Article Figures & Data
Tables
- Table 1
Diabetes Measures, Demographics, and Survey Response Rates in Higher- and Lower-Performing Practices
Quintile and Practice Absolute % Change at 18 Months Improvement Indexa at 18 Months First NCQA Levelb (2008–2009) Type of Practice Size of Practicec Adaptive Reserve/Burnout Survey Response Rate, % HbA1c <7% BP <130/80 mm Hg LDL-C <100 mg/dL Higher performing Practice A 15.8 35.1 14.4 21.7 2 Private Small 72 Practice B 13.5 20.7 20.3 18.2 1 FQHC Small 75 Practice C 12.5 12.6 10.2 11.8 3 Private Small 71 Practice D 0.8 11.9 20.3 11.0 3 Private Medium 97 Practice E 1.5 17.3 9.3 9.4 3 Private Medium 12 Average 8.8 19.5 14.9 14.4 2.4 – – 61 Lower performing Practice U −12.1 −4.1 −8.7 −8.3 1 FQHC Small 63 Practice V −10.0 −6.4 −10.8 −9.0 1 Health system Medium 18 Practice W −9.2 −17.7d −7.7 −11.6 3 Private Solo/partner 58 Practice X −9.6 −11.2 −14.2 −11.7 2 Private Medium 39 Practice Y −18.1 −2.1 −24.7 −15.0 1 Private Solo/partner 73 Average −11.8 −8.3 −13.2 −11.1 1.6 – – 44 -
HbA1c = glycated hemoglobin; BP = blood pressure; LDL-C = low-density lipoprotein cholesterol; NCQA = National Committee for Quality Assurance; FQHC = Federally Qualified Health Center.
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Note: Practices were classified as higher or lower performing at 18 months (December 2009) as measured by the improvement index. Source: Clinical and NCQA data submitted by practices to the Improving Performance in Practice program.
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↵a Calculated for each practice as the arithmetic mean of the absolute percent improvement in the 3 outcomes from baseline to 18 months.
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↵b First NCQA Physician Practice Connections Patient-Centered Medical Home (PPC-PCMH) recognition level; possible levels range from 1 (lowest) to 3 (highest).
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↵c Practice size categories were based on the number full-time equivalent (FTE) clinicians as solo/partner (1–2 FTE clinicians), small (3–4), or medium (5–9).
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↵d Calculated from baseline to January 2010 because of an obvious data error in December 2009.
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- Table 2
Structural and Organizational Characteristics of Higher- and Lower-Performing Practices
Number Higher Performing (5 Practices)a Number Lower Performing (4 Practices)a Characteristic Preintervention Postintervention Preintervention Postintervention Practices in which clinicians use a shared communication system to contact diabetic patients who... ...are due for HbA1c testing 3 4 0 3 ...are due for cholesterol testing 3 4 0 3 ...are due for eye examination 2 4 0 3 ...are due for nephropathy monitoring 2 4 0 3 ...have not had an appointment in the practice for an extended period (longer than clinically appropriate) 1 4 1 2 EHR use Number of EHR features present, median (range)b 11 (0–18) 16 (14–19) 5 (0–7) 14 (9–17) Using an EHR 4 5 2 5 Have staff to support diabetic patientsc 3 5 1 3 -
HbA1c=glycated hemoglobin; EHR=electronic health record.
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Source: Survey of practice leaders.
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↵a Preintervention survey responses reflect practice characteristics in 2008. Postintervention survey responses reflect practice characteristics in 2011.
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↵b Out of 20 possible features.
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↵c Presence of specially trained nonphysician staff who help patients better manage their diabetes.
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Element Higher-Performing Practices Lower-Performing Practices Managing competing demands to medical home implementation Technology Most had existing EHRs Most installed new EHRs during medical home implementation Finances Had stable financial systems and processes Had less stable financial systems and processes Leadership and vision Shared vision and buy-in Champions emphasized the need for all practice members to be on board with the initiative
Careful articulation and reinforcement of how the medical home will help patients and the practice and the need for changesLittle to no dissemination of information about the motivations for joining the initiative
Confusion about changing roles, uncertainty about processes and expected outcomesDeliberate planning and testing of changes Careful, deliberate plan of action, starting slowly with diabetic patients only and with 1 clinician and 1 office staff trying out novel methods and working out the kinks before implementing across the practice Inconsistent roll-out of methods Building teams and resource capacity Sense of team Collective problem solving and shared decision making
High levels of trust, respect, and collaboration
Regular multidisciplinary meetings and communicationTop-down approach to decision making
Less clarity on roles and responsibilities
Noninclusive approach to meetings and communicationCultivating human resources Strategic development of team in terms of composition and education/training
Expansion of the role of the medical assistant
Relatively stable staffingLess effort to form an integrated team and insufficient education/training for staff
Role of the medical assistant remains more limited
Moderate to high staff turnoverMonitoring progress and obtaining feedback Feedback systems Systematic ongoing processes to solicit and share feedback Feedback was not systemic; lack of opportunity to provide feedback; little dissemination of feedback Benchmarking Data shared across practice regularly; stimulates changes and healthy competition among clinicians Data not shared regularly or widely Planning and implementation of changes Shared planning and decision making regarding changes Unclear processes in terms of who is involved and what procedures in place to implement changes -
EHR=electronic health record.
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Source: Site visit observations and semistructured interviews.
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Key Factor Description Health information technology Early adoption of EHRs (4 of 5 higher-performing practices had EHRs in place =2 years before PCMH implementation) Administrative leadership Highly engaged practice administrators who championed the PCMH transformation Clinician leadership Regular clinician meetings to discuss performance, agree on clinical guidelines, and establish standards of care Shared vision and buy-in Careful articulation and reinforcement of how the medical home will help patients and the practice and the need for changes Staff development Team orientation and early development of medical assistant role Focus on improvement Meetings revolve around PCMH and clinical quality improvement Shared decision making Feedback from practice consistently sought on changes before, during, and after implementation Accountability Clear roles and responsibilities and accountability to these roles and responsibilities Finances Stable billing and administrative systems Financial autonomy Direct receipt of and ability to invest PCMH financial incentives Benchmarking Monthly clinician-specific benchmarking to identify best practices and breakdowns in PCMH processes Reporting and documentation Careful attention to data reporting and documentation of PCMH changes Inclusivity Collective problem solving and open communication Staff stability Minimal staff turnover -
EHR = electronic health record; PCMH = patient-centered medical home.
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Note: A variety of factors supported PCMH implementation in the higher-performing practices.
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Source: Site visit observations and semistructured interviews in the higher-performing practices.
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Additional Files
Supplemental Appendix
Supplemental Appendix. Key Contextual Factors and Noteworthy Contextual Changes
Files in this Data Supplement:
- Supplemental data: Appendix - PDF file, 3 pages, 139 KB
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