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

Paul A. Nutting, MD, MSPH; William L. Miller, MD, MA; Benjamin F. Crabtree, PhD; Carlos Roberto Jaen, MD, PhD; Elizabeth E. Stewart, PhD; Kurt C. Stange, MD, PhD

Disclosures

June 09, 2009

Abstract and Introduction

Abstract

The patient-centered medical home (PCMH) is emerging as a potential catalyst for multiple health care reform efforts. Demonstration projects are beginning in nearly every state, with a broad base of support from employers, insurers, state and federal agencies, and professional organizations. A sense of urgency to show the feasibility of the PCMH, along with a 3-tiered recognition process of the National Committee on Quality Assurance, are influencing the design and implementation of many demonstrations. In June 2006, the American Academy of Family Physicians launched the first National Demonstration Project (NDP) to test a model of the PCMH in a diverse national sample of 36 family practices. The authors make up an independent evaluation team for the NDP that used a multimethod evaluation strategy, including direct observation, in-depth interviews, chart audit, and patient and practice surveys. Early lessons from the real-time qualitative analysis of the NDP raise some serious concerns about the current direction of many of the proposed PCMH demonstration projects and point to some positive opportunities. We describe 6 early lessons from the NDP that address these concerns and then offer 4 recommendations for those assisting the transformation of primary care practices and 4 recommendations for individual practices attempting transformation.

Introduction

The patient-centered medical home (PCMH) is rapidly becoming a powerful engine for multiple reform efforts related to health care delivery, reimbursement, and primary care.[1,2,3,4,5,6,7,8,9,10,11,12,13] During the next few years, we can expect thousands of primary care practices to attempt to convert their offices into PCMHs. Demonstration projects are underway in numerous states and supported by amazingly diverse constituencies that include professional organizations, major employers, insurers, Medicare, state governments, not-for-profit foundations, and others. These diverse and rapidly growing efforts are being initiated based on an appealing idea but with little direct empirical support.[4,5] The PCMH represents an innovative and exciting national conversation that melds core primary care principles, relationship-centered patient care, reimbursement reform, new information technology, and the chronic care model. Unfortunately, the rush to demonstrate operational and financial feasibility of the PCMH, proceeding apace with the recognition process of the National Committee for Quality Assurance (NCQA)[14] risks premature closure of the larger PCMH conversations and potentially stifles evolution of the PCMH to meet important patient, practice, and system needs.

The "Future of Family Medicine" report[15] was published in 2004 and detailed the "New Model of Family Medicine."[16] This report helped to initiate the national conversations leading to the PCMH. The National Demonstration Project (NDP) was launched in June 2006 by the American Academy of Family Physicians[17] to test this new model and was updated to be consistent with the emerging consensus principles of the PCMH.[10] Thirty-six family practices were selected from 337 practices completing a well-publicized, comprehensive on-line application. Practice selection attempted to maximize a diversity of geography, size, age, and ownership arrangements. For the most part, the participating practices were highly motivated to test the new models of care and in many cases had begun a local process of innovation.

Practices were randomized into either facilitated or self-directed groups. Facilitated practices received ongoing assistance from a change facilitator, as well as on-going consultation from a panel of experts in practice economics, health information technology, quality improvement, and discounted software technology, training, and support. They were also involved in 4 learning sessions and regular group conference telephone calls. Self-directed practices were given access to Web-based practice improvement tools and services, but they did not have on-site assistance. They self-organized their own learning session halfway through the 2-year project and participated in the final learning session.

The NDP officially concluded, after 2 years, in June 2008. The authors of this report make up an independent evaluation team that designed and is continuing to analyze a multimethod assessment of the NDP. The evaluation addresses both the effect of the PCMH model on patient and practice outcomes and the effectiveness of the facilitated intervention in bringing about transformation.

Even though analysis of the NDP is not yet complete, we feel compelled to share early lessons in advance of more-exhaustive mixed methods research reports planned for early next year. As close observers of these practices for 2 years, we have gained a perspective on the implementation process that we feel deserves attention and public discussion even before the final outcome analysis is completed. In the process of working with these practices, our team has seen the day-to-day reality of changing community-based practices into the current idealized model of the PCMH. We have already learned enough from the NDP to identify some potentially dangerous red flags fluttering over the demonstrations just getting underway. Our early analysis raises concerns that current demonstration designs seriously underestimate the magnitude and time frame for the required changes, overestimate the readiness and expectations of information technology, and are seriously undercapitalized. We fear that with current assumptions, many demonstrations place participating practices at substantial risk and may jeopardize the evolution of the PCMH as unrealistic expectations set up demonstrations and evaluations for failure.

The lessons described below arise from both the real-time or "live" qualitative analysis conducted during the NDP and the in-depth and comprehensive analysis currently underway. The live analysis included real-time reading of all data and multidisciplinary analysis team discussion in biweekly conference calls, quarterly reports to the NDP board,[18] site visits by a member of the evaluation team, 3 analytic retreats, and member checking with NDP facilitators and practice participants to both expand understanding and seek disconfirming data. This special report, based on our ongoing analysis, raises timely concerns and opportunities. The pressure toward widespread adoption of this is model is gaining momentum so rapidly that we feel compelled to share our observations and summarize the early process-evaluation lessons. We describe 6 critical lessons, suggest 4 recommendations for health policy and 4 for practices, and raise hopeful warnings at this critical juncture for primary care reform.

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