Summary of the National Demonstration Project and Recommendations for the Patient-Centered Medical Home

Abstract

This article summarizes fi ndings from the National Demonstration Project (NDP) and makes recommendations for policy makers and those implementing patientcentered medical homes (PCMHs) based on these fi ndings and an understanding of diverse efforts to transform primary care.The NDP was launched in June 2006 as the fi rst national test of a particular PCMH model in a diverse sample of 36 family practices, randomized to facilitated or self-directed groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical record audits, and patient and clinical staff surveys. Peerreviewed manuscripts from the NDP provide answers to 4 key questions: (1) Can the NDP model be built? (2) What does it take to build the NDP model? (3) Does the NDP model make a difference in quality of care? and (4) Can the NDP model be widely disseminated?We fi nd that although it is feasible to transform independent practices into the NDP conceptualization of a PCMH, this transformation requires tremendous effort and motivation, and benefi ts from external support. Most practices will need additional resources for this magnitude of transformation.Recommendations focus on the need for the PCMH model to continue to evolve, for delivery system reform, and for suffi cient resources for implementing personal and practice development plans. In the meantime, we fi nd that much can be done before larger health system reform. INTRODUCTIONE merging consensus among policy makers, professional organizations, clinicians, and payers bears witness that health care in the United States has reached a defi ning moment. 1 The landmark 2001 Institute of Medicine report Crossing the Quality Chasm called for extensive overhaul and redesign of US health care.2 The patient-centered medical home (PCMH) is a popular model that proponents hope addresses many of the concerns raised in that report. [3][4][5][6][7] The PCMH concept is endorsed by the major primary care professional organizations, who issued a joint statement on principles of the PCMH in 2007, emphasizing patients' ongoing relationship with a personal physician; team approaches to care; a wholeperson orientation; mechanisms to support care integration, quality, safety and access; and payment for added value. 8 During the past several years, a growing number of PCMH demonstration projects have been undertaken. 9 Some of these focus on chronic care. [9][10][11] Most are regional in scope 9,10,12 or are conducted within a particular integrated health care system. 9,[13][14][15] Relatively few both are comprehensive in scope and include diverse, especially small, independent practices. 9,16 The National Demonstration Project (NDP) launched by the American Academy of Family Physicians (AAFP) S81NDP SU M M A RY A ND R ECO M MENDAT IONS F OR P C MH demonstration project on a national sample of practices designed to test a comprehensive model of the PCMH envisioned by the Future of Family Medicine report. 17In...

Minnesota’s Early Experience with Medical Home Implementation: Viewpoints from the Front Lines

“…3 Research evaluating the PCMH's effectiveness in achieving the goals of improved care quality, patient experience, and reduced healthcare costs has encouraged further refinement of the model. [4][5][6][7][8][9][10][11] Facilitators and barriers to the creation of a successful PCMH have been explored in a limited number of heterogeneous settings, including small practices, large group practices, high-performing practices, and safety net clinics. [12][13][14][15][16][17] To date, significant challenges have been identified; specifically, the investment of resources for infrastructure changes and the leadership skills needed to guide an organization through paradigm-shifting cultural change.…”

“…[12][13][14][15][16][17] To date, significant challenges have been identified; specifically, the investment of resources for infrastructure changes and the leadership skills needed to guide an organization through paradigm-shifting cultural change. 5,14,18 Common facilitators have included valuing innovation, quality improvement, and patient-centeredness. 12,13,16 We sought to augment the literature on motivations, barriers, and facilitators to PCMH implementation by describing a large-scale initiative with some unique features.…”

Primary Care Clinicians’ Recognition and Management of Depression: A Model of Depression Care in Real-World Primary Care Practice

“…The other three-fourths of PC practices are individual or small group practices with scarcer resources. Recent PCMH investigations in smaller practices 45,47,48 suggest the possibility of multiple paths to achieve desired outcomes and that a ground-up approach tailored to complex local contexts and perspectives is key to the successful development and enduring transformation of practices. Assisting personal transformations of clinicians and other agents, while conceptualizing such transformation as evolving (vs. mechanistic) interactions is an important dimension for such practice transformations.…”

“…[25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] Research aligned with still-developing PCMH concepts attempt to address patients as whole persons and make changes in systems that support the capacity of clinicians to provide care more consistent with PC core concepts. [41][42][43][44][45][46][47][48] Results of interventions to date suggest that more comprehensive interventions are more effective, but they tend to be costly and conducted mostly in large health care systems. [49][50][51] In addition, although Veterans Affairs systems have begun to see early positive results, 33,40 even more comprehensive interventions have yielded limited enduring effects in real-world practices.…”

The Patient-Centered Medical Home: Preparation of the Workforce, More Questions than Answers

“…Over time, this process should continue to emphasize core attributes of collaborative care within primary care and attention to mental and public health. 16 The Veterans Health Administration (VA) is the largest organization to have engaged in training clinicians in a PCMH model that includes undergraduate, graduate, and postgraduate levels of an array of health professionals. 17,18 Through the PCMH-like model known as the Patient Aligned Care Team (PACT), the VA has hired and trained clinicians in the skills needed to deliver health care in more than 900 ambulatory practices through interprofessional teams as part of its New Models of Care transformation initiative introduced in 2011.…”