Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home

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Full text is available at:
http://www.annfammed.org/cgi/content/full/7/3/254

Synopsis

A preliminary evaluation of a two-year national demonstration conducted by the American Academy of Family Physicians suggests that it is possible to transform a primary care practice into a patient-centered medical home. The results also suggest that those leading other medical home demonstrations around the country vastly underestimate the magnitude, timeframe, technology, and capital required to implement this transformation.


The Issue

Nutting ITL Pull QuoteThe patient-centered medical home is rapidly gaining recognition as a superior way to deliver primary care, particularly for people with complex health care needs. Its salient features include: a personal physician, a whole-person orientation, use of evidence-based medicine and health information technology, enhanced access to care, and reimbursement that reflects the care coordination services furnished by the provider. In nearly every state, demonstration projects have been launched to transform primary care practices into patient-centered medical homes. The authors of this report caution that the rush to demonstrate the viability of the patient-centered medical home could undermine its effectiveness.


Key Findings

  • Transforming a primary care practice into a patient-centered medical home requires wholesale practice redesign and continuous commitment to enhancing the patient experience. Transformation will likely include a host of interdependent components, such as new scheduling arrangements, better coordination with other parts of the health care system, more point-of-care services, and development of team-based care, among others. "Change is hard enough; transformation to a patient-centered medical home requires epic whole-practice reimagination and redesign."
  • Developing and implementing an information technology infrastructure to support this transformation is more difficult and time-consuming than may be anticipated. Information technology is currently underdeveloped to meet the needs of the patient-centered medical home.
  • Transformation involves a shift from physician-centered care to a team approach, in which patient care is shared among office staff.
  • Rapid transformation can result in staff burnout, turnover, and financial distress.
  • Moving toward the patient-centered medical home model is a developmental process that can take up to five years to achieve; successful transformation is highly dependent on local conditions that affect health care practices and their surrounding health care system.


Addressing the Problem

Based on their evaluation, the authors make several recommendations to support practices in their efforts to adopt the patient-centered medical home model:

  • Pilot programs should include up-front capital to help purchase and implement new information technologies, and ongoing funding to support personnel changes needed to implement better care management.
  • Practices must determine the specifications and path toward achieving their own transformation, but facilitation through consultation and other services can play an important role.
  • Professional organizations should help doctors acquire the patient and practice management skills needed to make this transformation.
  • The National Committee for Quality Assurance may need to revise its process for recognizing patient-centered medical homes to encourage a more developmental approach at the practice level.


About the Study

The authors conducted a qualitative evaluation of outcomes from the National Demonstration Project, a two-year pilot program that included a national sample of 36 primary care practices. Some of the practices received facilitated support (assistance from a change facilitator, ongoing consultation in practice economics, health information technology, quality improvement, and discounted software technology, training, and support), while others were self-directed. The authors examined the effectiveness of the patient-centered medical home model on patient and practice outcomes. They also looked at the effectiveness of facilitated support in transforming the practices into patient-centered medical homes.


The Bottom Line

Transforming primary care practices into patient-centered medical homes will require substantially larger investments than those currently made in time, money, and physician and technology support.

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Publication Details

Publication Date:
May 13, 2009
Authors:
Paul A. Nutting, M.D., M.S.P.H., William L. Miller, M.D., M.A., Benjamin F. Crabtree, Ph.D., Carlos Roberto Jaén, M.D., Ph.D., Elizabeth E. Stewart, Ph.D., and Kurt C. Stange, M.D., Ph.D.
Citation:
P. A. Nutting, W. L. Miller, B. F. Crabtree et al., "Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home," Annals of Family Medicine, May/June 2009 7(3):254–60.

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