Process and Outcomes of Patient-Centered Medical Care With Alaska Native People at Southcentral Foundation

Abstract

PURPOSE This study describes key elements of the transition to a patient-centered medical home (PCMH) model at Southcentral Foundation (SCF), a tribally owned and managed primary care system, and evaluates changes in emergency care use for any reason, for asthma, and for unintentional injuries, during and after the transition. METHODSWe conducted a time series analyses of emergency care use from medical record data. We also conducted 45 individual, in-depth interviews with PCMH patients (customer-owners), primary care clinicians, health system employees, and tribal leaders. RESULTSEmergency care use for all causes was increasing before the PCMH implementation, dropped during and immediately after the implementation, and subsequently leveled off. Emergency care use for adult asthma dropped before, during, and immediately after implementation, subsequently leveling off approximately 5 years after implementation. Emergency care use for unintentional injuries, a comparison variable, showed an increasing trend before and during implementation and decreasing trends after implementation. Interview participants observed improved access to primary care services after the transition to the PCMH tempered by increased staff fatigue. Additional themes of PCMH transformation included the building of relationships for coordinated, team-based care, and the important role of leadership in PCMH implementation.CONCLUSIONS All reported measures of emergency care use show a decreasing trend after the PCMH implementation. Before the implementation, overall use and use for unintentional injuries had been increasing. The combined quantitative and qualitative results are consistent with decreased emergency care use resulting from a decreased need for emergency care services due to increased availability of primary care services and same-day appointments.

“We’ve Not Gotten Even Close to What We Want to Do”: a Qualitative Study of Early Patient-Centered Medical Home Implementation

“…Trade-offs between different outcome measures and staff satisfaction have been found in other systems implementing PCMH models. 7 Monitoring and addressing burnout will be important throughout PACT implementation.…”

“…4 Medical home features, such as enhanced patient access, improved scheduling, care provider continuity, and care coordination activities, have been associated with lower rates of avoidable hospitalizations and decreased Emergency Department use. [5][6][7][8] Multiple difficulties in implementing the PCMH model, however, have been documented. The move away from a physician-centric model of care towards one that is truly team-oriented, and the challenges of aligning financial reimbursement with the PCMH's emphasis on proactive prevention, are only two of the model's persistent challenges across diverse primary care practices.…”

Transformational change in healthcare: an examination of four case studies

“…14 In the 1980s the Alaskan healthcare system was very poor. It was grossly inefficient, with exceptionally long waiting times to see family doctors, escalating emergency room activity, and 'atrocious' health outcomes with low life expectancy and endemic chronic illness.…”

“…15 There were significant setbacks during implementation, including stress on providers, resignations and retirements; however, in time, primary care 'grew and grew'. 14 Finally, Southcentral Foundation uses sophisticated data and performance management systems. Their 'Data Mall', which commenced in 2003, is an intranet system that provides realtime feedback and performance data.…”

The impact of improving access to primary care

“…However, there is much less information about what would happen if ready access to primary care suddenly occurred 22, 23, 24. There is little evidence about how quickly and how much utilization would shift and costs change if ready access to primary care were provided.…”