Susan E. Hernandez

Implementation of the Patient-Centered Medical Home in the Veterans Health Administration: Associations With Patient Satisfaction, Quality of Care, Staff Burnout, and Hospital and Emergency Department Use

IMPORTANCE In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation. OBJECTIVES To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. DESIGN, SETTING, AND PARTICIPANTS We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care. MAIN OUTCOMES AND MEASURES Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. RESULTS Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001). CONCLUSIONS AND RELEVANCE The extent of PCMH implementation, as measured by the Pi2, was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.

Latino Access to the Patient-Centered Medical Home

BackgroundDisparities can be caused by minorities receiving care in low-quality settings. The patient-centered medical home (PCMH) has been identified as a model of high-quality primary care that can eliminate disparities. However, Latinos are less likely to have PCMHs.ObjectiveTo identify Latino subgroup variations in having a PCMH, its impact on disparities, and to identify factors associated with Latinos having a PCMH.DesignAnalysis of the 2005 MEPS Household Component, a nationally representative survey with an oversample of Latino adults. The total sample was 24,000 adults, including 6,200 Latinos.MeasurementsThe PCMH was defined as having a regular provider, who provides total care, fosters patient engagement in care, and offers easy access to care. Self reports of preventive care (cholesterol screening, blood pressure check, mammography, and prostate-specific antigen screening) and patient experiences were examined.ResultsWhite (57.1%) and Puerto Rican (59.3%) adults were most likely to have a PCMH, while Mexican/Mexican Americans (35.4%) and Central and South Americans (34.2%) were least likely. Much of the disparity was caused by lack of access to a regular provider. Respondents with a PCMH had higher rates of preventive care and positive patient experiences. Disparities in care were eliminated or reduced for Latinos with PCMHs. The regression models showed private insurance, which is less common among all Latinos, was an important predictor of having a PCMH.ConclusionsEliminating health-care disparities will require assuring access to the PCMH. Addressing differences in health-care coverage that contribute to lower rates of Latino access to the PCMH will also reduce disparities.

Patient-Centered Medical Home Initiative Produced Modest Economic Results For Veterans Health Administration, 2010–12

In 2010 the Veterans Health Administration (VHA) began a nationwide initiative called Patient Aligned Care Teams (PACT) that reorganized care at all VHA primary care clinics in accordance with the patient-centered medical home model. We analyzed data for fiscal years 2003-12 to assess how trends in health care use and costs changed after the implementation of PACT. We found that PACT was associated with modest increases in primary care visits and with modest decreases in both hospitalizations for ambulatory care-sensitive conditions and outpatient visits with mental health specialists. We estimated that these changes avoided

Patient-centered innovation in health care organizations: A conceptual framework and case study application

596 million in costs, compared to the investment in PACT of

Innovation in patient-centered care: lessons from a qualitative study of innovative health care organizations in Washington State

774 million, for a potential net loss of

A First Look at PCMH Implementation for Minority Veterans: Room for Improvement.

178 million in the study period. Although PACT has not generated a positive return, it is still maturing, and trends in costs and use are favorable. Adopting patient-centered care does not appear to have been a major financial risk for the VHA.

Patient-centered medical home implementation and primary care provider turnover

BACKGROUND Patient-centered innovation is spreading at the federal and state levels. A conceptual framework can help frame real-world examples and extract systematic learning from an array of innovative applications currently underway. The statutory, economic, and political environment in Washington State offers a special contextual laboratory for observing the interplay of these factors. PURPOSE We propose a framework for understanding the process of initiating patient-centered innovations-particularly innovations addressing patient-centered goals of improved access, continuity, communication and coordination, cultural competency, and family- and person-focused care over time. The framework to a case study of a provider organization in Washington State actively engaged in such innovations was applied in this article. METHODS We conducted a selective review of peer-reviewed evidence and theory regarding determinants of organizational change. On the basis of the literature review and the particular examples of patient-centric innovation, we developed a conceptual framework. Semistructured key informant interviews were conducted to illustrate the framework with concrete examples of patient-centered innovation. FINDINGS The primary determinants of initiating patient-centered innovation are (a) effective leadership, with the necessary technical and professional expertise and creative skills; (b) strong internal and external motivation to change; (c) clear and internally consistent organizational mission; (d) aligned organizational strategy; (e) robust organizational capability; and (f) continuous feedback and organizational learning. The internal hierarchy of actors is important in shaping patient-centered innovation. External financial incentives and government regulations also significantly shape innovation. PRACTICE IMPLICATIONS Patient-centered care innovation is a complex process. A general framework that could help managers and executives organize their thoughts around innovation within their organization is presented.

Patient Reports of the Quality of Care in Community Health Centers: The Importance of Having a Regular Provider

BackgroundGrowing interest in the promise of patient-centered care has led to numerous health care innovations, including the patient-centered medical home, shared decision-making, and payment reforms. How best to vet and adopt innovations is an open question. Washington State has been a leader in health care reform and is a rich laboratory for patient-centered innovations. We sought to understand the process of patient-centered care innovation undertaken by innovative health care organizations – from strategic planning to goal selection to implementation to maintenance.MethodsWe conducted key-informant interviews with executives at five health plans, five provider organizations, and ten primary care clinics in Washington State. At least two readers of each interview transcript identified themes inductively; final themes were determined by consensus.ResultsInnovation in patient-centered care was a strategic objective chosen by nearly every organization in this study. However, other goals were paramount: cost containment, quality improvement, and organization survival. Organizations commonly perceived effective chronic disease management and integrated health information technology as key elements for successful patient-centered care innovation. Inertia, resource deficits, fee-for-service payment, and regulatory limits on scope of practice were cited as barriers to innovation, while organization leadership, human capital, and adaptive culture facilitated innovation.ConclusionsPatient-centered care innovations reflected organizational perspectives: health plans emphasized cost-effectiveness while providers emphasized health care delivery processes. Health plans and providers shared many objectives, yet the two rarely collaborated to achieve them. The process of innovation is heavily dependent on organizational culture and leadership. Policymakers can improve the pace and quality of patient-centered innovation by setting targets and addressing conditions for innovation.

Association between local area unemployment rates and use of Veterans Affairs outpatient health services.

Background:Implementation of Patient Aligned Care Teams (PACT), a patient-centered medical home model, has been inconsistent among the >900 primary care facilities in the Veterans Health Administration. Objective:Estimate if the degree of PACT implementation at a facility varied with the percentage of minority veteran patients at the facility. Research Design:Cross-sectional, facility-level analysis of PACT implementation measures in 2012. Subjects:Veterans Health Administration hospital-based and community-based primary care facilities. Measures:We used a previously validated PACT Implementation Progress Index (Pi2) and its 8 domains: access, continuity of care, care coordination, comprehensiveness, self-management support, and patient-centered care and communication, shared decision-making domains, and team functioning. Facilities were categorized as low (<5.2%, n=208), medium (5.2%–25.8%, n=413), and high (>25.8%, n=206) percent minority based on the percent of their own veteran population. Results:Most minority veterans received care in high minority (69%) and medium minority facilities (29%). In adjusted analyses, medium and high minority facilities scored 0.773 (P=0.009) and 0.930 (P=0.008) points lower on the Pi2 score relative to low minority facilities. Relative to low minority facilities, both medium and high minority facilities were less likely of having high Pi2 scores (≥2) and more likely of having low Pi2 scores (⩽−2). Both medium and high minority facilities had the same 3 domain scores lower than low minority facilities (care coordination, comprehensiveness, and self-management). Conclusion:Overall PACT implementation varied with respect to the racial/ethnic composition of a facility, with medium and high minority facilities having a lower implementation scores.

Local Area Unemployment and the Demand for Inpatient Care Among Veterans Affairs Enrollees.

Background:The Veterans Health Administration (VHA) began implementing a patient-centered medical home (PCMH) model of care delivery in April 2010 through its Patient Aligned Care Team (PACT) initiative. PACT represents a substantial system reengineering of VHA primary care and its potential effect on primary care provider (PCP) turnover is an important but unexplored relationship. This study examined the association between a system-wide PCMH implementation and PCP turnover. Methods:This was a retrospective, longitudinal study of VHA-employed PCPs spanning 29 calendar quarters before PACT and eight quarters of PACT implementation. PCP employment periods were identified from administrative data and turnover was defined by an indicator on the last quarter of each uncensored period. An interrupted time series model was used to estimate the association between PACT and turnover, adjusting for secular trend and seasonality, provider and job characteristics, and local unemployment. We calculated average marginal effects (AME), which reflected the change in turnover probability associated with PACT implementation. Results:The quarterly rate of PCP turnover was 3.06% before PACT and 3.38% after initiation of PACT. In adjusted analysis, PACT was associated with a modest increase in turnover (AME=4.0 additional PCPs per 1000 PCPs per quarter, P=0.004). Models with interaction terms suggested that the PACT-related change in turnover was increasing in provider age and experience. Conclusions:PACT was associated with a modest increase in PCP turnover, concentrated among older and more experienced providers, during initial implementation. Our findings suggest that policymakers should evaluate potential workforce effects when implementing PCMH.