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Research ArticleOriginal Articles

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

Jeanne W. McAllister, W. Carl Cooley, Jeanne Van Cleave, Alexy Arauz Boudreau and Karen Kuhlthau
The Annals of Family Medicine May 2013, 11 (Suppl 1) S90-S98; DOI: https://doi.org/10.1370/afm.1528
Jeanne W. McAllister
1Center for Medical Home Improvement, Crotched Mountain Foundation, Concord, New Hampshire
BSN, MS, MHA
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  • For correspondence: mcallisterjeanne3@gmail.com
W. Carl Cooley
1Center for Medical Home Improvement, Crotched Mountain Foundation, Concord, New Hampshire
MD
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Jeanne Van Cleave
2Center for Child & Adolescent Health Research and Policy, Massachusetts General Hospital, Boston, Massachusetts
MD
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Alexy Arauz Boudreau
2Center for Child & Adolescent Health Research and Policy, Massachusetts General Hospital, Boston, Massachusetts
MD
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Karen Kuhlthau
2Center for Child & Adolescent Health Research and Policy, Massachusetts General Hospital, Boston, Massachusetts
PhD
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    Figure 1

    MHI scores for the practices at 3 points in time and adaptive reserve (N = 12).

    MHI = Medical Home Index; MHLC = Medical Home Learning Collaborative.

    Note: Total MHI scores are expressed as a percentage of a maximum of 100; higher values indicate greater levels of “homeness.” Adaptive reserve scores are expressed on a 100-point scale, with higher scores indicating greater reserve. The MHI and adaptive reserve scores were correlated (Pearson coefficient=0.867).

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    Table 1

    Practice Characteristics

    PracticeYears Since MHLCLocationPractice TypeOwnershipPatients, Visits per Year, No.Registry of Number of CYSHCNPractice-Based Care Coordinator RoleSupplemental Medical Home Supporta
    17Mountain stateAcademic continuity clinicAcademic4,000 visitsNoYesCoordination grant from medical school
    27Mountain statePrivate, rural, small (2 clinicians)Independent, small528 patients, 2,000 visitsYesNoNo extra support
    36Mid AtlanticMultispecialist network, suburban, urbanHospital owned22,500 patientsYesYesNo extra support
    47NortheastAcademic medical centerHospital owned6,790 visitsYesYesLimited Medicaid PCCM
    57Mountain stateNetwork, suburban and ruralHospital owned13,511 patientsYesYesSmall AUCD/LEND contract for care coordination
    66MidwestPrivate, suburbanIndependent, large12,000 patients, 7,000 visitsYesYesNo extra support
    77MidwestPrivate, suburbanIndependent, large13,000 patientsYesYesNo extra support
    86South centralCommunity health center, HispanicCommunity health center (FQHC)13,410 patientsYesYesMedicaid $3–$5 PMPM to “keep population well”
    97MidwestIntegrated network, urbanHospital owned and based4,600 visitsYesYesMedicaid payment for 300 complex patients
    107Mid AtlanticSuburban networkHospital owned6,000 visitsYesYesSmall PMPM
    117Mid AtlanticPrivate, suburban, multisiteIndependent, large12,000 patientsYesYesHealth plan P4P
    126MidwestNetwork, suburbanHospital owned27,597 patientsYesYesPMPM for complex patients
    • AUCD = Association of University Centers on Disabilities; CYSHCN = children/youth with special health care needs; FQHC = Federally Qualified Health Center; LEND = Leadership Education in Neurodevelopmental & Related Disabilities; MHLC = medical home learning collaborative; P4P = pay for performance; PCCM = Primary Care Case Management; PMPM = per member per month.

    • ↵a Support could have been in the form of P4P, PMPM, a grant, or a contract.

    • View popup
    Table 2

    Semistructured Interview Domains and Top Subdomains

    Domain and Subdomain; Items Coded, No. (%)aSubdomain Coding DensitySubdomain ItemEssential Medical Home Attribute(s) Supportedb
    Medical Home Learning Collaborative; 223 (3)
     In what way was the Medical Home Learning Collaborative helpful?c57Provided information/tools/measuresQI
    47Family participation built inFCC
    47Provided structure and standards for the transformation effortQI
    Drivers/barriers for practice transformationd; 2,850 (39)
     Key internal/external factors that help/hurt a practice transform to a medical home?516Ability to be reimbursed—
    352LeadershipQI
    324Patient collaboration/encouragementFCC
    268Practice environment/extended environment (eg, hospital linked to practice)—
    244Staff capacityTBC
    208An electronic health record—
    143Gained time for innovation and reflectionQI, TBC
    Medical home characteristicse; 3,429 (47)
     What are the important (characteristics) features/factors of the medical home model in this site?681Care coordination/planned coordinated careCC
    663Family-friendly materials and actions; family participationFCC
    422Teamwork, attitudeTBC
    252Care planCC, FCC
    247Community engagement and resourcesCC, FCC
    232Focus on children with special health care needs as populationQI
    226Access and communication about accessCC, FCC
    Key outcomes of becoming a medical homef; 800 (11)
     Medical home outcomes/impact on staff and patients/families?338Patient satisfaction—
    267Quality of careFCC/CC
    182Clinician/staff satisfaction—
    • ↵a Out of 7,302 total items.

    • ↵b Items aligned with attributes are labeled as follows: quality improvement (QI), family-centered care (FCC), team-based care (TBC), and care coordination (CC).

    • ↵c Top 3 of 6 subdomains with the highest coding density are shown.

    • ↵d Top 7 of 25 subdomains are shown.

    • ↵e Top 7 of 16 subdomains are shown.

    • ↵f Top 3 of 5 highest-density items are shown.

    • View popup
    Table 3

    Primary Data Sources Analyzed Across Essential Medical Home Attributes

    Essential Medical Home AttributePrimary Data Source
    MHIaClinician Staff QuestionnairebSemistructured Interviews
    Continuous QIMHI domain of QI was most improved theme between precollaborative time point (3.16) and current time point (5.79)AR mean score was 0.75; of 23 AR items, 12 relate to QI functionsInterviews emphasized QI as ongoing and enduring (rather than rapid, time-limited transformation)
    FCCMHI question about “practice knowledge and application” of FCC principles; 100% of cohort knowledgeable and sometimes (25%) or regularly (75%) apply FCCMean score for CMHI question on practice team “value of family engagement” was 0.80Interviews emphasized value of family involvement in the MHLC; this emphasis continues today; practice actions and materials emphasized FCC
    Team-based care/teamworkMHI scores converted to a 100-point scale improved overall between precollaborative and current time points (34%); concept of “team” integrated across the MHIAR mean score was 0.75; AR is a measure of the team’s ability to make and sustain changesInterviews highly emphasized teamwork and team attitude
    CC (team-based CC)MHI domain of CC improved between precollaborative time point (3.82) and current time point (6.39)AR mean score was 0.75; combines and averages lead PCP and CC scores (as key team members)Interviews of highest emphasis included quotes referencing CC, teamwork, and attitude (of 47% characteristic quotes 50% address)
    • AR = adaptive reserve; CC = care coordination; CMHI = Center for Medical Home Improvement; FCC = family-centered care; MHI = Medical Home Index; MHLC = medical home learning collaborative; PCP = primary care provider; QI = quality improvement.

    • ↵a MHI scale ranged from 1 to 8. Total MHI scores are expressed as a percentage of a maximum of 100.

    • ↵b AR scores were transformed to a 100-point scale to allow comparison with MHI scores. AR scale ranged from 0.0 to 1.0.

Additional Files

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  • Supplemental Appendix

    Supplemental Appendix. Context Matters

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    • Supplemental data: Appendix - PDF file, 3 pages, 160 KB
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The Annals of Family Medicine: 11 (Suppl 1)
The Annals of Family Medicine: 11 (Suppl 1)
Vol. 11, Issue Suppl 1
May/June 2013
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Medical Home Transformation in Pediatric Primary Care—What Drives Change?
Jeanne W. McAllister, W. Carl Cooley, Jeanne Van Cleave, Alexy Arauz Boudreau, Karen Kuhlthau
The Annals of Family Medicine May 2013, 11 (Suppl 1) S90-S98; DOI: 10.1370/afm.1528

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Medical Home Transformation in Pediatric Primary Care—What Drives Change?
Jeanne W. McAllister, W. Carl Cooley, Jeanne Van Cleave, Alexy Arauz Boudreau, Karen Kuhlthau
The Annals of Family Medicine May 2013, 11 (Suppl 1) S90-S98; DOI: 10.1370/afm.1528
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Cited By...

  • Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels
  • Challenges of Medical Home Transformation Reported by 118 Patient-Centered Medical Home (PCMH) Leaders
  • From pediatric practice to family-centered medical home: What drives change?
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More in this TOC Section

  • Facilitators of Transforming Primary Care: A Look Under the Hood at Practice Leadership
  • Medical Home Transformation: A Gradual Process and a Continuum of Attainment
  • Assessment and Measurement of Patient-Centered Medical Home Implementation: The BCBSM Experience
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Subjects

  • Person groups:
    • Children's health
    • Family
  • Methods:
    • Qualitative methods
  • Other research types:
    • Professional practice
  • Core values of primary care:
    • Coordination / integration of care

Keywords

  • change
  • organizational
  • children with special health care needs
  • disabled children
  • medical home
  • practice-based research
  • primary care
  • transformation

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