Paul A. Nutting

Defining and measuring the patient-centered medical home

AbstractThe patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices’ internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare.The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care.The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following:Giving primacy to the core tenets of primary careAssessing practice and system changes that are hypothesized to provide added valueAssessing development of practices’ core processes and adaptive reserveAssessing integration with more functional healthcare system and community resourcesEvaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspectsRecognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings.Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

Improving depression outcomes in community primary care practice: a randomized trial of the quEST intervention. Quality Enhancement by Strategic Teaming.

AbstractOBJECTIVE: To determine whether redefining primary care team roles would improve outcomes for patients beginning a new treatment episode for major depression. DESIGN: Following stratification, 6 of 12 practices were randomly assigned to the intervention condition. Intervention effectiveness was evaluated by patient reports of 6-month change in 100-point depression symptom and functional status scales. SETTING: Twelve community primary care practices across the country employing no onsite mental health professional. PATIENTS: Using two-stage screening, practices enrolled 479 depressed adult patients (73.4% of those eligible); 90.2% completed six-month follow-up. INTERVENTION: Two primary care physicians, one nurse, and one administrative staff member in each intervention practice received brief training to improve the detection and management of major depression. MAIN RESULTS: In patients beginning a new treatment episode, the intervention improved depression symptoms by 8.2 points (95% confidence interval [CI], 0.2 to 16.1; P=.04). Within this group, the intervention improved depression symptoms by 16.2 points (95% CI, 4.5 to 27.9; P=.007), physical role functioning by 14.1 points (95% CI, 1.1 to 29.2; P=.07), and satisfaction with care (P=.02) for patients who reported antidepressant medication was an acceptable treatment at baseline. Patients already in treatment at enrollment did not benefit from the intervention. CONCLUSIONS: In practices without onsite mental health professionals, brief interventions training primary care teams to assume redefined roles can significantly improve depression outcomes in patients beginning a new treatment episode. Such interventions should target patients who report that antidepressant medication is an acceptable treatment for their condition. More research is needed to determine how primary care teams can best sustain these redefined roles over time.

Primary Care Patients with Depression Are Less Accepting of Treatment Than Those Seen by Mental Health Specialists

OBJECTIVE: This study examined whether depressed patients treated exclusively in primary care report less need for care and less acceptability of treatment options than those depressed patients treated in the specialty mental health setting after up to 6 months of treatment.DESIGN: Cross-sectional study.SETTING: Forty-five community primary care practices.PARTICIPANTS: A total of 881 persons with major depression who had received mental health services in the previous 6 months and who enrolled in 3 of the 4 Quality Improvement for Depression Collaboration Studies.MEASUREMENTS AND RESULTS: Patients were categorized into 1 of 2 groups: 1) having received mental health services exclusively from a primary care provider (45%), or 2) having received any services from a mental health specialist (55%) in the previous 6 months. Compared with patients who received care from mental health specialists, patients who received mental health services exclusively from primary care providers had 2.7-fold the odds (95% confidence interval [CI], 1.6 to 4.4) of reporting that no treatment was definitely acceptable and had 2.4-fold the odds (95% CI, 1.5 to 3.9) of reporting that evidence-based treatment options (antidepressant medication) were definitely not acceptable. These results were adjusted for demographic, social/behavioral, depression severity, and economic factors using multiple logistic regression analysis.CONCLUSIONS: Patients with depression treated exclusively by primary care providers have attitudes and beliefs more averse to care than those seen by mental health specialists. These differences in attitudes and beliefs may contribute to lower quality depression care observed in comparisons of primary care and specialty mental health providers.

Small Primary Care Practices Face Four Hurdles—Including A Physician-Centric Mind-Set—In Becoming Medical Homes

Transforming small independent practices to patient-centered medical homes is widely believed to be a critical step in reforming the US health care system. Our team has conducted research on improving primary care practices for more than fifteen years. We have found four characteristics of small primary care practices that seriously inhibit their ability to make the transformation to this new care model. We found that small practices were extremely physician-centric, lacked meaningful communication among physicians, were dominated by authoritarian leadership behavior, and were underserved by midlevel clinicians who had been cast into unimaginative roles. Our analysis suggests that in addition to payment reform, a shift in the mind-set of primary care physicians is needed. Unless primary care physicians can adopt new mental models and think in new ways about themselves and their practices, it will be very difficult for them and their practices to create innovative care teams, become learning organizations, and act as good citizens within the health care neighborhood.

Implementing a Depression Improvement Intervention in Five Health Care Organizations: Experience from the RESPECT-Depression Trial

A growing body of research provides strong evidence for the effectiveness of programs to improve the primary care of depression based on the chronic care model. At the same time these changes are difficult to sustain in their original research settings and more difficult to widely disseminate in primary care practice. The RESPECT-Depression trial tested an implementation and dissemination strategy by working through five community-based health care organizations (HCOs) to implement the Three Component Model (TCM) for improving depression care. This report describes the results of extensive interviews of project principals, health care program managers, depression care managers, and practicing primary care clinicians to understand the characteristics of organizations and the intervention components that were associated with implementation and dissemination of the TCM. In two of the organizations all 29 participating practices continued the TCM, while all 31 practices from the other three organizations did not. Successful continuation and dissemination appeared to be related to a broadly shared vision and commitment among all levels of the organization, clearly articulated by clinical leadership, for pursuing a systematic change strategy to improve chronic care that included, but extended beyond, depression, independent of clear evidence for cost-effectiveness of expanding depression management. Factors associated with inability to sustain the TCM included lack of a shared change strategy throughout the organization and inability to rationalize an economic model of depression care.

Are attributes of organizational performance in large health care organizations relevant in primary care practices

Are organizational attributes associated with better health outcomes in large health care organizations applicable to primary care practices? In comparative case studies of two community family practices, it was found that attributes of organizational performance identified in larger health care organizations must be tailored to their unique context of primary care. Further work is required to adapt or establish the significance of the attributes of management infrastructure and information mastery.

Patient Centered Medical Home: A Journey Not a Destination

The Patient-Centered Medical Home (PCMH) is proposed as a vehicle to deliver primary health care to older adults. The PCMH has the ability to improve the quality of care and reduce unnecessary expenditures while fostering functional independence and improving quality of life. Steps to develop a PCMH for older adults include clarity of purpose, team building, process improvement, setting time for reflection and course adjustment, defining accountability, providing a supportive and safe work environment, fully utilizing capabilities of the electronic health record and building relationships with external community partners. Building and maintaining a PCMH requires payment changes in the form of blended or direct primary care payments. Some organizational structures beyond the PCMH can hinder development of the PCMH by excessive standardization and micromanaging or they can facilitate development by providing appropriate support with facilitative leadership. The PCMH is a journey, not a destination and requires ongoing evolution of medical models and attention to patient preferences.