Trends in quality during medical home transformation

The quality of migrant patients' primary healthcare experiences and patient-centered medical home achievement by community health centers: results from the China greater bay area study

BACKGROUND

In China, Community Health Centers (CHCs) provide primary healthcare (PHC); however, few studies have examined the quality of PHC services experienced by migrant patients. We examined the potential association between the quality of migrant patients' PHC experiences and the achievement of Patient-Centered Medical Home by CHCs in China.

METHODS

Between August 2019 and September 2021, 482 migrant patients were recruited from ten CHCs in China's Greater Bay Area. We evaluated CHC service quality using the National Committee for Quality Assurance Patient-Centered Medical Home (NCQA-PCMH) questionnaire. We additionally assessed the quality of migrant patients' PHC experiences using the Primary Care Assessment Tools (PCAT). General linear models (GLM) were used to examine the association between the quality of migrant patients' PHC experiences and the achievement of PCMH by CHCs, adjusting for covariates.

RESULTS

The recruited CHCs performed poorly on PCMH1, Patient-Centered Access (7.2 ± 2.0), and PCMH2, Team-Based Care (7.4 ± 2.5). Similarly, migrant patients assigned low scores to PCAT dimension C-First-contact care-which assesses access (2.98 ± 0.03), and D-Ongoing care (2.89 ± 0.03). On the other hand, higher-quality CHCs were significantly associated with higher total and dimensional PCAT scores, except for dimensions B and J. For example, the total PCAT score increased by 0.11 (95% CI: 0.07-0.16) with each increase of CHC PCMH level. We additionally identified associations between older migrant patients (> 60 years) and total PCAT and dimension scores, except for dimension E. For instance, the average PCAT score for dimension C among older migrant patients increased by 0.42 (95% CI: 0.27-0.57) with each increase of CHC PCMH level. Among younger migrant patients, this dimension only increased by 0.09 (95% CI: 0.03-0.16).

CONCLUSION

Migrant patients treated at higher-quality CHCs reported better PHC experiences. All observed associations were stronger for older migrants. Our results may inform future healthcare quality improvement studies that focus on the PHC service needs of migrant patients.

The Value of the Patient-Centered Medical Home in Getting Adults Suffering From Acute Conditions Back to Work: An Integrative Literature Review

Acute conditions are the leading cause of work restrictions and missed workdays, contributing to over $27 billion in lost productivity each year and negatively impacting workers' health and quality of life. Primary care services, specifically patient-centered medical homes (PCMHs), play an essential role in supporting timely acute illness or injury recovery for working adults. The purpose of this review is to synthesize the evidence on the relationship between PCMH implementation, care processes, and outcomes. In addition, we discuss the empirical connection between this evidence and return-to-work outcomes, as well as the need for further research.

Community social determinants and health outcomes drive availability of patient-centered medical homes

The collaborative design of America's patient-centered medical homes places these practices at the forefront of emerging efforts to address longstanding inequities in the quality of primary care experienced among socially and economically marginalized populations. We assessed the geographic distribution of the country's medical homes and assessed whether they are appearing within communities that face greater burdens of disease and social vulnerability. We assessed overlapping spatial clusters of mental and physical health surveys; health behaviors, including alcohol-impaired driving deaths and drug overdose deaths; as well as premature mortality with clusters of medical home saturation and community socioeconomic characteristics. Overlapping spatial clusters were assessed using odds ratios and marginal effects models, producing four different scenarios of resource need and resource availability. All analyses were conducted using county-level data for the contiguous US states. Counties having lower uninsured rates and lower poverty rates were the most consistent indicators of medical home availability. Overall, the analyses indicated that medical homes are more likely to emerge within communities that have more favorable health and socioeconomic conditions to begin with. These findings suggest that intersecting the spatial footprints of medical homes in relation to health and socioeconomic data can provide crucial information for policy makers and payers invested in narrowing the gaps between clinic availability and the communities that experience the brunt of health and social inequalities.

Association of the Patient-Centered Medical Home Implementation with Chronic Disease Quality in Patients with Multimorbidity

BACKGROUND

The patient-centered medical home (PCMH) was established in part to improve chronic disease management, yet evidence is limited for effects on patients with multimorbidity.

OBJECTIVE

To examine the association of Patient-Aligned Care Team (PACT) implementation, the Veterans Health Administration (VA) PCMH model, and care quality for multimorbid patients enrolled in VA primary care from 2012 to 2014.

DESIGN

Retrospective cohort.

PATIENTS

318,764 multimorbid (> 3 chronic diseases) patients receiving care in 917 clinics.

MAIN MEASURES

PCMH implementation was measured using the PACT Implementation Progress Index (PI²) for clinics in 2012. The PI² is a validated composite measure of administrative and survey data with higher scores associated with greater care quality. Quality outcomes from 2013 to 2014 were assessed from External Peer Review Program (EPRP) metrics. Outcomes included preventative care, chronic disease management, and mental health and substance use metrics. We used generalized estimating equations to model associations adjusting for patient and clinic characteristics. We also examined associations for a subgroup with > 5 chronic diseases.

KEY RESULTS

For one-third of metrics (5/15), greater implementation of PACT in 2012 was associated with higher predicted probability of meeting the quality metric in 2013-2014. This association persisted for only two metrics (diabetic glycemic control, P < 0.001; lipid control in ischemic heart disease, P = 0.02) among patients with > 5 chronic diseases.

CONCLUSIONS

Multimorbid patients engaged in care from clinics with higher PCMH implementation received higher quality care across several quality domains, but this association was reduced in patients with > 5 chronic diseases.

Organizational Factors and Quality Improvement Strategies Associated With Lower Radiation Dose From CT Examinations

PURPOSE

The aim of this study was to identify organizational factors and quality improvement strategies associated with lower radiation doses from abdominal CT.

METHODS

Cross-sectional survey was administered to radiology leaders, along with simultaneous measurement of CT radiation dose among 19 health care organizations with 100 imaging centers throughout the United States, Europe, and Japan, using a common dose management software system. After adjusting for patient age, gender, and size, quality improvement strategies were tested for association with mean abdominal CT radiation dose and the odds of a high-dose examination.

RESULTS

Completed surveys were received from 90 imaging centers (90%), and 182,415 abdominal CT scans were collected during the study period. Radiation doses varied considerably across organizations and centers. Univariate analyses identified eight strategies and systems that were significantly associated with lower average doses or lower frequency of high doses for abdominal CT examinations: tracking patient safety measures, assessing the impact of CT changes, identifying areas for improvement, setting specific goals, organizing improvement teams, tailoring decisions to sites, testing process changes before full implementation, and standardizing workflow. These processes were associated with an 18% to 37% reduction in high-dose examinations (P < .001-.03). In multivariate analysis, having a tracking system for patient safety measures, supportive radiology leaders, and obtaining clear images were associated with a 47% reduction in high-dose examinations.

CONCLUSIONS

This documentation of the relation between quality improvement strategies and radiation exposure from CT examinations has identified important information for others interested in reducing the radiation exposure of their patients.

Review of patient-reported experience within Patient-Centered Medical Homes: insights for Australian Health Care Homes

Understanding patient experience is necessary to advance the patient-centred approach to health service delivery. Australia's primary healthcare model, the 'Health Care Home', is based on the 'Patient-Centered Medical Home' (PCMH) model developed in the United States. Both these models aim to improve patient experience; however, the majority of existing PCMH model evaluations have focussed on funding, management and quality assurance measures. This review investigated the scope of evidence reported by adult patients using a PCMH. Using a systematic framework, the review identified 39 studies, sourced from 33 individual datasets, which used both quantitative and qualitative approaches. Patient experience was reported for model attributes, including the patient-physician and patient-practice relationships; care-coordination; access to care; and, patient engagement, goal setting and shared decision-making. Results were mixed, with the patient experience improving under the PCMH model for some attributes, and some studies indicating no difference in patient experience following PCMH implementation. The scope and quality of existing evidence does not demonstrate improvement in adult patient experience when using the PCMH. Better measures to evaluate patient experience in the Australian Health Care Home model are required.

Implementation of Practice Transformation: Patient Experience According to Practice Leaders

OBJECTIVE

Examine practice leaders' perceptions and experiences of how patient-centered medical home (PCMH) transformation improves patient experience.

SUBJECTS

Thirty-six interviews with lead physicians (n = 13), site clinic administrators (n = 13), and nurse supervisors (n = 10).

METHODS

Semi-structured interviews at 14 primary care practices within a large urban Federally Qualified Health Center (FQHC) delivery system to identify critical patient experience domains and mechanisms of change. Identified patient experience domains were compared with Consumer Assessment of Healthcare Providers and Systems (CAHPS) items.

RESULTS

We identified 28 patient experience domains improved by PCMH transformation, of which 22 are measured by CAHPS, and identified 24 mechanisms of change commonly reported by practice leaders during PCMH transformation.

CONCLUSIONS

PCMH practice transformation can improve patient experience. Most patient experience domains reported as improved during PCMH efforts are measured by CAHPS items. Practices would benefit from collecting specific information on staff behaviors related to teamwork, team-based communication, scheduling, emergency and inpatient follow-up, and referrals. All 3 types of practice leaders reported 4 main mechanisms of PCMH change that improved patient experience. Our findings provide guidance for practice leaders on which strategies of PCMH practice transformation lead to specific improvements in patient experience measures. Further research is needed on the relationship between PCMH changes and changes in CAHPS patient experience scores.

Impacts of Initial Transformation to a Patient-Centered Medical Home on Diabetes Outcomes in Federally Qualified Health Centers in Florida

OBJECTIVE

Federally qualified health centers (FQHCs) in Florida see large numbers of vulnerable patients with diabetes. Patient-centered medical home (PCMH) models can lead to improvements in health for patients with chronic conditions and cost savings for providers. Therefore, FQHCs are increasingly moving to PCMH models of care. The study objective was to examine the effects of initial transformation to a level 3 National Committee for Quality Assurance (NCQA) certified PCMH in 2011, on clinical diabetes outcomes among 27 clinic sites from a network of FQHCs in Florida.

METHODS

We used de-identified, longitudinal electronic health record (EHR) data from 2010-2012 and multivariate logistic regression to analyze the effects of initial transformation on the odds of having well-controlled HbA1c, body mass index (BMI), and blood pressure (BP) among vulnerable patients with diabetes. Models controlled for clustering by year, patient, and organizational characteristics.

RESULTS

Overall, transformation to a PCMH was associated with 19% greater odds of having well-controlled HbA1c values with no statistically significant impact on BMI or BP. Subanalyses showed transformation had less of an effect on BP for African American patients and HbA1c control for Medicare enrollees but a greater effect on weight control for patients older than 35 years.

CONCLUSION

Transformation to a PCMH in FQHCs appears to improve the health of vulnerable patients with diabetes, with less improvement for subsets of patients. Future research should seek to understand the heterogeneous effects of patient-centered transformation on various subgroups.

Patient Experience with the Patient-Centered Medical Home in Michigan's Statewide Multi-Payer Demonstration: A Cross-Sectional Study

BACKGROUND

The literature on patient-centered medical homes (PCMHs) and patient experience is somewhat mixed. Government and private payers are promoting multi-payer PCMH initiatives to align requirements and resources and to enhance practice transformation outcomes. To this end, the multipayer Michigan Primary Care Transformation (MiPCT) demonstration project was carried out.

OBJECTIVE

To examine whether the PCMH is associated with a better patient experience, and whether a mature, multi-payer PCMH demonstration is associated with even further improvement in the patient experience.

DESIGN

This is a cross-sectional comparison of adults attributed to MiPCT PCMH, non-participating PCMH, and non-PCMH practices, statistically controlling for potential confounders, and conducted among both general and high-risk patient samples.

PARTICIPANTS

Responses came from 3893 patients in the general population and 4605 in the high-risk population (response rates of 31.8% and 34.1%, respectively).

MAIN MEASURES

The Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey, with PCMH supplemental questions, was administered in January and February 2015.

KEY RESULTS

MiPCT general and high-risk patients reported a significantly better experience than non-PCMH patients in most domains. Adjusted mean differences were as follows: access (0.35**, 0.36***), communication (0.19*, 0.18*), and coordination (0.33**, 0.35***), respectively (on a 10-point scale, with significance indicated by: *= p<0.05, **= p<0.01, and ***= p<0.001). Adjusted mean differences in overall provider ratings were not significant. Global odds ratios were significant for the domains of self-management support (1.38**, 1.41***) and comprehensiveness (1.67***, 1.61***). Non-participating PCMH ratings fell between MiPCT and non-PCMH across all domains and populations, sometimes attaining statistical significance.

CONCLUSIONS

PCMH practices have more positive patient experiences across domains characteristic of advanced primary care. A mature multi-payer model has the strongest, most consistent association with a better patient experience, pointing to the need to provide consistent expectations, resources, and time for practice transformation. Our results held for a general population and a high-risk population which has much more contact with the healthcare system.

Utilizing Actionable Data Analytics to Support Patient Navigation Enrollment and Retention Within Federally Qualified Health Centers

INTRODUCTION

Emergency departments (EDs) have become the primary source of care for increasing number of patients, leading to treatment of nonemergent cases, which divert resources from true emergency situations and represent poor cost-effectiveness for treating such cases. There is evidence that suggests that patient navigation (PN) integrated into the ED and other case management techniques can help reduce the number of primary care-related ED visits and these navigation programs are more cost-effective than the ED visits themselves. The Greater New Orleans Community Health Connection Primary Care Capacity Project Quality Improvement Initiative (GNOPQii) is a pilot project aimed at improving the efficiency of PN for patients who have had avoidable ED encounters or inpatient readmissions through applied data and technology program.

METHODS

Partnering Federally Qualified Health Centers were equipped with actionable ED utilization data to integrate with their own patient clinical data to track patient ED activity. The pilot design also included the use of patient navigators to address the nonclinical cultural and behavioral barriers to care. As part of the overall evaluation, comparisons of data utilization and PN services pre- and post-GNOPQii were conducted.

RESULTS

A total of 337 referrals were made, and 145 patients were enrolled into the GNOPQii pilot program. The direct services needed the most by patients were transportation and medication resources. Of those who enrolled (N = 145), 63 patients graduated, meaning program compliance and 90 days without visits to the ED, resulting in a 43% success rate.

DISCUSSION

If an estimated $1898 savings for every nonemergency ED encounter replaced by an office-based encounter is applied to our results, the GNOPQii program contributed to a minimum of $119 574.00 savings even if only 1 deterred ED visit per graduate is assumed. Future research is needed to systematically test the efficacy of GNOPQii in reducing nonemergent ED visits.

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.

Longitudinal evaluation of physician payment reform and team-based care for chronic disease management and prevention

BACKGROUND

We evaluated a large-scale transition of primary care physicians to blended capitation models and team-based care in Ontario, Canada, to understand the effect of each type of reform on the management and prevention of chronic disease.

METHODS

We used population-based administrative data to assess monitoring of diabetes mellitus and screening for cervical, breast and colorectal cancer among patients belonging to team-based capitation, non-team-based capitation or enhanced fee-for-service medical homes as of Mar. 31, 2011 (n = 10 675 480). We used Poisson regression models to examine these associations for 2011. We then used a fitted nonlinear model to compare changes in outcomes between 2001 and 2011 by type of medical home.

RESULTS

In 2011, patients in a team-based capitation setting were more likely than those in an enhanced fee-for-service setting to receive diabetes monitoring (39.7% v. 31.6%, adjusted relative risk [RR] 1.22, 95% confidence interval [CI] 1.18 to 1.25), mammography (76.6% v. 71.5%, adjusted RR 1.06, 95% CI 1.06 to 1.07) and colorectal cancer screening (63.0% v. 60.9%, adjusted RR 1.03, 95% CI 1.02 to 1.04). Over time, patients in medical homes with team-based capitation experienced the greatest improvement in diabetes monitoring (absolute difference in improvement 10.6% [95% CI 7.9% to 13.2%] compared with enhanced fee for service; 6.4% [95% CI 3.8% to 9.1%] compared with non-team-based capitation) and cervical cancer screening (absolute difference in improvement 7.0% [95% CI 5.5% to 8.5%] compared with enhanced fee for service; 5.3% [95% CI 3.8% to 6.8%] compared with non-team-based capitation). For breast and colorectal cancer screening, there were no significant differences in change over time between different types of medical homes.

INTERPRETATION

The shift to capitation payment and the addition of team-based care in Ontario were associated with moderate improvements in processes related to diabetes care, but the effects on cancer screening were less clear.

Physician Satisfaction in Practices That Transformed Into Patient-Centered Medical Homes: A Statewide Study in New York

Patient-centered medical home (PCMH) transformation can significantly affect physicians' job satisfaction, which in turn can affect the quality of patient care. Between November 2012 and March 2013, the study team surveyed 159 community-based physicians in 159 practice sites that had experienced PCMH practice transformations in New York State. Of the 159 physicians, 121 responded (77% response rate) to the online survey. Nearly two thirds (60%) of physicians reported being somewhat or very satisfied overall with their practice after PCMH transformation. Overall satisfaction was lower than satisfaction with specific domains of practice: patient-centered care (82%), coordination of care (81%), access to care (79%), efficiency (76%), organizational culture (69%), and quality (69%). Although the physicians were moderately satisfied with care quality in their practices after PCMH transformation, their overall satisfaction was notably lower. The findings reveal a need to identify factors beyond quality for measuring physician satisfaction in PCMH transformed practices.

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.

A method to determine the impact of patient-centered care interventions in primary care

OBJECTIVE

The implementation of patient-centered care (PCC) innovations continues to be poorly understood. We used the implementation effectiveness framework to pilot a method for measuring the impact of a PCC innovation in primary care practices.

METHODS

We analyzed data from a prior study that assessed the implementation of an electronic geriatric quality-of-life (QOL) module in 3 primary care practices in central North Carolina in 2011-2012. Patients responded to the items and the subsequent patient-provider encounter was coded using the Roter Interaction Analysis System (RIAS) system. We developed an implementation effectiveness measure specific to the QOL module (i.e., frequency of usage during the encounter) using RIAS and then tested if there were differences with RIAS codes using analysis of variance.

RESULTS

A total of 60 patient-provider encounters examined differences in the uptake of the QOL module (i.e., implementation-effectiveness measure) with the frequency of RIAS codes during the encounter (i.e., patient-centeredness measure). There was a significant association between the effectiveness measure and patient-centered RIAS codes.

CONCLUSION

The concept of implementation effectiveness provided a useful framework determine the impact of a PCC innovation.

PRACTICE IMPLICATIONS

A method that captures real-time interactions between patients and care staff over time can meaningfully evaluate PCC innovations.

Do patient-centered medical homes reduce emergency department visits?

OBJECTIVE

To assess whether adoption of the patient-centered medical home (PCMH) reduces emergency department (ED) utilization among patients with and without chronic illness.

DATA SOURCES

Data from approximately 460,000 Independence Blue Cross patients enrolled in 280 primary care practices, all converting to PCMH status between 2008 and 2012.

RESEARCH DESIGN

We estimate the effect of a practice becoming PCMH-certified on ED visits and costs using a difference-in-differences approach which exploits variation in the timing of PCMH certification, employing either practice or patient fixed effects. We analyzed patients with and without chronic illness across six chronic illness categories.

PRINCIPAL FINDINGS

Among chronically ill patients, transition to PCMH status was associated with 5-8 percent reductions in ED utilization. This finding was robust to a number of specifications, including analyzing avoidable and weekend ED visits alone. The largest reductions in ED visits are concentrated among chronic patients with diabetes and hypertension.

CONCLUSIONS

Adoption of the PCMH model was associated with lower ED utilization for chronically ill patients, but not for those without chronic illness. The effectiveness of the PCMH model varies by chronic condition. Analysis of weekend and avoidable ED visits suggests that reductions in ED utilization stem from better management of chronic illness rather than expanding access to primary care clinics.

Effectiveness of diabetes interventions in the patient-centered medical home

The patient-centered medical home (PCMH) is an innovative care model for the provision of primary care that is being rapidly adopted in the U.S. with the support of federal agencies and professional organizations. Its goal is to provide comprehensive, patient-centered care with increased access, quality, and efficiency. Diabetes, as a common, costly, chronic disease that requires ongoing management by patients and providers, is a condition that is frequently monitored as a test case in PCMH implementations. While in theory a PCMH care model that supports patient engagement and between-visit care may help improve diabetes care delivery and outcomes, the success of this approach may depend largely upon the specific strategies used and implementation approach. The cost-effectiveness of diabetes care in the PCMH model is not yet clear. Interventions have been most effective and most cost-effective for those with the poorest diabetes management at baseline.

Key activities used by community based primary care practices to improve the quality of diabetes care in response to practice facilitation

BACKGROUND

A recent systematic review suggests that practice facilitation (PF) is a robust intervention for implementing evidence-based preventive care guidelines in primary care, but the ability of PF to improve chronic illness care remains unclear.

AIMS

To examine the specific activities and Chronic Care model (CCM) components that primary care practices implemented and sustained in response to a 12-month PF intervention.

METHODS

The ABC trial tested the effectiveness of PF to improve care for diabetes in 40 small community-based primary care practices that were randomized to "initial" or "delayed" intervention arms. A trained facilitator met with each practice over 12-months. Facilitators used interactive consensus building to help practices implement one or more of quality improvement activities based on the CCM. Facilitators prospectively recorded implementation activities reported by practice teams during monthly meetings and confirmed which of these were sustained at the end of the intervention.

RESULTS

37 practices implemented and sustained a total of 43 unique activities [range 1-15, average 6.5 (SD=2.9)]. The number (%) of practices that implemented 1 or more key activities in each CCM component varied: Patient Self-Management Support: 37 (100%); Clinical Information Systems: 24 (64.9%), Delivery System Design: 14 (37.8%), Decision Support: 13 (35.1%), Community Linkages: 2 (5.4%); Healthcare System Support: 2 (2.7%). The majority of practices (59%) only implemented activities from 1 or 2 CCM components. The number of sustained activities was associated with the number of PF visits, but not with practice characteristics.

CONCLUSIONS

In spite of the PF intervention, it was difficult for these small practices to implement comprehensive CCM changes. Although practices implemented and sustained a remarkable number and variety of key activities, the majority of these focused on patient self-management support, as opposed to other components of the CCM, such as clinical information systems, decision support, delivery system redesign, and community linkages.

Reducing preventable emergency department utilization and costs by using community health workers as patient navigators

Primary care-related emergency department (PCR-ED) utilization, including for conditions that are preventable or treatable with appropriate primary care, is associated with decreased efficiency of and increased costs to the health system. Many PCR-ED users experience actual or perceived problems accessing appropriate, ongoing sources of medical care. Patient navigation, an intervention used most often in the cancer care continuum, may help to address these barriers among medically underserved populations, such as those who are low income, uninsured, publicly insured, or recent U.S. immigrants. We examined a patient navigation program designed to promote appropriate primary care utilization and prevent or reduce PCR-ED use at Memorial Hermann Health System in Houston, Texas. The intervention is facilitated by bilingual, state-certified community health workers (CHWs) who are trained in peer-to-peer counseling and connect medically underserved patients with medical homes and related support services. The CHWs provide education about the importance of primary care, assist with appointment scheduling, and follow up with patients to monitor and address additional barriers. Our study found that the patient navigation intervention was associated with decreased odds of returning to the ED among less frequent PCR-ED users. Among patients who returned to the ED for PCR reasons, the pre/post mean visits declined significantly over a 12-month pre/post-observation period but not over a 24-month period. The savings associated with reduced PCR-ED visits were greater than the cost to implement the navigation program. Our findings suggest that an ED-based patient navigation program led by CHWs should be further evaluated as a tool to help reduce PCR-ED visits among vulnerable populations.

Outcomes among chronically ill adults in a medical home prototype

OBJECTIVES

To compare quality, utilization, and cost outcomes for patients with selected chronic illnesses at a patient-centered medical home (PCMH) prototype site with outcomes for patients with the same chronic illnesses at 19 nonintervention control sites.

STUDY DESIGN

Nonequivalent pretest-posttest control group design.

METHODS

PCMH redesign results were investigated for patients with preexisting diabetes, hypertension, and/or coronary heart disease. Data from automated databases were collected for eligible enrollees in an integrated healthcare delivery system. Multivariable regression models tested for adjusted differences between PCMH patients and controls during the baseline and follow-up periods. Dependent measures under study included clinical processes and, outcomes, monthly healthcare utilization, and costs.

RESULTS

Compared with controls over 2 years, patients at the PCMH prototype clinic had slightly better clinical outcome control in coronary heart disease (2.20 mg/dL lower mean low-density lipoprotein cholesterol; P <.001). PCMH patients changed their patterns of primary care utilization, as reflected by 86% more secure electronic message contacts (P <.001), 10% more telephone contacts (P = .003), and 6% fewer in-person primary care visits (P <.001). PCMH patients had 21% fewer ambulatory care-sensitive hospitalizations (P <.001) and 7% fewer total inpatient admissions (P = .002) than controls. During the 2-year redesign, we observed 17% lower inpatient costs (P <.001) and 7% lower total healthcare costs (P <.001) among patients at the PCMH prototype clinic.

CONCLUSIONS

A clinic-level population-based PCMH redesign can decrease downstream utilization and reduce total healthcare costs in a subpopulation of patients with common chronic illnesses.

A randomized trial of practice facilitation to improve the delivery of chronic illness care in primary care: initial and sustained effects

Background

Practice facilitation (PF) is an implementation strategy now commonly used in primary care settings for improvement initiatives. PF occurs when a trained external facilitator engages and supports the practice in its change efforts. The purpose of this group-randomized trial is to assess PF as an intervention to improve the delivery of chronic illness care in primary care.

Methods

A randomized trial of 40 small primary care practices who were randomized to an initial or a delayed intervention (control) group. Trained practice facilitators worked with each practice for one year to implement tailored changes to improve delivery of diabetes care within the Chronic Care Model framework. The Assessment of Chronic Illness Care (ACIC) survey was administered at baseline and at one-year intervals to clinicians and staff in both groups of practices. Repeated-measures analyses of variance were used to assess the main effects (mean differences between groups) and the within-group change over time.

Results

There was significant improvement in ACIC scores (p < 0.05) within initial intervention practices, from 5.58 (SD 1.89) to 6.33 (SD 1.50), compared to the delayed intervention (control) practices where there was a small decline, from 5.56 (SD 1.54) to 5.27 (SD 1.62). The increase in ACIC scores was sustained one year after withdrawal of the PF intervention in the initial intervention group, from 6.33 (SD 1.50) to 6.60 (SD 1.94), and improved in the delayed intervention (control) practices during their one year of PF intervention, from 5.27 (SD 1.62) to 5.99 (SD 1.75).

Conclusions

Practice facilitation resulted in a significant and sustained improvement in delivery of care consistent with the CCM as reported by those involved in direct patient care in small primary care practices. The impact of the observed change on clinical outcomes remains uncertain.

Trial registration

This protocol followed the CONSORT guidelines and is registered per ICMJE guidelines: Clinical Trial Registration Number: NCT00482768.

The patient-centered medical home: an evaluation of a single private payer demonstration in New Jersey

BACKGROUND

The patient-centered medical home (PCMH) has increasingly been looked to by policy makers, health care providers, and private insurers as a potential solution to the fragmented and inefficient US health care system. Whether the PCMH achieves these goals is not known.

OBJECTIVES

To evaluate a PCMH demonstration project implemented in 2011 in 8 New Jersey primary care practices covering over 10,000 plan members.

RESEARCH DESIGN

We conduct difference-in-differences analysis, comparing changes in outcomes at 8 medical home practices to a group of 24 comparison practices before (2010) and after (2011) the medical home implementation occurred. We use Mahalanobis distance matching to select the 24 comparison practices, matching on practice characteristics. We focus on the effect of the PCMH pilot on 3 groups of outcomes: health care utilization, costs, and quality.

RESULTS

The study cohort included 35,059 members during the study period 2010-2011-10,004 in the 8 PCMH practices and 25,055 in the 24 comparison practices. Health care utilization and costs did not significantly change with adoption of the PCMH model. In testing for changes in Healthcare Effectiveness and Data Information Set (HEDIS) quality measures, rates of mammography increased in PCMH practices after PCMH implementation compared to non-PCMH practices, by 2.2 percentage points on a base of 69.5% (P<0.001). Rates of nephropathy screening also increased (by 6.6 percentage points on a base of 51.8%; P=0.05). Changes in 7 other HEDIS quality measures following PCMH implementation were not statistically significant.

CONCLUSIONS

We find little evidence of reductions in health care utilization or cost and minimal evidence of improvements in quality of care. Ongoing work is needed to understand why this model of care seems to work in some cases and not others and to evaluate how to improve the medical home.

Quality and efficiency in small practices transitioning to patient centered medical homes: a randomized trial

BACKGROUND

There is growing evidence that even small and solo primary care practices can successfully transition to full Patient Centered Medical Home (PCMH) status when provided with support, including practice redesign, care managers, and a revised payment plan. Less is known about the quality and efficiency outcomes associated with this transition.

OBJECTIVE

Test quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices.

DESIGN

Randomized Controlled Trial.

PARTICIPANTS

Eighteen intervention practices with 43 physicians and 14 control practices with 24 physicians; all from adult primary care practices.

INTERVENTIONS

Modeled on 2008 NCQA PPC®-PCMH™, intervention practices received 18 months of tailored practice redesign support; 2 years of revised payment, including up to $2.50 per member per month (PMPM) for achieving quality targets and up to $2.50 PMPM for PPC-PCMH recognition; and 18 months of embedded care management support. Controls received yearly participation payments.

MAIN MEASURES

Eleven clinical quality indicators from the 2009 HEDIS process and health outcomes measures derived from patient claims data; Ten efficiency indicators based on Thomson Reuter efficiency indexes and Emergency Department (ED) Visit Ratios; and a panel of costs of care measures.

KEY RESULTS

Compared to control physicians, intervention physicians significantly improved TWO of 11 quality indicators: hypertensive blood pressure control over 2 years (intervention +23 percentage points, control -2 percentage points, p =0.02) and breast cancer screening over 3 years (intervention +3.5 percentage points, control -0.4 percentage points, p =0.03). Compared to control physicians, intervention physicians significantly improved ONE of ten efficiency indicators: number of care episodes resulting in ED visits was reduced (intervention -0.7 percentage points, control + 0.5 percentage points, p = 0.002), with 3.8 fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year. There were no significant cost-savings on any of the pre-specified costs of care measures.

CONCLUSIONS

In a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.

Contrasting trajectories of change in primary care clinics: lessons from New Orleans safety net

PURPOSE

We sought to compare and contrast patterns of change toward patient-centered medical homes (PCMHs) in 5 New Orleans primary care safety net clinics in the aftermath of Hurricane Katrina. We assessed the general direction of change in practice to discover possible reasons for differences in patterns of change, and to identify impediments to change.

METHODS

Data collection consisted of 5 semiannual telephone interviews with clinic leadership over 2.5 years supplemented by administrative audits. We used standard survey indexes of PCMH to monitor practice change. We conducted site visits and unstructured in-person interviews with clinicians and staff of the 5 clinics.

RESULTS

PCMH index scores improved during the observation period with variations in rates of change and initial levels of PCMH. Qualitative analysis suggested possible explanations for this differential success: (1) early vs later starts in practice change, (2) funding based on patient outcomes, (3) demands that compete with practice change, (4) qualities of clinic leadership, and (5) relations with the communities where patients live. Barriers to practice change included high demand for services, deficient linkages between hospital and specialty care, lack of staff resources, and a need to focus on clinic finances.

CONCLUSIONS

The PCMH model can successfully address the needs of safety net populations. Stable leadership committed to serving safety net patients via the PCMH model is important for successful practice transformation. Beyond clinic walls, cultivating deep ties to the communities that clinics serve also supports the PCMH model.

Medical home transformation: a gradual process and a continuum of attainment

PURPOSE

The patient-centered medical home is often discussed as though there exist either traditional practices or medical homes, with marked differences between them. We analyzed data from an evaluation of certified medical homes in Minnesota to study this topic.

METHODS

We obtained publicly reported composite measures for quality of care outcomes pertaining to diabetes and vascular disease for all clinics in Minnesota from 2008 to 2010. The extent of and change in practice systems over that same time period for the first 120 clinics serving adults certified as health care homes (HCHs) was measured by the Physician Practice Connections Research Survey (PPC-RS), a self-report tool similar to the National Committee for Quality Assurance standards for patient-centered medical homes. Measures were compared between these clinics and 518 non-HCH clinics in the state.

RESULTS

Among the 102 clinics for which we had precertification and postcertification scores for both the PPC-RS and either diabetes or vascular disease measures, the mean increase in systems score over 3 years was an absolute 29.1% (SD = 16.7%) from a baseline score of 38.8% (SD = 16.5%, P ≤.001). The proportion of clinics in which all patients had optimal diabetes measures improved by an absolute 2.1% (SD = 5.5%, P ≤.001) and the proportion in which all had optimal cardiovascular disease measures by 4.4% (SD = 7.5%, P ≤.001), but all measures varied widely among clinics. Mean performance rates of HCH clinics were higher than those of non-HCH clinics, but there was extensive overlap, and neither group changed much over this time period.

CONCLUSIONS

The extensive variation among HCH clinics, their overlap with non-HCH clinics, and the small change in performance over time suggest that medical homes are not similar, that change in outcomes is slow, and that there is a continuum of transformation.

Improved cost, health, and satisfaction with a health home benefit plan for self-insured employers and small physician practices

We compared the impacts on total costs, health, and satisfaction among 615 adults enrolled 2 years in an employer's health home benefit plan to their baseline year in a standard preferred provider organization plan. The new plan combined strong continuity care incentives with nurse coaching support. After 24 months, total medical costs were 23% lower than the baseline year, biometric measures improved for more than 85% of members, and patient satisfaction exceeded 85%. Emergency department visits decreased by 16% and hospital days decreased by 48%. Health home benefit plans engaging small primary care physician practices and members in coordinated continuity care can deliver high value.

Improving patient experience by transforming primary care: evidence from Geisinger's patient-centered medical homes

Patient-centered medical homes (PCMHs) have the potential to improve patient experience of care. Since 2006, Geisinger Health System has implemented its own version of an advanced PCMH model, referred to as ProvenHealth Navigator (PHN). To evaluate the impact of PHN on patient experience of care, the authors conducted a survey of patients whose primary care clinics had been transformed to "PHN sites" and were under case management at the time of the survey. A comparable survey of patients from non-PHN sites also was conducted for comparison. The results suggest that patients in PHN sites were significantly more likely to report positive changes in their care experience and quality; moreover, they were more likely to cite the physician's office as their usual source of care rather than the emergency room (83% vs. 68% for physician's office; 11% vs. 23% for emergency room). However, the results also suggest that there was no significant difference between PHN and non-PHN patients in their perceptions of access to care or primary care physician performance in terms of patient-centered care (eg, listening, explaining, involving patients in decision making). These findings are consistent with the expectation that transformation of primary care into PCMH can lead to improved patient experience of care.

Are characteristics of the medical home associated with diabetes care costs?

OBJECTIVE

To examine the relationship between primary care medical home clinical practice systems corresponding to the domains of the Chronic Care Model and annual diabetes-related health care costs incurred by members of a health plan with type-2 diabetes and receiving care at one of 27 Minnesota-based medical groups.

STUDY DESIGN

Cross-sectional analysis of the relation between patient-level costs and Patient-Centered Medical Home (PCMH) practice systems as measured by the Physician Practice Connections Readiness Survey.

METHODS

Multivariate regressions adjusting for patient demographics, health status, and comorbidities estimated the relationship between the use of PCMH clinical practice systems and 3 annual cost outcomes: total costs of diabetes-related care, outpatient medical costs of diabetes-related care, and inpatient costs of diabetes-related care (ie, inpatient and emergency care).

RESULTS

Overall PCMH scores were not significantly related to any annual cost outcome; however, 2 of 5 subdomains were related. Health Care Organization scores were related to significantly lower total (P=0.04) and inpatient costs (P=0.03). Clinical Decision Support was marginally related to a lower total cost (P=0.06) and significantly related to lower inpatient costs (P=0.02). A detailed analysis of the Health Care Organization domain showed that compared with medical groups with only quality improvement, those with performance measurement and individual provider feedback averaged $245/patient less. Medical groups with clinical reminders for counseling averaged $338/patient less.

CONCLUSIONS

Certain PCMH practice systems were related to lower costs, but these effects are small compared with total costs. Further research about how these and other PCMH domains affect costs over time is needed.

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.

Training the next generation of providers in addiction medicine

Within the United States there exists a profound discrepancy between the significant public health problem of substance abuse and the access to treatment for addicted individuals. Part of the insufficient access to treatment is a function of relatively low levels or professional experts in addiction medicine. Part of the low levels of professional addiction experts is the result of inadequate addiction medicine training of medical students and residents. This article outlines deficits in addiction medicine training among medical students and residents, yet real change in the addiction medicine training process will always be subject to the complexity of producing alterations across multiple credentialing institutions as well as the keen competition between educators for “more time” for their particular subject. Other hurdles include the broad-based issue of stigma regarding alcoholism and other substance abuse that likely impact all systems that regulate physician addiction medicine training. As noted in the discussion of psychiatry residency, even psychiatry residents manifest stigma regarding substance abusing patients. Five currently active processes may allow for fundamental change to the inertia in physician addiction medicine training while also potentially impacting stigma: 1. We appear to be at the beginning of the integration of addiction into traditional medicine through the formation of a legitimized addiction medicine subspecialty. 2. The training of primary care trainees and practitioners in the use of SBIRT is accelerating, thus creating another process of addiction integration into traditional medicine. 3. The PCMH is being established as a model for primary care 4. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) became effective for group health care plan years beginning on or after July 1, 2010; thereby, substance abuse benefits and cost are to be the same as general medical or surgical benefits. 5. The equalizer is prescription drug abuse, which is increasing recognition of addiction among populations where it was previously ignored or denied. The first three activities will create a medical office “experience” that is largely unknown but carries the power to change the perception of addiction: patients visiting their primary care physicians, who then screen them for addiction problems and give the same attention to treatment and prevention of addiction problems as they might give to treatment and prevention of cardiovascular disease and other medical issues. The personal experience of the aforementioned medical scene by members of US society may also provide a very positive impact on psychiatrists, including those who specialize in addiction medicine. It is quite possible that the recognition of addiction medicine as a traditional medical subspecialty as well as the integration of addiction throughout medicine will precede any substantive change in the integration of mental health care with the rest of medicine. Yet, any integration of addiction within the entire field of medicine may open a path for mental health to follow. Psychiatrists, including those who are addiction experts, need to be a part of this new medical integration process. Being a part of new treatment models is why we proposed six future skillsets for psychiatrists who specialize in addiction. The selection of these proposed skillsets anticipates an integrated health care team utilizing some form of a patient-centered approach-three are skillsets that are already required, while the last three address new skillsets that will be helpful in working with the integrative health care team model. Whatever form the future of addiction care takes, psychiatrists who specialize in addiction medicine can provide positive and core contributions as expert addiction and mental health consultants including: 1. How does one screen for major depression and/or an anxiety disorder and also determine a diagnosis? 2. In prescribing, what constitutes legitimate follow-up of patients on antidepressants and antianxiety agents, including how to avoid additional substance abuse problems when prescribing sedative-hypnotics? 3. When and how should patients be referred to a psychiatrist? Finally, it is important to note that any of the potential changes described in this article need to influence only 10% of the approximately 17 million current heavy drinkers to seek treatment to equal the approximately 1.7 million heavy drinkers who are now in treatment, let alone any of the approximately 50 million current at-risk drinkers, virtually none of whom are in treatment. Among other social changes that will alter the future of addiction treatment, the integration of addiction into traditional medicine may go a long way in altering the current ratios of who seeks treatment and is willing to participate in treatment.