ECF is a significant and independent correlate of functional status in normal aging. Traditional dementia case finding is likely to underestimate cognition-related disability. Neither a normal baseline MMSE score nor stable MMSE scores over time preclude functionally significant changes in ECF.

PURPOSE Participatory decision making (PDM) is associated with improved diabetes control. We examine a causal model linking PDM to improved clinical outcomes that included patient activation and medication adherence. METHODSThis observational study was conducted in 5 family physician offi ces. Diabetic patients were recruited by mail and by completing a study interest card at the conclusion of their offi ce visit. Two survey questionnaires, administered 12 months apart, elicited patients' ratings of their physician's PDM style at baseline and their level of activation and medication adherence both at baseline and at follow-up. Measures of glycated hemoglobin (hemoglobin A 1c ), systolic blood pressure, and low-density lipoprotein (LDL) cholesterol were abstracted from the medical record starting 12 months before the baseline survey to 12 months after the follow-up survey. A path analysis using a structural equation model was used to test hypotheses. RESULTSWe mailed questionnaires to 236 participants; 166 (70%) returned the baseline questionnaire, and 141 (80%) returned the follow-up questionnaire. Hemoglobin A 1c levels, systolic blood pressure, and LDL cholesterol values all declined signifi cantly, and patient activation and medication adherence improved. PDM at baseline was associated with patient activation at follow-up. Patient activation at follow-up was associated with medication adherence at follow-up, and medication adherence at follow-up was associated with change in hemoglobin A 1c levels and LDL cholesterol values but not with systolic blood pressure.CONCLUSIONS Participatory decision making during primary care encounters by patients with type 2 diabetes resulted in improvements in hemoglobin A 1c levels and LDL cholesterol values by improving patient activation, which in turn improved medication adherence.

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.

PURPOSE The objective of this study was to elucidate the effect of facilitation on practice outcomes in the 2-year patient-centered medical home (PCMH) National Demonstration Project (NDP) intervention, and to describe practices' experience in implementing different components of the NDP model of the PCMH.METHODS Thirty-six family practices were randomized to a facilitated intervention group or a self-directed intervention group. We measured 3 practice-level outcomes: (1) the proportion of 39 components of the NDP model that practices implemented, (2) the aggregate patient rating of the practices' PCMH attributes, and (3) the practices' ability to make and sustain change, which we term adaptive reserve. We used a repeated-measures analysis of variance to test the intervention effects.RESULTS By the end of the 2 years of the NDP, practices in both facilitated and self-directed groups had at least 70% of the NDP model components in place. Implementation was relatively harder if the model component affected multiple roles and processes, required coordination across work units, necessitated additional resources and expertise, or challenged the traditional model of primary care. Electronic visits, group visits, team-based care, wellness promotion, and proactive population management presented the greatest challenges. Controlling for baseline differences and practice size, facilitated practices had greater increases in adaptive reserve (group difference by time, P = .005) and the proportion of NDP model components implemented (group difference by time, P = .02); the latter increased from 42% to 72% in the facilitated group and from 54% to 70% in the self-directed group. Patient ratings of the practices' PCMH attributes did not differ between groups and, in fact, diminished in both of them.CONCLUSIONS Highly motivated practices can implement many components of the PCMH in 2 years, but apparently at a cost of diminishing the patient's experience of care. Intense facilitation increases the number of components implemented and improves practices' adaptive reserve. Longer follow-up is needed to assess the sustained and evolving effects of moving independent practices toward PCMHs Ann Fam Med 2010;8(Suppl 1):s33-s44.

Neighborhood type was a predictor of cognitive impairment. Education affected MMSE scores similarly in both ethnic groups. MMSE scores <24, indicative of cognitive impairment, were uniformly associated with functional impairment in both the Mexican Americans and European Americans. Among older Mexican Americans, MMSE-classified cognitive impairment was significantly associated with poorer performance on timed tasks with varying levels of cognitive demand independent of other correlates. A similar pattern of association was observed in European Americans. Thus, the MMSE appears to be a valid indicator of cognitive impairment in survey research in both older Mexican Americans and European Americans.

Objectives: Previous research established that low literacy is independently associated with poorer health. Our objective was to determine whether low literacy skill also is associated with higher health care charges.Methods: We studied persons enrolled in Medicaid because of medical need/indigence by testing literacy skills in English or Spanish and measuring annual health care charges. Statistical analyses determined if, after adjusting for sociodemographic variables, literacy was associated with charges.Results: Mean charges among subjects with very low literacy skills (<3rd-grade reading level) were $10,688/year, but only $2,891 for those with better literacy skills (>4th-grade reading level), statistically significant difference (P ‫؍‬ .025). This difference persisted after adjustment for potentially confounding sociodemographic variables.Conclusions: Based on this small study, very limited reading skills seem to be independently associated with higher health care charges among medically needy and medically indigent Medicaid patients.

ECF is a strong, significant, and independent correlate of functional status in normal aging. In contrast, decline in memory, as measured using the CVLT, has no independent association with the rate of change in functional status. This suggests that amnestic mild cognitive impairment can be associated with dementia only though the subsequent or comorbid development of ECF impairment.

PURPOSE Understanding the transformation of primary care practices to patientcentered medical homes (PCMHs) requires making sense of the change process, multilevel outcomes, and context. We describe the methods used to evaluate the country's fi rst national demonstration project of the PCMH concept, with an emphasis on the quantitative measures and lessons for multimethod evaluation approaches. METHODSThe National Demonstration Project (NDP) was a group-randomized clinical trial of facilitated and self-directed implementation strategies for the PCMH. An independent evaluation team developed an integrated package of quantitative and qualitative methods to evaluate the process and outcomes of the NDP for practices and patients. Data were collected by an ethnographic analyst and a research nurse who visited each practice, and from multiple data sources including a medical record audit, patient and staff surveys, direct observation, interviews, and text review. Analyses aimed to provide real-time feedback to the NDP implementation team and lessons that would be transferable to the larger practice, policy, education, and research communities.RESULTS Real-time analyses and feedback appeared to be helpful to the facilitators. Medical record audits provided data on process-of-care outcomes. Patient surveys contributed important information about patient-rated primary care attributes and patient-centered outcomes. Clinician and staff surveys provided important practice experience and organizational data. Ethnographic observations supplied insights about the process of practice development. Most practices were not able to provide detailed fi nancial information.CONCLUSIONS A multimethod approach is challenging, but feasible and vital to understanding the process and outcome of a practice development process. Additional longitudinal follow-up of NDP practices and their patients is needed.Ann Fam Med 2010;8(Suppl 1):s9-s20. doi:10.1370/afm.1108. INTRODUCTIONT he 2004 Future of Family Medicine report documented the current crisis in the US health care system and made the case for a "New Model" of practice.1,2 This model has evolved to be consistent with the emerging consensus principles of the patient-centered medical home (PCMH). 3 The PCMH model of primary care incorporates current best practices in terms of access to care, prevention, chronic disease management, care coordination, and responsiveness to patients. [4][5][6][7][8][9][10][11][12][13][14] This model also acknowledges the trend toward health care consumerism and seeks to leverage information technology to improve outcomes and communication. 15 In June 2006, the American Academy of Family Physicians (AAFP) began a trial to implement the PCMH model in 36 volunteer practices over the course of 2 years. The AAFP contracted with the Center for Research in Family Medicine and Primary Care to conduct an independent evaluation. This article describes the key methodologic strategies used for the evaluation and includes a comprehensive list of the data colCarlos ...