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IIR 09-082 – HSR&D Study

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IIR 09-082
Implementation and Impact of VA Patient-Centered Medical Home
Elizabeth M. Yano PhD MSPH
VA Greater Los Angeles Healthcare System, Sepulveda, CA
Sepulveda, CA
Funding Period: October 2010 - March 2013

BACKGROUND/RATIONALE:
The Veterans Health Administration (VA) launched its national patient-centered medical home (PCMH) initiative, called Patient Aligned Care Teams (PACT), in 2010, building on growing evidence that the PCMH model of care holds promise for improving quality, patient experience, and provider/staff satisfaction, while lowering unnecessary utilization and costs of care. While evidence outside the VA documents PCMH effects, VA policymakers and managers lack needed information on the relationships between specific VA PCMH features and outcomes among Veterans, and the facility and practice characteristics that promote their adoption. This study capitalized on unique national primary care (PC) organizational survey data that predated PACT implementation, in the context of interdisciplinary consensus development techniques and secondary data on patient experiences and quality of care metrics, for arriving at a VA-focused model of medical home implementation and impact for use in VA policy and planning.

OBJECTIVE(S):
Our aims have been to evaluate the impacts of existing VA patient-centered The main goal of this study was to examine the state of implementation of VA medical homes prior to PACT implementation, to characterize their key features, success factors and performance, and ultimately to inform evidence-based practice and policy recommendations for ongoing improvement.
We used national VA PC organizational and performance data (2007-2010) to:
1) Evaluate the impacts of existing VA PCMH models on quality of care, including which elements are most effective;
2) Determine factors related to successful site adoption of PCMH models and features in VA;
3) Use expert panel methods to integrate and apply findings from the first two aims to develop practice and policy recommendations on evidence-based PC delivery models.


METHODS:
This mixed methods study incorporated secondary analyses of existing multilevel data (area, organizational and patient-level measures), cross-case analyses to examine patterns of PCMH feature adoption and quality metrics, and expert panel methods to come to consensus on definitional elements and success factors related to a VA-focused framework for PCMH measurement. Secondary data sources included (1) the VA Clinical Practice Organizational Survey (CPOS) (2006-07); (2) the VA National Primary Care Survey (NPCS) (2008-09); (3) the American College of Physicians' Medical Home Builder Survey (ACP-MHB) (2009); (4) VA External Peer Review Program (EPRP) chart-based quality indicators (2007-10); (5) the VA Survey of Healthcare Experiences of Patients (SHEP) data (2007-10); and (6) Area Resource File data (2008). CPOS and NPCS included VAs serving 4000+ PC patients and delivered 20,000+ PC visits (n=250); ACP-MHB surveys included all VA PC practices (n>850), including VA-staffed and contract community-based outpatient clinics (CBOCs). Patient-level EPRP (e.g., diabetes process measures, preventive practices) and SHEP (e.g., patient ratings of care) data were mapped to their respective home sites using substation identifiers. Facility SHEP scores of accessibility, continuity, coordination were also used as PCMH definitional features in selected analyses. We conducted two expert panels using modified Delphi techniques. The first panel identified and came to consensus on core definitional PCMH features vs. (enabling) success factors. We mapped CPOS and NPCS measures to the resulting PCMH features and success factors, and tested for associations with PCMH outcomes. We received supplemental funding to integrate ACP-MHB and later quality data (2009-10) to cross-validate findings and examine alternate specifications of the definitional VA PCMH features. We convened a second panel meeting to generate hypothesized relationships without data, and then underwent structured review and discussion of study results.

FINDINGS/RESULTS:
The expert panel arrived at seven definitional elements of a VA PCMH (e.g., PC provider supported by a team; practice ensures continuous care by one provider; appropriate use of technology; performance monitoring to improve quality; integrated mental health; ongoing assessment of patients' communication needs; practice ensures accessibility). They also came to consensus on five success factors (e.g., adequate PC provider support staffing; adequate pharmacist staffing; care coordination in the PCMH "neighborhood"; strong quality improvement culture; incentive use to improve quality). Mapping of expert panel derived definitional elements and success factors to existing data sources varied in completeness of construct coverage.

Pre-PACT (2007), 6% of VA practices had all seven definitional PCMH features. Overall, VAs with more PCMH features did not have significant performance advantages over those with fewer features, though very uneven implementation of individual features may have limited predictive power. Nonetheless, as hypothesized, many discrete definitional features of PCMH had significant relationships to patient experiences and quality of care metrics. For example, having more explicit or technological mechanisms for notifying PC providers about healthcare events that occurred outside of the practice (e.g., hospitalizations, emergency visits, specialty consults) was associated with better patient-reported continuity, coordination and overall quality. Having mechanisms in place to address patient communication, self-management needs and patient preferences was associated with better patient experiences (e.g., access, coordination and/or overall quality). In contrast, no PCMH features were consistently and positively associated with a preponderance of quality metrics. Instead, some quality metrics appeared more sensitive to PCMH than others (e.g., substance use disorder screening positively associated with PCMH-ness as a whole and with four of seven PCMH features).

Organizational factors outside of PC (e.g., academic affiliation and size) and area factors (e.g., region) appeared to be important quality determinants and were, themselves, associated with implementation of different PCMH features. For example, Veterans seen in VAMCs were more likely to report that they received care quickly compared to CBOCs, but rated CBOCs more highly in doctor-nurse communication and overall health care quality. We also noted decrements in patient ratings of access and coordination for every 1,000 more patients seen in VA settings, consistent with larger facility size and greater organizational complexity.

IMPACT:
Despite historical gains in PC delivery during VA's quality transformation of the mid-1990s, very few VA facilities retained the range of PC features needed to meet PCMH requirements, demonstrating the importance of the PACT initiative. In the absence of full PCMH models, we found evidence of key linkages between individual PCMH features and patient experiences of VA care and VA quality of care metrics that may inform ongoing refinement of the VA PACT model and insights into opportunities for focused improvements in implementation priorities. Contextual factors at the facility and area levels also appear to be critical both to local PCMH implementation and the quality VA PACTs can achieve, and will likely require greater attention.

PUBLICATIONS:

Journal Articles

  1. Farmer MM, Rose DE, Rubenstein LV, Canelo IA, Schectman G, Stark R, Yano EM. Challenges facing primary care practices aiming to implement patient-centered medical homes. Journal of general internal medicine. 2014 Jul 1; 29 Suppl 2:S555-62.
  2. Kanwal F, Hoang T, Chrusciel T, Kramer JR, El-Serag HB, Durfee J, Dominitz JA, Yano EM, Asch SM. Association between facility characteristics and the process of care delivered to patients with hepatitis C virus infection. Digestive diseases and sciences. 2014 Feb 1; 59(2):273-81.
  3. Yoon J, Rose DE, Canelo I, Upadhyay AS, Schectman G, Stark R, Rubenstein LV, Yano EM. Medical Home Features of VHA Primary Care Clinics and Avoidable Hospitalizations. Journal of general internal medicine. 2013 Sep 1; 28(9):1188-94.
  4. Glasgow JM, Yano EM, Kaboli PJ. Impacts of organizational context on quality improvement. American journal of medical quality : the official journal of the American College of Medical Quality. 2013 May 1; 28(3):196-205.
  5. Chang ET, Rose DE, Yano EM, Wells KB, Metzger ME, Post EP, Lee ML, Rubenstein LV. Determinants of readiness for primary care-mental health integration (PC-MHI) in the VA Health Care System. Journal of general internal medicine. 2013 Mar 1; 28(3):353-62.
  6. Kocarnik BM, Liu CF, Wong ES, Perkins M, Maciejewski ML, Yano EM, Au DH, Piette JD, Bryson CL. Does the presence of a pharmacist in primary care clinics improve diabetes medication adherence? BMC health services research. 2012 Nov 13; 12(1):391.
  7. Yoon J, Yano EM, Altman L, Cordasco KM, Stockdale SE, Chow A, Barnett PG, Rubenstein LV. Reducing costs of acute care for ambulatory care-sensitive medical conditions: the central roles of comorbid mental illness. Medical care. 2012 Aug 1; 50(8):705-13.
  8. So C, Kirby KA, Mehta K, Hoffman RM, Powell AA, Freedland SJ, Sirovich B, Yano EM, Walter LC. Medical center characteristics associated with PSA screening in elderly veterans with limited life expectancy. Journal of general internal medicine. 2012 Jun 1; 27(6):653-60.
  9. Farmer MM, Rose DE, Riopelle D, Lanto AB, Yano EM. Gender differences in smoking and smoking cessation treatment: an examination of the organizational features related to care. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2011 Jul 1; 21(4 Suppl):S182-9.
HSR&D Article

  1. Cordasco KM, Rubenstein LV. Care Coordination and PACT: Progress, Promise, and Work To Be Done. HSR&D FORUM. 2014 Aug 19; 6(3): 1.
  2. Rose DE, Farmer Coste MM, Yano EM. Opportunities for Improved Care Coordination in VA’s Medical Neighborhoods. VA HSR&D Forum. 2014 Aug 1; 2014(8): 4.
Conference Presentations

  1. Farmer Coste MM, Rose DE, Canelo IA, Stark R, Schectman G, Rubenstein LV, Yano EM. Organizational Determinants of Women Veterans Getting Needed Care. Poster session presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA.
  2. Rose DE, Farmer Coste MM, Canelo IA, Schectman G, Stark R, Rubenstein LV, Yano EM. Is Patient Centered Medical Home Readiness associated with Receipt of Cancer Screenings in VA? Poster session presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA.
  3. Rose DE, Canelo IA, Farmer Coste MM, Rubenstein LV, Yano EM. Impact of PCMH features on VA primary care patients’ ratings of healthcare quality. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.
  4. Rose DE, Farmer Coste MM, Canelo IA, Rubenstein LV, Yano EM, Schectman G, Stark R. Prevalence and organizational correlates of good care coordination in VA primary care. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.
  5. Yoon J, Cordasco KM, Rubenstein LV, Chow A. ED Visits after Medical Home Implementation in VA Primary Care Clinics. Paper presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.
  6. Rubenstein LV, Stockdale S, Sapir N, Altman L, Dresselhaus T, Salem-Schatz S, Vivell S, Ovretveit J, Hamilton AB, Yano EM. A patient-centered primary care practice approach using evidence-based quality improvement: Rationale, methods, and early assessment of implementation. Poster session presented at: Academy for Healthcare Improvement Annual Meeting; 2014 May 27; Washington, DC.
  7. Rose DE, Farmer MM, Canelo IA, Schectman G, Stark R, Rubenstein LV, Yano EM. In VA, is Patient Centered Medical Home Readiness Associated with Cancer Screenings? Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 23; Baltimore, MD.
  8. Taylor SL, Rose DE, Farmer Coste MM, Canelo IA, Rubenstein LV, Yano EM, Ahluwalia SC. Prevalence of Patient-Centered Medical Homes Features in VA Facilities – Results of a National Survey. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 23; Baltimore, MD.
  9. Chang ET, Magnabosco J, Chaney E, Lanto AB, Simon BF, Yano EM, Rubenstein LV. Predictors of primary care management of depression in the VA. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 22; Baltimore, MD.
  10. Chou AF, Rose DE, Farmer Coste MM, Canelo IA, Yano EM. Organizational Factors Affecting the Likelihood of Cancer Screening among VA Patients. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.
  11. Farmer Coste MM, Rose DE, Rubenstein LV, Canelo IA, Taylor SL, Schectman G, Stark R, Yano EM. Frontline Challenges to Delivering Primary Care. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.
  12. Farmer Coste MM, Rose DE, Rubenstein LV, Canelo IA, Taylor SL, Schectman G, Stark R, Yano EM. Challenges in Meeting the VA Primary Care Needs of OEF/OIF Veterans. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.
  13. Rose DE, Farmer Coste MM, Mitchell MN, Canelo IA, Yano EM. Moving into the Medical Neighborhood: Predictors of Specialty Care Coordination Problems. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 11; Seattle, WA.
  14. Chou AF, Rose DE, Yano EM. Organizational Factors Affecting the Likelihood of Cancer Screening among VA Patients. Paper presented at: Healthcare Organizational Research Association Annual Conference; 2011 Jun 9; Seattle, WA.
  15. Rose DE, Klap RS, Farmer Coste MM, Mitchell MN, Canelo IA, Yano EM. Use of Provider Feedback and Clinical Champions Associated with Depression Screening : Findings from the External Peer Review Program and VHA Clinical Practice Organizational Survey, 2007. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; Washington, DC.


DRA: Health Systems
DRE: Treatment - Comparative Effectiveness
Keywords: Organizational Structure, Quality Improvement
MeSH Terms: none