Defining High Value Elements for Reducing Cost and Utilization in Patient-Centered Medical Homes for the TOPMED Trial

Abstract

Introduction: Like most patient-centered medical home (PCMH) models, Oregon’s program, the Patient-Centered Primary Care Home (PCPCH), aims to improve care while reducing costs; however, previous work shows that PCMH models do not uniformly achieve desired outcomes. Our objective was to describe a process for refining PCMH models to identify high value elements (HVEs) that reduce cost and utilization. Methods: We performed a targeted literature review of each PCPCH core attribute. Value-related concepts and their metrics were abstracted, and studies were assessed for relevance and strength of evidence. Focus groups were held with stakeholders and patients, and themes related to each attribute were identified; calculation of HVE attainment versus PCPCH criteria were completed on eight primary care clinics. Analyses consisted of descriptive statistics and criterion validity with stakeholder input. Results: 2,126 abstracts were reviewed; 22 met inclusion criteria. From these articles and focus groups of stakeholders/experts (n = 49; 4 groups) and patients (n = 7; 1 group), 12 HVEs were identified that may reduce cost and utilization. At baseline, clinics achieved, on average, 31.3 percent HVE levels compared to an average of 87.9 percent of the 35 PCMH measures. Discussion: A subset of measures from the PCPCH model were identified as “high value” in reducing cost and utilization. HVE performance was significantly lower than standard measures, and may better calibrate clinic ability to reduce costs. Conclusion: Through literature review and stakeholder engagement, we created a novel set of high value elements for advanced primary care likely to be more related to cost and utilization than other models.

The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Cluster Randomized Controlled Trial

“…Our previous work from this study has shown promise in improving the patient experience of care and in engaging practices in transformation. 26,35 This study, however, did not show clear benefits to cost and utilization. The ability to change individual trajectories of patients' health with PCMH and advanced primary care models may be limited without organizationally focused team-driven and patient-driven approaches; programs that facilitate structured care planning with clear tailoring and patient-directed goal setting may also overcome the challenges found in this work.…”

“…Previous results from this trial showed improvement in patient experience of care29 and no change in teamwork and adaptive reserve across the clinics 35. This result was despite significant engagement in the model and improvement in both the HVEs and other QI metrics 26. The time-based modeling showed promising decreases over time, indicating a longer time window may have show different results.…”

“…35 This result was despite significant engagement in the model and improvement in both the HVEs and other QI metrics. 26 The timebased modeling showed promising decreases over time, indicating a longer time window may have show different results.…”

“…All practices received access to an IT system for milestone reporting, financial incentives based on self-selected QI goals, and QI guidance from a practice facilitator (PF). Intervention clinics were directed to select their QI goals from a list of 12 HVEs (Table 1), which our team identified from the literature and stakeholder and patient focus groups as likely to reduce cost and utilization and improve patient outcomes 26. Control clinics selected goals related to PCMH measures; baseline performance on these measures was assessed.…”

“…Intervention clinics were directed to select their QI goals from a list of 12 HVEs (Table 1), which our team identified from the literature and stakeholder and patient focus groups as likely to reduce cost and utilization and improve patient outcomes. 26 Control clinics selected goals related to PCMH measures; baseline performance on these measures was assessed. Overall resources provided to the clinics were equal and allowed teams to maintain autonomy, flexibility in decision-making.…”