The facilitators and barriers associated with implementation of a patient-centered medical home in VHA

Abstract

BackgroundThe patient-centered medical home (PCMH) is a team-based, comprehensive model of primary care. When effectively implemented, PCMH is associated with higher patient satisfaction, lower staff burnout, and lower hospitalization for ambulatory care-sensitive conditions. However, less is known about what factors contribute to (or hinder) PCMH implementation.We explored the associations of specific facilitators and barriers reported by primary care employees with a previously validated, clinic-level measure of PCMH implementation, the Patient Aligned Care Team Implementation Progress Index (Pi2).MethodsWe used a 2012 survey of primary care employees in the Veterans Health Administration to perform cross-sectional, respondent-level multinomial regressions. The dependent variable was the Pi2 categorized as high implementation (top decile, 54 clinics, 235 respondents), medium implementation (middle eight deciles, 547 clinics, 4537 respondents), and low implementation (lowest decile, 42 clinics, 297 respondents) among primary care clinics. The independent variables were ordinal survey items rating 19 barriers to patient-centered care and 10 facilitators of PCMH implementation. For facilitators, we explored clinic Pi2 score decile both as a function of respondent-reported availability of facilitators and of rating of facilitator helpfulness.ResultsThe availability of five facilitators was associated with higher odds of a respondent’s clinic’s Pi2 scores being in the highest versus lowest decile: teamlet huddles (OR = 3.91), measurement tools (OR = 3.47), regular team meetings (OR = 2.88), information systems (OR = 2.42), and disease registries (OR = 2.01). The helpfulness of four facilitators was associated with higher odds of a respondent’s clinic’s Pi2 scores being in the highest versus lowest decile. Six barriers were associated with significantly higher odds of a respondent’s clinic’s Pi2 scores being in the lowest versus highest decile, with the strongest associations for the difficulty recruiting and retaining providers (OR = 2.37) and non-provider clinicians (OR = 2.17). Results for medium versus low Pi2 score clinics were similar, with fewer, smaller significant associations, all in the expected direction.ConclusionsA number of specific barriers and facilitators were associated with PCMH implementation, notably recruitment and retention of clinicians, team huddles, and local education. These findings can guide future research, and may help healthcare policy makers and leaders decide where to focus attention and limited resources.

Patient Centred Medical Home (PCMH) transitions in western Sydney, Australia: A qualitative study

“…Transition processes described by PCMH interviewees aligned with the ten building blocks of highperforming primary care (8), particularly the foundational elements of engaged leadership, teambased care, and data-driven improvement. Consistent with international literature, our findings indicated that engaged leadership was imperative in driving PCMH transitions (6,7,42,43), and that team-based care was key to the model, requiring protected time for meetings to plan patient care (6,42,44). Conversely, lack of leadership and an absence of staff engagement, particularly among former PCMH interviewees, were cited as barriers to transition, as reported in other studies (7,45).…”

Implementation of a patient centred medical home (PCMH) initiative in general practices in New South Wales, Australia

“…Consistent with other studies our findings indicate that communication between all key project players is crucial for successful project implementation. Routine meetings are important to discuss practice change and to ensure whole team buy-in to the projects (12,45). Ongoing communication and relationship building with allied health services and LHD staff is important for service integration (46).…”

Staff Perspectives on Primary Care Teams as De Facto “Hubs” for Care Coordination in VA: a Qualitative Study

“…14,15 Effective care coordination, however, requires appropriate resources. 16 In the VA, inadequate staffing and time constraints are well-documented challenges of PACT implementation, [17][18][19][20] often associated with higher staff burnout 18 and lower scores on PACT implementation metrics. 19 Competing care delivery priorities and lack of communication from leadership about PACT performance metrics are additional challenges.…”

“…16 In the VA, inadequate staffing and time constraints are well-documented challenges of PACT implementation, [17][18][19][20] often associated with higher staff burnout 18 and lower scores on PACT implementation metrics. 19 Competing care delivery priorities and lack of communication from leadership about PACT performance metrics are additional challenges. 19 Although the literature notes these challenges for PACT, less is known about how care coordination occurs in the context of the resource constraints and competing priorities of routine care.…”

“…19 Competing care delivery priorities and lack of communication from leadership about PACT performance metrics are additional challenges. 19 Although the literature notes these challenges for PACT, less is known about how care coordination occurs in the context of the resource constraints and competing priorities of routine care. Awareness of PACT staff perspectives on care coordination can provide key information to align centrally initiated care coordination initiatives with frontline needs.…”