First things first: foundational requirements for a medical home in an academic medical center.

BACKGROUND: In 2010, the Veterans Health Administration (VHA) began implementation of its medical home, Patient Aligned Care Teams (PACT), in 900 primary care clinics nationwide, with 120 located in academically affiliated medical centers. The literature on Patient-Centered Medical Home (PCMH) implementation has focused mainly on small, nonacademic practices. OBJECTIVE: To understand the experiences of primary care leadership, physicians and staff during early PACT implementation in a VHA academically affiliated primary care clinic and provide insights to guide future PCMH implementation. DESIGN: We conducted a qualitative case study during early PACT implementation. PARTICIPANTS: Primary care clinical leadership, primary care providers, residents, and staff. APPROACH: Between February 2011 and March 2012, we conducted 22 semi-structured interviews, purposively sampling participants by clinic role, and convenience sampling within role. We also conducted observations of 30 nurse case manager staff meetings, and collected data on growth in the number of patients, staff, and physicians. We used a template organizing approach to data analysis, using select constructs from the Consolidated Framework for Implementation Research (CFIR). KEY RESULTS: Establishing foundational requirements was an essential first step in implementing the PACT model, with teamlets able to do practice redesign work. Short-staffing undermined development of teamlet working relationships. Lack of co-location of teamlet members in clinic and difficulty communicating with residents when they were off-site hampered communication. Opportunities to educate and reinforce PACT principles were constrained by the limited clinic hours of part-time primary care providers and residents, and delays in teamlet formation. CONCLUSIONS: Large academic medical centers face special challenges in implementing the medical home model. In an era of increasing emphasis on patient-centered care, our findings will inform efforts to both improve patient care and train clinicians to move from physician-centric to multidisciplinary care delivery.

Four-year evolution of a large, state-wide patient-centered medical home designation program in Michigan.

BACKGROUND: The patient-centered medical home (PCMH) has been recognized as a strategy to redesign and improve the delivery of primary health care. Collaboration between Blue Cross Blue Shield of Michigan (BCBSM) and 39 Physician Organizations in Michigan laid the foundation for a state-wide medical home program. OBJECTIVE: The objective of the study was to describe a unique methodology developed and implemented by BCBSM to designate primary care physician practices as medical homes. METHODS: Since 2009, practices were designated annually as medical homes on the basis of (1) implementation of PCMH-related capabilities, and (2) performance on quality-of-care and health resource utilization measures. An overall score for each practice was calculated. Practices were ranked relative to each other, with the top portion of the continuum representing an achievable level of performance. RESULTS: The number of practices designated as medical homes more than tripled since the program's inception: 302 (1283 physicians) in 2009, 513 (1876 physicians) in 2010, 772 (2547 physicians) in 2011, and 994 (3028 physicians) in 2012. Designated practices reported implementing more than double the PCMH capabilities of nondesignated practices, yet all practices increased their number of implemented capabilities during the 4 years. DISCUSSION: This program represents the largest state-based PCMH program in the United States. Over the 4-year period, 1130 unique practices have received designation, representing 3469 unique physicians. An estimated 1.4 million BCBSM members in Michigan received care from these practices. This program will continue to develop, drawing on changes in the health system landscape, collaboration with the physician community, and knowledge gained from PCMH evaluations.

Public awareness and use of direct-to-consumer genetic tests: results from 3 state population-based surveys, 2006.

We conducted population-based surveys on direct-to-consumer nutrigenomic testing in Michigan, Oregon, and Utah as part of the 2006 Behavioral Risk Factor Surveillance System. Awareness of the tests was highest in Oregon (24.4%) and lowest in Michigan (7.6%). Predictors of awareness were more education, higher income, and increasing age, except among those 65 years or older. Less than 1% had used a health-related direct-to-consumer genetic test. Public health systems should increase consumer and provider education and continue surveillance on direct-to-consumer genetic tests.