Support and Strategies for Change Among Small Patient-Centered Medical Home Practices

Sarah Hudson Scholle; Stephen E. Asche; Suzanne Morton; Leif I. Solberg; Manasi A. Tirodkar; Carlos Roberto Jaén

doi:10.1370/afm.1487

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Table 1

Characteristics of Practices and Responding Physicians

		Recognition Level

Characteristic	Overall (N=249)	Level 1 (n=91)	Level 3^a (n=158)
Practice
Solo physician practice, %	34.9	40.7	31.7
Physicians/NPs/PAs, mean (SD), No.	2.9 (1.6)	2.7 (1.6)	3.0 (1.5)
Total staff (excluding physicians/NPs/PAs), mean (SD), No.	8.2 (5.0)	7.6 (4.8)	8.5 (5.1)
Practice type, %
Federally designated health center or community health center	14.9	14.3	15.2
Physician owned, independent	20.9	28.5	16.5
Physician owned, affiliated with larger group	27.7	23.1	30.4
Hospital/health system owned	36.5	34.1	38.0
Region, %
New England (CT, ME, MA, NH, RI, VT)	24.1	28.6	21.5
Northeast (NY, NJ)	13.7	17.6	11.4
Mid-Atlantic (DC, MD, PA, VA, WV)	10.4	15.4	7.6
Southeast (AL, FL, GA, KY, MS, NC, SC, TN)	20.1	12.1	24.7
Midwest (IL, IN, MI, MN, OH, WI)	18.1	15.4	19.6
Southwest (AR, LA, NM, OK, TX)	7.2	8.8	6.3
Plains (IA, KS, MO, NE)	2.8	2.2	3.2
Mountain (CO, MT, ND, SD, UT, WY)	3.2	0.0	5.1
West (AZ, CA, HI, NV)	0.4	0.0	0.6
Northwest (AK, ID, OR, WA)	0.0	0.0	0.0
Fully electronic health record, %^b	79.6	67.5	86.2
Physician
Female, %	35.0	33.3	36.0
Race/ethnicity, %^c
White, non-Hispanic	78.6	80.2	77.7
Black, non-Hispanic	6.0	10.5	3.4
Asian, non-Hispanic	9.8	8.1	10.8
Hispanic	4.7	1.2	6.8
Other/mixed	0.9	0.0	1.3
Time in this practice, mean (SD), y	13.9 (9.0)	14.8 (9.9)	13.3 (8.5)
Time since graduation from medical school, mean (SD), y^c	23.4 (9.6)	25.5 (9.7)	22.2 (9.4)

NP=nurse practitioner; PA=physician assistant.
Note: Pearson χ² test for categorical variables and independent samples t tests for continuous variables.
↵a Includes practices that entered the study at Level 3 and practices that advanced from Level 1 to Level 3 during the study.
↵b P <.01, difference by level.
↵c P <.05, difference by level.

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Table 2

Drivers of Change Among Patient-Centered Medical Home Practices

		Recognition Level

Change Driver	Overall (N=249)	Level 1 (n=91)	Level 3^a (n=158)
Priority for “making practice more of a patient-centered medical home,”^b %	29.8	24.4	32.9
Motivations for PCMH, mean (SD) rating^c
To improve quality of patient care	4.4 (0.9)	4.3 (1.0)	4.4 (0.9)
To improve patient experiences of care	4.4 (0.9)	4.3 (1.3)	4.4 (0.8)
To function more efficiently	4.1 (1.2)	4.1 (1.1)	4.0 (1.2)
To become eligible for financial incentives	4.0 (1.1)	4.1 (1.1)	3.9 (1.1)
To meet expectations/requirements set by our medical group or delivery system	3.9 (1.2)	4.0 (1.2)	3.9 (1.3)
To improve clinician experience	3.6 (1.3)	3.5 (1.4)	3.6 (1.3)
To meet expectations/requirements from my specialty society or board	2.8 (1.5)	3.0 (1.4)	2.7 (1.5)
Barriers to PCMH implementation, mean (SD) rating^c
Time^d	3.7 (1.2)	3.9 (1.2)	3.6 (1.2)
Money and other resources to invest in staff, training, or equipment^e	3.3 (1.3)	3.6 (1.3)	3.1 (1.3)
Information systems^d	2.7 (1.3)	3.0 (1.4)	2.5 (1.3)
Knowledge and experience	2.5 (1.1)	2.7 (1.2)	2.4 (1.1)
Clinician/staff resistance to change	2.4 (1.2)	2.5 (1.2)	2.3 (1.2)
Clinician/staff turnover	1.9 (1.2)	1.8 (1.3)	2.0 (1.2)

PCMH=patient-centered medical home.
Note: Pearson χ² test for categorical variables and independent samples t tests for continuous variables.
↵a Includes practices that entered the study at Level 3 and practices that advanced from Level 1 to Level 3 during the study.
↵b Rating of 9 or 10 on scale of 0 to 10.
↵c Range: 1 to 5, with higher ratings indicating greater barrier.
↵d P <.05, difference by level.
↵e P <.01, difference by level.

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Table 3

Participation in Demonstration Projects, Receipt of Payment, and Type of Help for Patient-Centered Medical Home Implementation

		Recognition Level

Measure	Overall (N=249)	Level 1 (n=91)	Level 3^a (n=158)
Participate in demonstration/pilot project and/or received payment for being PCMH, % responding yes^b
Did not participate in a project or receive payment	21.7	14.3	26.0
Participated in project only	8.8	11.0	7.6
Received payment for PCMH only	24.1	33.0	19.0
Both participated and received PCMH payment	45.4	41.8	47.5
Received help for PCMH implementation, % yes
Training for staff	85.5	81.8	87.7
Training for clinicians	84.2	82.0	85.4
Training for patients/consumer advocates	31.4	28.4	33.1
Consultation/coaching/facilitation specific to practice	63.9	61.6	65.2
Access to a learning collaborative	59.3	55.7	61.4
Training on how to meet NCQA’s recognition requirements^b	81.3	87.8	77.6
Assistance with preparing documentation of application requirements for NCQA’s recognition program	81.0	86.5	77.8
Of those who received help, % who found it very useful
Training for staff	43.5	44.4	43.0
Training for clinicians	41.1	38.4	42.5
Training for consumer advocates	31.6	20.0	37.3
Consultation/coaching/facilitation specific to your practice	47.4	52.8	44.6
Access to a learning collaborative	43.4	51.0	39.4
Training on how to meet NCQA’s recognition requirements	52.5	50.6	53.7
Assistance with preparing documentation of application requirements for NCQA’s recognition program	67.4	63.6	69.8

NCQA = National Committee for Quality Assurance; PCMH = patient-centered medical home.
Note: Differences calculated with the Pearson χ² test.
↵a Includes practices that entered the study at Level 3 and practices that advanced from Level 1 to Level 3 during the study.
↵b P <.05, difference by level.

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Table 4

Strategies for Practice Change

		Recognition Level

Strategy	Overall (N=249)	Level 1 (n=91)	Level 3^a (n=158)
Use of specific strategies, % reporting that it worked well
Changing or creating systems in the practice that make it easier to provide high-quality care	86.5	82.2	89.0
Providing information and skills training to clinicians and staff^b	79.0	70.3	84.1
Designing care improvements to make the care process more beneficial to the patient	78.9	82.4	76.7
Periodically measuring care quality to assess compliance with any new approach to care	76.0	72.2	78.2
Setting goals and benchmarking rates of performance quality	73.6	71.1	75.0
Including front-line staff on quality improvement committees or teams	69.1	65.9	71.0
Removing or reducing barriers to better quality of care	65.6	63.3	66.9
Providing to those who are charged with implementing improved care the power to authorize and make the desired changes^b	64.9	55.6	70.3
Delegating to nonclinician staff the responsibility to carry out aspects of care that were the responsibility of clinicians^b	63.9	55.6	68.8
Organizing people into teams focused on accomplishing the change process for improved care	60.9	58.0	62.6
Reporting measurements of individual clinician performance for comparison with peer clinicians^c	60.3	48.9	66.9
Using opinion leaders or role modeling or other strategies to encourage support for changes	57.3	54.4	59.0
Using piloting or pretesting of changes and evaluating the impact before introducing practicewide changes^c	51.4	38.2	59.0
Designing care improvements to make physician participation less work than before^b	46.9	38.9	51.6
Providing training to clinicians and staff on how to involve patients/families in quality improvement	30.1	27.4	31.6
Using formal quality improvement or efficiency approaches (eg, Lean, Plan-Do-Study-Act, rapid cycles, Six Sigma, Model for Improvement)	30.5	26.7	32.9
Including patients on quality improvement committees or teams	15.5	12.1	17.5
Overall score, mean (SD)^b	11.5 (3.8)	10.7 (4.1)	11.9 (3.5)

Note: Pearson χ² test for categorical variables and independent samples t tests for continuous variables.
↵a Includes practices that entered the study at Level 3 and practices that advanced from Level 1 to Level 3 during the study.
↵b P <.05, difference by level.
↵c P <.01, difference by level.
d Range: 0 to 18, with higher scores indicating greater use of strategies.

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Table 5

Items Assessing Organizational Change Ability

		Recognition Level

Item	Overall (N=249)	Level 1, % (n=91)	Level 3,^a % (n=158)
The clinicians in our practice adhere to practice policies.	83.3	82.2	83.9
The leaders of our efforts to improve care quality are enthusiastic about their task.^b	82.3	74.4	86.7
The clinicians in our practice espouse a shared mission and policies.	79.8	75.8	82.1
The working environment in our practice is collaborative and cohesive, with a shared sense of purpose, cooperation, and willingness to contribute to the common good.	77.4	76.9	77.1
When making changes at our practice, we choose new processes of care that are more advantageous than the old for everyone involved (patients, clinicians, and our entire practice).	68.7	71.1	67.3
The thinking of our leadership is strongly oriented toward systems.	68.0	61.1	72.1
We have greatly improved the quality of care in the past year.	67.3	61.1	70.9
We have many clinician and staff champions interested in leading the improvement of care quality.	64.2	58.4	67.5
Most of the other health care resources in our community (hospitals, community groups, specialist offices) are supportive of the medical home concept.	59.5	59.6	59.5
Our practice operations rely heavily on organized systems.^b	58.5	48.9	64.1
Our practice attaches more priority to quality of care than to finances.	57.7	62.5	55.1
We have received feedback from patients that they have benefited from the changes we have made.	56.5	53.3	58.2
Our practice is undergoing considerable stress as the result of internal changes. (reverse coded)	41.9	47.2	38.9
Our resources (personnel, time, financial) are too tightly limited to improve care quality now. (reverse coded)^b	21.1	28.1	17.2
Overall score, mean (SD)^b,^c	9.5 (3.0)	9.0 (3.2)	9.8 (2.8)

Note: Values are percentage that agree or strongly agree. Pearson χ² test for categorical variables and independent samples t tests for continuous variables.
↵a Includes practices that entered the study at Level 3 and practices that advanced from Level 1 to Level 3 during
↵b P <.05, difference by level.
↵c Range: 1 to 14, with higher scores indicating greater change ability.

Additional Files

Tables

Supplemental Appendix & Figures 1-2

Supplemental Appendix. Contextual Factors; Figure 1. Number of NCQA-recognized patient-centered medical home (PCMH) practices by state (as of October 31, 2012); Figure 2. States with public and private patient-centered medical home (PCMH) initiatives that use NCQA recognition.

Files in this Data Supplement:

Supplemental data: Appendix & Figures - PDF file, 4 pages, 1.3MB