Differences in Diabetes Care With and Without Certification as a Medical Home

Leif I. Solberg; Caroline Carlin; Kevin A. Peterson; Milton Eder

doi:10.1370/afm.2492

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Complex care: Figuring out what works and for which patients
Peter F. Cronholm (1,2,3)

Published on: 08 April 2020
Re:Medical Home Improves Diabetes Care - Key Ingredient is Care Management
Robert Watkins

Published on: 12 February 2020
Medical Home Improves Diabetes Care - Key Ingredient is Care Management
Robert A. Gabbay

Published on: 29 January 2020

Published on: (8 April 2020)
Page navigation anchor for Complex care: Figuring out what works and for which patients
Complex care: Figuring out what works and for which patients
Peter F. Cronholm (1,2,3), Associate Professor
Other Contributors:
We appreciate the efforts of Solberg et al. to better understand what components of healthcare systems meaningfully improve health outcomes for patients with conditions like diabetes which are often strongly shaped by social and behavioral factors. Consideration of the study results and discussion prompts numerous points of reflection which inform our understanding and deserve comment. It was not surprising to these authors...
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We appreciate the efforts of Solberg et al. to better understand what components of healthcare systems meaningfully improve health outcomes for patients with conditions like diabetes which are often strongly shaped by social and behavioral factors. Consideration of the study results and discussion prompts numerous points of reflection which inform our understanding and deserve comment. It was not surprising to these authors that that the findings showed small changes in outcomes associated with incremental medical home infrastructure. The medical home model, while aspiring to bring about transformational change to primary care, has been fundamentally encumbered from its inception with care processes that are anchored in traditional models such that clinical teams are required to sustain all of the previous tasks of antiquated care models while "tacking on" medical home quality efforts. The needed alterative to this approach is a fundamental reimaging and redesign of care processes to truly achieve the quadruple aim, expanding the traditional triple aim of improved care to also include clinical team satisfaction/sustainability. The necessary redesign would map deliverables and workflows onto novel staffing models and leverage the tools of population health to supply data and identify need in a timely manner. While the spirit of the PCMH aligns with this need, little has changed in terms of daily operations and role advancement in most practices compounded by the lag between payment models and meaningful service transformation.
Another recent publication detailing the results of a randomized control trial (RCT) of a different transformational model of care redesign highlights the need for rigorous methodologies to evaluate the ultimate impact of systemic changes aimed at improved outcomes. In addition to the need for RCT-level evidence of outcomes, the results of Solberg's medical home study and the Camden Coalition RCT both suggest to us the need for a broader array of outcome measures to assess how changes in healthcare paradigms are creating value for patients and other stakeholders. Meaningful outcomes would certainly include the real societal cost of healthcare, the experience of patients, and measurable health and quality of life outcomes. Such future research should include qualitative analysis that can examine the context of patient care in ways that clarifies the appropriateness of traditional metrics and clarifies real determinates of value, feasibility, and sustainability for the new models that may not be identifiable at the outset of an investigation. We need to be thoughtful in using data differently, emphasizing meaningful engagement with the stakeholders of the process, and challenging traditional paradigms to redesign healthcare delivery. True change needs to be rooted in fundamental redesign at the macro-structural level beyond the confines of the healthcare system as we better align healthcare systems within their community resource base and developing foundational support for better self-management. The promise and opportunity for PCMH transformation and other innovative efforts at care redesign is to develop and rigorously evaluate clinical workflows and roles that considers the full spectrum of patient needs and align with community partners to mitigate the impact of the macrosocial drivers of health. The Solberg article illustrates how true transformation is more than just checking boxes and adding on new tasks; instead, it requires fundamental culture change and practice redesign.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (12 February 2020)
Page navigation anchor for Re:Medical Home Improves Diabetes Care - Key Ingredient is Care Management
Re:Medical Home Improves Diabetes Care - Key Ingredient is Care Management
Robert Watkins, Private Practice Family Physician
Is there any evidence that, all else being equal, having a care plan improves outcomes in patients with diabetes?
Competing interests: None

Competing Interests: None declared.
Published on: (29 January 2020)
Page navigation anchor for Medical Home Improves Diabetes Care - Key Ingredient is Care Management
Medical Home Improves Diabetes Care - Key Ingredient is Care Management
Robert A. Gabbay, Chief Medical Officer
This study aimed to determine whether positive diabetes measures are more prominent in primary care practices which are certified as medical homes compared to those which are not. The authors collected surveys from 416 adult practices in Minnesota on medical home practice systems and reviewed data on standardized diabetes measures. In this careful study, Solberg, Carlin, Peterson, and Eder found that PCMH-certified practices...
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This study aimed to determine whether positive diabetes measures are more prominent in primary care practices which are certified as medical homes compared to those which are not. The authors collected surveys from 416 adult practices in Minnesota on medical home practice systems and reviewed data on standardized diabetes measures. In this careful study, Solberg, Carlin, Peterson, and Eder found that PCMH-certified practices had better diabetes quality measures. Uncertified practices were more likely to be rural and had a lower overall level of diabetes care, but had comparable patient populations to those certified as Medical Homes. A notable strength of the study population is that the groups of practices were mostly in the same geographic area and did not have disparate numbers of FQHCs.
Interestingly, the two groups of practices were similar in their structure, as 74.9% of non-PCMH practices had medical home practice systems in place. The main differences between the certified and non-certified groups were in regards to coordinated care and care plans. We find this consistent with our work in Pennsylvania.
The Pennsylvania Chronic Care Initiative was the largest early pilot of Medical Home implementation involving 150 primary care practices and 178 payers in a series of regional rollouts across the state. Using a positive deviance approach to examine practices that most improved diabetes measures, we identified a series of care management functions that were consistently present in practices that had improved their diabetes quality measures the most including care plans and functions of coordinated care (Taliani et al. 2013). Interestingly, the practices studied in Minnesota had an exceptionally high level of performance in terms of PCMH attributes at baseline, a tribute to the great work done over the years around system based care improvement across that state. This may have underestimated the overall impact of PCMH implementation given that, at baseline, many of the attributes of PCMH were present even in non-PCMH practices.
The authors note that their 2010 study showed that those practices which ultimately received Medical Home certification improved most in the years leading up to their certification. Those practices which had not yet been certified actually exhibited greater rates of improvement, which suggests that there may be a plateau in quality improvement after the first year or two of certification. This raises the question of the details of the funding allocation to practices and possibly how these funds were utilized. As care management was shown in the present study to be an area of difference between certified vs. non-certified practices, there may have been particular investments made toward care management early in the period of attaining certification that may have not persisted. This plateau may be an interesting trend, the causes of which are worth exploring to help identify how to continue to foster quality improvement.
References:
1. Solberg LI, Carlin C, Peterson KA, Eder M. Differences in Diabetes Care With and Without Certification as a Medical Home. Ann Fam Med. 2020; 18(1): 66-72.
2. Taliani CA, Bricker PL, Adelman AM, Cronholm PF, Gabbay RA. Implementing effective care management in the patient-centered medical home. Am J Manag Care. 2013; 19(12): 957-964.
Competing interests: None declared
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Competing Interests: None declared.