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Journal of General Internal Medicine

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01-12-2020 | Care | Original Research

Nationwide Qualitative Study of Practice Leader Perspectives on What It Takes to Transform into a Patient-Centered Medical Home

Authors: Nabeel Qureshi, MPH, Denise D. Quigley, PhD, Ron D. Hays, PhD

Published in: Journal of General Internal Medicine | Issue 12/2020

Abstract

Background

Despite widespread adoption of patient-centered medical home (PCMH), little is known about why practices pursue PCMH and what is needed to undergo transformation.

Objective

Examine reasons practices obtained and maintained PCMH recognition and what resources were needed.

Design

Qualitative study of practice leader perspectives on PCMH transformation, based on a random sample of primary care practices engaged in PCMH transformation, stratified by US region, practice size, PCMH recognition history, and practice use of Consumer Assessment of Healthcare Providers and Systems (CAHPS®) PCMH survey.

Participants

105 practice leaders from 294 sampled practices (36% response rate).

Approach

Content analysis of interviews with practice leaders to identify themes.

Results

Most practice leaders had local control of PCMH transformation decisions, even if practices adopted quality initiatives under the direction of an organization or network. Financial incentives, being in a statewide effort, and the intrinsic desire to improve care or experiences were the most common reasons practice leaders decided to obtain PCMH recognition and pursue associated care delivery changes. Leadership support and direction were highlighted as essential throughout PCMH transformation. Practice leaders reported needing specialized staff knowledge and significant resources to meet PCMH requirements, including staff knowledgeable about how to implement PCMH changes, track and monitor improvements, and navigate implementation of simultaneous changes, and staff with specific quality improvement (QI) expertise related to evaluating changes and scaling-up programs.

Conclusion

PCMH efforts necessitated support and assistance to frontline, on-site practice leaders leading care delivery changes. Such change efforts should include financial incentives (e.g., direct payment or additional reimbursement), leadership direction and support, and internal or external staff with experience with the PCMH application process, implementation changes, and QI expertise in monitoring process and outcome data. Policies that recognize and meet the needs of on-site practice leaders will better promote primary care practice transformation and move practices further toward their PCMH transformation goals.

Available only for authorised users

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.

Berwick DM. A user’s manual for the IOM’s ‘Quality Chasm’ report. Health Aff (Millwood). 2002;21(3):80-90.CrossRef

Schoenbaum SC, McCarthy D, Shih A, Nuzum R, Davis K, Gauthier A. Organizing the U.S. Health Care Delivery System for High Performance. New York, NY: The Commonwealth Fund; 2008.

Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469-75.CrossRef

Ferrer RL, Hambidge SJ, Maly RC. The essential role of generalists in health care systems. Ann Intern Med. 2005;142(8):691-9.CrossRef

Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA. 2002;288(7):889-93.CrossRef

Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291(10):1246-51.CrossRef

Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA. 2009;301(19):2038-40.CrossRef

Rosenthal TC. The medical home: growing evidence to support a new approach to primary care. J Am Board Fam Med. 2008;21(5):427-40.CrossRef

10.

Starfield B, Shi L. The medical home, access to care, and insurance: a review of evidence. Pediatrics. 2004;113(5 Suppl):1493-8.PubMed

11.

The Robert Graham Center. The patient-centered medical home: history, seven core features, evidence and transformational change 2007 [Available from: http://www.graham-center.org/content/dam/rgc/documents/publications-reports/monographs-books/rgcmo-medical-home.pdf.

12.

National Committee for Quality Assurance. Renewing your recognition using the redesigned process Washington, DC: National Committee for Quality Assurance; 2018 [Available from: https://www.ncqa.org/programs/health-care-providers-practices/patient-centered-medical-home-pcmh/current-customers/.

13.

Nutting PA, Crabtree BF, Miller WL, Stewart EE, Stange KC, Jaen CR. Journey to the patient-centered medical home: a qualitative analysis of the experiences of practices in the National Demonstration Project. Ann Fam Med. 2010;8 Suppl 1:S45-56; S92.

14.

Paustian ML, Alexander JA, El Reda DK, Wise CG, Green LA, Fetters MD. Partial and incremental PCMH practice transformation: implications for quality and costs. Health Serv Res. 2014;49(1):52-74.CrossRef

15.

Tirodkar MA, Morton S, Whiting T, Monahan P, McBee E, Saunders R, et al. There’s more than one way to build a medical home. Am J Manag Care. 2014;20(12):e582-9.PubMed

16.

Vest JR, Kern LM, Jung HY, Ancker JS, Richardson JE, Silver MD, et al. Patient-centered medical homes: observable types derived from national recognition assessment scores. J Ambul Care Manage. 2015;38(2):144-52.CrossRef

17.

Zickafoose JS, Clark SJ, Sakshaug JW, Chen LM, Hollingsworth JM. Readiness of primary care practices for medical home certification. Pediatrics. 2013;131(3):473-82.CrossRef

18.

National Committee for Quality Assurance. Patient-Centered Medical Home (PCMH) Washington, DC: National Committee for Quality Assurance; 2018 [Available from: https://www.ncqa.org/programs/health-care-providers-practices/patient-centered-medical-home-pcmh/.

19.

Holt JM. Patient Experience in Primary Care: A Systematic Review of CG-CAHPS Surveys. J Patient Exp. 2019;6(2):93-102.CrossRef

20.

National Committee for Quality Assurance. NCQA PCMH standards and guidelines (2017 edition) Washington, DC: National Committee for Quality Assurance; 2018 [Available from: http://store.ncqa.org/index.php/catalog/product/view/id/2776/s/2017-pcmh-standards-and-guidelines-epub/.

21.

Agency for Healthcare Research and Quality (AHRQ). CAHPS PCMH Fact Sheet. AHRQ Publication No. 10-CAHPS003. Rockville, MD: Agency for Healthcare Research and Quality; 2010.

22.

Hays RD, Berman LJ, Kanter MH, Hugh M, Oglesby RR, Kim CY, et al. Evaluating the psychometric properties of the CAHPS Patient-centered Medical Home survey. Clin Ther. 2014;36(5):689-96 e1.CrossRef

23.

Ng JH, Henry E, Overlander T, Shi P, Hudson Scholle S. Shortening a patient experiences survey for medical homes. Healthcare. 2016;4(1).

24.

Scholle SH, Vuong O, Ding L, Fry S, Gallagher P, Brown JA, et al. Development of and field test results for the CAHPS PCMH Survey. Med Care. 2012;50 Suppl:S2-10.CrossRef

25.

National Committee for Quality Assurance. Distinction in Patient Experience Reporting Washington, DC: Distinction in Patient Experience Reporting; [Available from: https://www.wvpca.org/files/NCQA%20Pt%20Experience%20Distinction%20Fact%20Sheet.pdf.

26.

National Committee for Quality Assurance. Internal data from NCQA’s Monthly Progress Reports. Recognition Programs Operations. Washington, DC: National Committee for Quality Assurance; 2015. Contract No.: October 2.

27.

National Committee for Quality Assurance. Report Cards: Practices. Washington, DC: National Committee for Quality Assurance; 2017.

28.

Quigley DD, Mendel PJ, Predmore ZS, Chen AY, Hays RD. Use of CAHPS® patient experience survey data as part of a patient-centered medical home quality improvement initiative. J Healthc Leadersh. 2015;7:41-54.PubMedPubMedCentral

29.

Quigley DD, Predmore ZS, Chen A, Hays RH. Implementation and Sequencing of Practice Transformation in Urban Practices with Underserved Patients. Qual Manag Health Care. 2017;26(1):7-14.PubMed

30.

van den Berk-Clark C, Doucette E, Rottnek F, Manard W, Prada MA, Hughes R, et al. Do Patient-Centered Medical Homes Improve Health Behaviors, Outcomes, and Experiences of Low-Income Patients? A Systematic Review and Meta-Analysis. Health Serv Res. 2018;53(3):1777-98.CrossRef

31.

Friedberg MW, Safran DG, Coltin KL, Dresser M, Schneider EC. Readiness for the Patient-Centered Medical Home: structural capabilities of Massachusetts primary care practices. J Gen Intern Med. 2009;24(2):162-9.CrossRef

32.

Kern LM, Dhopeshwarkar RV, Edwards A, Kaushal R. Patient experience at the time of practice transformation into Patient-Centered Medical Homes. Eur J Pers Cent Healthc. 2012;1(2):290-7.

33.

Kern LM, Dhopeshwarkar RV, Edwards A, Kaushal R. Patient experience over time in patient-centered medical homes. Am J Manag Care. 2013;19(5):403-10.PubMed

34.

Gifford WA, Davies BL, Graham ID, Tourangeau A, Woodend AK, Lefebre N. Developing leadership capacity for guideline use: a pilot cluster randomized control trial. Worldviews Evid Based Nurs. 2013;10(1):51-65.CrossRef

35.

Matthew-Maich N, Ploeg J, Jack S, Dobbins M. Leading on the frontlines with passion and persistence: a necessary condition for Breastfeeding Best Practice Guideline uptake. J Clin Nurs. 2013;22(11-12):1759-70.CrossRef

36.

Ploeg J, Skelly J, Rowan M, Edwards N, Davies B, Grinspun D, et al. The role of nursing best practice champions in diffusing practice guidelines: a mixed methods study. Worldviews Evid Based Nurs. 2010;7(4):238–51.CrossRef

37.

Stout S, Weeg S. The practice perspective on transformation: experience and learning from the frontlines. Med Care. 2014;52(11 Suppl 4):S23-5.CrossRef

38.

Coleman K, Phillips KE, Borkulo NV, Daniel DM, Johnson KE, Wagner EH, et al. Transforming care for vulnerable populations: Lessons from the safety net medical home initiative. Med Care. 2014;52(11 suppl 4):S11–S7.CrossRef

39.

Crabtree BF, Nutting PA, Miller WL, Stange KC, Stewart EE, Jaen CR. Summary of the National Demonstration Project and recommendations for the patient-centered medical home. Ann Fam Med. 2010;8 Suppl 1:S80-90; S2.

40.

Gale RC, Asch SM, Taylor T, Nelson KM, Luck J, Meredith LS, et al. The most used and most helpful facilitators for patient-centered medical home implementation. Implement Sci. 2015;10:52.CrossRef

41.

Goldberg DG, Mick SS, Kuzel AJ, Feng LB, Love LE. Why do some primary care practices engage in practice improvement efforts whereas others do not? Health Serv Res. 2013;48(2 Pt. 1):398-416.

42.

Mendel P, Chen EK, Green HD, Armstrong C, Timbie JW, Kress AM, et al. Pathways to medical home recognition: A qualitative comparative analysis of the PCMH transformation process. Health Serv Res. 2017.

43.

U.S. Department of Commerce. Census Regions and Divisions of the United States Washington, DC: U.S. Census Bureau; 2018 [Available from: https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf.

44.

SocioCultural Research Consultants, LLC,. Dedoose Version 8.0.35. Los Angeles, CA: SocioCultural Research Consultants, LLC; 2018.

45.

Bernard HR, Ryan GW. Chapter 4, Code books and Coding. Analyzing Qualitative Data: Systematic Approaches. Thousand Oaks, CA: Sage Publications; 2010. p. 75-105.

46.

Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42(4):1758-72.CrossRef

47.

Charmaz K. Grounded theory: Objectivist and constructivist methods. In: Denzin N, Lincoln Y, editors. Handbook of Qualitative Research. Thousand Oaks: Sage Publications 2000.

48.

Glaser B, Strauss A. The Discovery of Grounded Theory; Strategies for Qualitative Research. Chicago: Aldine Publishing Company; 1967.

49.

Cavanagh S. Content analysis: concepts, methods and applications. Nurse Res. 1997;4(3):5-16.PubMed

50.

Downe-Wamboldt B. Content analysis: method, applications, and issues. Health Care Women Int. 1992;13(3):313-21.CrossRef

51.

Miller W, Crabtree B. The dance of interpretation. In: Miller W, Crabtree B, editors. Doing Qualitative Research in Primary Care: Multiple Strategies 2nd ed. Newbury Park: Sage Publications 1999. p. 127–43.

52.

Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20(1):37-46.CrossRef

53.

Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-74.CrossRef

54.

Primary Care Collaborative. Maine Patient-Centered Medical Home Pilot Washington, DC: Primary Care Collaborative; 2016 [Available from: https://www.pcpcc.org/initiative/maine-patient-centered-medical-home-pilot.

55.

National Committee for Quality Assurance. New York State Patient-Centered Medical Home (NYS PCMH) Recognition Program Washington, DC: National Committee for Quality Assurance; 2020 [Available from: http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/new-york-state-pcmh.

56.

Vermont Blueprint for Health. Vermont Blueprint for Health Waterbury, VT: Vermont Blueprint for Health 2020 [Available from: http://blueprintforhealth.vermont.gov/.

57.

Primary Care Collaborative. Alaska Patient Centered Medical Home Initiative (AK-PCMH-I) Washington, DC: Primary Care Collaborative,; 2019 [Available from: https://www.pcpcc.org/initiative/alaska-patient-centered-medical-home-initiative-ak-pcmh-i.

58.

Primary Care Collaborative. Pennsylvania Washington, DC: Primary Care Collaborative; 2020 [Available from: https://www.pcpcc.org/initiatives/pennsylvania.

59.

Massachusetts Health Policy Commission. The HPC Patient-Centered Medical Home (PCMH) Certification Program Boston, MA: Massachusetts Health Policy Commission; 2020 [Available from: https://www.mass.gov/service-details/the-hpc-patient-centered-medical-home-pcmh-certification-program.

60.

Primary Care Collaborative. Community Care of North Carolina (CCNC) Washington, DC: Primary Care Collaborative; 2019 [Available from: https://www.pcpcc.org/initiative/community-care-north-carolina-ccnc-0.

61.

Husky Health Connecticut. DSS Person-Centered Medical Home Wallingford, CT: State of Connecticut; 2019 [Available from: https://www.huskyhealthct.org/providers/pcmh.html#.

62.

Care Transformation Collaborative Rhode Island. What is a patient-centered medical home? Providence, RI: Care Transformation Collaborative of Rhode Island; 2019 [Available from: https://www.ctc-ri.org/.

63.

Centers for Medicare & Medicaid Services. Accountable Care Organizations (ACOs): General Information Baltimore, MD: Centers for Medicare & Medicaid Services; 2020 [Available from: https://innovation.cms.gov/initiatives/aco/.

64.

Community Care of North Carolina. North Carolina Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Raleigh, NC: Community Care of North Carolina; 2011 [Available from: https://www.communitycarenc.org/media/related-downloads/multi-payer-faq.pdf.

65.

Centers for Medicare & Medicaid Services. Comprehensive Primary Care Plus Baltimore, MD: Centers for Medicare & Medicaid Services; 2019 [Available from: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus/.

66.

The Office of the National Coordinator for Health Information Technology (ONC). Meaningful Use Washington, DC: The Office of the National Coordinator for Health Information Technology (ONC); 2019 [Available from: https://www.healthit.gov/topic/contact-us.

67.

Centers for Medicare & Medicaid Services. MACRA Baltimore, MD: Centers for Medicare & Medicaid Services; 2018 [Available from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html.

68.

Nolan K, Schall MW, Erb F, Nolan T. Using a framework for spread: The case of patient access in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2005;31(6):339-47.PubMed

69.

Wolf JA. Patient Experience: The New Heart of Healthcare Leadership. Front Health Serv Manage. 2017;33(3):3-16.

70.

Quigley DD, Qureshi N, Al Masarweh L, Hays RD. Practice Leaders Report Targeting Several Types of Changes in Care Experienced by Patients During Patient-Centered Medical Home Transformation. J Pat Exp. Revise and resubmit.

71.

Han B, Yu H, Friedberg MW. Evaluating the impact of parent-reported medical home status on children’s health care utilization, expenditures, and quality: A Difference-in-differences analysis with causal inference methods. Health Serv Res. 2017;52(2):786-806.CrossRef

72.

May C, Finch T, Mair F, Ballini L, Dowrick C, Eccles M, et al. Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Serv Res. 2007;7:148.CrossRef

73.

May C, Sibley A, Hunt K. The nursing work of hospital-based clinical practice guideline implementation: an explanatory systematic review using Normalisation Process Theory. Int J Nurs Stud. 2014;51(2):289-99.CrossRef

74.

Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, et al. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med. 2010;8:63.CrossRef

Title: Nationwide Qualitative Study of Practice Leader Perspectives on What It Takes to Transform into a Patient-Centered Medical Home
Authors: Nabeel Qureshi, MPH
Denise D. Quigley, PhD
Ron D. Hays, PhD
Publication date: 01-12-2020
Publisher: Springer International Publishing
Keyword: Care
Published in: Journal of General Internal Medicine / Issue 12/2020
Print ISSN: 0884-8734
Electronic ISSN: 1525-1497
DOI: https://doi.org/10.1007/s11606-020-06052-1

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Abstract

Background

Objective

Design

Participants

Approach

Results

Conclusion

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