Context for understanding the National Demonstration Project and the patient-centered medical home

Quality and team care response to the pandemic stresses in high performing primary care practices: A qualitative study

OBJECTIVE

To learn how high performing primary care practices organized care for patients with diabetes during the initial months of the COVID-19 pandemic.

PARTICIPANTS AND METHODS

Semi-structured interviews were conducted between August 10 and December 10, 2020 with 16 leaders from 11 practices that had top quartile performance measures for diabetes outcomes pre-COVID. Each clinic had completed a similar interview and a survey about the existence of care management systems associated with quality outcomes before the pandemic. Transcript analysis utilized a theoretical thematic analysis at the semantic level.

RESULTS

The pandemic disrupted the primary care practices' operations and processes considered important for quality prior to the pandemic, particularly clinic reliance on proactive patient care. Safety concerns resulted from the shift to virtual visits, which produced documentation gaps and led practices to reorder their use of proactive patient care processes. Informal interactions with patients also declined. These practices' challenges were mitigated by technical, informational and operational help from the larger organizations of which they were a part. Care management processes had to accommodate both in-person and virtual visits.

CONCLUSION

These high performing practices demonstrated an ability to adapt their use of proactive patient care processes in pursuing quality outcomes for patients with diabetes during the pandemic. Continued clinic transformation and improvements in quality within primary care depend on the ability to restructure the responsibilities of care team members and their interactions with patients.

Performance of the Person Centered Primary Care Measure in Pediatric Continuity Clinic

OBJECTIVE

Improvement efforts in pediatric primary care would benefit from measures that capture families' holistic experience of the practice. We sought to assess the reliability and validity of the new Person-Centered Primary Care Measure (PCPCM) in a pediatric resident continuity clinic serving low-income families.

METHODS

We incorporated the 11-item PCPCM, stems adapted to reflect a parent responding about their child's visit, into a telephone survey of 194 parents presenting for care in October 2019 at a pediatric resident continuity clinic in Cleveland Ohio (64% response rate). We evaluated PCPCM items using factor analysis and Rasch modeling, and assessed associations of the PCPCM with parents' demographics and perceptions of specific elements of their child's care.

RESULTS

In this sample of low-income families, the PCPCM had good reliability (Cronbach's alpha 0.85). All items loaded onto a single factor in principal axes factor analysis. Of the 11 aspects of primary care represented in the scale, "shared experience" was most difficult for parents to endorse in Rasch modeling. All 11 items contributed significantly to the total scale score with corrected item-total correlations >0.4. The PCPCM score was independent of socio demographics and was associated with parent's report that their child's clinician spends enough time with them.

CONCLUSIONS

The PCPCM performs well in a pediatric continuity clinic setting, warranting consideration for its use as a parsimonious parent-reported measure of what patients and clinicians say matters most in pediatric primary care.

Change implementation: the association of adaptive reserve and burnout among inpatient medicine physicians and nurses

Adaptive Reserve (AR) is positively associated with implementing change in ambulatory settings. Deficits in AR may lead to change fatigue or burnout. We studied the association of self-reported AR and burnout among providers to hospitalized medicine patients in an academic medical center. An electronic survey containing a 23-item Adaptive Reserve scale, burnout inventory, and demographic questions was sent to a convenience sample of nurses, house staff team members, and hospitalists. A total of 119 self-administered, online surveys collected from June 2014 to March 2015 were analyzed. Ordinal regression analyses were used to examine the association between AR and burnout. Eighty percent of participants reported either level 1 or 2 burnout. Additionally, 10.9% of participants responded level 0% and 7.6% of participants reported level 3. Participants reporting higher burnout were about three times more likely to report lower AR levels. AR is strongly associated with self-reported burnout by physicians and nurses providing inpatient care at this academic medical center. Growing evidence supports the positive association of AR to successful change implementation in ambulatory settings. Similar studies are needed to determine whether certain levels of AR can predict successful change in hospital settings.

Family Medicine Research in the United States From the late 1960s Into the Future

When the new field of family medicine research began a half century ago, multiple individuals and organizations emphasized that research was a key mission. Since the field's inception, there have been notable research successes for which family medicine organizations, researchers, and leaders-assisted by federal and state governments and private foundations-can take credit. Research is a requirement for family medicine residency programs but not individual residents, and multiple family medicine departments offer research training in various forms for learners at all levels, including research fellowships. Family physicians have developed practice-based research networks (PBRNs) to conduct investigations and generate new knowledge. The field of family medicine has seen the creation of new journals to support the publication of research relevant to practicing family physicians. Nonetheless, in spite of much growth and many successes, family physicians and their research have been underrepresented in research funding. Clinical presentations in family medicine are often complex, poorly-differentiated, and exist as one of several patient complaints and diagnoses, and are not well-covered by the narrow basic-science and specialty research that defines most of the biomedical research enterprise. Overall health in the United States would benefit from a more robust research participation and greater support for family medicine research.

The benefits of respectful interactions: fluid alliancing and inter-occupational information sharing in primary care

Though inter-occupational interactions in health care have been the focus of increasing attention, we still know little about how such interactions shape information sharing in clinical settings. This is particularly true in primary care where research on teams and collaboration has been based on individual perceptions of work (using surveys and interviews) rather than observing the interactions that directly mediate the inter-occupational flow of information. To explore how interactions shape information sharing, we conducted a secondary analysis of ethnographic data from 27 primary care practices. Ease of information sharing among nurses and doctors is linked to the degree to which practices feature respectful interactions, with practices in the sample falling into one of three categories (those with low, uneven, and high degrees of respectful interactions). Those practices with the highest degree of respectful interactions demonstrate what we describe as fluid-alliancing: flexible interactions between individuals from different occupational groups in which bidirectional information sharing occurs for the benefit of patients and the efficacy of the practice community. We conclude by arguing that this process unlocks the strengths of all practice members, and that leadership should encourage respectful interactions to augment organisational efficacy and the ability of individual practice members to provide quality patient care.

Breast and prostate cancer survivors' experiences of patient-centered cancer follow-up care from primary care physicians and oncologists

PURPOSE

Patient-physician relationships impact health care seeking and preventive screening behaviors among patients. At the end of active treatment some cancer survivors report feeling disconnected from their care team. This study explores cancer survivors' experiences of patient-centered cancer follow-up care provided by primary care physicians (PCP) and oncologists (ONC).

METHODS

Three hundred five early stage, breast and prostate cancer survivors at least 2 years post treatment were surveyed from four community hospital oncology programs in New Jersey. Participants reported receipt of patient-centered care measured by care coordination, comprehensiveness of care, and personal relationship with PCPs and ONCs.

RESULTS

PCPs received higher ratings for coordination of care and comprehensive care than ONCs from all survivors (P < 0.01). However, prostate and breast cancer survivors rated strengths of their personal bonds with the physicians differently. While prostate cancer survivors rated PCPs significantly higher for all items (P < 0.028), breast cancer survivors rated ONCs significantly higher on four out of seven items including having been through a lot together, understanding what is important regarding health, knowing their medical history and taking their beliefs and wishes into account (P < 0.036).

CONCLUSIONS

Prostate and breast cancer survivors report different experiences with their PCPs and oncologists around the comprehensiveness and coordination of their cancer follow-up care in addition to the strength of their relationships with their physicians.

IMPLICATIONS FOR CANCER SURVIVORS

There are important differences in the experience of patient-centered care among cancer survivors that should be considered when planning care models and interventions for these different populations.

Boundary spanning and health: invitation to a learning community

Boundaries, which are essential for the healthy functioning of individuals and organisations, can become problematic when they limit creative thought and action. In this article, we present a framework for promoting health across boundaries and summarise preliminary insights from experience, conversations and reflection on how the process of boundary spanning may affect health. Boundary spanning requires specific individual qualities and skills. It can be facilitated or thwarted by organisational context. Boundary spanning often involves risk, but may reap abundant rewards. Boundary spanning is necessary to optimise health and health care. Exploring the process, the landscape and resources that enable boundary spanning may yield new opportunities for advancing health. We invite boundary spanners to join in a learning community to advance understanding and health.

A descriptive qualitative study of the roles of family members in older men's depression treatment from the perspectives of older men and primary care providers

OBJECTIVE

The aim of this study is to describe the roles of family members in older men's depression treatment from the perspectives of older men and primary care physicians (PCPs).

METHODS

Cross-sectional, descriptive qualitative study conducted from 2008-2011 in primary care clinics in an academic medical center and a safety-net county teaching hospital in California's Central Valley. Participants in this study were the following: (1) 77 age ≥ 60, noninstitutionalized men with a 1-year history of clinical depression and/or depression treatment who were identified through screening in primary care clinics and (2) a convenience sample of 15 PCPs from the same recruitment sites. Semi-structured and in-depth qualitative interviews were conducted and audiotaped then transcribed and analyzed thematically.

RESULTS

Treatment-promoting roles of family included providing an emotionally supportive home environment, promoting depression self-management and facilitating communication about depression during primary care visits. Treatment-impeding roles of family included triggering or worsening men's depression, hindering depression care during primary care visits, discouraging depression treatment and being unavailable to assist men with their depression care. Overall, more than 90% of the men and the PCPs described one or more treatment-promoting roles of family and over 75% of men and PCPs described one or more treatment-impeding roles of family.

CONCLUSIONS

Families play important roles in older men's depression treatment with the potential to promote as well as impede care. Interventions and services need to carefully assess the ongoing roles and attitudes of family members and to tailor treatment approaches to build on the positive aspects and mitigate the negative aspects of family support.

Using a facilitation model to achieve patient-centered medical home recognition

This article describes how a facilitation model that included a partnership between a Community Care of North Carolina network and undergraduates at a regional university supported rural primary care practices in transforming their practices to become National Committee for Quality Assurance-recognized patient-centered medical homes. Health care management and preprofessional undergraduate students worked with 14 rural primary care practices to redesign practice processes and complete the patient-centered medical home application. Twelve of the practices participated in the evaluation of the student contribution. A semistructured interview guide containing questions about practice characteristics, student competencies, and the value of the student's contribution to their practice's achievement of patient-centered medical home recognition was used to interview practice managers or their designee. Analysis included item-descriptive statistics and qualitative analysis of narrative content. All 12 participating practices achieved 2011 National Committee for Quality Assurance patient-centered medical home recognition, with 4 practices achieving level 3, 5 practices achieving level 2, and 3 practices achieving level 1. The facilitation model using partnerships between health care agencies and universities might be an option for enhancing a practice's internal capacity for successful transformation and should be explored further.

Practice adaptive reserve and colorectal cancer screening best practices at community health center clinics in 7 states

BACKGROUND

Enhancing the capability of community health centers to implement best practices (BPs) may mitigate health disparities. This study investigated the association of practice adaptive reserve (PAR) with the implementation of patient-centered medical home (PCMH) colorectal cancer (CRC) screening BPs at community health center clinics in 7 states.

METHODS

A convenience sample of clinic staff participated in a self-administered, online survey. Eight PCMH CRC screening BPs were scored as a composite ranging from 0 to 32. The PAR composite score was scaled from 0 to 1 and then categorized into 3 levels. Multilevel analyses examined the relation between PAR and self-reported implementation of PCMH BPs.

RESULTS

There were 296 respondents, and 59% reported 6 or more PCMH BPs at their clinics. The mean PAR score was 0.66 (standard deviation, 0.18), and the PCMH BP mean scores were significantly higher for respondents who reported higher clinic PAR categories. In comparison with the lowest PAR level, adjusted PCMH BP means were 25.0% higher at the middle PAR level (difference, 3.2; standard error, 1.3; t = 2.44; P = .015) and 63.2% higher at the highest PAR level (difference, 8.0; standard error, 1.9; t = 4.86; P < .0001).

CONCLUSIONS

A higher adaptive reserve, as measured by the PAR score, was positively associated with self-reported implementation of PCMH CRC screening BPs by clinic staff. Future research is needed to determine the PAR levels most conducive to implementing CRC screening and to develop interventions that enhance PAR in primary care settings.

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.

Coaching strategies for enhancing practice transformation

BACKGROUND

Current research on primary care practice redesign suggests that outside facilitation can be an important source of support for achieving substantial change.

OBJECTIVES

To analyse the specific sequence of strategies used by a successful practice facilitator during the American Academy of Family Physicians' (AAFP) National Demonstration Project (NDP).

METHODS

This secondary analysis describes a sequence of strategies used to produce change in family medicine practices attempting to adopt a new model of care. The authors analysed qualitative data generated by one facilitator and six practices by coding facilitator field notes, site visit reports, qualitative summaries, depth interviews and email strings.

RESULTS

The facilitator utilized practice member coaching in addition to consulting, negotiating and connecting approaches. Coaching strategies encouraged: (i) expansive, multi-directional, attentive styles of communication; (ii) solving practical problems together; (iii) modelling facilitative leadership and (iv) encouraging an expanded vision of care. Practice members who received consistent coaching reported internal shifts and new ways of conceptualizing work, not just success at implementing model components. They indicated that their facilitator had helped them think and behave in new ways while helping them achieve benchmarks.

CONCLUSIONS

It was once believed that the transition from traditional models of family medicine practice to new models of care meant implementing new technological components, suggesting that outside facilitators should act as technological and care delivery consultants. However, coaches may be especially useful in helpful in practices undertake substantial changes.

Applying systems engineering to implement an evidence-based intervention at a community health center

Impressive results in patient care and cost reduction have increased the demand for systems-engineering methodologies in large health care systems. This Report from the Field describes the feasibility of applying systems-engineering techniques at a community health center currently lacking the dedicated expertise and resources to perform these activities.

How do rural patients benefit from the patient-centred medical home? A card study in the High Plains Research Network

Context The patient-centred medical home (PCMH) has become a dominant model for improving the quality and cost of primary care. Geographic isolation, small populations, privacy concerns and staffing requirements may limit implementation of the PCMH in clinical practice. Objective To determine the primary care provider perceived benefit of PCMH for patients in rural Colorado. Design, setting and participants The High Plains Research Network (HPRN) is a community and practice-based research network spanning 30 000 square miles in 16 counties in eastern Colorado. The HPRN consists of 58 practices, 120 primary care clinicians and 145 000 residents. Main outcome measures Providers' perceived benefit of PCMH for individual patients. Results Seventy-eight providers in 37 practices saw 1093 patients and completed 1016 surveys. There was wide variation among the provider-perceived benefits of PCMH elements ranging from 9% for group visits to 64% for electronic prescribing. Provider-perceived benefit was higher for patients with a chronic medical condition. Conclusions Rural primary care providers perceived patient benefit for numerous elements of the PCMH. There is need to consider what PCMH elements may be required in practice and what components might be optional. Our findings reveal that rural practices share PCMH aspirations including commitment to quality, safety, outcomes, cost reduction, and patient and provider satisfaction. These findings support the need for ongoing conversation about how to best provide a locally relevant medical home.

Permanent supportive housing: addressing homelessness and health disparities?

Permanent supportive housing (PSH) is an intervention to address long-term homelessness. Evidence has resulted in a shift in US policy toward using PSH rather than shelters and transitional housing. Despite recognizing that individuals transitioning from homelessness to PSH experience a high burden of disease and health disparities, public health research has not considered whether and how PSH improves physical health outcomes. Based on diverse areas of research, we argue that in addition to improved access to quality health care, social determinants of health (including housing itself, neighborhood characteristics, and built environment) affect health outcomes. We identify implications for practice and research, and conclude that federal and local efforts to end long-term homelessness can interact with concurrent efforts to build healthy communities.

Natural history of practice transformation: development and initial testing of an outcomes-based model

PURPOSE

Practice transformation is the cornerstone of the future of family medicine and health care reform, but little is known about how the process occurs. We sought to develop and test a model of the natural history of practice transformation.

METHODS

We developed an outcomes-based model of how a practice moves through practice transformation in 2 phases: (1) initial model created through meetings with collaborative experts and practice facilitators, and (2) clinical and practice systems change reports examined from the first group of participating North Carolina Improving Performance In Practice practices to test and further refine the model.

RESULTS

The resultant model described motivators and supports to transformation. Three emerging practice patterns were identified with the model: transformed practices experiencing robust improvement, activated practices with moderate change, and engaged practices with minimal change in measured quality over a 2-year period. Transformed practices showed broad-based improvement; some reached a threshold and others continued to improve. These practices had highly engaged leadership and used data to drive decisions. Activated practices had a slower improvement trajectory, usually encountering a barrier that took time to overcome (eg, extracting population data, spreading practice changes). Engaged practices did not improve or were unable to sustain change; despite good intentions, multiple competing distractions interfered with practice transformation.

CONCLUSIONS

Practice transformation is a continuous and long-term process. Internal and external practice motivations and specific practice supports provided by a community-based quality improvement program appear to have an impact on engagement, rate of quality improvement, and long-term sustainability. Early successes play a key role as practices learn how to change their performance.

Recognition as a patient-centered medical home: fundamental or incidental?

PURPOSE

Little is known about reasons why a medical group would seek recognition as a patient-centered medical home (PCMH). We examined the motivations for seeking recognition in one group and assessed why the group allowed recognition to lapse 3 years later.

METHODS

As part of a larger mixed methods case study, we conducted 38 key informant interviews with executives, clinicians, and front-line staff. Interviews were conducted according to a guide that evolved during the project and were audio-recorded and fully transcribed. Transcripts were analyzed and thematically coded.

RESULTS

PCMH principles were consistent with the organization's culture and mission, which valued innovation and putting patients first. Motivations for implementing specific PCMH components varied; some components were seen as part of the organization's patient-centered culture, whereas others helped the practice compete in its local market. Informants consistently reported that National Committee for Quality Assurance recognition arose incidentally because of a 1-time incentive from a local group of large employers and because the organization decided to allocate some organizational resources to respond to the complex reporting requirements for about one-half of its clinics.

CONCLUSIONS

Becoming patient centered and seeking recognition as such ran along separate but parallel tracks within this organization. As the Affordable Care Act continues to focus attention on primary care redesign, this apparent disconnect should be borne in mind.

Behavioral health providers' perspectives of delivering behavioral health services in primary care: a qualitative analysis

Background

Co-located, collaborative care (CCC) is one component of VA’s model of Integrated Primary Care that embeds behavioral health providers (BHPs) into primary care clinics to treat commonly occurring mental health concerns among Veterans. Key features of the CCC model include time-limited, brief treatments (up to 6 encounters of 30 minutes each) and emphasis on multi-dimensional functional assessment. Although CCC is a mandated model of care, the barriers and facilitators to implementing this approach as identified from the perspective of BHPs have not been previously identified.

Methods

This secondary data analysis used interview data captured as part of a quality improvement project in 2008. Fourteen BHPs (48% of providers in a regional VA network) agreed to participate in a 30-minute, semi-structured phone interview. The interview included questions about their perceived role as a CCC provider, depiction of usual practice styles and behaviors, and perceptions of typical barriers and facilitators to providing behavioral healthcare to Veterans in CCC. Interviews were transcribed verbatim into a text database and analyzed using grounded theory.

Results

Six main categories emerged from the analysis: (a) Working in the VA Context, (b) Managing Access to Care on the Front Line, (c) Assessing a Care Trajectory, (d) Developing a Local Integrated Model, (e) Working in Collaborative Teams, and (f) Being a Behavioral Health Generalist. These categories pointed to system, clinic, and provider level factors that impacted BHP’s role and ability to implement CCC. Across categories, participants identified ways in which they provided Veteran-centered care within variable environments.

Conclusions

This study provided a contextualized account of the experiences of BHP’s in CCC. Results suggest that these providers play a multifaceted role in delivering clinical services to Veterans while also acting as an interdependent component of the larger VA behavioral health and primary care systems. Based on the inherent challenges of enacting this role, BHPs in CCC may benefit from additional implementation support in their effort to promote health care integration and to increase access to patient-centered care in their local clinics.

Behavioral health providers' perspectives of delivering behavioral health services in primary care: a qualitative analysis

BACKGROUND

Co-located, collaborative care (CCC) is one component of VA's model of Integrated Primary Care that embeds behavioral health providers (BHPs) into primary care clinics to treat commonly occurring mental health concerns among Veterans. Key features of the CCC model include time-limited, brief treatments (up to 6 encounters of 30 minutes each) and emphasis on multi-dimensional functional assessment. Although CCC is a mandated model of care, the barriers and facilitators to implementing this approach as identified from the perspective of BHPs have not been previously identified.

METHODS

This secondary data analysis used interview data captured as part of a quality improvement project in 2008. Fourteen BHPs (48% of providers in a regional VA network) agreed to participate in a 30-minute, semi-structured phone interview. The interview included questions about their perceived role as a CCC provider, depiction of usual practice styles and behaviors, and perceptions of typical barriers and facilitators to providing behavioral healthcare to Veterans in CCC. Interviews were transcribed verbatim into a text database and analyzed using grounded theory.

RESULTS

Six main categories emerged from the analysis: (a) Working in the VA Context, (b) Managing Access to Care on the Front Line, (c) Assessing a Care Trajectory, (d) Developing a Local Integrated Model, (e) Working in Collaborative Teams, and (f) Being a Behavioral Health Generalist. These categories pointed to system, clinic, and provider level factors that impacted BHP's role and ability to implement CCC. Across categories, participants identified ways in which they provided Veteran-centered care within variable environments.

CONCLUSIONS

This study provided a contextualized account of the experiences of BHP's in CCC. Results suggest that these providers play a multifaceted role in delivering clinical services to Veterans while also acting as an interdependent component of the larger VA behavioral health and primary care systems. Based on the inherent challenges of enacting this role, BHPs in CCC may benefit from additional implementation support in their effort to promote health care integration and to increase access to patient-centered care in their local clinics.

Boundaries and e-health implementation in health and social care

Background

The major problem facing health and social care systems globally today is the growing challenge of an elderly population with complex health and social care needs. A longstanding challenge to the provision of high quality, effectively coordinated care for those with complex needs has been the historical separation of health and social care. Access to timely and accurate data about patients and their treatments has the potential to deliver better care at less cost.

Methods

To explore the way in which structural, professional and geographical boundaries have affected e-health implementation in health and social care, through an empirical study of the implementation of an electronic version of Single Shared Assessment (SSA) in Scotland, using three retrospective, qualitative case studies in three different health board locations.

Results

Progress in effectively sharing electronic data had been slow and uneven. One cause was the presence of established structural boundaries, which lead to competing priorities, incompatible IT systems and infrastructure, and poor cooperation. A second cause was the presence of established professional boundaries, which affect staffs’ understanding and acceptance of data sharing and their information requirements. Geographical boundaries featured but less prominently and contrasting perspectives were found with regard to issues such as co-location of health and social care professionals.

Conclusions

To provide holistic care to those with complex health and social care needs, it is essential that we develop integrated approaches to care delivery. Successful integration needs practices such as good project management and governance, ensuring system interoperability, leadership, good training and support, together with clear efforts to improve working relations across professional boundaries and communication of a clear project vision. This study shows that while technological developments make integration possible, long-standing boundaries constitute substantial risks to IT implementations across the health and social care interface which those initiating major changes would do well to consider before committing to the investment.

A re-emerging political space for linking person and community through primary health care

PURPOSE

The goal of the study was to understand how national policy key informants perceive the value and changing role of primary care in the context of emerging political opportunities.

METHODS

Thirteen semistructured interviews were conducted in May 2011 with leaders of federal agencies, think tanks, nonprofits, and quality standard-defining organizations with influence over healthcare reform policies and implementation. Interviews were recorded; an editing and immersion-crystallization analysis approach was used to identify themes.

RESULTS

Four themes were identified: (1) affirmation of primary care as the foundation of a more effective healthcare system, (2) the patient-centered medical home as a transitional step to foster practice innovation and payment reform, (3) the urgent need for an increased focus on community and population health in primary care, and (4) the ongoing need for advocacy and research efforts to keep primary care on public and policy agendas.

CONCLUSIONS

Current efforts to reform primary care are only intermediate steps toward a system with a greater focus on community and population health. Transformed and policy-enabled primary care is an essential link between personalized care and population health.

An evidence integration triangle for aligning science with policy and practice

Over-reliance on decontextualized, standardized implementation of efficacy evidence has contributed to slow integration of evidence-based interventions into health policy and practice. This article describes an "evidence integration triangle" (EIT) to guide translation, implementation, prevention efforts, comparative effectiveness research, funding, and policymaking. The EIT emphasizes interactions among three related components needed for effective evidence implementation: (1) practical evidence-based interventions; (2) pragmatic, longitudinal measures of progress; and (3) participatory implementation processes. At the center of the EIT is active engagement of key stakeholders and scientific evidence and attention to the context in which a program is implemented. The EIT model is a straightforward framework to guide practice, research, and policy toward greater effectiveness and is designed to be applicable across multiple levels-from individual-focused and patient-provider interventions, to health systems and policy-level change initiatives.

A reemerging political space for linking person and community through primary health care

OBJECTIVES

We sought to understand how national policy key informants perceive the value and changing role of primary care in the context of emerging political opportunities.

METHODS

We conducted 13 semistructured interviews in May 2011 with leaders of federal agencies, think tanks, nonprofits, and quality standard-defining organizations with influence over health care reform policies and implementation. We recorded the interviews and used an editing and immersion-crystallization analysis approach to identify themes.

RESULTS

We identified 4 themes: (1) affirmation of primary care as the foundation of a more effective health care system, (2) the patient-centered medical home as a transitional step to foster practice innovation and payment reform, (3) the urgent need for an increased focus on community and population health in primary care, and (4) the ongoing need for advocacy and research efforts to keep primary care on public and policy agendas.

CONCLUSIONS

Current efforts to reform primary care are only intermediate steps toward a system with a greater focus on community and population health. Transformed and policy-enabled primary care is an essential link between personalized care and population health.

Can integrating health literacy into the patient-centered medical home help us weather the perfect storm?

Improving health literacy is one key to buoying our nation's troubled health care system. As system-level health literacy improvement strategies take the stage among national priorities for health care, the patient-centered medical home (PCMH) model of care emerges as a compelling avenue for their widespread implementation. With a shared focus on effective communication and team-based care organized around patient needs, health literacy principles and the PCMH are well aligned. However, their synergy has received little attention, even as PCMH demonstration projects and health literacy interventions spring up nationwide. While many health literacy interventions are limited by their focus on a single point along the continuum of care, creating a "room" for health literacy within the PCMH may finally provide a multi-dimensional, system-level approach to tackling the full range of health literacy challenges. Increasing uptake coupled with federal support and financial incentives further boosts the model's potential for advancing health literacy. On the journey toward a revitalized health care system, integrating health literacy into the PCMH presents a promising opportunity that deserves consideration.

The Patient-Centered Medical Home: transforming primary care

The Patient-Centered Medical Home (PCMH) is a new care model that reorganizes primary care to improve access, coordination, quality, satisfaction, and comprehensive patient-centered care. Nurse practitioners should understand the PCMH concept, appraise the evidence, and become leaders in this transformation.

Enrolment in primary care networks: impact on outcomes and processes of care for patients with diabetes

BACKGROUND

Primary care networks are a newer model of primary care that focuses on improved access to care and the use of multidisciplinary teams for patients with chronic disease. We sought to determine the association between enrolment in primary care networks and the care and outcomes of patients with diabetes.

METHODS

We used administrative health care data to study the care and outcomes of patients with incident and prevalent diabetes separately. For patients with prevalent diabetes, we compared those whose care was managed by physicians who were or were not in a primary care network using propensity score matching. For patients with incident diabetes, we studied a cohort before and after primary care networks were established. Each cohort was further divided based on whether or not patients were cared for by physicians enrolled in a network. Our primary outcome was admissions to hospital or visits to emergency departments for ambulatory care sensitive conditions specific to diabetes.

RESULTS

Compared with patients whose prevalent diabetes is managed outside of primary care networks, patients in primary care networks had a lower rate of diabetes-specific ambulatory care sensitive conditions (adjusted incidence rate ratio 0.81, 95% confidence interval [CI] 0.75 to 0.87), were more likely to see an ophthalmologist or optometrist (risk ratio 1.19, 95% CI 1.17 to 1.21) and had better glycemic control (adjusted mean difference -0.067, 95% CI -0.081 to -0.052).

INTERPRETATION

Patients whose diabetes was managed in primary care networks received better care and had better clinical outcomes than patients whose condition was not managed in a network, although the differences were very small.

Improving chronic illness care for veterans within the framework of the Patient-Centered Medical Home: experiences from the Ann Arbor Patient-Aligned Care Team Laboratory

While key components of the Patient-Centered Medical Home (PCMH) have been described, improved patient outcomes and efficiencies have yet to be conclusively demonstrated. We describe the rationale, conceptual framework, and progress to date as part of the VA Ann Arbor Patient-Aligned Care Team (PACT) Demonstration Laboratory, a clinical care-research partnership designed to implement and evaluate PCMH programs. Evidence and experience underlying this initiative is presented. Key components of this innovation are: (a) a population-based registry; (b) a navigator system that matches veterans to programs; and (c) a menu of self-management support programs designed to improve between-visit support and leverage the assistance of patient-peers and informal caregivers. This approach integrates PCMH principles with novel implementation tools allowing patients, caregivers, and clinicians to improve disease management and self-care. Making changes within a complex organization and integrating programmatic and research goals represent unique opportunities and challenges for evidence-based healthcare improvements in the VA.

Meeting the challenge of practice quality improvement: a study of seven family medicine residency training practices

PURPOSE

Incorporating quality improvement (QI) into resident education and clinical care is challenging. This report explores key characteristics shaping the relative success or failure of QI efforts in seven primary care practices serving as family medicine residency training sites.

METHOD

The authors used data from the 2002-2008 Using Learning Teams for Reflective Adaptation study to conduct a comparative case analysis. This secondary data analysis focused on seven residency training practices' experiences with the reflective adaptive process (RAP), a 12-week intensive QI process. Field notes, meeting notes, and audiotapes of RAP meetings were used to construct case summaries. A matrix comparing key themes across practices was used to rate practices' QI progress during RAP on a scale of 0 to 3.

RESULTS

Three practices emerged as unsuccessful (scores of 0-1) and four as successful (scores of 2-3). Larger practices with previous QI experience, faculty with extensive exposure to QI literature, and an office manager, residency director, or medical director who advocated the process made substantial progress during RAP, succeeding at QI. Smaller practices without these characteristics were unable to do so. Successful practices also engaged residents in the QI process and identified serious problems as potential crises; unsuccessful practices did not.

CONCLUSIONS

Larger residency training practices are more likely to have the resources and characteristics that permit them to create a QI-supportive culture leading to QI success. The authors suggest, however, that smaller practices may increase their chances of success by adopting a developmental approach to QI.

Developing a network of community health centers with a common electronic health record: description of the Safety Net West Practice-based Research Network (SNW-PBRN)

In 2001, community health center (CHC) leaders in Oregon established an organization to facilitate the integration of health information technology, including a shared electronic health record (EHR), into safety net clinics. The Oregon Community Health Information Network (shortened to OCHIN as other states joined) became a CHC information technology hub, supporting a network-wide EHR with one master patient index, now linked across >40 safety net organizations serving >900,000 patients with nearly 800,000 distinct CHC visits. Recognizing the potential of OCHIN's multiclinic network and comprehensive EHR database for conducting safety net-based research, OCHIN leaders and local researchers formed the Safety Net West practice-based research network (PBRN). The Safety Net West "community- based laboratory," based at OCHIN, is positioned to become an important resource for many studies including: evaluation of the real-time impact of health care reform on uninsured populations; development of new models of primary care delivery; dissemination and translation of interventions from other EHR-based systems (e.g., Kaiser Permanente) into the community health setting; and analyses of factors influencing disparities in health and health care access. We describe the founding of Safety Net West, its infrastructure development, current projects, and the future goals of this community-based PBRN with a common EHR.

Having and being a personal physician: vision of the Pisacano scholars

Having a strong relationship with a personal physician can improve patient health outcomes. Yet achieving and sustaining this type of patient-physician relationship is often not possible in the current American health care system. Pisacano scholars and alumni, a group of young physician leaders supported by the American Board of Family Medicine, gathered for a 2-day symposium in June 2010 to explore the meaning of personal doctoring and its importance to our work as family physicians. Using the techniques of appreciative inquiry, the group discussed three questions: What is it like to have a personal physician? What is it like to be a personal physician? and, What are some feasible next steps toward making this possible? Symposium participants concluded that achieving the ideal patient-physician relationship for all patients and physicians would involve extensive alterations to the current health care system beyond what is outlined in the 2010 Patient Protection and Affordable Care Act. However, in the context of current health reform efforts, individual physicians, researchers, and policy makers must not lose sight of the importance of the patient-physician relationship and should continue to take concrete steps on an individual and system level to move us closer to this ideal.

Implementing quality improvement in small, autonomous primary care practices: implications for the patient-centred medical home

BACKGROUND

Implementing improvement programmes to enhance quality of care in primary care clinics is complex. Understanding how improvement strategies can be implemented in primary care is timely given the recent national movement towards transforming primary care into patient centred medical homes (PCMH). This study examined practice members' perceptions of the opportunities and challenges associated with implementing changes in their practice.

METHODS

Semi-structured interviews were conducted with a sample of 56 individuals working in 16 small, community based primary care practices. The interviews consisted of open-ended questions focused on participants' perceptions of: (1) practice vision, (2) perceived need for practice improvement and (3) barriers that hinder practice improvement. The interviews were conducted at the participating clinics and were tape-recorded, transcribed, and content analysed.

RESULTS

Content analysis identified two main domains for practice improvement related to: (1) the process of care, and (2) patients' involvement in their disease management. Examples of desired process of care changes included improvement in patient tracking and follow-up, standardisation of processes of care and overall clinic documentation. Changes related to patients' involvement in their care included improving (a) health education, and (b) self-care management. Among the internal barriers were: staff readiness for change, poor communication and relationship difficulties among team members. External barriers were insurance regulations, finances and patient health literacy.

CONCLUSIONS

Transforming practices to more patient-centred models of care will be a priority for primary care providers. Identifying opportunities and challenges associated with implementing change is critical for successful improvement programmes. Successful strategies for enhancing the adoption and uptake of PCMH elements should leverage areas of concordance between practice members' perceived needs and planned improvement efforts.

Defining and measuring the patient-centered medical home

The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices' internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare. The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care. The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following: Giving primacy to the core tenets of primary care. Assessing practice and system changes that are hypothesized to provide added value Assessing development of practices' core processes and adaptive reserve. Assessing integration with more functional healthcare system and community resources. Evaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspects. Recognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings. Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

Summary of the National Demonstration Project and recommendations for the patient-centered medical home

This article summarizes findings from the National Demonstration Project (NDP) and makes recommendations for policy makers and those implementing patient-centered medical homes (PCMHs) based on these findings and an understanding of diverse efforts to transform primary care. The NDP was launched in June 2006 as the first national test of a particular PCMH model in a diverse sample of 36 family practices, randomized to facilitated or self-directed groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical record audits, and patient and clinical staff surveys. Peer-reviewed manuscripts from the NDP provide answers to 4 key questions: (1) Can the NDP model be built? (2) What does it take to build the NDP model? (3) Does the NDP model make a difference in quality of care? and (4) Can the NDP model be widely disseminated? We find that although it is feasible to transform independent practices into the NDP conceptualization of a PCMH, this transformation requires tremendous effort and motivation, and benefits from external support. Most practices will need additional resources for this magnitude of transformation. Recommendations focus on the need for the PCMH model to continue to evolve, for delivery system reform, and for sufficient resources for implementing personal and practice development plans. In the meantime, we find that much can be done before larger health system reform.

Patient outcomes at 26 months in the patient-centered medical home National Demonstration Project

PURPOSE

The purpose of this study was to evaluate patient outcomes in the National Demonstration Project (NDP) of practices' transition to patient-centered medical homes (PCMHs).

METHODS

In 2006, a total of 36 family practices were randomized to facilitated or self-directed intervention groups. Progress toward the PCMH was measured by independent assessments of how many of 39 predominantly technological NDP model components the practices adopted. We evaluated 2 types of patient outcomes with repeated cross-sectional surveys and medical record audits at baseline, 9 months, and 26 months: patient-rated outcomes and condition-specific quality of care outcomes. Patient-rated outcomes included core primary care attributes, patient empowerment, general health status, and satisfaction with the service relationship. Condition-specific outcomes were measures of the quality of care from the Ambulatory Care Quality Alliance (ACQA) Starter Set and measures of delivery of clinical preventive services and chronic disease care.

RESULTS

Practices adopted substantial numbers of NDP components over 26 months. Facilitated practices adopted more new components on average than self-directed practices (10.7 components vs 7.7 components, P=.005). ACQA scores improved over time in both groups (by 8.3% in the facilitated group and by 9.1% in the self-directed group, P <.0001) as did chronic care scores (by 5.2% in the facilitated group and by 5.0% in the self-directed group, P=.002), with no significant differences between groups. There were no improvements in patient-rated outcomes. Adoption of PCMH components was associated with improved access (standardized beta [Sbeta]=0.32, P = .04) and better prevention scores (Sbeta=0.42, P=.001), ACQA scores (Sbeta=0.45, P = .007), and chronic care scores (Sbeta=0.25, P =.08).

CONCLUSIONS

After slightly more than 2 years, implementation of PCMH components, whether by facilitation or practice self-direction, was associated with small improvements in condition-specific quality of care but not patient experience. PCMH models that call for practice change without altering the broader delivery system may not achieve their intended results, at least in the short term.

Methods for evaluating practice change toward a patient-centered medical home

PURPOSE

Understanding the transformation of primary care practices to patient-centered medical homes (PCMHs) requires making sense of the change process, multilevel outcomes, and context. We describe the methods used to evaluate the country's first national demonstration project of the PCMH concept, with an emphasis on the quantitative measures and lessons for multimethod evaluation approaches.

METHODS

The National Demonstration Project (NDP) was a group-randomized clinical trial of facilitated and self-directed implementation strategies for the PCMH. An independent evaluation team developed an integrated package of quantitative and qualitative methods to evaluate the process and outcomes of the NDP for practices and patients. Data were collected by an ethnographic analyst and a research nurse who visited each practice, and from multiple data sources including a medical record audit, patient and staff surveys, direct observation, interviews, and text review. Analyses aimed to provide real-time feedback to the NDP implementation team and lessons that would be transferable to the larger practice, policy, education, and research communities.

RESULTS

Real-time analyses and feedback appeared to be helpful to the facilitators. Medical record audits provided data on process-of-care outcomes. Patient surveys contributed important information about patient-rated primary care attributes and patient-centered outcomes. Clinician and staff surveys provided important practice experience and organizational data. Ethnographic observations supplied insights about the process of practice development. Most practices were not able to provide detailed financial information.

CONCLUSIONS

A multimethod approach is challenging, but feasible and vital to understanding the process and outcome of a practice development process. Additional longitudinal follow-up of NDP practices and their patients is needed.