee for Quality Assurance’s PCMH designation is positively associated with achieving program Quality benchmarks, but negatively associated with program Efficiency benchmarks. This example illustrates some key issues for physicians in the current environment, and we provide suggestions for physicians and other stakeholders on understanding and acting on information from physician performance measurement programs.     

Recommendations for a Mixed Methods Approach to Evaluating the Patient-Centered Medical Home

PURPOSE

There is a strong push in the United States to evaluate whether the patient-centered medical home (PCMH) model produces desired results. The explanatory and contextually based questions of how and why PCMH succeeds in different practice settings are often neglected. We report the development of a comprehensive, mixed qualitative-quantitative evaluation set for researchers, policy makers, and clinician groups.

METHODS

To develop an evaluation set, the Brown Primary Care Transformation Initiative convened a multidisciplinary group of PCMH experts, reviewed the PCMH literature and evaluation strategies, developed key domains for evaluation, and selected or created methods and measures for inclusion.

RESULTS

The measures and methods in the evaluation set (survey instruments, PCMH meta-measures, patient outcomes, quality measures, qualitative interviews, participant observation, and process evaluation) are meant to be used together. PCMH evaluation must be sufficiently comprehensive to assess and explain both the context of transformation in different primary care practices and the experiences of diverse stakeholders. In addition to commonly assessed patient outcomes, quality, and cost, it is critical to include PCMH components integral to practice culture transformation: patient and family centeredness, authentic patient activation, mutual trust among practice employees and patients, and transparency, joy, and collaboration in delivering and receiving care in a changing environment.

CONCLUSIONS

This evaluation set offers a comprehensive methodology to enable understanding of how PCMH transformation occurs in different practice settings. This approach can foster insights about how transformation affects critical outcomes to achieve meaningful, patient-centered, high-quality, and cost-effective sustainable change among diverse primary care practices.     

Optimizing health care delivery by integrating workplaces, homes, and communities: how occupational and environmental medicine can serve as a vital connecting link between accountable care organizations and the patient-centered medical home

In recent years, the health care reform discussion in the United States has focused increasingly on the dual goals of cost-effective delivery and better patient outcomes. A number of new conceptual models for health care have been advanced to achieve these goals, including two that are well along in terms of practical development and implementation-the patient-centered medical home (PCMH) and accountable care organizations (ACOs). At the core of these two emerging concepts is a new emphasis on encouraging physicians, hospitals, and other health care stakeholders to work more closely together to better coordinate patient care through integrated goals and data sharing and to create team-based approaches that give a greater role to patients in health care decision-making. This approach aims to achieve better health outcomes at lower cost. The PCMH model emphasizes the central role of primary care and facilitation of partnerships between patient, physician, family, and other caregivers, and integrates this care along a spectrum that includes hospitals, specialty care, and nursing homes. Accountable care organizations make physicians and hospitals more accountable in the care system, emphasizing organizational integration and efficiencies coupled with outcome-oriented, performance-based medical strategies to improve the health of populations. The ACO model is meant to improve the value of health care services, controlling costs while improving quality as defined by outcomes, safety, and patient experience. This document urges adoption of the PCMH model and ACOs, but argues that in order for these new paradigms to succeed in the long term, all sectors with a stake in health care will need to become better aligned with them-including the employer community, which remains heavily invested in the health outcomes of millions of Americans. At present, ACOs are largely being developed as a part of the Medicare and Medicaid systems, and the PCMH model is still gathering momentum and evolving among physicians. But, the potential exists for implementation of both of these concepts across a much broader community of patients. By extending the well-conceived integrative concepts of the PCMH model and ACOs into the workforce via occupational and environmental medicine (OEM) physicians, the power of these concepts would be significantly enhanced. Occupational and environmental medicine provides a well-established infrastructure and parallel strategies that could serve as a force multiplier in achieving the fundamental goals of the PCMH model and ACOs. In this paradigm, the workplace-where millions of Americans spend a major portion of their daily lives-becomes an essential element, next to communities and homes, in an integrated system of health anchored by the PCMH and ACO concepts. To be successful, OEM physicians will need to think and work innovatively about how they can provide today's employer health services-ranging from primary care and preventive care to workers' compensation and disability management-within tomorrow's PCMH and ACO models.     

Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home

The patient-centered medical home (PCMH) is emerging as a potential catalyst for multiple health care reform efforts. Demonstration projects are beginning in nearly every state, with a broad base of support from employers, insurers, state and federal agencies, and professional organizations. A sense of urgency to show the feasibility of the PCMH, along with a 3-tiered recognition process of the National Committee on Quality Assurance, are influencing the design and implementation of many demonstrations. In June 2006, the American Academy of Family Physicians launched the first National Demonstration Project (NDP) to test a model of the PCMH in a diverse national sample of 36 family practices. The authors make up an independent evaluation team for the NDP that used a multimethod evaluation strategy, including direct observation, in-depth interviews, chart audit, and patient and practice surveys. Early lessons from the real-time qualitative analysis of the NDP raise some serious concerns about the current direction of many of the proposed PCMH demonstration projects and point to some positive opportunities. We describe 6 early lessons from the NDP that address these concerns and then offer 4 recommendations for those assisting the transformation of primary care practices and 4 recommendations for individual practices attempting transformation.     

Principles of the Patient-Centered Medical Home and Preventive Services Delivery

PURPOSE Limited research exists examining the principles of the patient-centered medical home (PCMH) and improved outcomes. We examined whether PCMH principles (personal physician, physician-directed team, whole-person orientation, coordination of care, quality and safety, and enhanced access) are associated with receipt of preventive services.METHODS We undertook cross-sectional analyses using baseline patient and practice member surveys and chart audits from a quality improvement trial in 24 primary care offices. Association of PCMH principles with preventive services (receipt of cancer screening, lipid screening, influenza vaccination, and behavioral counseling) was examined using hierarchical linear modeling.RESULTS Higher global PCMH scores were associated with receipt of preventive services (β=2.3; P <.001). Positive associations were found with principles of personal physician (β=3.7; P <.001), in particular, continuity with the same physician (β=4.4; P = .002) and number of visits within 2 years (15% higher for patients with 13 or more visits; P <.001); and whole-person orientation (β=5.6; P <.001), particularly, having a well-visit within 5 years (β=12.3; P <.001) and being treated for chronic diseases (6% higher if more than 3 chronic diseases; P = .002). Having referral systems to link patients to community programs for preventive counseling (β = 8.0; P <.001) and use of clinical decision-support tools (β = 5.0; P = .04) were also associated with receipt of preventive services.CONCLUSIONS Relationship-centered aspects of PCMH are more highly correlated with preventive services delivery in community primary care practices than are information technology capabilities. Demonstration projects and tools that measure PCMH principles should have greater emphasis on these key primary care attributes.     

Team-based care: Views from community health center staff

ABSTRACT

Community health centers (CHC) provide quality care for vulnerable patients, and a potentially contributing factor to this quality is the integration of a patient-centered medical home (PCMH). PCMH relies on a team-based approach, a principle in which social workers are trained and research examines in primary care environments. Less is known about team-based care in CHCs. An exploratory qualitative study with 14 CHC staff was conducted to examine the current state of team-based care and secondarily, to examine the role of social workers. Content analysis revealed four themes central to team-based care. Implications for CHCs and social workers are discussed.     

Community-Based Home Healthcare Project for Korean Older Adults

ObjectivesThe aim of this study was to identify the effects of community-based home healthcare projects that influence service performances with regard to Korean national long-term care insurance services in older adults.MethodsThe project's applicants were 18 operational agencies in national long-term care institutions in Korea, and participants were care recipients (n = 2263) registered in long-term care institutions. We applied our healthcare system to the recruited participants for a 3-month period from October 2012 to December 2012. We measured the community-based home healthcare services such as long-term care, health and medical service, and welfare and leisure service prior to and after applying the community-based home healthcare system.ResultsAfter the implementation of community-based home healthcare project, all community-based home healthcare services showed an increase than prior to the project implementation. The nutrition management service was the most increased and its increase rate was 628.6%. A comparison between the long-term care insurance beneficiaries and nonbeneficiaries showed that health and medical services’ increase rate of nonbeneficiaries was significantly higher than beneficiaries (p < 0.001).ConclusionOur community-based home healthcare project might improve the service implementation for older adults and there was a difference in the increase rate of health and medical services between Korean national long-term care insurance beneficiaries and nonbeneficiaries.     

Are Primary Care Practices Ready to Become Patient‐Centered Medical Homes?

Purpose: To measure the readiness of rural primary care practices to qualify as patient‐centered medical homes (PCMHs), one step toward participating in changes underway in health care finance and delivery. Methods: We used the 2008 Health Tracking Physician Survey to compare PCMH readiness scores among metropolitan and nonmetropolitan primary care practices. The National Committee on Quality Assurance (NCQA) assessment system served as a framework to assess the PCMH capabilities of primary care practices based on their services, processes, and policies. Findings: We found little difference between urban and rural practices. Approximately 41% of all primary care practices offer minimal or no PCMH services. We also found that large practices score higher on standards primarily related to information technology and care management. Conclusions: Achieving the benefits of the PCMH model in small rural practices may require additional national promotion, technical assistance, and financial incentives.     

Implications of reassigning patients for the medical home: a case study

PURPOSE Improving patient-doctor continuity is one goal of the medical home, but achieving this goal may require physicians to reduce panel size. This article examines the impact on patient experience and utilization of Group Health Cooperative’s process of reassigning patients to new physicians as part of their medical home demonstration project.METHODS This work represents a subanalysis of the Group Health medical home pilot evaluation. Study participants include 8,005 adults who received primary care in 2006 and 2007 at an urban practice owned and operated by a not-for-profit integrated delivery system. Approximately one-quarter of patients were selected to be reassigned to a new physician. Primary care, emergency department, secure messaging, and telephone utilization were captured through automated sources. Patients’ experience was measured before and after implementation of the medical home for a subset of 1,098 patients.RESULTS Patients who were retained by their existing physicians were older, sicker, and had longer preexisting patient-doctor relationships. After reassignment, reassigned patients were less likely to use primary care services but equally likely to use the emergency department. They were no less satisfied with their care experience.CONCLUSIONS Informational and managerial continuity may mitigate deleterious effects of reassignment, but more must be done to actively bind reassigned patients to the medical home to improve relational continuity with younger, healthier patients.     

Spreading a patient-centered medical home redesign: a case study

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.     

HMOS' continuum of care. How HMOs target their services to meet the needs of the elderly

As healthcare organizations begin to expand their services to serve the elderly, they can learn from the experience of managed care providers. Kaiser Permanente in San Diego, a health maintenance organization (HMO) integrates healthcare providers with more traditional hospital services such as discharge planning and placement coordination, as well as social services, care management, and rehabilitation. Having all these services in the same office facilitates good patient care and planning. When a patient goes into hospice, home care, or a skilled nursing facility, one of four physicians takes on sole responsibility for his or her treatment and continuity of care. Group Health Cooperative of Puget Sound, Seattle, is a consumer-governed HMO. Group Health makes decisions based on data about enrollees plus input from medical staff and senior groups. It emphasizes putting the right services with the right consumer using subgroupings based on functional status: healthy, moderately frail, and frail. Seniors Plus, a social HMO in Minneapolis, integrates acute and long-term care. Providers determine who needs functional assessment and care management by looking first at the diagnosis, then the severity of impairment and comorbidity, other medical problems such as depression and falling that indicate a need, and finally limitations in function and ability to perform activities of daily living.     

The Patient‐Centered Medical Home and Patient Experience

Objective

To examine the relationship between practices'' reported use of patient-centered medical home (PCMH) processes and patients'' perceptions of their care experience.

Data Source

Primary survey data from 393 physician practices and 1,304 patients receiving care in those practices.

Study Design

This is an observational, cross-sectional study. Using standard ordinary least-squares and a sample selection model, we estimated the association between patients'' care experience and the use of PCMH processes in the practices where they receive care.

Data Collection

We linked data from a nationally representative survey of individuals with chronic disease and two nationally representative surveys of physician practices.

Principal Findings

We found that practices'' use of PCMH processes was not associated with patient experience after controlling for sample selection as well as practice and patient characteristics.

Conclusions

In our study, which was large, but somewhat limited in its measures of the PCMH and of patient experience, we found no association between PCMH processes and patient experience. The continued accumulation of evidence related to the possibilities of the PCMH, how PCMH is measured, and how the impact of PCMH is gauged provides important information for health care decision makers.     

Challenges and Strategies in Serving the Uninsured in Nashville, Tennessee

The patient-centered medical home (PCMH) is being promoted as a cornerstone for transforming primary care. Physician organizations (POs) are playing a more prominent role by facilitating practices' transformation to PCMH. Using a framework of organizational integration, we investigate the changing relationship between POs and practices through qualitative interviews. Through increased integration, POs can support both the big-picture and day-to-day activities of practice transformation. Most PO-practice unit connections reflected new areas of engagement-competencies that POs were not developing in the past-that are proving integral to the broad-scale practice change of PCMH implementation.     

Patient-centered medical homes in the United States

The concept of a medical home is receiving increased attention as a potential means to improve care and reduce costs. This study describes the characteristics and capabilities of practices that have achieved recognition of National Committee for Quality Assurance as a "patient-centered medical home" (PCMH). Both small and large practices demonstrate capabilities related to the goals of PCMH of accessible, coordinated, and patient-centered care; however, practices affiliated with larger organizations achieve higher levels of PCMH recognition compared with unaffiliated small practices. Efforts to support practices to implement medical home capabilities are needed, particularly in the use of data for population management and patient self-management.