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...

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.

PURPOSEWe describe the experience of practices in transitioning toward patient-centered medical homes (PCMHs) in the National Demonstration Project (NDP). METHODSThe NDP was launched in June 2006 as the fi rst national test of a model of the PCMH in a diverse sample of 36 family practices, randomized to facilitated and self-directed intervention groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical records, and patient and practice surveys. The evaluation team reviewed data from all practices as they became available and produced interim summaries. Four 2-to 3-day evaluation team retreats were held during which case summaries of all practices were discussed and patterns were described. RESULTSThe 6 themes that emerged from the data refl ect major shifts in individual and practice roles and identities, as well as changes in practices' management strategies. The themes are (1) practice adaptive reserve is critical to managing change, (2) developmental pathways to success vary considerably by practice, (3) motivation of key practice members is critical, (4) the larger system can help or hinder, (5) practice transformation is more than a series of changes and requires shifts in roles and mental models, and (6) practice change is enabled by the multiple roles that facilitators play.CONCLUSIONS Transformation to a PCMH requires more than a sequence of discrete changes. The practice transformation process may be fostered by promoting adaptive reserve and local control of the developmental pathway.

This article summarizes fi ndings from the National Demonstration Project (NDP) and makes recommendations for policy makers and those implementing patientcentered medical homes (PCMHs) based on these fi ndings and an understanding of diverse efforts to transform primary care.The NDP was launched in June 2006 as the fi rst national test of a particular PCMH model in a diverse sample of 36 family practices, randomized to facilitated or self-directed groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical record audits, and patient and clinical staff surveys. Peerreviewed manuscripts from the NDP provide answers to 4 key questions: (1) Can the NDP model be built? (2) What does it take to build the NDP model? (3) Does the NDP model make a difference in quality of care? and (4) Can the NDP model be widely disseminated?We fi nd that although it is feasible to transform independent practices into the NDP conceptualization of a PCMH, this transformation requires tremendous effort and motivation, and benefi ts from external support. Most practices will need additional resources for this magnitude of transformation.Recommendations focus on the need for the PCMH model to continue to evolve, for delivery system reform, and for suffi cient resources for implementing personal and practice development plans. In the meantime, we fi nd that much can be done before larger health system reform. INTRODUCTIONE merging consensus among policy makers, professional organizations, clinicians, and payers bears witness that health care in the United States has reached a defi ning moment. 1 The landmark 2001 Institute of Medicine report Crossing the Quality Chasm called for extensive overhaul and redesign of US health care.2 The patient-centered medical home (PCMH) is a popular model that proponents hope addresses many of the concerns raised in that report. [3][4][5][6][7] The PCMH concept is endorsed by the major primary care professional organizations, who issued a joint statement on principles of the PCMH in 2007, emphasizing patients' ongoing relationship with a personal physician; team approaches to care; a wholeperson orientation; mechanisms to support care integration, quality, safety and access; and payment for added value. 8 During the past several years, a growing number of PCMH demonstration projects have been undertaken. 9 Some of these focus on chronic care. [9][10][11] Most are regional in scope 9,10,12 or are conducted within a particular integrated health care system. 9,[13][14][15] Relatively few both are comprehensive in scope and include diverse, especially small, independent practices. 9,16 The National Demonstration Project (NDP) launched by the American Academy of Family Physicians (AAFP) S81NDP SU M M A RY A ND R ECO M MENDAT IONS F OR P C MH demonstration project on a national sample of practices designed to test a comprehensive model of the PCMH envisioned by the Future of Family Medicine report. 17In...

After slightly more than 2 years, implementation of PCMH components, whether by facilitation or practice self-direction, was associated with small improvements in condition-specific quality of care but not patient experience. PCMH models that call for practice change without altering the broader delivery system may not achieve their intended results, at least in the short term.