Background

The patient-centered medical home (PCMH) is a key service delivery innovation in health reform. However, there are growing questions about whether the changes in clinics promoted by the PCMH model lead to improvements in the patient experience.

Objective

To test the hypothesis that PCMH improvements in safety-net primary care clinics are associated with a more positive patient experience.

Research design

Multilevel cross-sectional analysis of patients nested within the primary care clinics that serve them.

Subjects

Primary care clinic leaders and patients throughout the City of New Orleans health care safety-net.

Measures

Dependent variables included patient ratings of accessibility, coordination, and confidence in the quality/safety of care. The key independent variable was a score measuring PCMH structural and process improvements at the clinic level.

Results

Approximately two thirds of patients in New Orleans gave positive ratings to their clinics on access and quality/safety, but only one third did for care coordination. In all but the largest clinics, patient experiences of care coordination were positively associated with the clinic's use of PCMH structural and process changes. Results for patient ratings of access and quality/safety were mixed.

Conclusions

Among primary care clinics in the New Orleans safety-net, use of more PCMH improvements at the clinic level led to more positive patient rating of care coordination, but not of accessibility or confidence in quality/safety. Ongoing efforts to pilot, demonstrate, implement, and evaluate the PCMH should consider how the impact of medical practice transformation could vary across different aspects of the patient experience.

Background

The Patient-Centered Medical Home (PCMH) is a widely endorsed model of delivery system reform that emphasizes primary care. Pilot demonstration projects are underway in many states, sponsored by Medicare, Medicaid, major health plans and multi-payer coalitions.

Methods

In this paper we consider the development of a long-term policy-relevant research agenda on outcomes of the PCMH. We provide an overview of potential measures of PCMH impact, identify measurement challenges and recommend areas for further study. Although the PCMH should not be expected to solve every problem in the health care system, developing a research agenda for measuring outcomes of delivery system innovations such as the PCMH should be considered in the context of the larger effort to improve the US health care system, with the ultimate goal to improve population health.

Results

As a framework for our discussion, we have chosen the Institute of Medicine's six specific aims for 21st century health care: (1) safe, (2) effective, (3) patient-centered, (4) timely, (5) efficient and (6) equitable. In addition, we include potential areas of PCMH outcomes that do not easily fall under this framework and consider unintended consequences.

Conclusion

Multi-stakeholder involvement will be essential in developing a long-term policy-relevant research agenda for outcomes of the PCMH.

Hurricane Katrina destroyed much of the health care infrastructure in and around New Orleans in 2005. We describe a natural experiment that occurred afterward, amid efforts to rebuild the city's health care system, in which diverse safety-net clinics were transformed into medical homes. Using surveys of clinic leaders and administrative data, we found that clinics made substantial progress in implementing new clinical processes to improve access, quality and safety, and care coordination and integration. But there was wide variation, with some clinics making only minimal progress. Because the transformation was closely tied to the receipt of federal grants and bonus payments, we observed declines in performance toward the end of the study, when clinics faced diminished federal funding and refocused their priorities on survival. Now that federal funds have dried up, moreover, clinics may be losing ground in sustaining their practice changes. The experience shows that payment to support medical home transformation must be robust and stable, and clinics need to be fully integrated into the broader health care system to improve overall coordination of care.

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.

The Patient-Centered Medical Home (PCMH) is a widely endorsed model of delivery system reform that emphasizes primary care. Pilot demonstration projects are underway in many states, sponsored by Medicare, Medicaid, major health plans and multi-payer coalitions. In this paper we consider the development of a long-term policy-relevant research agenda on outcomes of the PCMH. We provide an overview of potential measures of PCMH impact, identify measurement challenges and recommend areas for further study. Although the PCMH should not be expected to solve every problem in the health care system, developing a research agenda for measuring outcomes of delivery system innovations such as the PCMH should be considered in the context of the larger effort to improve the US health care system, with the ultimate goal to improve population health. As a framework for our discussion, we have chosen the Institute of Medicine’s six specific aims for 21st century health care: (1) safe, (2) effective, (3) patient-centered, (4) timely, (5) efficient and (6) equitable. In addition, we include potential areas of PCMH outcomes that do not easily fall under this framework and consider unintended consequences. Multi-stakeholder involvement will be essential in developing a long-term policy-relevant research agenda for outcomes of the PCMH.

Objective

To evaluate safety-net clinics' responses to a novel community-wide Patient-Centered Medical Home (PCMH) financial incentive program in post-Katrina New Orleans.

Data sources/study setting

Between June 2008 and June 2010, we studied 50 primary care clinics in New Orleans receiving federal funds to expand services and improve care delivery.

Study design

Multiwave, longitudinal, observational study of a local safety-net primary care system.

Data collection

Clinic-level data from a semiannual survey of clinic leaders (89.3 percent response rate), augmented by administrative records.

Principal findings

Overall, 62 percent of the clinics responded to financial incentives by achieving PCMH recognition from the National Committee on Quality Assurance (NCQA). Higher patient volume, higher baseline PCMH scores, and type of ownership were significant predictors of achieving NCQA recognition. The steepest increase in adoption of PCMH processes occurred among clinics achieving the highest, Level 3, NCQA recognition. Following NCQA recognition, 88.9 percent stabilized or increased their use of PCMH processes, although several specific PCMH processes had very low rates of adoption overall.

Conclusions

Findings demonstrate that widespread PCMH implementation is possible in a safety-net environment when external financial incentives are aligned with the goal of practice innovation.

Objectives

An increasing number of federal initiatives allow states flexibility in selecting the strategies used to achieve initiative-specific goals. Variation in the foci and intensity of implementation may explain why federal policy initiatives succeed in some states and fail in others. The CMS State Innovation Models (SIM) initiative is a complex policy intervention implemented with substantial variation across states and may have variable impacts. This paper presents a method to characterize and account for that variation in states' implementation foci and intensity in natural policy experiments.

Study design

A combination of quantitative and qualitative measures of SIM implementation was used to characterize the foci of payment and delivery system reforms across states.

Methods

A modified Delphi expert panel process was used to prioritize the features of SIM implementation that would differentiate grantee states with respect to improved health outcomes. Three researchers then reviewed summaries of published evaluations and reports to characterize and score states on each implementation feature. Expert panelists guided the researchers on developing the criteria and weights applied to the focus areas when calculating SIM implementation intensity scores for states.

Results

Over 3 years of an expert panel process, 4 dimensions of SIM implementation that would most affect health outcomes were prioritized: 1) extent and breadth of stakeholder engagement, (2) extent that SIM implementation was focused on improving behavioral health, (3) amount of SIM funding per capita, and (4) breadth and depth of value-based payment reforms. Scoring states based on the prioritized factors resulted in composite scores that differentiated states into 3 categories: high, moderate, and low implementation intensity.

Conclusions

We developed a stakeholder-driven method to measure and account for variation in implementation foci and intensity in a federal policy initiative that was implemented heterogeneously across grantee states. Our method for characterizing state implementation variation may be useful for natural policy experiments examining the variable impact of policy initiatives.

Objective

We sought to determine the extent to which adoption of health information technology (HIT) by physician practices may differ from the extent of use by individual physicians, and to examine factors associated with adoption and use.

Materials and methods

Using cross-sectional survey data from the National Study of Small and Medium-Sized Physician Practices (July 2007-March 2009), we examined the extent to which organizational capabilities and external incentives were associated with the adoption of five key HIT functionalities by physician practices and with use of those functionalities by individual physicians.

Results

The rate of physician practices adopting any of the five HIT functionalities was 34.1%. When practices adopted HIT functionalities, on average, about one in seven physicians did not use those functionalities. One physician in five did not use prompts and reminders following adoption by their practice. After controlling for other factors, both adoption of HIT by practices and use of HIT by individual physicians were higher in primary care practices and larger practices. Practices reporting an emphasis on patient-centered management were not more likely than others to adopt, but their physicians were more likely to use HIT.

Discussion

Larger practices were most likely to have adopted HIT, but other factors, including specialty mix and self-reported patient-centered management, had a stronger influence on the use of HIT once adopted.

Conclusions

Adoption of HIT by practices does not mean that physicians will use the HIT.