When a safety-net teaching clinic in Los Angeles implemented some, but not all, of the components of the patient-centered medical home (PCMH) model as part of a yearlong study, patient satisfaction with access and overall care soared -- and so did the satisfaction of residents who worked in the clinic. Study results appear in "Patient-Centered Medical Home Intervention at an Internal Medicine Resident Safety-Net Clinic," published online Sept. 4 in JAMA Internal Medicine.
"We believe our study is the first controlled evaluation of a PCMH-guided intervention in a teaching setting," said Michael Hochman, M.D., M.P.H., the study's lead author. "While the study was done at an internal medicine clinic, it certainly is relevant to family medicine, as well."
The study was led by the Keck School of Medicine of the University of Southern California (USC), Los Angeles, with David Goldstein, M.D., chief of the school's Division of Geriatric, Hospital, Palliative and General Internal Medicine, serving as principal investigator and senior author. The intervention clinic is at the Los Angeles County + USC Medical Center (LAC+USC). Two similar internal medicine clinics at LAC+USC served as controls.
Hochman worked on the study while a fellow in the Robert Wood Johnson Foundation Clinical Scholars program at the University of California, Los Angeles, with support from the U.S. Department of Veterans Affairs. He now is medical director for innovation at AltaMed Health Services, a federally qualified health center in Southern California.
- Researchers made a limited number of changes related to the patient-centered medical home (PCMH) model in a safety-net internal medicine teaching clinic and found that one year after the changes, patient satisfaction with access and overall care had increased significantly.
- Resident physician satisfaction at the clinic also increased, as did interest in primary care careers, although the latter increase was small.
- Satisfaction increased even though the clinic didn't change enough to become a full-fledged PCMH.
Three PCMH Principles
The changes made in the intervention clinic reflected three central principles of the PCMH model: expanded access to care, enhanced care coordination and team-based care. The changes included
- creation of a call center staffed by two care coordinators during clinic hours,
- telephone renewal of prescriptions,
- the addition of urgent care appointment slots to each day's schedule, and
- initiation of 24/7 access to physicians.
A resident physician, supervised by an attending physician, was assigned to triage medically related calls and assist with case management.
The researchers assessed patient and resident satisfaction at baseline and again one year after the changes were made using the Agency for Healthcare Research and Quality's Consumer Assessment of Healthcare Providers and Systems survey for patients and a validated teaching clinic survey for residents.
"We found significant improvements in patient satisfaction regarding access to care and overall care in the intervention clinic," Hochman told AAFP News Now.
For example, satisfaction with the ease of making urgent appointments jumped from 12 percent to 53 percent for the intervention clinic compared with a rise of from 14 percent to 18 percent in the control clinics. Satisfaction with after-hours telephone access spiked from 15 percent to 63 percent for the intervention clinic compared with an increase of from 10 percent to 16 percent for the controls.
Patients' overall rating of care as good or excellent leapt from 56 percent to 80 percent in the intervention clinic, whereas the rating rose only from 62 percent to 64 percent in the control clinics.
There were no improvements in patient satisfaction with care coordination, "perhaps because the care-coordination enhancements affected patients indirectly," the authors wrote. "For example, care coordinators facilitated urgent specialty appointments for patients; however, this assistance occurred behind the scenes."
The intervention also demonstrated no effect on preventable emergency department visits, and hospitalization rates in the intervention clinic increased by a small but significant amount.
"Others in academic medicine had said that we wouldn't see a drop in ER use and hospitalization because when you expand access to an underserved population, there's usually a spike in use," Hochman said. "I was still hopeful, so I was personally surprised at these results. However, I'm optimistic that, with time, the clinic will start to have an impact on inappropriate use."
In the intervention clinic, residents' overall rating of the clinic experience rose from 47 percent to 57 percent, while the overall rating dropped from 39 percent to 36 percent in the control clinics. Similarly, the resident composite satisfaction score rose from 39 percent to 51 percent in the intervention clinic, but dropped from 46 percent to 42 percent in the controls.
In addition, residents who worked in the intervention clinic's call center reported it to be a valuable experience.
"Medical care is moving more and more to the team approach and away from the traditional model that rests on the shoulders of the superhuman primary care doctor -- which is good, because none of us is superhuman," said Hochman. "But, in order to make the team model work, physicians need a good understanding of each team member's role. Our intervention provided residents with a good opportunity to understand the role of the care coordinator and what happens in a call center, which is an important access point for patients."
Interest in Primary Care
The resident survey included a question about interest in primary care careers. Interest among residents in the intervention clinic increased, while interest dropped in the control clinics, said Hochman. "The increase didn't reach statistical significance because the sample size was small, but it's fair to say that there was a trend toward greater interest (among residents) in the intervention clinic."
Hochman pointed out that instituting PCMH components to improve the teaching clinic experience helps with only one factor influencing interest in primary care careers. "Other reforms are likely necessary, such as educational debt relief, higher salaries, and better primary care mentorship in academic institutions," he said.
Not Quite a PCMH
It's important to note that satisfaction increased even though the intervention clinic didn't change enough to become a full-fledged PCMH, Hochman said. He and another researcher performed retrospective assessments of the study clinics using the 2011 PCMH standards from the National Committee for Quality Assurance. At baseline, the intervention clinic did not qualify as a PCMH, scoring 35 of 100 possible points and meeting just one of the six must-pass elements. After the intervention, the clinic still didn't qualify as a PCMH, but its score increased to 53 and it achieved four of the six must-pass elements.
According to Goldstein, the study demonstrated that even a "minimal investment and reorientation in delivery, focused on the patient and enhanced access to care, could improve the satisfaction of patients, staff and physicians, even in an underfunded public environment."
The study's primary funding came from the UniHealth Foundation in Los Angeles.
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