Study Examines Outcomes Associated with VA Implementation of Patient-Centered Medical Home Model of Care

BACKGROUND:
Although the patient-centered medical home (PCMH) has been endorsed by most major primary care groups as a promising model to strengthen primary care, decrease costs, and improve quality, early assessment of PCMH impact has yielded mixed results. Since 2010, VA has undertaken national adoption of a PCMH model called PACT (Patient-Aligned Care Team). Investigators in this study sought to create an index to measure the extent and variation of PACT implementation, and then to conduct an observational study that would examine the association between the implementation index and key outcomes. The main outcomes measured included: patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. Data were collected from 5/12 through 12/12 on 75,000 Veterans who received care at 913 VA outpatient primary care clinics, along with 5,404 primary care staff. Methods of data collection included the PACT Primary Care Personnel Survey that targeted all VA primary care personnel, as well as administrative patient data (e.g., clinical characteristics, healthcare use). The PACT Implementation Progress Index (Pi2) was used to assess PACT domains, such as: access, continuity of care, care coordination, comprehensiveness, patient self-management support, patient-centered care and communication, shared decision-making, and delegation, staffing, and team functioning.

FINDINGS:

• The extent of PACT implementation was highly associated with important outcomes for both patients and providers. Significant trends were observed in the quality of care in relation to the Pi2 score: 77 sites that achieved the most effective implementation exhibited higher clinical quality outcome measures than less successful sites. Overall, of 48 measures, 41 were higher among sites with a higher Pi2 score.
• The rate of emergency department visits was significantly lower in sites with more effective PACT implementation than in those with less effective implementation (188 vs. 245 visits per 1,000 patients), and there were larger projected decreases in rates of ambulatory care sensitive condition (ACSC) admissions after the start of PACT.
• Patient satisfaction was significantly higher among sites that had effectively implemented PACT than among those that had not, and a similarly favorable pattern was observed for staff burnout.

LIMITATIONS:

• Several of the domain scores relied on patient-report, which is subject to biases.
• The primary care personnel survey had a low response rate, but results were consistent with those from other surveys of primary care providers – and with those from a survey of all VA employees.
• The cross-sectional design of the study did not permit assessing change over time.

AUTHOR/FUNDING INFORMATION:
Drs. Nelson, Helfrich, Maynard, Hebert, Liu, Taylor, and Sun are part of HSR&D's Center for Innovation for Veteran-Centered and Value-Driven Care in Seattle and Denver. They also are investigators for the PACT Demonstration Laboratory Coordinating Center, funded by the Office of Patient Care Services and the Office of Primary Care Operations.

Nelson K, Helfrich C, Sun H, et al. Implementation of the Patient-Centered Medical Home in the Veterans Health Administration: Associations with Patient Satisfaction, Quality of Care, Staff Burnout, and Hospital and ED Use. JAMA Internal Medicine. June 23, 2014;e-pub ahead of print.