Impact of Evidence-Based Quality Improvement on Tailoring VA's Patient-Centered Medical Home Model to Women Veterans' Needs.

BACKGROUND: Women Veterans' numerical minority, high rates of military sexual trauma, and gender-specific healthcare needs have complicated implementation of comprehensive primary care (PC) under VA's patient-centered medical home model, Patient Aligned Care Teams (PACT). OBJECTIVE: We deployed an evidence-based quality improvement (EBQI) approach to tailor PACT to meet women Veterans' needs and studied its effects on women's health (WH) care readiness, team-based care, and burnout. DESIGN: We evaluated EBQI effectiveness in a cluster randomized trial with unbalanced random allocation of 12 VAMCs (8 EBQI vs. 4 control). Clinicians/staff completed web-based surveys at baseline (2014) and 24 months (2016). We adjusted for individual-level covariates (e.g., years at VA) and weighted for non-response in difference-in-difference analyses for readiness and team-based care overall and by teamlet type (mixed-gender PC-PACTs vs. women-only WH-PACTs), as well as post-only burnout comparisons. PARTICIPANTS: We surveyed all clinicians/staff in general PC and WH clinics. INTERVENTION: EBQI involved structured engagement of multilevel, multidisciplinary stakeholders at network, VAMC, and clinic levels toward network-specific QI roadmaps. The research team provided QI training, formative feedback, and external practice facilitation, and support for cross-site collaboration calls to VAMC-level QI teams, which developed roadmap-linked projects adapted to local contexts. MAIN MEASURES: WH care readiness (confidence providing WH care, self-efficacy implementing PACT for women, barriers to providing care for women, gender sensitivity); team-based care (change-readiness, communication, decision-making, PACT-related QI, functioning); burnout. KEY RESULTS: Overall, EBQI had mixed effects which varied substantively by type of PACT. In PC-PACTs, EBQI increased self-efficacy implementing PACT for women and gender sensitivity, even as it lowered confidence. In contrast, in WH-PACTs, EBQI improved change-readiness, team-based communication, and functioning, and was associated with lower burnout. CONCLUSIONS: EBQI effectiveness varied, with WH-PACTs experiencing broader benefits and PC-PACTs improving basic WH care readiness. Lower confidence delivering WH care by PC-PACT members warrants further study. TRIAL REGISTRATION: The data in this paper represent results from a cluster randomized controlled trial registered in ClinicalTrials.gov (NCT02039856).

Integrating a Community-Based Health Information System with a Patient-Centered Medical Home to improve care of patients with hypertension: a longitudinal observational study protocol.

BACKGROUND: The primary healthcare system in Pakistan focuses on providing episodic, disease-based care. Health care for low-middle income communities is largely through a fee-for-service model that ignores preventive and health-promotive services. The growing burden of cardiovascular illnesses requires restructuring of the primary health care system allowing a community-to-clinic model of care to improve patient- and community-level health indicators. METHODS: We propose a model that integrates a Patient-Centered Medical Home (PCMH) with a Community-Based Health Information System (CBHIS) using hypertension (HTN) as an example. This protocol describes the integration and evaluation of the PCMH-CBHIS infrastructure through a population-based, observational, longitudinal study in a low-middle income, urban community in Pakistan. Participants are being enrolled in CBHIS and will be followed longitudinally over two years for HTN outcomes. A mixed-methods approach is adopted to evaluate the process of integrating PCMH with CBHIS. This involves building partnerships with the community through formal and informal meetings, focus group discussions, and a household health assessment survey (HAS). Community members identified with HTN are linked to PCMH for disease management. A customized electronic medical record system links community-level data with patient-level data to track changes in disease burden. The RE-AIM evaluation framework will be used to monitor community and individual-level metrics to guide implementation assessment, the potential for generalization, and the effectiveness of the PCMH in improving HTN-related health outcomes. Ethical clearance has been obtained from the Ethics Review Committee at Aga Khan University (2022-6723-20985). DISCUSSION: This study will evaluate the value of restructuring the primary care health system by ensuring systematic community engagement and measurement of health indicators at the patient- and community-level. While HTN is being used as a prototype to generate evidence for the effectiveness of this model, findings from this initiative will be leveraged towards strengthening the management of other acute and chronic conditions in primary care settings. If effective, the model can be used in Pakistan and other LMICs and resource-limited settings.

Age of Autism Spectrum Disorder Diagnosis and Patient-Centered Medical Home Components.

Early diagnosis of autism spectrum disorder (ASD) in children facilitates the provision of services and enhances opportunities for improving functioning via intervention. To date, limited studies have examined whether age of ASD diagnosis is associated with components of care of the patient-centered medical home (PCMH), a model of health care that emphasizes centralized, accessible, and coordinated care. The objective of the current study was to evaluate the associations between components of the PCMH and age of ASD diagnosis while controlling for associated clinical and socio-demographic factors, in a national sample of children 17 years and younger with ASD. The present study was a cross-sectional, observational study. Participants were caregivers of 1,193 children ages with ASD from the 2020 National Survey of Children's Health (NSCH). Hierarchical multiple linear regression analysis was run with age of ASD diagnosis as the criterion variable in two regression models. The binary composite medical home proxy variable was investigated as well as the five individual medical home components (usual source of care, personal doctor or nurse, family-centered care, care coordination, able to obtain referrals when needed). In the first regression analysis, the overall PCMH proxy variable was significantly correlated with the age of ASD diagnosis (standardized beta coefficient = -.08; p < .01). Of the five components of the PCMH assessed in the second regression model, only usual source of sick care was significantly associated with the age of ASD diagnosis (standardized beta coefficient = -.11; p < .01). Having a usual source of sick care may be an important factor in receiving an earlier ASD diagnosis for children and adolescents.

The Impact of Delivery Reform on Health Information Exchange with Behavioral Health Providers: Results from a National Representative Survey of Ambulatory Physicians.

Health information exchange (HIE) is an effective way to coordinate care, but HIE between health and behavioral health providers is limited. Recent delivery reform models, including the Accountable Care Organization (ACO) and Patient Centered Medical Home (PCMH) prioritize interprofessional collaboration, but little is known about their impact on behavioral health HIE. This study explores whether delivery reform participation affects behavioral health HIE among ambulatory health providers using pooled 2015-2019 data from the National Electronic Health Record Survey, a nationally representative survey of ambulatory physicians' technology use (n = 8,703). The independent variable in this analysis was provider participation in ACO, PCMH, Hybrid ACO-PCMH, or standard care. The dependent variable was HIE with behavioral health providers. Chi square analysis estimated unweighted rates of behavioral health HIE across reform models. Logistic regression estimated the impact of delivery reform participation on rates of behavioral health HIE. Unweighted estimates indicated that Hybrid ACO-PCMH providers had the highest rates of HIE (n = 330, 33%). In the fully adjust model, rates of HIE were higher among ACO (AOR = 2.66, p < .01), PCMH (AOR = 4.73, p < .001) and Hybrid ACO-PCMH participants (AOR = 5.55, p < .001) compared to standard care, but they did not significantly vary between delivery models. Physicians infrequently engage in HIE with behavioral health providers. Compared to standard care, higher rates of HIE were found across all models of delivery reform. More work is needed to identify common elements of delivery reform models that are most effective in supporting this behavior.

The quality of migrant patients' primary healthcare experiences and patient-centered medical home achievement by community health centers: results from the China greater bay area study.

BACKGROUND: In China, Community Health Centers (CHCs) provide primary healthcare (PHC); however, few studies have examined the quality of PHC services experienced by migrant patients. We examined the potential association between the quality of migrant patients' PHC experiences and the achievement of Patient-Centered Medical Home by CHCs in China. METHODS: Between August 2019 and September 2021, 482 migrant patients were recruited from ten CHCs in China's Greater Bay Area. We evaluated CHC service quality using the National Committee for Quality Assurance Patient-Centered Medical Home (NCQA-PCMH) questionnaire. We additionally assessed the quality of migrant patients' PHC experiences using the Primary Care Assessment Tools (PCAT). General linear models (GLM) were used to examine the association between the quality of migrant patients' PHC experiences and the achievement of PCMH by CHCs, adjusting for covariates. RESULTS: The recruited CHCs performed poorly on PCMH1, Patient-Centered Access (7.2 ± 2.0), and PCMH2, Team-Based Care (7.4 ± 2.5). Similarly, migrant patients assigned low scores to PCAT dimension C-First-contact care-which assesses access (2.98 ± 0.03), and D-Ongoing care (2.89 ± 0.03). On the other hand, higher-quality CHCs were significantly associated with higher total and dimensional PCAT scores, except for dimensions B and J. For example, the total PCAT score increased by 0.11 (95% CI: 0.07-0.16) with each increase of CHC PCMH level. We additionally identified associations between older migrant patients (> 60 years) and total PCAT and dimension scores, except for dimension E. For instance, the average PCAT score for dimension C among older migrant patients increased by 0.42 (95% CI: 0.27-0.57) with each increase of CHC PCMH level. Among younger migrant patients, this dimension only increased by 0.09 (95% CI: 0.03-0.16). CONCLUSION: Migrant patients treated at higher-quality CHCs reported better PHC experiences. All observed associations were stronger for older migrants. Our results may inform future healthcare quality improvement studies that focus on the PHC service needs of migrant patients.

How Patient-Centered Medical Homes Can Bring Meaning to Health Care: A Call for Person-Centered Care.

The development of patient-centered medical homes in the United States was, among other things, an attempt to improve patients' experiences of care. This and other improvement strategies, however, have failed to confront a major barrier, our disease-oriented medical model. Focusing on diseases has contributed to subspecialization and reductionism, which, for patients, has increased medical complexity and made it more difficult to engage in collaborative decision making. The progressive uncoupling of disease prevention and management from other outcomes that may matter more to patients has contributed to the dehumanization of care. An alternative approach, person-centered care, focuses clinical care directly on the aspirations of those seeking assistance, rather than assuming that these aspirations will be achieved if the person's medical problems can be resolved. We recommend the adoption of 2 complementary person-centered approaches, narrative medicine and goal-oriented care, both of which view health problems as obstacles, challenges, and often opportunities for a longer, more fulfilling life. The transformation of primary care practices into patient-centered medical homes has been an important step forward. The next step will require those patient-centered medical homes to become person centered.

Implementing team-based newborn well care: Perspectives of nurses and physicians.

PURPOSE: Pediatric primary care redesign includes changes to clinical teams and clinical workflows. This study described the perspectives of pediatric clinicians on their experience with redesign. DESIGN AND METHODS: This qualitative study explored clinician perspectives on a newborn care redesign pilot at a pediatric primary care site. Newborn Hallway (NBH), implemented in 2019, clustered morning newborn visits with a single physician, increased RN staffing, and provided newborn-specific training for RNs. NBH also revised visit documentation templates to promote communication between RNs and physicians and shared completion of history taking and education. We conducted semi-structured qualitative interviews with clinicians. The interview guide was developed using the Consolidated Framework for Implementation Research. Interviews were recorded and transcribed, and coded using an integrated approach. RESULTS: We interviewed 17 staff (8 physicians, 8 RNs, 1 nurse practitioner) from 3/2020 to 1/2021. Clinicians reported that NBH implementation was facilitated by widespread agreement on baseline challenges to newborn care, and interest in optimizing roles for RNs. Clinicians believed NBH facilitated teamwork, which mitigated unpredictability in newborn needs and arrival times, and improved staff satisfaction. Perceived barriers to NBH included staffing constraints and ambivalence about whether sharing tasks with RNs would negatively influence patient relationships and continuity. CONCLUSIONS: Pediatric primary care redesign focused on sharing tasks between RNs and physicians can promote teamwork and address unpredictability in clinical settings. PRACTICE IMPLICATIONS: Resolving questions about how redesign influences patient continuity and trust, and clarifying optimal staffing may help facilitate adoption of clinical team and workflow innovations.

Improving Primary Care Delivery for Patients Receiving Maintenance Hemodialysis.

The beneficial impact of primary care, focused on all aspects of a patient's health (rather than a disease-specific focus) is well established. Recognized benefits include greater receipt of preventive care and counseling, lower use of emergency care and hospitalization for ambulatory care-sensitive conditions, and decreased early mortality. Although the importance of primary care and care coordination at the primary care/specialty interface is well recognized, the role of primary care within traditional and emerging care models for patients receiving in-center maintenance hemodialysis remains ill-defined. In this perspective article, we will describe: (1) the role of primary care for patients receiving maintenance hemodialysis and the current evidence regarding the receipt of primary care among these patients; (2) the key challenges to delivery of primary care in these complex cases, including suboptimal care coordination between nephrology and primary care providers, the intensity of dialysis care, and the limited capacity of nephrologists and primary care providers to meet the broad health needs of hemodialysis patients; (3) potential strategies for improving the delivery of primary care for patients receiving hemodialysis; and (4) future research requirements to improve primary care delivery for this high-risk population.

What Do Patient-Centered Medical Home (PCMH) Teams Need to Improve Care for Primary Care Patients with Complex Needs?

BACKGROUND: Intensive primary care (IPC) programs for patients with complex needs do not generate cost savings in most settings. Strengthening existing patient-centered medical homes (PCMH) to address the needs of these patients in primary care is a potential high-value alternative. OBJECTIVES: Explore PCMH team functioning and characteristics that may impact their ability to perform IPC tasks; identify the IPC components that could be incorporated into PCMH teams' workflow; and identify additional resources, trainings, and staff needed to better manage patients with complex needs in primary care. METHODS: We interviewed 44 primary care leaders, PCMH team members (providers, nurses, social workers), and IPC program leaders at 5 VA IPC sites and analyzed a priori themes using a matrix analysis approach. RESULTS: Higher-functioning PCMH teams were described as already performing most IPC tasks, including panel management and care coordination. All sites reported that PCMH teams had the knowledge and skills to perform IPC tasks, but not with the same intensity as specialized IPC teams. Home visits/assessments and co-attending appointments were perceived as not feasible to perform. Key stakeholders identified 6 categories of supports and capabilities that PCMH teams would need to better manage complex patients, with care coordination/management and fully staffed teams as the most frequently mentioned. Many thought that PCMH teams could make better use of existing VA and non-VA resources, but might need training in identifying and using those resources. CONCLUSIONS: PCMH teams can potentially offer certain clinic-based services associated with IPC programs, but tasks that are time intensive or require physical absence from clinic might require collaboration with community service providers and better use of internal and external healthcare system resources. Future studies should explore the feasibility of PCMH adoption of IPC tasks and the impact on patient outcomes.

Effect of Integrated Gastroenterology Specialists in a Primary Care Setting: a Retrospective Cohort Study.

BACKGROUND: Gastrointestinal (GI) complaints are common in primary care practices. The patient-centered medical home (PCMH) may improve coordination and collaboration by facilitating coordination across healthcare settings and within the community, enhancing communication between providers, and focusing on quality of care delivery. OBJECTIVE: To investigate the effect of integrated community gastroenterology specialists (ICS-GI) model within a large primary care practice. DESIGN: Retrospective cohort with propensity-matched historic controls. PATIENTS: We identified 265 patients who had a visit with one of our ICS-GI specialists and matched them (1:2) to 530 similar patients seen prior to the implementation of the ICS-GI model. MAIN MEASURES: Frequency of diagnostic testing for GI indications, visits to our outpatient GI referral practice, emergency department and hospital utilization, and time to access of specialty care for the whole population and by GI condition group. KEY RESULTS: Patients seen in our ICS-GI model had similar outpatient care utilization (OR = 1.0, 95% CI 0.7-1.4, p = 0.90), were more likely to have visits in primary care (OR OR=1.5, 95% CI 1.1-2.2, p = 0.02), and were less likely to have visits to our GI outpatient referral practice (OR = 0.3, 95% CI 0.2-0.7, p < 0.0001). Condition-specific analyses show that all GI conditions experienced decreased visits to the outpatient GI referral practice outside of patients with GI neoplasm. Populations did not differ in emergency department, hospital, or diagnostic utilization. CONCLUSIONS: We observed that an embedded specialist in primary care model is associated with improved care coordination without compromising patient safety. The PCMH could be extended to include subspecialty care.

Impact of a patient-centered medical home demonstration on quality of life and patient activation for older adults with complex needs in Singapore.

BACKGROUND: The first Patient-Centered Medical Home (PCMH) demonstration in Singapore was launched in November 2016, which aimed to deliver integrated and patient-centered care for patients with bio-psycho-social needs. Implementation was guided by principles of comprehensiveness, coordinated care, shared decision-making, accessible services, and quality and safety. We aimed to investigate the impact of implementing the PCMH in primary care on quality of life (QoL) and patient activation. METHODS: The study design was a prospective single-arm pre-post study. We applied the 5-level EuroQol 5-dimension (EQ-5D-5L) and Visual Analog Scale (EQ VAS) instruments to assess health-related QoL. The CASP-19 tool was utilised to examine the degree that needs satisfaction was fulfilled in the domains of Control, Autonomy, Self-realisation, and Pleasure. The 13-item Patient Activation Measure (PAM-13) was used to evaluate knowledge, skills and confidence in management of conditions and ability to self-care. Multivariable linear regression models with random intercepts were applied to examine the impact of the PCMH intervention on outcome measures at 3 months and 6 months post-enrolment, compared to baseline. RESULTS: We analysed 165 study participants enrolled into the PCMH from November 2017 to April 2020, with mean age 77 years (SD: 9.9). Within-group pre-post (6 months) EQ-5D-5L Index (ß= -0.01, p-value = 0.35) and EQ VAS score (ß=-0.03, p-value = 0.99) had no change. Compared to baseline, there were improvements in CASP-19 total score at 3 months (ß = 1.34, p-value = 0.05) and 6 months post-enrolment (ß = 1.15, p-value = 0.08) that were marginally out of statistical significance. There was also a significant impact of the PCMH on the CASP-19 Pleasure domain (ß = 0.62, p = 0.03) at 6 months post-enrolment, compared to baseline. We found improved patient activation from a 15.2 % reduction in the proportion of participants in lower PAM levels, and a 23.4 and 16.7 % rise in proportion for higher PAM levels 3 and 4, respectively, from 3 months to 6 months post-enrolment. CONCLUSIONS: Preliminary demonstration of the PCMH model shows evidence of improved needs satisfaction and patient activation, with potential to have a greater impact after a longer intervention duration.

The Tennessee Medicaid medication therapy management program: early stage contextual factors and implementation outcomes.

BACKGROUND: First investigated in the 1990s, medication therapy management (MTM) is an evidence-based practice offered by pharmacists to ensure a patient's medication regimen is individualized to include the safest and most effective medications. MTM has been shown to a) improve quality of patient care, b) reduces health care costs, and c) lead to fewer medication-related adverse effects. However, there has been limited testing of evidence-based, a-priori implementation strategies that support MTM implementation on a large scale. METHODS: The study has two objectives assessed at the organizational and individual level: 1) to determine the adoption, feasibility, acceptability and appropriateness of a multi-faceted implementation strategy to support the MTM pilot program in Tennessee; and 2) to report on the contextual factors associated with program implementation based on the Consolidated Framework for Implementation Research (CFIR). The overall design of the study was a hybrid type 2 effectiveness-implementation study reporting outcomes of Tennessee state Medicaid's (TennCare) MTM Pilot program. This paper presents early stage implementation outcomes (e.g., adoption, feasibility, acceptability, appropriateness) and explores implementation barriers and facilitators using the CFIR. The study was assessed at the (a) organizational and (b) individual level. A mixed-methods approach was used including surveys, claims data, and semi-structured interviews. Interview data underwent initial, rapid qualitative analysis to provide real time feedback to TennCare leadership on project barriers and facilitators. RESULTS: The total reach of the program from July 2018 through June 2020 was 2033 MTM sessions provided by 17 Medicaid credentialed pharmacists. Preliminary findings suggest participants agreed that MTM was acceptable (µ = 16.22, SD = 0.28), appropriate (µ = 15.33, SD = 0.03), and feasible (µ = 14.72, SD = 0.46). Each of the scales had an excellent level of internal (> 0.70) consistency (feasibility, α = 0.91; acceptability, α = 0.96; appropriateness, α = 0.98;). Eight program participants were interviewed and were mapped to the following CFIR constructs: Process, Characteristics of Individuals, Intervention Characteristics, and Inner Setting. Rapid data analysis of the contextual inquiry allowed TennCare to alter initial implementation strategies during project rollout. CONCLUSION: The early stage implementation of a multi-faceted implementation strategy to support delivery of Tennessee Medicaid's MTM program was found to be well accepted and appropriate across multiple stakeholders including providers, administrators, and pharmacists. However, as the early stage of implementation progressed, barriers related to relative priority, characteristics of the intervention (e.g., complexity), and workflow impeded adoption. Programmatic changes to the MTM Pilot based on early stage contextual analysis and implementation outcomes had a positive impact on adoption.

Are There Performance Advantages Favoring Federally Qualified Health Centers in Medical Home Care for Persons with Severe Mental Illness?

To identify whether medical homes in FQHCs have advantages over other group and individual medical practices in caring for people with severe mental illness. Models estimated the effect of the type of medical home on monthly service utilization, medication adherence, and total Medicaid spending over a 4-year period for adults aged 18 or older with a major depressive disorder (N = 65,755), bipolar disorder (N = 19,925), or schizophrenia (N = 8501) enrolled in North Carolina's Medicaid program. Inverse probability of treatment weights (IPTW) were used to adjust for nonrandom assignment of patients to practices. Generalized estimating equations for repeated measures were used with gamma distributions and log links for the continuous measures of medication adherence and spending, and binomial distributions with logit links for binary measures of any outpatient or any emergency department visits. Adults with major depression or bipolar disorders in FQHC medical homes had a lower probability of outpatient service use than their counterparts in individual and group practices. The probability of emergency department use, medication adherence, and total Medicaid spending were relatively similar across the three settings. This study suggests that no one type of medical practice setting-whether FQHC, other group, or individual-consistently outperforms the others in providing medical home services to people with severe mental illness.

Association Between Difficulty with VA Patient-Centered Medical Home Model Components and Provider Emotional Exhaustion and Intent to Remain in Practice.

BACKGROUND: The patient-centered medical home (PCMH) model is intended to improve primary care, but evidence of its effects on provider well-being is mixed. Investigating the relationships between specific PCMH components and provider burnout and potential attrition may help improve the efficacy of the care model. OBJECTIVE: We analyzed provider attitudes toward specific components of PCMH in the Veterans Health Administration (VA) and their relation to emotional exhaustion (EE)-a central component of burnout-and intent to remain in VA primary care. DESIGN: Logistic regression analysis of a cross-sectional survey. SUBJECTS: 116 providers (physicians; nurse practitioners; physician assistants) in 21 practices between September 2015 and January 2016 in one VA region. MAIN MEASURES: Outcomes: burnout as measured with the emotional exhaustion (EE) subscale of the Maslach Burnout Inventory and intent to remain in VA primary care for the next 2 years; predictors: difficulties with components of PCMH, demographic characteristics. KEY RESULTS: Forty percent of providers reported high EE (≥ 27 points) and 63% reported an intent to remain in VA primary care for the next 2 years. Providers reporting high difficultly with PCMH elements were more likely to report high EE, for example, coordinating with specialists (odds ratio [OR] 8.32, 95% confidence interval [CI] 3.58-19.33), responding to EHR alerts (OR 6.88; 95% CI 1.93-24.43), and managing unscheduled visits (OR 7.53, 95% CI 2.01-28.23). Providers who reported high EE were also 87% less likely to intend to remain in VA primary care. CONCLUSIONS: To reduce EE and turnover in PCMH, primary care providers may need additional support and training to address challenges with specific aspects of the model.

Impact of Healthcare Delivery System Type on Clinical, Utilization, and Cost Outcomes of Patient-Centered Medical Homes: a Systematic Review.

BACKGROUND: As healthcare reimbursement shifts from being volume to value-focused, new delivery models aim to coordinate care and improve quality. The patient-centered medical home (PCMH) model is one such model that aims to deliver coordinated, accessible healthcare to improve outcomes and decrease costs. It is unclear how the types of delivery systems in which PCMHs operate differentially impact outcomes. We aim to describe economic, utilization, quality, clinical, and patient satisfaction outcomes resulting from PCMH interventions operating within integrated delivery and finance systems (IDFS), government systems including Veterans Administration, and non-integrated delivery systems. METHODS: We searched PubMed, the Cochrane Library, and Embase from 2004 to 2017. Observational studies and clinical trials occurring within the USA that met PCMH criteria (as defined by the Agency for Healthcare Research and Quality), addressed ambulatory adults, and reported utilization, economic, clinical, processes and quality of care, or patient satisfaction outcomes. RESULTS: Sixty-four studies were included. Twenty-four percent were within IDFS, 29% were within government systems, and 47% were within non-IDFS. IDFS studies reported decreased emergency department use, primary care use, and cost relative to other systems after PCMH implementation. Government systems reported increased primary care use relative to other systems after PCMH implementation. Clinical outcomes, processes and quality of care, and patient satisfaction were assessed heterogeneously or infrequently. DISCUSSION: Published articles assessing PCMH interventions generally report improved outcomes related to utilization and cost. IDFS and government systems exhibit different outcomes relative to non-integrated systems, demonstrating that different health systems and populations may be particularly sensitive to PCMH interventions. Both the definition of PCMH interventions and outcomes measured are heterogeneous, limiting the ability to perform direct comparisons or meta-analysis.

Patients' and Caregivers' Experiences with the Multi-Payer Advanced Primary Care Practice Demonstration.

BACKGROUND: The patient-centered medical home (PCMH) model aims to improve primary health care using a patient-centered approach. Little qualitative research has investigated how the PCMH model affects patient experience with care. OBJECTIVE: To understand Medicaid and Medicare patient and caregiver experiences with PCMHs participating in the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration. DESIGN: Qualitative study. PARTICIPANTS: Medicare, Medicaid, and dually eligible patients who were patients in primary care practices participating in the MAPCP Demonstration and caregivers of such patients (N = 490). APPROACH: From July through November 2014, a trained facilitator conducted 81 focus groups in the eight states participating in the MAPCP Demonstration. Separate groups were held for Medicare high-risk, Medicare low-risk, Medicaid, and dually eligible beneficiaries, their caregivers, and caregivers of Medicaid children (or, in Vermont, with patients participating in the Support and Services at Home program), in two different geographical areas in each state. Focus group discussions were recorded, transcribed, and analyzed using NVivo qualitative data analysis software. RESULTS: Participants' experiences with care were generally consistent with the expectations of a PCMH, although some exceptions were noted. Medicaid only and dually eligible beneficiaries generally had less-positive experiences than Medicare beneficiaries. Most participants said their practices had not solicited feedback from them about their experiences with care. Few participants knew what the term "medical home" meant or were aware that their practices were working to become PCMHs, but many had noticed changes in recent years, primarily related to the conversion to electronic health records. CONCLUSIONS: Most participants had positive experiences with their care. Opportunities exist, however, to improve care for Medicaid and dually eligible beneficiaries, and enhance patient awareness of and involvement in PCMH practice transformation.

Experiences of Patient-Centered Medical Home Staff Team Members Working in Interprofessional Training Environments.

BACKGROUND: Evidence is growing that interprofessional team-based models benefit providers, trainees, and patients, but less is understood about the experiences of staff who work beside trainees learning these models. OBJECTIVE: To understand the experiences of staff in five VA training clinics participating in an interprofessional team-based learning initiative. DESIGN: Individual semi-structured interviews with staff were conducted during site visits, qualitatively coded, and analyzed for themes across sites and participant groups. PARTICIPANTS: Patient-centered medical home (PCMH) staff members (n = 32; RNs, Clinical and Clerical Associates) in non-primary care provider (PCP) roles working on teams with trainees from medicine, nursing, pharmacy, and psychology. APPROACH: Benefits and challenges of working in an interprofessional, academic clinic were coded by the primary author using a hybrid inductive/directed thematic analytic approach, with review and iterative theme development by the interprofessional author team. KEY RESULTS: Efforts to improve interprofessional collaboration among trainees and providers, such as increased shared leadership, have positive spillover effects for PCMH staff members. These staff members perceive themselves playing an educational role for trainees that is not always acknowledged. Playing this role, learning from the "fresh" knowledge imparted by trainees, and contributing to the future of health care all bring satisfaction to staff members. Some constraints exist for full participation in the educational efforts of the clinic. CONCLUSIONS: Increased recognition of and expanded support for PCMH staff members to participate in educational endeavors is essential as interprofessional training clinics grow.

Strategies for expanding colorectal cancer screening at community health centers.

Community health centers are uniquely positioned to address disparities in colorectal cancer (CRC) screening as they have addressed other disparities. In 2012, the federal Health Resources and Services Administration, which is the funding agency for the health center program, added a requirement that health centers report CRC screening rates as a standard performance measure. These annually reported, publically available data are a major strategic opportunity to improve screening rates for CRC. The Patient Protection and Affordable Care Act enacted provisions to expand the capacity of the federal health center program. The recent report of the Institute of Medicine on integrating public health and primary care included an entire section devoted to CRC screening as a target for joint work. These developments make this the ideal time to integrate lifesaving CRC screening into the preventive care already offered by health centers. This article offers 5 strategies that address the challenges health centers face in increasing CRC screening rates. The first 2 strategies focus on improving the processes of primary care. The third emphasizes working productively with other medical providers and institutions. The fourth strategy is about aligning leadership. The final strategy is focused on using tools that have been derived from models that work.

Cancer Survivorship Care Roles for Primary Care Physicians.

PURPOSE: Despite a burgeoning population of cancer survivors and pending shortages of oncology services, clear definitions and systematic approaches for engaging primary care in cancer survivorship are lacking. We sought to understand how primary care clinicians perceive their role in delivering care to cancer survivors. METHODS: We conducted digitally recorded interviews with 38 clinicians in 14 primary care practices that had national reputations as workforce innovators. Interviews took place during intense case study data collection and explored clinicians' perspectives regarding their role in cancer survivorship care. We analyzed verbatim transcripts using an inductive and iterative immersion-crystallization process. RESULTS: Divergent views exist regarding primary care's role in cancer survivor care with a lack of coherence about the concept of survivorship. A few clinicians believed any follow-up care after acute cancer treatment was oncology's responsibility; however, most felt cancer survivor care was within their purview. Some primary care clinicians considered cancer survivors as a distinct population; others felt cancer survivors were like any other patient with a chronic disease. In further interpretative analysis, we discovered a deeply ingrained philosophy of whole-person care that creates a professional identity dilemma for primary care clinicians when faced with rapidly changing specialized knowledge. CONCLUSIONS: This study exposes an emerging identity crisis for primary care that goes beyond cancer survivorship care. Facilitated national conversations might help specialists and primary care develop knowledge translation platforms to support the prioritizing, integrating, and personalizing functions of primary care for patients with highly complicated issues requiring specialized knowledge.

Primary Care Practice Transformation Introduces Different Staff Roles.

PURPOSE: Practices in the 4-year Comprehensive Primary Care (CPC) initiative changed staffing patterns during 2012-2016 to improve care delivery. We sought to characterize these changes and to compare practice patterns with those in similar non-CPC practices in 2016. METHODS: We conducted an online survey among selected US primary care practices. We statistically tested 2012-2016 changes in practice-reported staff composition among 461 CPC practices using 2-tailed t tests. Using logistic regression analysis, we compared differences in staff types between the CPC practices and 358 comparison practices that participated in the survey in 2016. RESULTS: In 2012, most CPC practices reported having physicians (100%), administrative staff (99%), and medical assistants (90%). By 2016, 84% reported having care managers/care coordinators (up from 24% in 2012), and 29% reported having behavioral health professionals, clinical psychologists, or social workers (up from 19% in 2014). There were also smaller increases (of less than 10 percentage points) in the share of practices having pharmacists, nutritionists, registered nurses, quality improvement specialists, and health educators. Larger and system-affiliated practices were more likely to report having care managers/care coordinators and behavioral health professionals. In 2016, relative to comparison practices, CPC practices were more likely to report having various staff types-notably, care managers/care coordinators (84% of CPC vs 36% of comparison practices), behavioral health professionals (29% vs 12%), and pharmacists (18% vs 4%). CONCLUSIONS: During the CPC initiative, CPC practices added different staff types to a fairly traditional staffing model of physicians with medical assistants. They most commonly added care managers/care coordinators and behavioral health staff to support the CPC model and, at the end of CPC, were more likely to have these staff members than comparison practices.