The Patient Centered Medical Home: Mental Models and Practice Culture Driving the Transformation Process

Abstract

BACKGROUND:The Patient-Centered Medical Home (PCMH) has become a dominant model of primary care re-design. The PCMH model is a departure from more traditional models of healthcare delivery and requires significant transformation to be realized. OBJECTIVE: To describe factors shaping mental models and practice culture driving the PCMH transformation process in a large multi-payer PCMH demonstration project. DESIGN: Individual interviews were conducted at 17 primary care practices in South Eastern Pennsylvania. PARTICIPANTS: A total of 118 individual interviews were conducted with clinicians (N=47), patient educators (N=4), office administrators (N=12), medical assistants (N=26), front office staff (N=7), nurses (N=4), care managers (N=11), social workers (N =4), and other stakeholders (N = 3). A multi-disciplinary research team used a grounded theory approach to develop the key constructs describing factors shaping successful practice transformation. KEY RESULTS: Three central themes emerged from the data related to changes in practice culture and mental models necessary for PCMH practice transformation: 1) shifting practice perspectives towards proactive, population-oriented care based in practice-patient partnerships; 2) creating a culture of self-examination; and 3) challenges to developing new roles within the practice through distribution of responsibilities and team-based care. The most tension in shifting the required mental models was displayed between clinician and medical assistant participants, revealing significant barriers towards moving away from clinician-centric care. CONCLUSIONS: Key factors driving the PCMH transformation process require shifting mental models at the individual level and culture change at the practice level. Transformation is based upon structural and process changes that support orientation of practice mental models towards perceptions of population health, selfassessment, and the development of shared decisionmaking. Staff buy-in to the new roles and responsibilities driving PCMH transformation was described as central to making sustainable change at the practice level; however, key barriers related to clinician autonomy appeared to interfere with the formation of teambased care.KEY WORDS: patient-centered care; primary health care; delivery of health care; workplace; program evaluation.

Evaluating the Content of the Communication Items in the CAHPS® Clinician and Group Survey and Supplemental Items with What High-Performing Physicians Say They Do

“…1 The Patient Protection and Affordable Care Act (HR3590) includes funding for federal PCMH demonstration programs, and PCMH implementation is underway in a wide variety of settings. 2,3 A comprehensive PCMH model deviates from more traditional models of care by striving to: 1) deliver whole-person, coordinated care to transform primary care into "what patients want it to be"; 2) value clinician-patient relationships and continuity to keep patients healthy between visits; 1 In March 2014, National Committee for Quality Assurance (NCQA) released an updated version of its standards for primary care practices to attain formal recognition as a PCMH. The sixth standard, pertaining to performance measurement and quality improvement (QI), requires medical practices to measure patient/family experience and to use this data to implement continuous QI.…”

Maximizing the Patient-Centered Medical Home (PCMH) by Choosing Words Wisely

“…21,27,28 Such transformation relies, in part, on the shifting of mental models and the creative reimagining of practice roles. 15,29,30 Our data suggest that these innovative practices recognize that developing new terminology around those roles can facilitate and deepen that process. At the same time, we must guard against quick or trivial fixes.…”

“…16 However, many physicians are deeply invested in the very hierarchies that are reinforced by the language we have identified as being in need of change. 15 While research has noted that transformation to a PCMH "requires personal transformation of physicians," 22 language within the PCMH often preserves traditional hierarchies. Primary care physicians are regularly referred to as "quarterbacks," 23,24 "captains," 25 and "hubs of all relevant care," 26 each with connotations of authority and power.…”

“…Cultural change is not simply a matter of rebranding; however, incorporating new language may be an important first step in overcoming old habits and ingrained mental models. 15,16 This article highlights new language currently used in some PCMHs. These terms exemplify how language can be adopted to facilitate practice transformation.…”

System Transformation in Patient-Centered Medical Home (PCMH): Variable Impact on Chronically Ill Patients' Utilization

“…Significant changes are needed in technology, roles, and responsibilities, requiring staff buy-in and the devel-opment of a supportive culture and shared decision-making processes. 7 It is important to recognize that transformation is a continuum, with an overlap between clinics recognized as medical homes and those not yet so recognized. 8 The majority of the literature connecting PCMH transformation with health care utilization does not recognize this complexity of transformation.…”