Elements of the Patient-Centered Medical Home in Family Practices in Virginia

Debora Goetz Goldberg; Anton J. Kuzel

doi:10.1370/afm.1021

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Figure 1.
Derivation of Study Sample

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Table 1.

Core Features and Corresponding Elements of the Patient-Centered Medical Home⁴

Core Feature	Elements
From the Joint Principles of the Patient-Centered Medical Home, 2007.⁴
Personal physician	Each patient has a personal physician that provides first-contact, continuous, and comprehensive care
Physician-led team	Physician-directed medical practice with a multidisciplinary team of individuals who care for patients
Whole-person orientation	Care for all stages of life, acute care, chronic care, preventative services, and end-of-life care
Coordinated care	Care that is facilitated by registries, information technology, health information exchange, and culturally and linguistically appropriate services
Quality and safety	Physician-patient partnerships, evidence-based medicine, quality improvement, patient participation in care, practice participation in voluntary recognition process
Alternative scheduling arrangements	Patient access to care through open scheduling, expanded hours, and various methods for communication between patients and their physician or care team
Payment reform	Alignment of financial incentives to support coordination of care, alternative scheduling arrangements, use of new technologies, and improved quality of care

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Table 2.

Comparison of Sample With Population Characteristics

Variable	Sample (n=342^a) No. (%)	Population (N=916) No. (%)	Pearson χ²(Asym Sign)
Asym sign=asymptotic significance (2-sided).
^a Two cases without geographic information.
^b Practice has Medicare/Medicaid-participating clinician who either accepts new patients or continues to care for existing Medicare and Medicaid patients.
Geographic characteristics
Rural	282 (82.9)	773 (84.4)	0.386 (.584)
Urban	58 (17.1)	143 (15.6)
Virginia region
Northwestern	53 (15.6)	153 (16.7)	2.084 (.720)
Northern	68 (20.0)	202 (22.1)
Southwestern	62 (18.2)	169 (18.4)
Central	76 (22.4)	174 (19.0)
Eastern	81 (23.8)	218 (23.8)
Government insurance^b
Accepts Medicare	315 (92.6)	820 (89.5)	2.602 (.107)
Accepts Medicaid	249 (73.7)	665 (72.6)	0.032 (.858)

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Table 3.

Organizational Characteristics of Participating Family Practices (N = 342)

Characteristics	No. (%)
Specialty
Single specialty	246 (71.9)
Multispecialty—primary care only (family medicine, internal medicine, pediatrics)	48 (14.0)
Multispecialty—primary care and specialty care	48 (14.0)
Type
Private practice	280 (81.8)
Nonprofit federally or state funded	22 (6.5)
Nonprofit privately funded	19 (5.6)
Academic	12 (3.5)
Urgent care plus primary care	9 (2.9)
Ownership
Not owned by outside entity	190 (55.6)
Hospital	54 (15.8)
Health plan	53 (15.5)
Other	45 (13.2)
Location
Not primary care shortage area	263 (76.9)
Primary care shortage area	79 (23.1)
Number of physicians
1	90 (26.4)
2–9	218 (63.9)
10–49	34 (10.0)

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Table 4.

Measured Elements and Core Features of the Patient-Centered Medical Home (N = 342)

Elements	Response No. (%)	Practices Awarded Point No. (%)
Elements of personal physician		299 (87.4)^a
Continuity of care	299 (87.4)	299 (87.4), 1 point if yes
Elements of medical team		80 (23.4)^a
Ancillary care clinicians		119 (34.8), 1 point if yes to 3 or more questions
Nurse(s)	214 (62.6)
Medical assistant(s)	169 (49.4)
Nurse-practitioner(s)	149 (43.6)
Patient educator(s)	80 (23.4)
Physician’s assistants	67 (19.6)
Mental health specialist(s)	30 (8.8)
Offer programs for employee morale/teamwork	181 (52.9)	181 (52.9), 1 point for yes
Elements of whole-person orientation		254 (74.3)^a
Patient types seen		260 (76.0), 1 point if yes to all
Adults	342 (100.0)
Children	316 (92.4)
Infants	260 (76.0)
Type of care provided		327 (95.6), 1 point if yes to all
Preventive	339 (99.1)
Acute	336 (98.2)
Chronic illness	333 (97.4)
Elements of care coordination and integration		12 (3.5)^a
Existence of patient registry		66 (19.3), 1 point if yes to 3 or more questions
Diabetes	97 (28.2)
Asthma	73 (21.1)
Congestive heart failure	64 (18.5)
Coronary artery disease	64 (18.5)
Depression	58 (16.7)
Other	36 (10.6)
Electronic medical record (EMR) components—internal coordination		135 (39.5), 1 point for yes to 3 out of 6 questions
Problem list	133 (38.9)
Ambulatory visits	134 (39.2)
Medication lists	134 (39.2)
Laboratory findings	127 (37.1)
Medication-ordering reminders, drug interaction	107 (31.3)
Radiology findings	118 (34.5)
EMR components—external coordination		97 (28.4), 1 point for 2 out of 3 questions,
Services by other specialists	109 (31.9)
Inpatient stays	91 (26.6)
Emergency room visits	83 (24.3)
Community linkages for care	107 (31.3)	107 (31.3), 1 point for yes
Linguistic services	168 (49.1)	168 (49.1), 1 point for yes
Elements of enhanced access		124 (36.3)^a
Alternative scheduling arrangements		124 (36.3), 1 point if yes to 3 or more questions
Rapid access	299 (87.4)
Scheduled evenings or weekend visits	134 (39.2)
Telephone consultations	134 (39.2)
On-call evenings or weekends	116 (33.9)
E-mail consultations	43 (12.6)
Group visits	34 (9.9)
Elements of quality and safety		60 (17.5)^a
Clinical guidelines		223 (65.2), 1 point if yes to 2 or more questions
Use of clinical guidelines	263 (76.9)
Physician training on clinical guidelines	227 (66.4)
EMR with problem-specific clinical guidelines	64 (18.7)
Patient satisfaction surveys		133 (38.9), 1 point for yes to both questions
Administers surveys	163 (47.7)
Initiates changes based on surveys	136 (39.8)
Performance measurement and monitoring		97 (28.4), 1 point if yes to 2 or more questions
Tracks clinician use of evidence-based guidelines	80 (23.4)
Tracks results of quality improvement projects	81 (23.7)
Tracks clinical outcomes	80 (23.4)
Provides written performance reports to physicians	99 (28.9)

Supplemental Appendix

Supplemental Appendix. Virginia Commonwealth University Family Medicine Practice Survey.

Files in this Data Supplement:

Supplemental data: Appendix - PDF file, 8 pages, 157
The Article in Brief

Elements of the Patient-Centered Medical Home in Family Practices in Virginia

Debora Goetz Goldberg , and colleagues

Background The Patient-Centered Medical Home (PCMH) is a new model of care designed to help primary care practices improve access, quality of care, and business functions. This study reports on characteristics of family practices in Virginia and how they compare to core features of the PCMH.

What This Study Found Most family practices in this study have components of the PCMH model pertaining to whole-person orientation and care by a personal physician. Fewer practices have components that require considerable financial and knowledge resources. Specifically, most practices report use of continuity-of-care processes (87%) and clinical guidelines (77%). Fewer report use of patient surveys (48%), electronic medical records for internal coordination (38%), community linkages for care (31%) and clinical performance measurement (28%). A small number report patient registries for multiple diseases (19%).

Implications

These study results can help guide efforts, evaluate progress, and develop policies for health care model reform.
Increased attention is needed to transform family practices in the areas of quality and safety, coordination of care, team-based care, and enhanced access to care.