By David Pittman, Washington Correspondent, MedPage Today
Published: May 20, 2013
The path to becoming a patient-centered medical home is long, rough, and varies for each practice, but getting there is essential to providing high-quality, affordable healthcare to all Americans, researchers concluded.
The Agency for Healthcare Research and Quality (AHRQ) came to that conclusion in summarizing the results of 14 grants it issued in the summer of 2010 to understand the processes and determinants of transforming primary care practices.
The grants -- which totaled $4.1 million each year in a 2-year study -- allowed practices of varying size, geography, and scope to retrospectively analyze the process of becoming a patient-centered medical home (PCMH). The results were published Monday in a special supplement of the Annals of Family Medicine.
"The lessons learned demonstrate that true transformation to the PCMH model is not only possible but desirable, although not without its challenges," wrote Robert McNellis, MPH, PA, and colleagues at AHRQ's Center for Primary Care, Prevention, and Clinical Partnerships in Rockville, Md. "These lessons provide valuable insight that will likely be helpful to other practices considering or beginning this transformation."
It is difficult to know whether practices that are successful in their transformation are successful because they've become a PCMH, or whether better-performing practices are more likely to become PCMHs.
"This uncertainty has implications for how to invest resources in those practices that are not currently highly functioning, many of which are resource-starved and understaffed, and often serving as safety-net practices for large groups of uninsured or underinsured patients," the authors wrote.
Most investigators concluded a practice can be a true PCMH without having formal recognition from an accrediting body like the National Committee for Quality Assurance (NCQA).
It was tough to measure financial impact on transforming a practice, they found. "It was difficult to measure new revenue or costs of delivering new services. It was also difficult to compare pre-transformational costs with post-transformational costs," McNellis and co-authors wrote.
In one study, Sarah Hudson Scholle, DrPH, of the NCQA in Washington, and others surveyed nearly 250 small practices (fewer than five physicians) on their barriers and motivations to becoming a PCMH.
They found that time and resources were the biggest obstacles for practices to overcome, but that receiving financial rewards for becoming a PCMH would help.
A similar survey by Carolyn Berry, PhD, of the New York University School of Medicine, analyzed small practices in New York City serving mostly Medicaid or minority patient populations and concluded more flexible strategies for PCMH implementation were needed.
"We were especially struck by the relatively low use of formal mechanisms such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless," Berry and others wrote. "It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH."
In a study of 12 high-performing pediatric medical homes, Jeanne McAllister, MHA, of the Center for Medical Home Improvement in Concord, N.H., and colleagues identified four common attributes that drove change: a culture that promoted quality improvement, a family-centered care plan involving parents, and team-based and coordinated care.
"Delivering care within a family-centered medical home proved highly satisfying to physicians and coordinators," the authors wrote. "As efforts expanded, professional gratification and staff resilience appeared linked."