Medical Home Transformation: A Gradual Process and a Continuum of Attainment

Abstract

PURPOSEThe 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 certifi ed medical homes in Minnesota to study this topic. METHODSWe 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 fi rst 120 clinics serving adults certifi ed 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 precertifi cation and postcertifi cation 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. CONCLUSIONSThe 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.Ann Fam Med 2013;11:S108-S114. doi:10.1370/afm.1478. INTRODUCTIONT here has been controversy about the defi nition, measurement, and recognition of primary care clinics as patient-centered medical homes (PCMHs).1,2 It is not surprising that such a recent development, especially one with widely divergent high expectations from different perspectives, would be so ambiguous and full of unanswered questions about what a PCMH is, how it might be measured, what its effects are, and how a traditional primary care practice best becomes one.1-3 Although the PCMH recognition program of the National Committee for Quality Assurance (NCQA) was the fi rst and is still the largest program for identifying PCMHs, several other national programs and local demonstration projects have come up with their own operational defi nitions. 4 Advocates of medical homes often describe them as uniquely and markedly different from traditional practices, in both process and outcomes. 5 As a result, medical homes are often compared with non-medical homes. The research literature, on the other hand, is more cautious about S109MEDIC A L HO ME T R A NSF OR M AT ION this difference. For ex...

“We’ve Not Gotten Even Close to What We Want to Do”: a Qualitative Study of Early Patient-Centered Medical Home Implementation

“…9,17,20,25,26 A survey of medical home implementation in 65 safety-net clinics found that greater implementation of characteristics of the medical home was associated with both higher morale and higher provider burnout. 27 This finding is consistent with the context we encountered, where many participants described PACT implementation as both exciting and stressful.…”

Challenges of Medical Home Transformation Reported by 118 Patient-Centered Medical Home (PCMH) Leaders

“…We demonstrated in a previous publication that this practice systems measure is associated with changes in performance measures for patients with diabetes or cardiovascular disease. 21 Many of the items in Tables 2 and 3 were suggested as important by others, usually based on expert opinion. In fact, some of them (patient engagement, care coordinator job description, focus on care plans, use of formal quality improvement techniques) are required by the certification process in Minnesota.…”

“…Their performance on quality measures may vary within the group of certified practices, but, on average, it is significantly higher than the average for noncertified clinics (although it was also higher 3 years before being certified. 35 Therefore, it is possible that these higher-performing clinics chose to be certified based on a longstanding goal of being leaders, with recognition and payment as collateral goals, rather than because the certification process documented the improvement. Only time will tell whether certification leads to an increase in their lead over noncertified clinics.…”

Minnesota’s Early Experience with Medical Home Implementation: Viewpoints from the Front Lines

“…3 Research evaluating the PCMH's effectiveness in achieving the goals of improved care quality, patient experience, and reduced healthcare costs has encouraged further refinement of the model. [4][5][6][7][8][9][10][11] Facilitators and barriers to the creation of a successful PCMH have been explored in a limited number of heterogeneous settings, including small practices, large group practices, high-performing practices, and safety net clinics. [12][13][14][15][16][17] To date, significant challenges have been identified; specifically, the investment of resources for infrastructure changes and the leadership skills needed to guide an organization through paradigm-shifting cultural change.…”