Categories of Practice Transformation in a Statewide Medical Home Pilot and their Association with Medical Home Recognition

Abstract

BACKGROUND: Healthcare purchasers have created financial incentives for primary care practices to achieve medical home recognition. Little is known about how changes in practice structure vary across practices or relate to medical home recognition. OBJECTIVE: We aimed to characterize patterns of structural change among primary care practices participating in a statewide medical home pilot. DESIGN: We surveyed practices at baseline and year 3 of the pilot, measured associations between changes in structural capabilities and National Committee for Quality Assurance (NCQA) medical home recognition levels, and used latent class analysis to identify distinct classes of structural transformation. PARTICIPANTS: Eighty-one practices that completed surveys at baseline and year 3 participated in the study. MAIN MEASURES: Study measures included overall structural capability score (mean of 69 capabilities); eight structural subscale scores; and NCQA recognition levels. RESULTS: Practices achieving higher year-3 NCQA recognition levels had higher overall structural capability scores at baseline (Level 1: 28.4 % of surveyed capabilities, Level 2: 40.9 %, Level 3: 48.7 %; p value=0.001). We found no association between NCQA recognition level and change in structural capability scores (Level 1: 33.2 % increase, Level 2: 30.8 %, Level 3: 33.7 %; p value=0.88). There were four classes of practice transformation: 27 % of practices underwent "minimal" transformation (changing little on any scale); 20 % underwent "provider-facing" transformation (adopting electronic health records, patient registries, and care reminders); 26 % underwent "patient-facing" transformation (adopting shared systems for communicating with patients, care managers, referral to community resources, and after-hours care); and 26 % underwent "broad" transformation (highest or secondhighest levels of transformation on each subscale). CONCLUSIONS AND RELEVANCE: In a large, statebased medical home pilot, multiple types of practice transformation could be distinguished, and higher levels of medical home recognition were associated with practices' capabilities at baseline, rather than transformation over time. By identifying and explicitly incentivizing the most effective types of transformation, program designers may improve the effectiveness of medical home interventions.

Linking Structural Capabilities and Workplace Climate in Community Health Centers

“…Previous studies have shown that practices in PCMH demonstrations adopt different combinations of structural characteristics. 21 A better understanding of trade-offs of structural and practice climate investments has important implications for improving quality and reducing costs for CHCs and other primary care practices.…”

Cost of Transformation among Primary Care Practices Participating in a Medical Home Pilot

“…To assess structural transformation, we sent a survey to one leader of each practice at baseline and at the end of pilot year 3 (in each region) that queried the presence of capabilities such as patient registries, care managers, information technology, and after-hours access. 17 Based on survey responses, we calculated each practice's change on an overall structural capability score. To assess functional transformation, we measured changes in each practice's performance on quality (nine measures of chronic disease and preventive care) and costs of care over 3 years using claims data from 8 of the 12 participating health plans.…”

Health Services and Primary Care Research Study: Comprehensive Report

“…Studies documenting PCMH transformation and outcomes-many of which have been federally funded-have likewise multiplied (Agency for Healthcare Research and Quality, undated-g). Findings indicate that transforming primary care is challenging (Martsolf et al, 2015;Crabtree et al, 2010). There is evidence that practices of transformation vary in how they put the concepts of PCMH into practice (Rittenhouse et al, 2013;Solberg, 2011;Tomoaia-Cotisel et al, 2016), and that implementation can improve outcomes such as cost, quality, and patient satisfaction (Friedberg et al, 2014(Friedberg et al, , 2015Strickland et al, 2011;Rosenthal, 2008;Shi et al, 2017;Farrell et al, 2015) (health care systems and services impact, patient impact).…”