The Post-Katrina Conversion Of Clinics In New Orleans To Medical Homes Shows Change Is Possible, But Hard To Sustain

Abstract

Hurricane Katrina destroyed much of the health care infrastructure in and around New Orleans in 2005. We describe a natural experiment that occurred afterward, amid efforts to rebuild the city's health care system, in which diverse safety-net clinics were transformed into medical homes. Using surveys of clinic leaders and administrative data, we found that clinics made substantial progress in implementing new clinical processes to improve access, quality and safety, and care coordination and integration. But there was wide variation, with some clinics making only minimal progress. Because the transformation was closely tied to the receipt of federal grants and bonus payments, we observed declines in performance toward the end of the study, when clinics faced diminished federal funding and refocused their priorities on survival. Now that federal funds have dried up, moreover, clinics may be losing ground in sustaining their practice changes. The experience shows that payment to support medical home transformation must be robust and stable, and clinics need to be fully integrated into the broader health care system to improve overall coordination of care.

Transforming Primary Care in the New Orleans Safety-net

“…A spate of national PCMH demonstrations focuses on different aspects of the medical home, 40 and real-world experiments are beginning to unfold under diverse conditions in preparation for implementing health reform. 30,34,41 Such variation in the goals and contexts of change are likely to lead to equally varied effects on the patient experience and other outcomes.…”

“…These 3 outcome measures were drawn from a wide range of items included in the patient survey, many drawn from prior studies of patient experience and satisfaction, including those reviewed above. 34 To develop the 3 indices, we inspected the distributions of all raw items in the survey for range, skewness, and central tendency (eg, medians). From this, we found that items pertaining to the more concrete aspects of the patient experience-actual behaviors and events-elicited a wider range of responses, and therefore better-differentiated patient experiences, compared with items asking for more subjective attitudes towards the clinic.…”

“…Of primary interest was the clinic's PCMH Score based on a 27-item index capturing the extent to which the clinic had adopted PCMH structural and process improvements. 34 This index was adapted from survey instruments used in the National Study of Small and Medium-Sized Physician Practices 36,37 and the National Committee on Quality Assurance Physician Practice Connection-PCMH Instrument. 38 The 27 items capture a range of PCMH improvements, including enhanced access (eg, after hours, phone access), care coordination (eg, use of patient registries, care managers), and quality/safety improvements (eg, Plan-Do-Study-Act cycles and performance feedback to clinicians).…”

“…33,34 Data collection involved 1-hour computer-assisted telephone interviews with leaders from each primary care clinic during March 2009. To improve accuracy, we performed additional validation interviews by telephone with the same respondents from all 26 clinics.…”

Contrasting Trajectories of Change in Primary Care Clinics: Lessons From New Orleans Safety Net

“…8 As a part of that evaluation, we conducted semiannual survey telephone interviews with clinic leaders. These interviews were supplemented with routine administrative data on each clinic collected semiannually by the Louisiana Public Health Institute staff at approximately the same time.…”