Clinical Quality and the Patient-Centered Medical Home

Nelson, Karin M.; Sylling, Philip; Taylor, Larry E.; Rose, Danielle E.; Mori, Alaina; Fihn, Stephan D.

doi:10.1001/jamainternmed.2017.0963

Cited by 20 publications

(23 citation statements)

References 6 publications

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“…This ability of clinics to transform, including experiencing improvement in PCMH capabilities over time, represents a fundamentally different construct than what has been captured in prior cross-sectional studies, to our knowledge. 9,25 Our study is consistent with findings by Martsolf et al 26 that suggested that longitudinal analyses could attenuate the estimated associations seen in cross-sectional designs. While these prior studies used different measures of PCMH capabilities than our study, such as National Committee for Quality Assurance-level accreditation and Medical Home Index, they also demonstrated that patient outcomes were sensitive to the methods chosen for analysis.…”

Section: Discussionsupporting

confidence: 92%

Association of High-Cost Health Care Utilization With Longitudinal Changes in Patient-Centered Medical Home Implementation

et al. 2020

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IMPORTANCE In 2010, the US Veterans Health Administration (VHA) implemented one of the largest patient-centered medical home (PCMH) models in the United States, the Patient Aligned Care Team initiative. Early evaluations demonstrated promising associations with improved patient outcomes, but limited evidence exists on the longitudinal association of PCMH implementation with changes in health care utilization. OBJECTIVE To determine whether a change in PCMH implementation is associated with changes in emergency department (ED) visits, hospitalizations for ambulatory care-sensitive conditions (ACSCs), or all-cause hospitalizations. DESIGN, SETTING, AND PARTICIPANTS This cohort study used national patient-level data from the VHA and Centers for Medicare & Medicaid Services between October 1, 2012, and September 30, 2015. A total of 1 650 976 patients from 897 included clinics were divided into 2 cohorts: patients younger than 65 years who received primary care at VHA sites affiliated with a VHA ED and patients 65 years or older who were enrolled in both VHA and Medicare services. EXPOSURES Clinics were categorized on improvement or decline in PCMH implementation based on their Patient Aligned Care Team implementation progress index (Pi 2) score. MAIN OUTCOMES AND MEASURES Change in the number of ED visits, ACSC hospitalizations, and all-cause hospitalizations among patients at each clinic site. RESULTS The study included a total of 1 650 976 patients, of whom 581 167 (35.20%) were younger than 65 years (mean [SD] age, 49.03 [10.28] years; 495 247 [85.22%] men) and 1 069 809 (64.80%) were 65 years or older (mean [SD] age, 74.64 [7.41] years; 1 050 110 [98.16%] men). Among patients younger than 65 years, there were fewer ED visits among patients seen at clinics that had improved PCMH implementation (110.8 fewer visits per 1000 patients; P < .001) and clinics that had somewhat worse implementation (69.0 fewer visits per 1000 patients; P < .001) compared with clinics that had no change in Pi 2 score. There were no associations of change in Pi 2 scores with all-cause hospitalizations or ACSC hospitalizations among patients younger than 65 years. In patients 65 years or older, those seen at clinics that had somewhat worse PCMH implementation experienced fewer ED visits (20.1 fewer visits per 1000 patients; P = .002) and all-cause hospitalizations (12.4 fewer hospitalizations per 1000 patients; P = .007) compared with clinics with no change in Pi 2 score. There was no association between change in Pi 2 score with ACSC hospitalizations among patients 65 years or older. (continued) Key Points Question Is a change in patientcentered medical home implementation associated with changes in high-cost health care utilization in the US Veterans Health Administration health care system? Findings In this cohort study including 1 650 976 veterans, neither improvement nor decline in patientcentered medical home implementation was consistently associated with changes in the numbers of emergency department visits, ambulatory caresensitiv...

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Section: Discussionsupporting

confidence: 92%

Association of High-Cost Health Care Utilization With Longitudinal Changes in Patient-Centered Medical Home Implementation

et al. 2020

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“…To our knowledge, WellNet study is the rst study to evaluate the changes in HRQoL among patients with one or more chronic conditions in Australian primary care settings based on the principles of PCMH model. Findings of this study are consistent with the growing body of evidence showing strong association between patients' HRQoL and several core elements of the PCMH such as involvement of a MDT [40,41], continuity of care [42,43], and shared decision making and patient-provider communication [22,23]. Previous Australian studies by McCaffrey et al [24] and others [44] have reported on health utilities and HRQoL on the general population norms using cross-sectional data.…”

Section: Discussionsupporting

confidence: 89%

Changes in health-related quality of life before and after a 12-month enhanced primary care model among chronically ill primary care patients in Australia.

John

Tannous

Jones

2020

Preprint

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Purpose: Evidence suggests that Patient-centred Medical Home (PCMH) model facilitates person-centred care and improves health-related quality of life for patients with chronic illness. This study aims to evaluate changes in health-related quality of life (HRQoL), before and after enrolment into a 12-month integrated care program called ‘WellNet’. Methods: This study includes 616 eligible consented patients aged 40 years and above with one or more chronic conditions from six general practices across Sydney, Australia. The WellNet program included a team of general practitioners (GPs) and clinical coordinators (CCs) providing patient-tailored care plans configured to individual risk and complexity. HRQoL was recorded using the validated EuroQol five dimensions five levels (EQ-5D-5L) instrument at baseline and 12 months. Additionally, patients diagnosed with osteoarthritis also reported HRQoL using short versions of Knee and/or Hip disability and osteoarthritis outcome scores (KOOSjr and HOOSjr). A case-series study design with repeated measures analysis of covariance (ANCOVA) was used to assess changes in mean differences of EQ-5D index scores after controlling for baseline covariates. Additionally, backward stepwise multivariable linear regression models were conducted to determine significant predictors of EQ-5D index scores at follow-up. Results: Out of 616 patients, 417 (68%) reported EQ-5D scores at follow-up. Almost half (48%) of the WellNet patients reported improved EQ-5D index scores at follow-up. After controlling for baseline covariates, the adjusted mean difference was statistically significant whilst also meeting the bare minimal clinically important difference (MCID) with a change of 0.03 (95% CI 0.01, 0.05). The multivariable regression models determined that baseline EQ-5D scores and positive diagnosis of a respiratory illness were significant predictors of HRQoL at follow-up. There were significant improvements across both KOOS and HOOS assessments, specifically, the pain and symptom scores in both scales met statistical significance in addition to meeting the MCID.Conclusion: Patient-tailored chronic disease management (CDM) plans designed by team of GPs and CDM clinical coordinators could lead to better HRQoL among primary care patients.

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“…To our knowledge, WellNet study is the first study to evaluate the changes in HRQoL among patients with one or more chronic conditions in Australian primary care settings based on the principles of PCMH model. Findings of this study are consistent with the growing body of evidence showing strong association between patients' HRQoL and several core elements of the PCMH such as involvement of a MDT [36,37], continuity of care [38,39], and shared decision making and patient-provider communication [22,23]. Previous Australian studies by McCaffrey et al [24] and others [40] have reported on health utilities and HRQoL on general population norms using cross-sectional data.…”

Section: Discussionsupporting

confidence: 89%

Changes in Health-Related Quality of Life Before and After a 12-month Enhanced Primary Care Model Among Chronically Ill Primary Care Patients in Australia.

John

Tannous

Jones

2020

Preprint

View full text Add to dashboard Cite

Purpose: Evidence suggests that Patient-centred Medical Home (PCMH) model facilitates person-centred care and improves health-related quality of life for patients with chronic illness. This study aims to evaluate changes in health-related quality of life (HRQoL), before and after enrolment into a 12-month integrated care program called ‘WellNet’. Methods: This study includes 616 eligible consented patients aged 40 years and above with one or more chronic conditions from six general practices in Sydney, Australia. The WellNet program included a team of general practitioners (GPs) and specially trained chronic disease management (CDM) clinical coordinators (CCs) providing patient-tailored CDM plans configured to individual risk and complexity. HRQoL was recorded using the validated EuroQol EQ-5D-5L instrument. A case-series study design with repeated measures ANCOVA was used to assess changes in EQ-5D index scores after controlling for baseline covariates. Per-protocol analysis and imputed model, the latter using Markov Chain Monte Carlo (MCMC) algorithm of multiple imputation were analysed. A backward stepwise multivariate linear regression models were conducted to determine predictors of EQ-5D index scores at follow-up. In addition to EQ-5D instrument, a supplementary analysis was carried out with use of the short versions of Knee and/or Hip disability and osteoarthritis outcome scores (KOOS and HOOS) reported by patients diagnosed with osteoarthritis. Results: Out of 616 patients, 417 (69%) reported EQ-5D scores at follow-up. Almost half (48%) of the WellNet patients reported improved EQ-5D index scores at follow-up. After controlling for baseline covariates, the adjusted mean difference was statistically significant whilst also meeting the bare minimal clinically important difference (MCID) with a change of 0.03 (95% CI 0.01, 0.05). However, the imputed model failed to meet statistical significance. The multivariate regression models determined that baseline EQ-5D scores, positive diagnosis of a respiratory illness, and private health insurance status were significant predictors of HRQoL at follow-up. There were significant improvements across both KOOS and HOOS assessments, specifically, the pain and symptom scores in both scales met statistical significance in addition to meeting the MCID.Conclusion: Patient-tailored CDM plans designed by team of GPs and CDM clinical coordinators could lead to better HRQoL among primary care patients.

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Clinical Quality and the Patient-Centered Medical Home

Cited by 20 publications

References 6 publications

Association of High-Cost Health Care Utilization With Longitudinal Changes in Patient-Centered Medical Home Implementation

Association of High-Cost Health Care Utilization With Longitudinal Changes in Patient-Centered Medical Home Implementation

Changes in health-related quality of life before and after a 12-month enhanced primary care model among chronically ill primary care patients in Australia.

Changes in Health-Related Quality of Life Before and After a 12-month Enhanced Primary Care Model Among Chronically Ill Primary Care Patients in Australia.

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