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Research Questions Findings ACQA = Ambulatory Care Quality Alliance; EMR = electronic medical record; NDP = National Demonstration Project; PCMH = patient-centered medical home. Implementing the Patient-Centered Medical Home: Observation and Description of the National Demonstration Project19 What did the NDP look like? How did it unfold and evolve over time? The NDP model emphasized technological components
The facilitated implementation strategy emphasized getting model components in place and used all reasonable efforts to do so
The NDP did not alter the reimbursement system and had limited connection to the larger medical neighborhood
The NDP model evolved over time in response to the national debate on the PCMH
Journey to the Patient-Centered Medical Home: A Qualitative Analysis of the Experiences of Practices in the National Demonstration Project23 What were the experiences of the practices in the NDP in implementing model components of a PCMH? Six themes included: Practice adaptive reserve is critical to managing change
Developmental pathways to success vary by practice
Motivation of key practice members is critical
The larger system can help or hinder
Transformation is more than a series of changes and requires shifts in roles and mental models
Practices benefit from multiple facilitator roles: consultant, coach, negotiator, connector, and facilitator
Effects of Facilitation on Practice Outcomes in the National Demonstration Project Model of the Patient-Centered Medical Home22 Compared with self-direction, did facilitation lead to a greater increase in implementation of NDP model components?
Compared with self-direction, did facilitation lead to a greater increase in patient ratings of the practices’ PCMH attributes?
Compared with self-direction, did facilitation lead to a greater increase in adaptive reserve?
Was adaptive reserve at baseline associated with implementing more NDP model components, controlling for the intervention?
Were the practices able to implement the NDP model components?
1. Both facilitated and self-directed practices had an increase in the proportion of components in place (P <.001), but the increase was greater in the facilitated group (P=.005)
2. Both facilitated and self-directed practices had a decrease in patients’ ratings of the practices as PCMHs (P = .03), with no significant difference between groups (P=.34)
3. Facilitated practices had an increase in adaptive reserve, whereas self-directed practices did not (P=.02)
4. There was a nonsignificant trend whereby practices having more adaptive reserve at baseline tended to implement more components (P = .08), with power needed to detect a significant difference (P <.05) estimated to be only 60%
5a. Over 2 years, NDP practices in both groups were able to put just over 70% of the NDP model components in place
5b. The NDP practices appeared to be early adopters of health information technology: at baseline, the proportion using EMRs exceeded the national norm
5c. Most practices in both groups were able to implement same-day appointments, electronic pre- scribing, and making laboratory results highly accessible to patients. Many practices were able to improve practice management processes, adopt more efficient office designs, and create a practice Web site. A fully functioning patient portal was a greater challenge
5d. Practices in both groups struggled with electronic visits (e-visits), group visits, wellness promotion, proactive population management, and team-based care
Patient Outcomes at 26 Months in the Patient-Centered Medical Home National Demonstration Project21 1. Were changes in patient outcomes superior in facilitated vs self-directed practices? 1a. There were no significant improvements in patient-rated outcomes for the facilitated vs self-directed practices, and there were nonsignificant trends for very small decreases in coordination of care (P=.11), comprehensive care (P = .06), and access to care (P = .11) in both groups 1b. Scores for an ACQA measure of care improved (by 8.3% in facilitated practices and 9.1% in self-directed practices, P <.0001) as did scores for chronic disease care (by 5.2% in facilitated practices and 5.0% in self-directed practices, P=.002), with no significant difference between groups 2. Did adoption of NDP model components improve patient outcomes, regardless of group assignment? 2a. Adoption of model components during the NDP was associated with improved access (standardization beta (Sβ)=0.32, P = .04) and with better prevention scores (S β =0.42, P=.001), ACQA scores (S β =0.45, P = .007), and chronic disease care scores (S β =0.25, P=.08) 2b. Adoption of NDP model components was associated with patient-rated outcomes for access, but not for health status, satisfaction with the service relationship, patient empowerment, comprehensive care, coordination of care, personal relationship over time, or global practice experience ACO = Accountable Care Organization; EMR = electronic medical record; NCQA = National Committee for Quality Assurance; PCMH = patient-centered medical home; wRVUs = work-related value units. The PCMH model must continue to evolve Emphasize the 4 core attributes of primary care Consider moving beyond the physician-led PCMH to more collaborative care models Encourage disruptive innovations, given that incremental changes may not be enough Promote local variations in PCMH model development and implementation Discourage limited pilot projects that are underfunded, focus on disease, or last less than 2 years Delivery system reform and resources must be in place for implementing PCMH development Change how primary care is paid: Separate documentation of care from billing and eliminate wRVUs Encourage capitation, bundling, direct care, or some mix thereof Promote business models that encourage integration across the health care system Promote pilot projects that test the PCMH and ACO linkage, and that last more than 2 years Develop a nationally shared online platform for communication and coordination of care Develop EMRs prioritizing clinical care as opposed to billing documentation Implement the extension agent model nationally for training in the areas of leadership, management of change, and practice operations, and for leveraging health information technology resources In the meantime, much can be done At the practice level: Help primary care practices strengthen their core, develop their adaptive reserve, and enhance their attentiveness to the local environment Promote and assist continued evolution of the NCQA PCMH recognition process not only to emphasize the core attributes of primary care and patient-centeredness, but also to include lengthening the time span and addition of categories that help practices prioritize their efforts to develop their internal capability In the area of medical education: Prepare current clinicians for less episodic care and more population-based care Prepare current clinicians for partnering with collaborators in their practice Increase experimentation and flexibility in primary care residency training Support changes in medical school admissions and premedical requirements to encourage more generalists In the area of health care research: Promote research that seeks better understanding of the practice development process Encourage all pilot projects of PCMH to include mixed-method evaluation with a strong qualitative component and then ensure adequate funding of the evaluation Accelerate work to develop better measures of the 4 core attributes of primary care, whole- person health within a community context, and healing relationships
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