Article Figures & Data
Tables
- Table 1.
Data Sources and Indicators Used to Measure the Principles of the Patient-Centered Medical Home
Principle Data Source Indicator CD = computer disk; PDA = personal digital assistant. a 0 = never, 1 = rarely, 2=sometimes, 3 = usually, 4 = always. b 0 = no, 1 = yes. c 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree. d 1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent. Personal physician: ongoing relationship for first- contact, continuous, and comprehensive care Patient survey “When I get sick, I contact this practice first (before going to a specialist or emergency room).”a “How often do you see the same doctor when getting care at this practice?”a Chart audit Number of months seen at practice Number of visits in past 2 years Physician-directed team: physician leads team of individuals who care for patients Director survey Practice has nurse practitioners or physician assistantsb Use of nurses or health educators for preventive counselingb Practice member survey “This practice encourages nursing staff input for making changes.”c Whole-person orientation: Care for all stages of life, acute care, chronic care, preventive services, end of life care Chart audit Patient has well-visit in last 5 yearsb Patient was treated at practice for acute illnessb Number of chronic diseases Care coordination: coordinated/integrated across all elements of complex health system—within practice and between consultants, ancillary providers, and community resources Practice member survey “We have a system to make sure results from testing/consultation reports are available during patient visits.”c “We have a system for communicating results from testing to patients.”c Director survey Use of referral system to link patients with community programs for education, support, or preventive counselingb Clinicians make hospital or nursing home visitsb Quality and safety: achieved through physician- patient partnerships, evidence-based medicine, clinical decision-support tools, continuous quality improvement, patient participation and feedback, information technology, voluntary recognition process Director survey Use of electronic medical recordsb Use of information technology (PDA, online literature searching, CD or Internet-based knowledge bases)a Use of clinical decision-support tools (reminder systems for identifying patients due for screening, prompting clinicians about needed tests, reminding patients about visits, checklists/flowcharts for chronic disease or screening, risk factor chart stickers or electronic flags)a Continuous quality improvement (use of patient satisfaction surveys, periodic chart audits)b Enhanced access: through systems such as open scheduling, expanded hours, new options for communication Patient survey “How long you waited to get an appointment”d “Getting through to the office by phone”d Director survey Use of e-mail with patientsb Use of Web site for marketingb Characteristic Value Patients (N = 568) Age, mean (SD), y 64.4 (4.3) Sex, male, mean (SD), % 39.7 (11.8) Race, nonwhite, mean (SD), % 31.3 (31.9) Insurance, commercial, mean (SD), % 51.6 (24.3) Education level, high school or less, mean (SD), % 36.2 (17.9) Practices (N = 24) Type of practice, n (%) Family medicine 17 (70.8) Internal medicine 5 (20.8) Family and internal medicine 2 (8.3) Years in business, n (%) 0–5 7 (29.2) 6–10 6 (25.0) 11–15 4 (16.7) 16–20 4 (16.7) >20 3 (12.5) Clinicians per practice, n (%) 1 3 (12.5) 2–5 14 (58.3) ≥6 7 (29.2) Practice ownership, n (%) Physician owned 17 (73.9) Hospital or university 5 (21.7) Public sponsor 1 (4.4) - Table 3.
Association of Patient Characteristics With Percentage of Preventive Services Received (N = 568)
Patient Characteristica Mean (SD)b P Value a Confounding variables used in multivariate models. b Mean percentage of preventive services that was up-to-date (total number of services for which patients received divided by the total number of services patients were eligible) and standard deviation across practices. Rate of preventive services delivery 42.7 (20.4) Age, y .26 50–59 43.1 (20.7) 60–69 44.4 (20.9) ≥70 40.8 (19.6) Sex .01 Male 45.3 (20.6) Female 41.0 (20.1) Race .03 White 41.3 (20.3) Black 45.2 (21.1) Hispanic 49.0 (19.4) Other 42.8 (18.5) Insurance .02 Commercial 40.9 (19.4) Medicare 42.8 (21.0) Other 50.1 (20.2) Education level .55 Less than high school 44.1 (19.8) High school diploma or some college 41.2 (19.6) College or graduate school degree 43.0 (20.9) Self-rated health .06 Excellent/good 41.5 (20.5) Fair/poor 44.8 (20.3) - Table 4.
Association of Principles of PCMH With Percentage of Preventive Services Received
Receipt of Preventive Services Principles of PCMH βa (95% CI) P Value PCMH = patient-centered medical home; Ref = reference. a Adjusted for patient age, sex, race/ethnicity, education level, insurance status, and self-rated health while accounting for correlation between patients within practices. Each β is from a separate model. b Analyzed as continuous variable. c Use of e-mail with patients was not included in multivariate models because of unstable estimates (only 3 practices used e-mail). Global PCMH score 2.3 (1.4 to 3.2) <.001 High-touch principles 3.4 (2.2 to 4.5) <.001 Personal physician 3.7 (1.7 to 5.8) <.001 Months patient enrolled in practice 0.03 (−0.01 to 0.07)b .13b Number of visits in previous 2 years 0.9 (0.6 to 1.3)b <.001b <5 Ref 5–8 9.6 (4.6 to 14.7) <.001 9–12 12.4 (7.6 to 17.2) <.001 ≥13 15.3 (10.6 to 20.1) <.001 Patient sees same doctor when getting care at practice 4.4 (1.6 to 7.1) .002 Patient contacts primary care practice first when ill 0.5 (−1.3 to 2.3) .56 Physician-directed team 1.8 (−1.8 to 5.4) .32 Practice has nurse practitioners or physician assistants 0.5 (−5.4 to 6.5) .86 Practice uses nurses/health educators for preventive counseling 3.1 (−2.6 to 8.7) .29 Practice leadership seeks nursing input for making changes 1.0 (−1.2 to 3.4) .37 Whole-person orientation 5.6 (4.2 to 7.1) <.001 Well-visit in last 5 years 12.3 (7.6 to 17.1) <.001 Treated at practice for acute illness 0.7 (−3.9 to 5.3) .78 Number of chronic diseases 2.8 (1.8 to 3.8)b <.001b ≤3 Ref ≥4 5.8 (2.8 to 8.8) <.001 Coordination of care 1.4 (−0.7 to 3.5) .20 Reports from tests/consultations available during patient visits 0.4 (−4.2 to 4.9) .87 Results of tests communicated to patients 2.5 (−0.5 to 5.6) .10 Referral system to link patients to community programs 8.0 (3.8 to 12.3) <.001 Clinicians make hospital or nursing home visits 0.9 (−4.4 to 6.2) .74 High-tech principles 0.3 (−1.1 to 1.7) .64 Quality and safety 0.8 (−1.2 to 2.8) .45 Use of electronic medical records −2.1 (−7.8 to 3.7) .48 Use of information technology 1.1 (−4.3 to 6.6) .68 Use of clinical decision support tools 5.0 (0.3 to 9.7) .04 Performs continuous quality improvement 1.6 (−3.4 to 6.6) .52 Enhanced accessc −0.3 (−2.3 to 1.7) .74 Waiting time for appointment −0.2 (−1.4 to 1.0) .76 Getting through the office by telephone −0.4 (−1.9 to 0.9) .52 Use of Web site for marketing −0.3 (−5.8 to 5.2) .91
Additional Files
The Article in Brief
Principles of the Patient-Centered Medical Home and Preventive Services Delivery
Jeanne M. Ferrante , and colleagues
Background The patient-centered medical home (PCMH) is being promoted as a means of making primary care practice, as well as US health care, more effective, efficient, and economical. PCMH principles include an ongoing relationship with a personal physician, care by a physician-directed team, whole-person orientation, coordinated care, quality and safety, enhanced access, and payment reform. This study examines the relationship between PCMH principles and receipt of preventive services in community primary care practices.
What This Study Found Patient-centered medical home principles, particularly relationship-centered aspects, are associated with higher rates of preventive services delivery in community primary care practices. Having more primary care visits and a well visit in the past 5 years had the greatest impact on the number of preventive services received. The only high-tech indicator that was significantly associated with receipt of preventive services was use of clinical decision-support tools.
Implications
- The authors suggest that PCMH demonstration projects and measurement tools focus more on "high-touch," relationship-centered qualities, which are shown to improve health care, rather than high-tech aspects of care.
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