Spreading a Medical Home Redesign: Effects on Emergency Department Use and Hospital Admissions

Abstract

PURPOSEThe patient-centered medical home (PCMH) is being rapidly deployed in many settings to strengthen US primary care, improve quality, and control costs; however, evidence supporting this transformation is still lacking. We describe the Group Health experience in attempting to replicate the effects on health care use seen in a PCMH prototype clinic via a systemwide spread using Lean as the change strategy. METHODSWe used an interrupted time series analysis with a patient-month unit of analysis over a 4-year period that included baseline, implementation, and stabilization periods for 412,943 patients. To account for secular trends across these periods, we compared changes in use of face-to-face primary care visits, emergency department visits, and inpatient admissions with those of a nonequivalent comparison group of patients served by community network practices. RESULTSAfter accounting for secular trends among network patients, patients empaneled to the PCMH clinics had 5.1% and 6.7% declines in primary care offi ce visits in early and later stabilization years, respectively, after the implementation year. This trend was accompanied by a 123% increase in the use of secure electronic message threads and a 20% increase in telephone encounters. Declines were also seen in emergency department visits at 1 and 2 years (13.7% and 18.5%) compared with what would be expected based on secular trends in network practices. No statistically signifi cant changes were found for hospital admissions.CONCLUSIONS The Group Health experience shows it is possible to reduce emergency department use with PCMH transformation across a diverse set of clinics using a clear change strategy (Lean) and suffi cient resources and supports.Ann Fam Med 2013;11:S19-S26. doi:10.1370/afm.1476. INTRODUCTIONO n the basis of convincing evidence that strong primary care is associated with lower costs and improved quality of care, 1 there is a rapid move to implement the patient-centered medical home (PCMH) across the United States in various settings including independent practices, integrated delivery systems, community health centers, and large government systems. [2][3][4][5] Although these demonstration initiatives share the PCMH guiding principles, 6 they differ considerably with respect to their settings, organizational structures, payer participation, intervention components, and implementation strategies. 2,7 Early results are promising, 8,9 but more extensive and rigorous evaluations are needed. [8][9][10][11] As substantial infrastructure investments are often required to build medical home capabilities, 12 policy makers and health plan leaders are particularly interested in whether and when adoption of this model results in overall cost savings. Since 2006, Group Health Cooperative, a large nonprofi t, consumer-governed, integrated health insurance and care delivery system in the Pacifi c Northwest, has pioneered the medical home redesign. In contrast to small independent practices in the United States, Group Health has traditi...

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

Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model

“…47 Our study fills an important gap in the literature because existing demonstration-project evaluation efforts have focused on system-level cost savings (eg, through fewer emergency department or specialty visits), which have been inconsistently observed. 10,[14][15][16]18,[48][49][50][51][52][53][54][55][56][57][58][59][60][61][62] For many practices, revenue gains must be observed at the practice level to justify practice-level workforce and time use changes. Another key advantage is that our modeling allows us to compare different reforms in the same practices, unlike demonstration projects for which it is unclear whether differences in outcomes are due to differences in the PCMH funding program itself or preexisting practice differences.…”

No Place to Call Home — Policies to Reduce ED Use in Medicaid

“…Medical-home initiatives emphasize prevention and post-acute care, and preliminary studies have shown these models to be effective in reducing ED use among Medicaid beneficiaries. 5 The ACA includes an optional program that gives states additional funding to support providers that develop "health homes" for Medicaid beneficiaries with multiple chronic physical conditions or severe mental illness. The program has been adopted by 16 states to date.…”