Ann S. O’Malley

Two-Year Costs and Quality in the Comprehensive Primary Care Initiative

BACKGROUND The 4-year, multipayer Comprehensive Primary Care Initiative was started in October 2012 to determine whether several forms of support would produce changes in care delivery that would improve the quality and reduce the costs of care at 497 primary care practices in seven regions across the United States. Support included the provision of care-management fees, the opportunity to earn shared savings, and the provision of data feedback and learning support. METHODS We tracked changes in the delivery of care by practices participating in the initiative and used difference-in-differences regressions to compare changes over the first 2 years of the initiative in Medicare expenditures, health care utilization, claims-based measures of quality, and patient experience for Medicare fee-for-service beneficiaries attributed to initiative practices and a group of matched comparison practices. RESULTS During the first 2 years, initiative practices received a median of

After-Hours Care and its Coordination with Primary Care in the U.S.

115,000 per clinician in care-management fees. The practices reported improvements in approaches to the delivery of primary care in areas such as management of the care of high-risk patients and enhanced access to care. Changes in average monthly Medicare expenditures per beneficiary did not differ significantly between initiative and comparison practices when care-management fees were not taken into account (-

Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study

11; 95% confidence interval [CI], -

Predictors of the Growing Influence of Clinical Practice Guidelines

23 to

Disentangling the Linkage of Primary Care Features to Patient Outcomes: A Review of Current Literature, Data Sources, and Measurement Needs

1; P=0.07; negative values indicate less growth in spending at initiative practices) or when these fees were taken into account (

Measuring Comprehensiveness of Primary Care: Challenges and Opportunities

7; 95% CI, -

Using the Consolidated Framework for Implementation Research (CFIR) to produce actionable findings: a rapid-cycle evaluation approach to improving implementation

5 to

Provider Experiences with Chronic Care Management (CCM) Services and Fees: A Qualitative Research Study

19; P=0.27). The only significant differences in other measures were a 3% reduction in primary care visits for initiative practices relative to comparison practices (P<0.001) and changes in two of the six domains of patient experience--discussion of decisions regarding medication with patients and the provision of support for patients taking care of their own health--both of which showed a small improvement in initiative practices relative to comparison practices (P=0.006 and P<0.001, respectively). CONCLUSIONS Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience. (Funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services; ClinicalTrials.gov number, NCT02320591.).

Barriers to and Facilitators of Evidence-Based Decision Making at the Point of Care Implications for Delivery Systems, Payers, and Policy Makers

ABSTRACTBACKGROUNDDespite expectations that medical homes provide “24 × 7 coverage” there is little to guide primary care practices in developing sustainable models for accessible and coordinated after–hours care.OBJECTIVETo identify and describe models of after-hours care in the U.S. that are delivered in primary care sites or coordinated with a patient’s usual primary care provider.DESIGNQualitative analysis of data from in-depth telephone interviews.SETTINGPrimary care practices in 16 states and the organizations they partner with to provide after-hours coverage.PARTICIPANTSForty-four primary care physicians, practice managers, nurses and health plan representatives from 28 organizations.APPROACHAnalyses examined after-hours care models, facilitators, barriers and lessons learned.RESULTSBased on 28 organizations interviewed, five broad models of after-hours care were identified, ranging in the extent to which they provide continuity and patient access. Key themes included: 1) The feasibility of a model varies for many reasons, including patient preferences and needs, the local health care market supply, and financial compensation; 2) A shared electronic health record and systematic notification procedures were extremely helpful in maintaining information continuity between providers; and 3) after-hours care is best implemented as part of a larger practice approach to access and continuity.CONCLUSIONAfter-hours care coordinated with a patient’s usual primary care provider is facilitated by consideration of patient demand, provider capacity, a shared electronic health record, systematic notification procedures and a broader practice approach to improving primary care access and continuity. Payer support is important to increasing patients’ access to after-hours care.Despite expectations that medical homes provide “24 × 7 coverage” there is little to guide primary care practices in developing sustainable models for accessible and coordinated after–hours care. To identify and describe models of after-hours care in the U.S. that are delivered in primary care sites or coordinated with a patient’s usual primary care provider. Qualitative analysis of data from in-depth telephone interviews. Primary care practices in 16 states and the organizations they partner with to provide after-hours coverage. Forty-four primary care physicians, practice managers, nurses and health plan representatives from 28 organizations. Analyses examined after-hours care models, facilitators, barriers and lessons learned. Based on 28 organizations interviewed, five broad models of after-hours care were identified, ranging in the extent to which they provide continuity and patient access. Key themes included: 1) The feasibility of a model varies for many reasons, including patient preferences and needs, the local health care market supply, and financial compensation; 2) A shared electronic health record and systematic notification procedures were extremely helpful in maintaining information continuity between providers; and 3) after-hours care is best implemented as part of a larger practice approach to access and continuity. After-hours care coordinated with a patient’s usual primary care provider is facilitated by consideration of patient demand, provider capacity, a shared electronic health record, systematic notification procedures and a broader practice approach to improving primary care access and continuity. Payer support is important to increasing patients’ access to after-hours care.

How to Deliver Care Management: Guidance from an Analysis of Communication Patterns in Primary Care

BackgroundThere is emerging consensus that enhanced inter-professional teamwork is necessary for the effective and efficient delivery of primary care, but there is less practical information specific to primary care available to guide practices on how to better work as teams.ObjectiveThe purpose of this study was to describe how primary care practices have overcome challenges to providing team-based primary care and the implications for care delivery and policy.ApproachPractices for this qualitative study were selected from those recognized as patient-centered medical homes (PCMHs) via the most recent National Committee for Quality Assurance PCMH tool, which included a domain on practice teamwork.ParticipantsSixty-three respondents, ranging from physicians to front-desk staff, were interviewed from May through December of 2013. Practice respondents came from 27 primary care practices ranging in size, type, geography, and population served.Key ResultsPractices emphasizing teamwork overcame common challenges through the incremental delegation of non-clinical tasks away from physicians. The roles of medical assistants and nurses are expanding to include template-guided information collection from patients prior to the physician office visit as well as many other tasks. The inclusion of staff input in care workflow redesign and the use of data to demonstrate how team care process changes improved patient care were helpful in gaining staff buy-in. Team “huddles” guided by pre-visit planning were reported to assist in role delegation, consistency of information collected from patients, and structured communication among team members. Nurse care managers were found to be important team members in working with patients and their physicians on care plan design and execution. Most practices had not participated in formal teamwork training, but respondents expressed a desire for training for key team members, particularly if they could access it on-site (e.g., via practice coaches or the Internet).ConclusionsParticipants who adopted new forms of delegation and care processes using teamwork approaches, and who were supported with resources, system support, and data feedback, reported improved provider satisfaction and productivity. There appears to be a need for more on-site teamwork training.