Abstract
Background/Aims Hopes are high for revitalizing primary care through transformation to a Patient- Centered Medical Home (PCMH) model. This model has been implemented in some capitated integrated delivery systems, but the transferability of PCMH to practices with a mixture of fee-for- service (FFS) and capitation contracts is uncertain. This study documents and analyzes how a transformation into a PCMH was achieved in a largely FFS multispecialty group practice in Northern California which has 30 clinics in three geographically distinct divisions. Division A was certified by NCQA at level 3 PCMH, Divisions B and C at level 2 PCMH.
Methods Multi-method case study includes qualitative data from semi-structured key informant interviews and quantitative data from medical records and administrative sources in 2005–2010. Key informants were purposefully sampled to capture experiences in all divisions and included executives, frontline physicians, nurse, health educators and medical assistants. We report on the interviews that were audio recorded, transcribed and analyzed thematically. We also present some initial quantitative findings on the association between the levels of NCQA PCMH certification and measures of process and outcomes of care.
Results Thirty-three key informant interviews have been completed to date. Four emerging themes are:
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quality improvement efforts and responses to local market pressures pre-dated the national focus on PCMH;
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successful implementation of some PCMH components occurred in a top-down fashion with physician champions;
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dominant business line (FFS) presents disincentive for some PCMH components; and
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organizational culture differences may affect how well certain initiatives are taken up and sustained.
EHR data reveal that the level 3 PCMH division had the shortest wait time to a 3rd next available appointment for a longer visit (i.e., improved access), the highest proportion of patients with diabetes having their HbA1c measured every 6 months (improved process) and the highest proportion of patients with diabetes with their blood pressure under control (130/80) (improved outcomes).
Discussion We conclude that implementation of many PCMH components pre-dated the national focus on PCMH. Successfully implemented elements had organizational champions in practice cultures supportive of innovations. Some clinical process and outcome performance are consistent with the level of NCQA certification.
