Implementing the patient-centered medical home in complex adaptive systems

Abstract

Background-This study explores the implementation experience of nine primary care practices becoming patient-centered medical homes (PCMH) as part of the New Hampshire Citizens Health Initiative Multi-Stakeholder Medical Home Pilot.

Addressing uncertainty : contributions of knowing patients and team members to negotiating team-based primary care

“…Team-based care is a relatively recent development in the Canadian primary care system (Shortt, 2004), with a vision that emphasizes the need for health care professionals from various disciplines to work to their full scope of practice, share expertise, and work together to improve service delivery and patient care outcomes (Kirby & LeBreton, 2002;Romanow, 2002). While most provincial governments have identified team-based care as a cornerstone of sustainable, high quality primary care (Government of Manitoba, 2012;Government of Ontario, 2010;Government of Saskatchewan, 2016), implementation of team-based care across the country has been variable, and evaluation of team outcomes and models in primary care remain mixed with positive and negative findings (Flieger, 2016;Glazier, Zagorski, &Rayner, 2012;Rodriguez, Rogers, Marshall, & Safran, 2007).…”

“…In the United States, a model that has been widely adopted, implemented, and evaluated is the Patient Centered Medical Home (PCMH). The PCMH is a blending of the patient medical home, a term coined in 1967 in response to a call to house a child's medical records in a central location (American Academy of Pediatrics, 2016), and Wegner's Chronic Care Model (Flieger, 2016). The PCMH renews the focus on primary care (Sweeney, Bazemore, Phillips, Etz, & Stange, 2012).…”

“…Services have been realigned with hopes of bridging disciplinary silos 1 (Sahota, 2009) and flattening hierarchies (Nutting, Crabtree, & McDaniel, 2012). Yet structures can be shifted more quickly than relationships (Flieger, 2016), and health care professionals can be significantly affected with implementation of new models of care delivery (Armstrong, 2013).…”

“…Other factors, such as opportunity for team-building activities (Brown et al 2010), a shared vision (Brown et al, 2015;Smith-Carrier & Neysmith, 2014), and leadership (Allan et al, 2014;Cromp et al, 2015, Flieger, 2016Rodriguez et al, 2014;Smith-Carrier et al, 2016), are indicators of high-functioning teams. Examining the process of how and whether these facilitators are present in this research will contribute to knowledge about team-based primary care implementation in northern BC.…”

“…Seeking to uncover how primary care is negotiated between patients and health care professionals is to be reminded that relationship is a priori to content in primary care (McWhinney, 1996). There is a need to examine more attentively the roles that relationships play in order for the PMH to be implemented successfully (Flieger, 2016), and sustained. While the relationship with the patient is considered central to primary care (Sweeney et al, 2012), a neglected facet may be "the extension of relationships with trusted colleagues to patients" (Stange, Burge, & Haggerty, 2014, p. 274).…”