Medical Home Transformation in Pediatric Primary Care--What Drives Change?

McAllister, Jeanne W.; Cooley, W. Carl; Cleave, Jeanne Van; Boudreau, Alexy Arauz; Kuhlthau, Karen

doi:10.1370/afm.1528

Cited by 42 publications

(33 citation statements)

References 18 publications

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“…40,41 The methodology was developed to address health problems in developing countries, but has been recently used in the United States to identify effective approaches to improving quality of care. 40,[42][43][44][45][46][47][48] Positive deviants are identified using established performance measures, and then qualitative interviews are conducted with these individuals to develop hypotheses about their distinctive strategies. Some researchers additionally conduct qualitative research with low or average performers, as was done in this study, so that positive deviants' strategies can be distinguished from those used by others.…”

Section: Methodsmentioning

confidence: 99%

Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels

et al. 2016

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PURPOSE We aimed to identify the strategies used to support patient behavior change by clinicians whose patients had an increase in patient activation.METHODS This mixed methods study was conducted in collaboration with Fairview Health Services, a Pioneer Accountable Care Organization. We aggregated data on the change in patient activation measure (PAM) score for 7,144 patients to the primary care clinician level. We conducted in-depth interviews with 10 clinicians whose patients' score increases were among the highest and 10 whose patients' score changes were among the lowest. Transcripts of the interviews were analyzed to identify key strategies that differentiated the clinicians whose patients had top PAM change scores. RESULTSClinicians whose patients had relatively large activation increases reported using 5 key strategies to support patient behavior change (mean = 3.9 strategies): emphasizing patient ownership; partnering with patients; identifying small steps; scheduling frequent follow-up visits to cheer successes, problem solve, or both; and showing caring and concern for patients. Clinicians whose patients had lesser change in activation were far less likely to describe using these approaches (mean = 1.3 strategies). Most clinicians, regardless of group, reported developing their own approach to support patient behavior change. Those whose patients showed high activation change reported spending more time with patients on counseling and education than did those whose patients showed less improvement in activation.CONCLUSIONS Clinicians vary in the strategies they use to promote behavior change and in the time spent with patients on such activities. The 5 key strategies used by clinicians with high patient activation change are promising approaches to supporting patient behavior change that should be tested in a larger sample of clinicians to validate their effectiveness. 2016;14:148-154. doi:10.1370/afm.1904. Ann Fam Med INTRODUCTIONT hrough policies such as pay for performance and public reporting of clinicians' quality of care, clinicians are increasingly responsible for their patients' care outcomes. [1][2][3][4] Yet, for health outcomes to improve, patients must do their part, following through on treatment regimens and making recommended lifestyle changes.5-7 Given the key role that patients play in determining health outcomes, policy makers have made patient engagement and patient activation a major focus, including embedding approaches for increasing engagement in the Patient Protection and Affordable Care Act. 8,9 Patient activation, which is defined as having the knowledge, confidence, and skills to take care of one's health and health care, has been shown to be associated with a broad range of health-related outcomes, including better self-management and clinical indicators, fewer hospitalizations, and lower health care costs. [10][11][12][13][14][15][16][17][18][19][20] [34][35][36] Also, patients' assessment of clinician support of the chronic care model has been associated with hig...

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Section: Methodsmentioning

confidence: 99%

Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels

et al. 2016

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“…[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. 5,14,18 Common facilitators have included valuing innovation, quality improvement, and patient-centeredness.…”

Section: Introductionmentioning

confidence: 99%

“…5,14,18 Common facilitators have included valuing innovation, quality improvement, and patient-centeredness. 12,13,16 We sought to augment the literature on motivations, barriers, and facilitators to PCMH implementation by describing a large-scale initiative with some unique features.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2014

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BACKGROUND:Evidence is evolving about the impact of patient-centered medical homes (PCMHs) on important outcomes in primary care. Minnesota has developed its own PCMH certification process, envisioned as an all-payer initiative with an emphasis on patientcenteredness, which may add unique experiences and outcomes to the national discussion. OBJECTIVE: We aimed to identify the facilitators and barriers encountered by nine diverse primary care practices selected from the first 80 to achieve PCMH certification in Minnesota. DESIGN: This was a qualitative analysis of semistructured, in-person interviews. PARTICIPANTS: Thirty-one administrative and clinical leaders, including clinic managers, physician champions, medical directors, nursing supervisors, and care coordinators participated in the study. KEY RESULTS: Six factors emerged as most important to the efforts to become PMCHs: leadership support, organizational culture, finances, quality improvement (QI) experience, information technology (IT) resources, and patient involvement. Facilitators included committed leadership at local and higher levels, prior experience and ongoing support for QI initiatives, and adequate financial and IT resources. Reimbursement was a significant barrier due to perceived inadequacy and inconsistent participation by health plans. The unsuitability of electronic medical records (EMRs) to PCMH documentation requirements likewise presented ongoing challenges. Many interviewees described patient input as helpful to their clinics' PCMHrelated changes and were enthusiastic about their "patient partners." The majority of interviewees felt that becoming a PCMH was right for patients and was personally worthwhile, even while acknowledging the tremendous effort involved and voicing skepticism about reimbursement over the short term. CONCLUSIONS: The experience of participants in Minnesota's state-wide initiative to legislate PCMH transformation provides a broad view of facilitators and barriers. Unique facilitators included a requirement for patient involvement, which pushed practices to create patient-centered innovations, and new reimbursement models based on quality indicators for a population.Among barriers were the costs to practices and patients, and EMRs that failed to accommodate PCMH requirements.

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“…8 This was part of a larger study to examine change toward the medical home model. 9 We used a positive deviance approach 10,11 and mixed methods 12,13 to examine successful practices that had participated in a national medical home learning collaborative in 2003 to identify factors or processes that contributed to implementation that could then be translated to other practices. Here, we focus on how care coordination evolved after the learning collaborative.…”

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confidence: 99%

Care Coordination Over Time in Medical Homes for Children With Special Health Care Needs

et al. 2015

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OBJECTIVES: To explore how care coordination changes conceptually and practically in primary care practices when implementing the medical home and to identify reasons for different types of changes.METHODS: Six years after a 2003-2004 national learning collaborative to implement the medical home model for children with special health care needs, we examined care coordination in 12 pediatric practices with the highest postintervention Medical Home Index scores, indicating high level of adoption of the model. Data included interviews of 48 clinicians, care coordinators, and parents and medical record reviews of 60 patients with special health care needs receiving care in these practices.RESULTS: Initially, care coordination activities were prompted by patients' acute problems, and over time activities, tools, and policies were implemented to avert many such problems and expand the scope of services offered to patients. Example activities were making previsit calls with families, writing care plans, developing relationships with community agencies, and tracking referrals. Although some activities were common across practices, the persons involved and efforts toward different activities varied with practice context. Drivers included motivation and creativity of medical home teams, organizational changes, funding to expand care coordinator positions, protected time for such activities, and adoption of electronic record systems. CONCLUSIONS:In high-performing medical homes, care coordination activities changed from being mostly reactive to patients' episodic needs to being more systematically proactive and comprehensive. This shift was promoted by factors external and internal to the practice. Ensuring these factors in medical home implementation may accelerate adoption of proactive care coordination activities. WHAT'S KNOWN ON THIS SUBJECT:Care coordination is a central part of the medical home model. Little is known about how care coordination is implemented in pediatrics and how it changes over time in primary care practices successfully adopting medical home principles. WHAT THIS STUDY ADDS:In high-performing medical homes, care coordination evolved toward designing and carrying out routine activities and policies that aimed to forestall disruptions in care delivery. Investing in medical home teams, engaging electronic medical record systems, and improving workflow supported these changes.

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Medical Home Transformation in Pediatric Primary Care--What Drives Change?

Cited by 42 publications

References 18 publications

Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels

Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels

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

Care Coordination Over Time in Medical Homes for Children With Special Health Care Needs

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