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

Abstract

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.

Impact of Case Mix Severity on Quality Improvement in a Patient-centered Medical Home (PCMH) in the Maryland Multi-Payor Program

“…This is consistent with reports from other state-level programs where the use of control practices was used in various formats but not consistently across each domain. 21,22 Another limita- Continued tion is the limited observation period, from 2011 to 2013, which may include the period when practices were transforming to an NCQA-recognized PCMH and actual quality gains may be just starting to manifest. All NCQA-level achievement observations in the tables are from 2011/2012 in year 1, and ACG observations are also from 2011 data.…”

Patient-Centered Models of Care: Closing the Gaps in Physician Readiness

“…In addition, the number of combined MD/MBA programs grew from six in 1993 to over 50 today, with over 500 graduates per year. 2 Nevertheless, the need remains great to prepare physicians to develop facility with speaking the language of health care finance, understanding health care policy and applying that knowledge and skill in the health care environment. A greater proficiency with the business side of health care will also help future physicians to responsibly address costs of care and at the same time innovate new policy approaches that optimize the wellbeing of patients and caregivers.…”

“…2 These factors likely not only facilitate PCMH implementation, but also characterize knowledge and skills that physicians need to lead any meaningful systems change. How is medical education doing in addressing these domains of knowledge and skill?…”

Concept Mapping as a Method to Engage Patients in Clinical Quality Improvement

“…Early evidence suggests that practices that have involved patients in medical home transformation efforts view the engagement positively. 6,7 Attempts to engage patients in quality improvement efforts remain uncommon, however. A recent survey of 123 PCMHs found that fewer than one-third engaged patients in these efforts, although most of them reported soliciting patient input in other areas.…”