The long-awaited analysis of a massive patient-centered medical home, or PCMH, national demonstration project, or NDP, conducted from June 2006 to May 2008 now has been published in a special supplement(www.annfammed.org) to the May/June Annals of Family Medicine.
The demonstration project, which was designed by TransforMED(www.transformed.com), a wholly owned subsidiary of the AAFP, tested the ability of family medicine practices to implement and sustain the medical home model of care.
Thirty-six diverse family medicine practices were chosen to participate; however, only 31 completed the project. The practices were split into two groups: one had the benefit of experienced practice facilitators to guide them, and the other, nonfacilitated, group worked through practice changes on their own.
According to a press release from the AAFP, the NDP practice redesign initiative "served as a learning lab to gain better insight into the kinds of hands-on technical support family physicians want and need to implement the PCMH model of care."
The final report on the project, titled "Evaluation of the American Academy of Family Physicians' Patient-Centered Medical Home National Demonstration Project," comprises eight manuscripts written by an independent evaluation team. Topics range from methods for evaluating practice change to implementing the PCMH and assessing patient outcomes.
According to TransforMED's President and CEO Terry McGeeney, M.D., M.B.A., the feasibility and sustainability of the PCMH model was still in question at the end of the NDP in 2008. However, subsequent pilots and projects by TransforMED and other organizations "have demonstrated that the concepts of the patient-centered medical home can indeed improve quality and lower costs of care."
The two-year project engineered by TransforMED made it clear that "most practices need some level of support to make the necessary changes," said McGeeney, adding that the transformation process "is disruptive at multiple levels within a practice."
McGeeney said that during the course of the project, the evaluation team met regularly with the TransforMED facilitation team "to share observations so that the model of care itself -- as well as support to the practices involved in the project -- could be adjusted in real time."
One unanticipated finding, said McGeeney, was that patient satisfaction with family medicine practices in the project did not improve, indicating that the disruption trickles down to affect patient perceptions.
The evaluation team's observations echoed McGeeney's, albeit in slightly stronger terms: "The level of change needed is daunting and requires tremendous motivation of all practice participants," wrote the report authors in the summary section.
They noted that although the PCMH "represents the essentials for better primary care," the model is still evolving. In addition, they said, funding from a combination of federal, state and local governments, as well as from insurance companies and other health system sources, is vital to a successful redesign.
"Expecting practices to front the cost of transformation with the hope of more appropriate reimbursement in the future is unlikely to succeed," the evaluators concluded.
"Ultimately, for the PCMH to spread and become the norm, the delivery system must be reformed to support this approach to care."
The report answers four basic questions regarding the demonstration project and the PCMH model of care.
- Can the model be built? Authors noted that even though it is possible to implement the NDP in highly motivated practices, "doing so may slightly worsen patients' perception of care, at least in the short term." One challenge, noted evaluators, is for practices to implement changes without negatively influencing patients' experiences. "Amidst the substantial practice, personal and financial challenges practices face, it is easy to lose the patient at the center of the PCMH."
- What will it take to build the model? The evaluation team concluded that for most practices, making the changes necessary to fulfill the requirements of a PCMH would take "more time than anyone imagined." They noted that few of the NDP practices completed the transition in two years, even with intense facilitation. "It is apparent that for most practices, the process will take a high degree of motivation, communication and leadership; considerable time and resources; and probably some outside facilitation," said the evaluators.
- Does the model make a difference in the quality of care provided to patients? "The jury is still out on the actual impact on quality of care and patient outcomes," wrote the report's authors. They said that to improve patient outcomes, a wide range of practice structures and processes need to be in place and fully integrated into the daily care of patients.
- Can the NDP model be widely disseminated? Evaluators said the experiences of the practices involved in the project highlighted the fact that becoming a PCMH entails more than a series of incremental changes. "Ongoing problem solving is necessary," said the authors. They noted that for practices to succeed, they must embrace the four pillars of primary care -- easy access to first-contact care, comprehensive care, coordination of care and a long-term personal relationship -- as well as technological components, such as use of electronic health records.
Staff members at TransforMED are continually creating resources to support family medicine practices as they do the hard work needed to become patient-centered medical homes, or PCMHs. Here are some of the newest offerings:
- The Change Readiness Assessment(www.transformed.com) is designed to help assess a practice's readiness to implement change.
- The Patient Experience Assessment Tool(www.transformed.com) is a short questionnaire that provides practices with insight into their patients' view of services provided.
- The Financial Assessment Revenue Opportunity Tool(www.transformed.com) helps practices assess their revenue cycle management functions and identify deficiencies and opportunities.
- A variety of publications and PCMH workbooks(www.transformed.com) are the result of a partnership between TransforMED and the Medical Group Management Association and provide practices with step-by-step information on relevant topics about health care delivery.
In addition, "most primary care practices in the United States will need external resources to successfully undertake the magnitude of redesign envisioned in the PCMH," said the authors. "The NDP model can, thus, probably be disseminated, but only if sufficient time and resources are made available."
McGeeney noted that the NDP practices were able, for the most part, to sustain their momentum. "They continue to meet as a group twice yearly to share their continued learning and progress. They are now called the Touchstone Group," he said.
McGeeney also noted, "The future of the patient-centered medical home is in the concepts of the medical home, not the name. The concepts allow a framework for meaningful transformation that is being leveraged in multiple pilots and projects across the United States."