| 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
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| 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
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| 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
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| 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 |