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

Article Figures & Data

Table 1

Practice Characteristics

Practice	Years Since MHLC	Location	Practice Type	Ownership	Patients, Visits per Year, No.	Registry of Number of CYSHCN	Practice-Based Care Coordinator Role	Supplemental Medical Home Support^a
1	7	Mountain state	Academic continuity clinic	Academic	4,000 visits	No	Yes	Coordination grant from medical school
2	7	Mountain state	Private, rural, small (2 clinicians)	Independent, small	528 patients, 2,000 visits	Yes	No	No extra support
3	6	Mid Atlantic	Multispecialist network, suburban, urban	Hospital owned	22,500 patients	Yes	Yes	No extra support
4	7	Northeast	Academic medical center	Hospital owned	6,790 visits	Yes	Yes	Limited Medicaid PCCM
5	7	Mountain state	Network, suburban and rural	Hospital owned	13,511 patients	Yes	Yes	Small AUCD/LEND contract for care coordination
6	6	Midwest	Private, suburban	Independent, large	12,000 patients, 7,000 visits	Yes	Yes	No extra support
7	7	Midwest	Private, suburban	Independent, large	13,000 patients	Yes	Yes	No extra support
8	6	South central	Community health center, Hispanic	Community health center (FQHC)	13,410 patients	Yes	Yes	Medicaid $3–$5 PMPM to “keep population well”
9	7	Midwest	Integrated network, urban	Hospital owned and based	4,600 visits	Yes	Yes	Medicaid payment for 300 complex patients
10	7	Mid Atlantic	Suburban network	Hospital owned	6,000 visits	Yes	Yes	Small PMPM
11	7	Mid Atlantic	Private, suburban, multisite	Independent, large	12,000 patients	Yes	Yes	Health plan P4P
12	6	Midwest	Network, suburban	Hospital owned	27,597 patients	Yes	Yes	PMPM 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.

Table 2

Semistructured Interview Domains and Top Subdomains

Domain and Subdomain; Items Coded, No. (%)^a	Subdomain Coding Density	Subdomain Item	Essential Medical Home Attribute(s) Supported^b
Medical Home Learning Collaborative; 223 (3)
In what way was the Medical Home Learning Collaborative helpful?^c	57	Provided information/tools/measures	QI
	47	Family participation built in	FCC
	47	Provided structure and standards for the transformation effort	QI
Drivers/barriers for practice transformation^d; 2,850 (39)
Key internal/external factors that help/hurt a practice transform to a medical home?	516	Ability to be reimbursed	—
	352	Leadership	QI
	324	Patient collaboration/encouragement	FCC
	268	Practice environment/extended environment (eg, hospital linked to practice)	—
	244	Staff capacity	TBC
	208	An electronic health record	—
	143	Gained time for innovation and reflection	QI, TBC
Medical home characteristics^e; 3,429 (47)
What are the important (characteristics) features/factors of the medical home model in this site?	681	Care coordination/planned coordinated care	CC
	663	Family-friendly materials and actions; family participation	FCC
	422	Teamwork, attitude	TBC
	252	Care plan	CC, FCC
	247	Community engagement and resources	CC, FCC
	232	Focus on children with special health care needs as population	QI
	226	Access and communication about access	CC, FCC
Key outcomes of becoming a medical home^f; 800 (11)
Medical home outcomes/impact on staff and patients/families?	338	Patient satisfaction	—
	267	Quality of care	FCC/CC
	182	Clinician/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.

Table 3

Primary Data Sources Analyzed Across Essential Medical Home Attributes

Essential Medical Home Attribute	Primary Data Source

	MHI^a	Clinician Staff Questionnaire^b	Semistructured Interviews
Continuous QI	MHI 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 functions	Interviews emphasized QI as ongoing and enduring (rather than rapid, time-limited transformation)
FCC	MHI question about “practice knowledge and application” of FCC principles; 100% of cohort knowledgeable and sometimes (25%) or regularly (75%) apply FCC	Mean score for CMHI question on practice team “value of family engagement” was 0.80	Interviews emphasized value of family involvement in the MHLC; this emphasis continues today; practice actions and materials emphasized FCC
Team-based care/teamwork	MHI scores converted to a 100-point scale improved overall between precollaborative and current time points (34%); concept of “team” integrated across the MHI	AR mean score was 0.75; AR is a measure of the team’s ability to make and sustain changes	Interviews 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.