Increasing Access to Health Care Providers Through Medical Home Model May Abolish Racial Disparity in Diabetes Care: Evidence From a Cross-sectional Study

Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation

Patient-centered medical homes (PCMH) are primary care delivery models that improve care access and population-level health outcomes, yet they have not been observed to narrow racial-ethnic disparities in the Veteran Health Administration (VHA) or other health systems. We aimed to identify and compare underlying drivers of persistent hypertension and diabetes control differences between non-Hispanic Black (Black) and Hispanic versus non-Hispanic White (White) patients before and after PCMH implementation in the VHA. Among Black and Hispanic versus White VHA primary care patients in 2009 (nhypertension = 26,906; ndiabetes = 21,141) and 2014 (nhypertension = 83,809; ndiabetes = 38,887), we retrospectively examined hypertension control (blood pressure<140/90) and diabetes control (hemoglobin A1c <9) obtained through random chart abstraction of patient health records nationally via VHA's quality monitoring program. We fit linear probability regression models, adjusting for age, gender, comorbidity, and socioeconomic status (SES). Blinder-Oaxaca and Smith-Welch decomposition methods were used to parse out explained and unexplained contributors to health disparity between racial-ethnic groups pre- and post-PCMH implementation. Compared to White patients, hypertension and diabetes control remained significantly lower for Black (-6.2%[0.4%] and -3.1%[0.6%], respectively; p's<0.001) and Hispanic (-1.4%[0.8%] and -4.0%[1.0%], respectively; p's<0.001) patients following VHA PCMH implementation. Most racial-ethnic differences (55.7-92.3%; all p<0.05) were not attributed to age, gender, comorbidity, and SES. The contribution of explained versus unexplained factors did not significantly change over time. While many explanations for persistent racial-ethnic disparities in disease control among veterans exist, our study did not find that it was due to an influx of "sick" or "socioeconomically vulnerable" patients into the VHA following PCMH implementation. Instead, unexplained differences may be due to differential healthcare and community experiences (e.g., discrimination). Understanding underlying pathways leading to health disparities will better inform policy and clinical interventions to improve PCMH care delivery to racial-ethnic minority patients in health systems.

The Impact of the Patient-Centered Medical Home on Health Care Disparities: Exploring Stakeholder Perspectives on Current Standards and Future Directions

Over the past decade, the Patient-Centered Medical Home (PCMH) has become a preeminent model for primary care delivery. Simultaneously, health care disparities have gained increasing attention. There has been limited research on whether and how the PCMH can or should affect health care disparities. The authors conducted qualitative interviews with key stakeholders and experts on the PCMH model and health care disparities, including grant and policy makers, accreditors, researchers, patient advocates, primary care practices, practice transformation organizations, and payers, to assess perspectives on the role of the PCMH in addressing health care disparities. The application of grounded theory and thematic analysis elucidated best practice recommendations for the PCMH model's role in addressing health care disparities. Although the majority of stakeholders support greater integration of efforts to reduce health care disparities into the PCMH model, most stakeholders view the current PCMH model as having minimal or indirect influence on health care disparities. The majority supported greater integration of efforts to reduce health care disparities into the PCMH model. As the PCMH model continues to be refined, and as the health care system strives toward improving population health, there must be reflection on the policies and delivery systems that impact health care disparities.

Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model

PURPOSE

We assess the financial implications for primary care practices of participating in patient-centered medical home (PCMH) funding initiatives.

METHODS

We estimated practices' changes in net revenue under 3 PCMH funding initiatives: increased fee-for-service (FFS) payments, traditional FFS with additional per-member-per-month (PMPM) payments, or traditional FFS with PMPM and pay-for-performance (P4P) payments. Net revenue estimates were based on a validated microsimulation model utilizing national practice surveys. Simulated practices reflecting the national range of practice size, location, and patient population were examined under several potential changes in clinical services: investments in patient tracking, communications, and quality improvement; increased support staff; altered visit templates to accommodate longer visits, telephone visits or electronic visits; and extended service delivery hours.

RESULTS

Under the status quo of traditional FFS payments, clinics operate near their maximum estimated possible net revenue levels, suggesting they respond strongly to existing financial incentives. Practices gained substantial additional net annual revenue per full-time physician under PMPM or PMPM plus P4P payments ($113,300 per year, 95% CI, $28,500 to $198,200) but not under increased FFS payments (-$53,500, 95% CI, -$69,700 to -$37,200), after accounting for costs of meeting PCMH funding requirements. Expanding services beyond minimum required levels decreased net revenue, because traditional FFS revenues decreased.

CONCLUSIONS

PCMH funding through PMPM payments could substantially improve practice finances but will not offer sufficient financial incentives to expand services beyond minimum requirements for PCMH funding.

Medical home implementation and trends in diabetes quality measures for AN/AI primary care patients

AIMS

Patient-centered medical home (PCMH) principles including provider continuity, coordination of care, and advanced access align with healthcare needs of patients with Type II diabetes mellitus (DM-II). We investigate changes in trend for DM-II quality indicators after PCMH implementation at Southcentral Foundation, a tribal health organization in Alaska.

METHODS

Monthly rates of DM-II incidence, hemoglobin A1c (HbA1c) measurements, and service utilization were calculated from electronic health records from 1996 to 2009. We performed interrupted time series analysis to estimate changes in trend.

RESULTS

Rates of new DM-II diagnoses were stable prior to (p=0.349) and increased after implementation (p<0.001). DM-II rates of HbA1c screening increased, though not significantly, before (p=0.058) and remained stable after implementation (p=0.969). There was non-significant increasing trend in both periods for percent with average HbA1c less than 7% (53 mmol/mol; p=0.154 and p=0.687, respectively). Number of emergency visits increased before (p<0.001) and decreased after implementation (p<0.001). Number of inpatient days decreased in both periods, but not significantly (p=0.058 and p=0.101, respectively).

CONCLUSIONS

We found positive changes in DM-II quality trends following PCMH implementation of varying strength and onset of change, as well as duration of sustained trend.

Racial comparisons of diabetes care and intermediate outcomes in a patient-centered medical home

OBJECTIVE To assess racial differences in diabetes processes and intermediate outcomes of care in an internal medicine, patient-centered medical home (PCMH) group practice. RESEARCH DESIGN AND METHODS We conducted a retrospective cohort study of 1,457 adults with diabetes receiving care from 89 medical providers within a PCMH-designated academic practice between 1 July 2009 and 31 July 2010. We used mixed models to assess independent associations between patient race (non-Hispanic white or black) and 1) receipt of processes of care (A1C and LDL testing, foot and retinal examination, and influenza and pneumococcal vaccination) and 2) achievement of intermediate outcomes (LDL <100 mg/dL, blood pressure [BP] <140/90 mmHg, A1C <7.0% [<53 mmol/mol], and A1C >9.0% [>75 mmol/mol]), controlling for sociodemographic factors, health status, treatment intensity, and clinical continuity. RESULTS Compared with non-Hispanic white patients, black patients were younger, were more often single, had lower educational attainment, and were less likely to have commercial insurance. In unadjusted analyses, fewer black patients received a retinal examination and influenza vaccination during the study period or any lifetime pneumococcal vaccination (P < 0.05 [all comparisons]). Fewer black patients achieved an LDL <100 mg/dL, BP <140/90 mmHg, or A1C <7.0% (<53 mmol/mol), while more black patients had an A1C >9.0% (>75 mmol/mol) (P < 0.05 [all comparisons]). In multivariable models, black patients were less likely to receive A1C testing (odds ratio [OR] 0.57 [95% CI 0.34-0.95]) or influenza vaccination (OR 0.75 [95% CI 0.57-0.99]) or to achieve an LDL <100 mg/dL (OR 0.74 [95% CI 0.55-0.99]) or BP <140/90 mmHg (OR 0.64 [95% CI 0.49-0.84]). CONCLUSIONS Racial differences in processes and intermediate outcomes of diabetes care were present within this PCMH-designated practice, controlling for differences in sociodemographic, clinical, and treatment factors.

Redesigning medical education to improve health care delivery and outcomes

The need to improve the health of individuals and populations by providing high-quality health care has become a priority and has led to the implementation of various quality indicators to measure performance and outcomes. However, significant disparities exist in the health care delivery and outcomes among individuals that can only intensify, considering the future projections for an aging and increasingly diverse population. This article provides the authors' perspectives on how these issues can be addressed and overcome by redesigning medical education so the future generations of physicians have the necessary knowledge, skills, and attitudes to provide high-quality, patient-centered, and culturally sensitive care.

Transforming community members into diabetes cultural health brokers: the Neighborhood Health Talker project

PURPOSE

The purpose of this study was to evaluate a community-based diabetes education pilot project. The Neighborhood Health Talker project aimed to train and implement cultural health brokers primarily targeting communities of color to improve community members' diabetes knowledge and diabetes self-management skills. A secondary aim was to establish diabetes resource libraries accessible to communities that normally experience barriers to these resources.

METHODS

Recruited community members completed 1 week of formal training developed by a multidisciplinary team in Buffalo, NY. The effect of training was evaluated through the use of baseline surveys, a pretest/posttest covering all training content, and daily quizzes evaluating knowledge relevant to each of the five training modules. Trained NHTs then held at least five community conversations in various locations and administered anonymous postconversation surveys to participants. Descriptive statistics and qualitative analysis techniques were used to summarize test, quiz, and survey results.

RESULTS

Twelve women and 1 man completed the training program. Working alone as well as in pairs, each held at least five community conversations reaching over 700 community members of all ages over 3 months and established 8 diabetes resource libraries in the community. All trainees increased their diabetes knowledge and confidence as well as their abilities to perform the tasks of a cultural health broker. Trainees also indicated that the goals they set at training initiation were met.

CONCLUSIONS

The training was successful in increasing trainee knowledge and confidence about diabetes prevention and self-management. Participants not only developed proficiency in discussing diabetes, they also made important lifestyle changes that demonstrated their commitment to the cause and the project. Low-cost initiatives like this are easily reproducible in other communities of color and could be modified to meet the needs of other communities as well.

Does the patient-centred medical home work? A critical synthesis of research on patient-centred medical homes and patient-related outcomes

Health-care systems in the USA and most of western Europe face challenges in the coordination and integration of care for patients, particularly those with chronic conditions. In response to these problems, interest in the patient-centred medical home (PCMH) model has increased significantly in recent years in the USA, with PCMH implementation underway in a wide variety of practice settings across the country. Despite this enthusiasm, there have been relatively few attempts to examine the empirical evidence on the effects of PCMH on quality and access-related outcomes for patients. This article reviews findings from empirical evaluations of the effects of PCMH on patient-related outcomes and critically examines methodological and conceptual issues in the growing body of PCMH literature. The results of this review suggest that published evaluations are predominantly weighted towards findings that indicate that PCMH is associated with a wide range of positive patient outcomes. However, methodological and measurement issues present in much of this research should be considered when evaluating these findings. The article concludes with recommendations for future PCMH evaluation.

Evaluating a Culturally Competent Health Coach Intervention for Chinese American Patients with Diabetes

Abstract

Background. Type 2 diabetes is a growing concern among medically underserved Chinese Americans. However, very few interventions have been developed or adapted for Chinese Americans with diabetes.

Objective. To use a participatory research approach to evaluate the effectiveness of a culturally tailored, linguistically appropriate model for diabetes care employing health coaches to improve A1C levels among Chinese-American patients in a federally qualified health center setting.

Methods. We compared change in A1C between intervention participants (n = 46), who received a health coaching intervention, and control participants (n = 46), who received usual care over a period of ~ 6 months.

Results. Intervention participants showed a decrease in mean A1C at follow-up (−0.40%) compared to control subjects (+0.04%), although this difference was not statistically significant. At the 6-month follow-up, a significantly higher percentage of intervention participants (45.7%) had well-controlled A1C levels compared to control subjects (23.9%) (P = 0.048).

Conclusions. It is feasible to implement a culturally tailored, linguistically appropriate teamlet model of care for Chinese Americans with type 2 diabetes. Such a model may be helpful in reducing A1C levels. Given trends in A1C improvement during a 6-month pilot, future randomized trials with a larger sample capable of providing adequate statistical power to detect improvements are warranted.

Medical home access among American Indian and Alaska Native children in 7 states: National Survey of Children's Health

To describe the prevalence of medical home among American Indian and Alaska Native children (AIAN) compared to non-Hispanic white (NHW) children and identify areas for improvement in the provision of care within a medical home. Prevalence of medical home, defined as family-centered, comprehensive, coordinated, compassionate, culturally effective care, including a personal doctor or nurse and usual care location, was estimated using 2007 National Survey of Children's Health data. Analyses included 1-17 year-olds in states reporting AIAN race as a distinct category (Alaska, Arizona, Montana, New Mexico, North Dakota, Oklahoma, and South Dakota, n = 9,764). Associations between medical home and demographic (child's age, household education and income, and state) and health-related [child's insurance status, special health care need status, and past year Indian Health Service (IHS) utilization] characteristics were assessed among AIAN children. Overall, the prevalence of medical home was 27 % lower among AIAN children (42.6, 95 % CI = 34.4-50.8) than NHW children (58.3, 95 % CI = 56.2-60.4). Child's age (adjusted OR [aOR] = 2.7, 95 % CI = 1.3-5.6) was significantly associated with medical home. IHS utilization was associated with medical home among AIAN children with private insurance (aOR = 0.2, 95 % CI = 0.1-0.4), but not among uninsured or publicly insured children. Care coordination and family-centered care were noted areas for improvement among AIAN children. Less than half of AIAN children had a medical home. Future studies should further examine the intersection between insurance and IHS to determine if enhanced coordination is needed for this population, which is often served by multiple federally-funded health-related programs.