The patient-centered medical home (PCMH) is emerging as a potential catalyst for multiple health care reform efforts. Demonstration projects are beginning in nearly every state, with a broad base of support from employers, insurers, state and federal agencies, and professional organizations. A sense of urgency to show the feasibility of the PCMH, along with a 3-tiered recognition process of the National Committee on Quality Assurance, are infl uencing the design and implementation of many demonstrations. In June 2006, the American Academy of Family Physicians launched the fi rst National Demonstration Project (NDP) to test a model of the PCMH in a diverse national sample of 36 family practices. The authors make up an independent evaluation team for the NDP that used a multimethod evaluation strategy, including direct observation, in-depth interviews, chart audit, and patient and practice surveys. Early lessons from the realtime qualitative analysis of the NDP raise some serious concerns about the current direction of many of the proposed PCMH demonstration projects and point to some positive opportunities. We describe 6 early lessons from the NDP that address these concerns and then offer 4 recommendations for those assisting the transformation of primary care practices and 4 recommendations for individual practices attempting transformation. INTRODUCTIONThe patient-centered medical home (PCMH) is rapidly becoming a powerful engine for multiple reform efforts related to health care delivery, reimbursement, and primary care. [1][2][3][4][5][6][7][8][9][10][11][12][13] During the next few years, we can expect thousands of primary care practices to attempt to convert their offi ces into PCMHs. Demonstration projects are underway in numerous states and supported by amazingly diverse constituencies that include professional organizations, major employers, insurers, Medicare, state governments, not-for-profi t foundations, and others. These diverse and rapidly growing efforts are being initiated based on an appealing idea but with little direct empirical support. 4,5 The PCMH represents an innovative and exciting national conversation that melds core primary care principles, relationship-centered patient care, reimbursement reform, new information technology, and the chronic care model. Unfortunately, the rush to demonstrate operational and fi nancial feasibility of the PCMH, proceeding apace with the recognition process of the National Committee for Quality Assurance (NCQA) 14 risks premature closure of the larger PCMH conversations and potentially stifl es evolution of the PCMH to meet important patient, practice, and system needs.The "Future of Family Medicine" report 15 10 Thirty-six family practices were selected from 337 practices completing a well-publicized, comprehensive on-line application. Practice selection attempted to maximize a diversity of geography, size, age, and ownership arrangements. For the most part, the participating practices were highly motivated to test the new models of care and...
The 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.Electronic supplementary materialThe online version of this article (doi:10.1007/s11606-010-1291-3) contains supplementary material, which is available to authorized users.
The validity of the medical record and patient questionnaire for measuring delivery of different health services varied with the service. This report can be used to choose the optimal nonobservational method of measuring the delivery of specific ambulatory medical services for research and physician profiling and to interpret existing health services research studies using these common measures.
Many commentators view the conversion of small, independent primary care practices into patient-centered medical homes as a vital step in creating a better-performing health care system. The country’s first national medical home demonstration, which ran from June 1, 2006, to May 31, 2008, and involved thirty-six practices, showed that this transformation can be lengthy and complex. Among other features, the transformation process requires an internal capability for organizational learning and development; changes in the way primary care clinicians think about themselves and their relationships with patients as well as other clinicians on the care team; and awareness on the part of primary care clinicians that they will need to make long-term commitments to change that may require three to five years of external assistance. Additionally, transforming primary care requires synchronizing practice redesign with development of the health care “neighborhood,” which is made up of a broad range of health and health care resources available to patients. It also requires payment reform that supports practice development and a policy environment that sets reasonable expectations and time frames for the adoption of appropriate innovations.
PURPOSE Numerous primary care practice development efforts, many related to the patient-centered medical home (PCMH), are emerging across the United States with few guides available to inform them. This article presents a relationship-centered practice development approach to understand practice and to aid in fostering practice development to advance key attributes of primary care that include access to fi rst-contact care, comprehensive care, coordination of care, and a personal relationship over time. METHODSInformed by complexity theory and relational theories of organizational learning, we built on discoveries from the American Academy of Family Physicians' National Demonstration Project (NDP) and 15 years of research to understand and improve primary care practice.RESULTS Primary care practices can fruitfully be understood as complex adaptive systems consisting of a core (a practice's key resources, organizational structure, and functional processes), adaptive reserve (practice features that enhance resilience, such as relationships), and attentiveness to the local environment. The effectiveness of these attributes represents the practice's internal capability. With adequate motivation, healthy, thriving practices advance along a pathway of slow, continuous developmental change with occasional rapid periods of transformation as they evolve better fi ts with their environment. Practice development is enhanced through systematically using strategies that involve setting direction and boundaries, implementing sensing systems, focusing on creative tensions, and fostering learning conversations.CONCLUSIONS Successful practice development begins with changes that strengthen practices' core, build adaptive reserve, and expand attentiveness to the local environment. Development progresses toward transformation through enhancing primary care attributes. INTRODUCTIONF or more than a century, small, physician-led medical practices were the most common source of primary care throughout the western world.1 The future viability of this cottage industry is now in doubt, and primary care in the United States and elsewhere is seriously weakening. 2 Hopeful energy for changing and transforming primary care practices arises from this deteriorating situation.3 Practice development activities are emerging as part of state initiatives, Medicare pilot programs, health system projects, and independent innovations. [4][5][6] The diffi culties and resistances challenging this hard work are daunting, with few research-informed approaches available to help guide these critically important initiatives. [7][8][9][10] In this article, we offer a theory-based, evidence-informed relationship-centered approach for primary care practice development derived from 15 years of research on primary care practice improvement 11 and, most recently, from the American Academy of Family Physicians' National Demonstration Project (NDP) S69 R EL AT IONSHIP-CENT ER ED PR AC T ICE DE V ELOPMENTone of the fi rst research trials seeking to implemen...
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