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Research ArticleOriginal Research

Effect of Facilitation on Practice Outcomes in the National Demonstration Project Model of the Patient-Centered Medical Home

Paul A. Nutting, Benjamin F. Crabtree, Elizabeth E. Stewart, William L. Miller, Raymond F. Palmer, Kurt C. Stange and Carlos Roberto Jaén
The Annals of Family Medicine May 2010, 8 (Suppl 1) S33-S44; DOI: https://doi.org/10.1370/afm.1119
Paul A. Nutting
MD, MSPH
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Benjamin F. Crabtree
PhD
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Elizabeth E. Stewart
PhD
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William L. Miller
MD, MA
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Raymond F. Palmer
PhD
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Kurt C. Stange
MD, PhD
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Carlos Roberto Jaén
MD, PhD
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    Table 1.

    Comparison of Facilitated and Self-Directed Practices at Baseline

    CharacteristicFacilitated PracticesSelf-Directed PracticesP Value
    NDP = National Demonstration Project; PCMH = patient-centered medical home.
    Notes: Data are based on 35 practices that started the NDP; 1 of the original 36 practices was not able to obtain approval for the project from their institutional review board and withdrew their baseline data.
    a Values are percentages.
    b Values are ratings on a scale from 0 to 1, where higher values indicate a higher level of the attribute.
    Demographicsan=17n=18
    Age of practice, y.22
        ≤53533
        6–10245
        11–20629
        >203533
    Size.35
        Solo (± midlevel clinicians)3522
        Small (2–3 physicians)2412
        Medium (4–6 physicians)1744
        Large (≥7 physicians)2422
    Setting.85
        Rural2933
        Suburban5355
        Urban1811
    Ownership structure.89
        Physician owned5961
        Health or hospital system owned4139
    NDP model components in placean=16n=15
    Access to care and information (overall, 6 items)3030.92
        Same-day appointments4453.59
        Group visits67.96
        e-Visits60.32
    Care management (overall, 4 items)3848.22
    Practice services (overall, 5 items)9591.29
    Continuity of care (overall, 5 items)5665.25
        Maternity care8187.68
        Hospital care88100.16
    Practice management (overall, 5 items)4259.04
    Quality and safety (overall, 5 items)3243.19
        Medication management6293.04
        Patient satisfaction feedback4453.59
    Health information technology (overall, 5 items)2831.66
        Electronic medical record6973.78
        Electronic prescribing4440.83
        Practice Web site2533.61
        Interactive patient portal00–
    Practice-based care teams (overall, 4 items)2048.001
    Patient-rated PCMH attributesbn=17n=16
    Comprehensive care.81.84.08
    Coordination of care.74.76.53
    Access to care.88.88.89
    Personal relationship over time.76.76.58
    Global practice experience.27.32.28
    • View popup
    Table 2.

    Components of the Patient-Rated PCMH Scale

    ComponentItems
    ACES = Ambulatory Care Experience Survey; CPCI = Components of Primary Care Index; PCMH = patient-centered medical home.
    Notes: Scores on this scale consisted of the average summed responses of the 23 items in 5 subscales. Cronbach α for the 23-item scale was .92.
    Comprehensive care (from CPCI18)Handles emergencies
    Care of almost any medical problem I may have
    Go for help with a personal or medical problem
    Go for care for an ongoing medical problem such as high blood pressure
    Go for a checkup to prevent illness
    Coordination of care (from CPCI18)Keeps track of all my health care
    Follows up on a problem I’ve had, either at the next visit or by mail, e-mail, or phone
    Follows up on my visit to other health care professionals
    Helps me interpret my laboratory tests, x-rays, or visits to other doctors
    Communicates with other health professionals I see
    Access to care (from ACES19)Help as soon as needed for an illness or injury
    Appointment for a checkup or routine care as soon as needed
    Answer to medical question the same day when calling during regular office hours
    Help or advice needed when calling after regular office hours
    Personal relationship over time (from CPCI18)Knows a lot about my family medical history
    Have been through a lot together
    Understands what is important to me regarding my health
    Knows my medical history very well
    Takes my beliefs and wishes into account in caring for me
    Knows whether or not I exercise, eat right, smoke, or drink alcohol
    Knows me well as a person (such as hobbies, job, etc)
    Global practice experience (new scale20)I receive the care I want and need when and how I want and need it
    I am delighted with this practice
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    Table 3.

    Components of the Practice Adaptive Reserve Scale

    ComponentItems (Attributes Measured)
    Notes: Scores on this scale were computed as the summed averaged of the individual responses for each practice. Cronbach α for the 23-item scale was .97.
    Relationship infrastructurePeople in our practice actively seek new ways to improve how we do things (mindfulness)
    People at all levels of this office openly talk about what is and isn’t working (mindfulness)
    We regularly take time to consider ways to improve how we do things (mindfulness)
    People are aware of how their actions affect others in this practice (heedful interactions)
    Most people in this practice are willing to change how they do things in response to feedback from others (respectful interaction)
    After trying something new, we take time to think about how it worked (reflection)
    We regularly take time to reflect on how we do things (reflection)
    This practice encourages everyone (front office staff, clinical staff, nurses, and clinicians) to share ideas (cognitive diversity)
    I can rely on the other people in this practice to do their jobs well (trust)
    Difficult problems are solved through face-to-face discussions in this practice (communication)
    Facilitative leadershipPractice leadership promotes an environment that is an enjoyable place to work
    Leadership in this practice creates an environment where things can be accomplished
    Leadership strongly supports practice change efforts
    The practice leadership makes sure that we have the time and space necessary to discuss changes to improve care
    SensemakingWhen we experience a problem in the practice, we make a serious effort to figure out what’s really going on
    People in this practice have the information that they need to do their jobs well
    TeamworkI have many opportunities to grow in my work
    People in this practice operate as a real team
    Work environmentMost of the people who work in our practice seem to enjoy their work
    This practice is a place of joy and hope
    Culture of learningMistakes have led to positive changes here
    It is hard to get things to change in our practice
    This practice learns from its mistakes
    • View popup
    Table 4.

    Comparison of Facilitated and Self-Directed Practices on 3 Main Outcomes

    OutcomeFacilitated Practices, Mean (SD) (n=16)Self-Directed Practices, Mean (SD) (n=15)ANOVA P Values
    ANOVA = analysis of variance; NDP = National Demonstration Project; PCMH = patient-centered medical home.
    Notes: Patient-rated PCMH and practice adaptive reserve are scale scores described in the text. ANOVA analyses were weighted by the number of respondents as a proxy for practice size.
    a The proportion of 39 measurable model components in place.
    b Scores represent the average summed responses for 23 items (shown in Table 2), with a range of 1 (strongly disagree) to 5 (strongly agree). Items were reverse-scored when appropriate so that higher numbers reflect more positive ratings.
    c Scores represent the average summed responses for 23 items (shown in Table 3). Items were reverse-scored when appropriate and rescaled to reflect a range from 0 to 1, where higher scores reflect more adaptive reserve.
    NDP model components in placea
        Baseline.42 (.40).54 (.40)Between group: .19
        26 months.72 (.45).70 (.47)Within group: <.001
    Group differences by time: .005
    Patient-rated PCMHb
        Baseline3.42 (0.66)3.51 (0.75)Between group: .41
        26 months3.38 (0.68)3.41 (0.93)Within group : .03
    Group differences by time: .34
    Practice adaptive reservec
        Baseline.69 (.35).69 (.38)Between group: .51
        26 months.74 (.38).68 (.46)Within group: .09
    Group differences by time: .02
    • View popup
    Table 5.

    NDP Model Domains and Components Implemented by Practice Group

    Facilitated Practices (n=16)Self-Directed Practices (n=15)All Practices (N=31)
    Domain and ComponentIn Place at BaselineImplemented During NDPImplemented in the 9 mo After NDPNot ImplementedIn Place at BaselineImplemented During NDPImplemented in the 9 mo After NDPNot ImplementedIn Place at BaselineImplemented During NDPImplemented in the 9 mo After NDPNot Implemented
    HR=human resources; NDP=National Demonstration Project.
    Notes: Values shown are numbers of practices. Within each group (facilitated, self-directed, or all), numbers total across rows.
    Access to care and information
        Same-day appointments78108610151420
        Laboratory results highly accessible87014740121441
        Online patient services19060456113512
        e-Visits150100301218022
        Group visits18251509213214
        After-hours access coverage142001500029200
    Care management
        Population management26082436410314
        Wellness promotion4309510994018
        Disease prevention115001320024700
        Patient engagement/education7504931216816
    Practice services
        Comprehensive acute and chronic care160001500031000
        Prevention screening124001230024700
        Surgical procedures160001500031000
        Ancillary therapeutic/support160001230028300
        Ancillary diagnostic services160001410030100
    Continuity of care
        Community-based services73068106154012
        Hospital care140021500029002
        Behavioral health care81078205163012
        Maternity care130031300226005
        Case management33010511884118
    Practice management
        Disciplined financial management96011032019921
        Cost-benefit decision making92231050019723
        Revenue enhancement5722442591147
        Personnel/HR management86111221020821
        Optimized office design3373830411677
    Quality and safety
        Medication management103031410024403
        Patient satisfaction feedback73068304156010
        Clinical outcomes analysis4507441689113
        Quality improvement4606522698212
        Practice-based team care141101608210118
    Health information technology
        Electronic medical record113021130122603
        Electronic prescribing77026900131602
        Population management/registry07091338110317
        Practice Web site4903542491327
        Interactive patient portal0529045609715
    Practice-based care teams
        Provider leadership5623931214935
        Shared mission and vision3715921312928
        Effective communication3724921312937
        Task designation by skill set26172715413212

Additional Files

  • Tables
  • Supplemental Appendixes 1-2

    Supplemental Appendix 1. National Demonstration Project Model Components; Supplemental Appendix 2. NDP Model Components Implemented by Practices in the Facilitated and Self-Directed Groups, and Overall

    Files in this Data Supplement:

    • Supplemental data: Appendix - PDF file, 4 pages, 92KB
    • Supplemental data: Appendix 2 - PDF file, 1 page, 89KB
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The Annals of Family Medicine: 8 (Suppl 1)
The Annals of Family Medicine: 8 (Suppl 1)
Vol. 8, Issue Suppl 1
1 May 2010
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Effect of Facilitation on Practice Outcomes in the National Demonstration Project Model of the Patient-Centered Medical Home
Paul A. Nutting, Benjamin F. Crabtree, Elizabeth E. Stewart, William L. Miller, Raymond F. Palmer, Kurt C. Stange, Carlos Roberto Jaén
The Annals of Family Medicine May 2010, 8 (Suppl 1) S33-S44; DOI: 10.1370/afm.1119

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Effect of Facilitation on Practice Outcomes in the National Demonstration Project Model of the Patient-Centered Medical Home
Paul A. Nutting, Benjamin F. Crabtree, Elizabeth E. Stewart, William L. Miller, Raymond F. Palmer, Kurt C. Stange, Carlos Roberto Jaén
The Annals of Family Medicine May 2010, 8 (Suppl 1) S33-S44; DOI: 10.1370/afm.1119
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