Quality, Satisfaction, and Financial Efficiency Associated With Elements of Primary Care Practice Transformation: Preliminary Findings

Abstract

PURPOSE We examined quality, satisfaction, fi nancial, and productivity outcomes associated with implementation of Care by Design (CBD), the University of Utah's version of the patient-centered medical home. METHODSWe measured the implementation of individual elements of CBD using a combination of observation, chart audit, and collection of data from operational reports. We assessed correlations between level of implementation of each element and measures of quality, patient and clinician satisfaction, fi nancial performance, and effi ciency. RESULTSTeam function elements had positive correlations (P ≤.05) with 6 quality measures, 4 patient satisfaction measure, and 3 clinician satisfaction measures. Continuity elements had positive correlations with 2 satisfaction measures and 1 quality measure. Clinician continuity was the key driver in the composite element of appropriate access. Unexpected fi ndings included the negative correlation of use of templated questionnaires with 3 patient satisfaction measures. Trade-offs were observed for performance of blood draws in the examination room and the effi ciency of visits, with some positive and some negative correlations depending on the outcome.CONCLUSIONS Elements related to care teams and continuity appear to be key elements of CBD as they infl uence all 3 CBD organizing principles: appropriate access, care teams, and planned care. These relationships, as well as unexpected, unfavorable ones, require further study and refi ned analyses to identify causal associations. Ann Fam Med INTRODUCTIOND espite widespread pilot implementation and favorable initial results of the patient-centered medical home (PCMH), 1 assessment of its impacts is in an early stage.2 Not enough is known about the model's implications to ascertain its results in terms of practice quality, satisfaction, or fi nances.3 Evidence is also lacking about relationships between individual elements of the PCMH model and specifi c benefi cial outcomes.In this study, in contrast to looking at the PCMH as a whole, we examined the relationship between individual elements of Care by Design (CBD), a comprehensive redesigned model of care that incorporates many elements of a PCMH, and multiple outcomes in quality of care, patient and clinician satisfaction, productivity, and operational costs.The University of Utah's Community Clinics introduced CBD in 2003. The model had 3 founding principles: appropriate access, care teams, and planned care. The transformation included expanded and new roles for support staff and redesigned workfl ows and processes. Implementation initially focused on improved access with an emphasis on same-day appointments. Appropriate access was designed primarily to improve patient satisfaction. By 2006, the model had incorporated additional elements including team-based care and more comprehensive planned care. Care teams enhanced effi ciency by using the time and skills of support staff, allowing clinicians to focus more on relationships with patients. Medical assistants (MAs)...

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

“…23 We found that most employees in all roles felt that PACT's recommended four-person team structure did work well, once in place. Our study's finding that Clinical and Clerical Associates in particular found increased job satisfaction within team-based care is interesting, in light of Day and colleagues' 8 finding that continuity and engagement in the Medical Assistant role was associated with several positive PCMH outcomes. Similarly, Gabbay and colleagues 24 found that an expanded medical assistant role was characteristic of higher performing PCMH practices.…”

“…4 Medical home features, such as enhanced patient access, improved scheduling, care provider continuity, and care coordination activities, have been associated with lower rates of avoidable hospitalizations and decreased Emergency Department use. [5][6][7][8] Multiple difficulties in implementing the PCMH model, however, have been documented. The move away from a physician-centric model of care towards one that is truly team-oriented, and the challenges of aligning financial reimbursement with the PCMH's emphasis on proactive prevention, are only two of the model's persistent challenges across diverse primary care practices.…”

The Transition of Primary Care Group Practices to Next Generation Models: Satisfaction of Staff, Clinicians, and Patients

“…21,24,25 Many patients, especially those with complex medical and social needs, may find the patient-centered team approach more convenient and efficient. Those who do not will likely vote with their feet as long as they are able.…”

First Things First: Foundational Requirements for a Medical Home in an Academic Medical Center

“…To date, qualitative studies of PCMH implementation have looked primarily at small, nonacademic practices with ten or fewer physicians, [16][17][18][19] and, with one exception, 19 have not focused on differences by practice size. [20][21][22] Few have assessed implementation in academic clinics. 23,24 Therefore, we conducted a qualitative case study within a large VHA academically affiliated primary care clinic to understand the experiences of primary care leadership, physicians, and staff during early PACT implementation, and to provide insights to help guide future PCMH implementation initiatives.…”