Nicole Merrithew
PAH 660
Draft Research Proposal
November 19, 2014
Title
Statewide Patient-Centered Medical Home Recognition Programs: Characteristics of Participating vs. Non-participating Practices
Background and Statement of the Problem
The concept of the Patient-Centered Medical Home (PCMH) was originally developed in the 1960s by the American Academy Pediatrics. As initially conceived, the model was focused on providing a central source of care and medical record specifically for children with special health care needs (cite). Since that time, several different definitions of and tools for assessing the medical home have been developed (cite). Although each definition includes different measures of primary care processes, outcomes, and experience, each also aims to achieve similar overarching goals of improving outcomes and patient experience while decreasing unnecessary utilization and costs.
There is a body of emerging evidence on PCMH interventions, many of which include use or implementation of national accreditation models and/or tools. These include the National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH), the Center for Medical Home Improvement’s Medical Home Index (MHI), the Joint Commission’s Primary Care Medical Home designation standards, and others. There is a much lesser body of evidence, however, comparing the effectiveness and characteristics associated with each of these definitions and tools (cite).
Oregon has taken the approach of defining its own version of a PCMH, the Patient-Centered Primary Care Home (PCPCH). The PCPCH model was developed by a broad stakeholder group and is defined by six core Attributes (Access to Care, Accountability, Comprehensive Whole Person Care, Continuity, Coordination and Integration, and Person and Family Centered Care) each with a corresponding number of standards and measures. It is similar to several of the national models but varies significantly in terms of its flexibility and process for certification.
The Oregon Health Authority (OHA) has developed a process by which practices are officially recognized by the State as meeting the PCPCH criteria. The process includes a self-attestation application component and only requires that a clinic implement a subset of the PCPCH standards to achieve official recognition. The intent of setting a lower threshold for recognition was to engage a larger population of clinics that could then be supported through educational opportunities and other resources to continue along the practice transformation spectrum. The underlying theory to this approach is that affecting a smaller, more incremental change across a broader population as opposed to a more significant change across a narrow population ultimately yields a bigger impact across the total populace.
While the OHA has taken a less onerous approach to certification requirements, other recognition programs such as the NCQA PCMH are comparably more prescriptive and require a more rigorous application process. It was noted from several clinicians and other stakeholders during the PCPCH model development process that these features of the NCQA model posed significant barriers to practice participation. This feedback, in part, led to the implementation approach taken by the OHA (cite).
It is of interest, both to the Oregon policy-making community as well as to the national PCMH stakeholder audience, to investigate whether a more incremental approach to statewide PCMH implementation yields a bigger impact across the entire intended population. As mentioned previously, there is an emerging body of evidence looking at implementation and characteristics of clinics that have pursued some kind of PCMH designation or accreditation. That same level of information has not been synthesized, however, for clinics that do not have PCMH accreditation. Further, there is little evidence comparing these characteristics of clinics in programs where the rigor of requirements for participation varies.
(NOTE: Does there need to be more in here re: outcomes, payment, payer choice of model, etc. to further validate significance of the problem?)
Project Aims
This study will discern whether there are differences in practice characteristics and capabilities in clinics that do and do not participate in PCMH programs and whether those characteristics differ by rigor of program requirements (Table 1).
Table 1. Project Aims
AIM 1 / Evaluate whether there are differences in practice characteristics and capabilities that do and do not participate in PCMH programs.AIM 2 / Evaluate whether characteristics identified in AIM 1 differ by rigor of program requirements.
Answering these questions will provide policymakers and other stakeholders with information about the types of clinical practices that may be unintentionally excluded from practice transformation initiatives depending on the implementation approach. As health care reform efforts continue to expand within Oregon and nationally, it will be increasingly important for policymakers to make intentional, informed decisions on which pieces of the health care system are included in those efforts.
(NOTE: Insert illustration of which methods are tied to each aim)
Technical Approach
Data Collection
To achieve the first aim, the OHA PCPCH Program application will be used gather information on practice characteristics and capabilities. The Program has collected data on over 500 practices in Oregon using this application which includes questions assessing competencies associated with medical home function that are specific to the PCPCH model, questions assessing competencies that are not specific to the PCPCH model, and general descriptive characteristics such as location, practice size and ownership. Specific to the PCPCH model, the application cover six domains:
1. Access to Care – including questions on in-person, after hours, and telephone and electronic access;
2. Accountability – including questions on performance and clinical quality, public reporting, and patient and family involvement in quality improvement;
3. Comprehensive Whole Person Care – including questions on preventive, mental health, substance abuse, and developmental services as well as health assessment and intervention;
4. Continuity – including questions on personal clinician assignment and continuity, clinical information exchange, and specialized care setting transitions;
5. Coordination and Integration – including questions on population data management, electronic health record, complex care coordination, and end of life planning; and
6. Person and Family-Centered Care – including questions on language/cultural interpretation, education and self-management support, and patient experience of care (cite).
(NOTE: Insert illustration of study design - each individual program split out into participants vs. non-participants)
This assessment will be administered electronically to 1) practices identified in Oregon as non-PCPCH practices; 2) practices in Minnesota that do and practices that do not participate in Minnesota’s Health Care Home Program; 3) practices in Vermont that do and practices that do not participate in Vermont’s Blueprint for Health Medical Home Program; and 4) practices in Oklahoma that do and practices that do not participate in Oklahoma’s SoonerCare Medical Home Program. Identification and collection of contact information for practices in Minnesota, Vermont, and Oklahoma will be accomplished in partnership with key program contacts in each state. Given that the PCPCH application requires that quantitative data submissions include a one year sample, practices included in survey administration must have been in operation for one year. Oregon’s PCPCH Program is open to any practice that provides primary care and can meet the PCPCH standards; therefore, practices invited to respond will include primary care practices, school-based health centers, community health centers, obstetrics/gynecology clinics, federally qualified health centers, naturopathic medicine clinics, and tribal clinics.
The assessment will be sent electronically on behalf of each program representative in the respective state to increase the likelihood that the contact name is recognizable and increase the chances of response. Practices will be given a four week response period with an electronic reminder sent at week two. The evaluation team will conduct targeted follow-up as needed to ensure a robust response rate. Previous survey administrations using the same approach have yielded between 69% and 88% response rates (cite).
Aim 2 will combine data collected through Aim 1 with program participation criteria for each Medical Home program in Oregon, Minnesota, Vermont, and Oklahoma. Key program components and requirements for participation will be collected and analyzed using the same approach as developed by Burton, Devers, and Berenson (cite). This methodology assesses PCMH tools by content domains and operational details (Table 2). Through this work they also identified two approaches to PCMH recognition termed High Bar for Recognition, which emphasizes practice structures and processes, and Low Bar for Recognition, which emphasizes quality improvement over the long run and improvement in patient outcomes. The four state programs included in this study will be categorized as either setting a “high bar” or “low bar” for recognition using this same framework (Table 3).
Analysis
An attribute scoring methodology was developed by Gelmon et. al. in order to provide a comprehensive snapshot of practice performance across multiple variables gleaned from the PCPCH application and supplemental survey data. The methodology drew upon existing index scoring approaches that have been developed for the purposes of measuring medical home infrastructure and implementation of the model, but was tailored specifically to the
Table 2. Content Domains and Operational Detail Assessment.
Content Domains / · Access to Care· Comprehensiveness of Care
· Continuity of Care
· Culturally Competent Communication
· Patient Engagement & Self-Management
· Coordination of Care
· Care Plan
· Population Management
· Team-Based Care
· Evidence-Based Care
· Quality Measurement
· Quality Improvement
· Community Resources
· Medical Records
· Health IT
· Standard Care (Non-PCMH)
· Adheres to Current Law
· Business Practices
· Presence of Policies
· Compact between Practice and Patient
Operational Details / · Website
· About Tool Developer
· Release Date
· Other Versions of the PCMH recognition tool
· Clinician Types that Can Lead Practice
· Who Provides Responses?
· Method of Providing Responses
· Answer Format
· Documentation Required?
· Total Number of Items
· Time to Complete Tool
· Administrative Burden
· Responses Verified?
· Scoring Instructions
· Tested for Validity and Reliability?
· Used By
· Endorsed By
· Cost
· How to Obtain Tool
· How to Obtain Accreditation
PCPCH Program application tool (cite). This same methodology will be used to calculate attribute scores for all survey respondents. Whereas the initial attribute scoring work in Oregon included information coming from both the PCPCH application and a supplemental survey, all of the necessary data components are now included in the PCPCH application removing the need for a separate supplemental survey.
(NOTE: Question for Neal: can I do this? This would make sense for this study, but the details of the methodology aren’t published - even though I know what they are).
Table 3. Two Approaches to PCMH Recognition (cite).
High Bar for Recognition / Low Bar for RecognitionWhich Practices Participate in Pilots? / Advanced practices that meet stringent criteria. / A large number of practices with varied capabilities that all commit to becoming a PCMH.
What is the Goal? / Help advanced practices become even more advanced. / Help all practices make at least modest improvements by focusing on “low-hanging fruit.”
When Does Practice Transformation Occur? / Primarily before enrolling in the PCMH effort, as a qualification for entry into the program. / On an ongoing, incremental basis, with performance targets continuously raised.
What Type of Content is Included in the PCMH Recognition Tool / Participation Criteria? / Tool measures a long list of practice capabilities that are believed (but not necessarily proven) to lead to improved outcomes in patients and can be easily documented. May not capture all of the key components of a PCMH. / Practices commit to engage in a few meaningful but hard-to-document PCMH activities (e.g., care coordination, chronic disease management, extended office hours, 24-hour live phone access). Subsequent measurement captures performance on (albeit imperfect) quality measures.
What do plans pay for? / The bulk of reimbursement is determined by a practice’s medical home score upon entrance into the program. / The bulk of reimbursement is based on a practice’s ongoing performance on a set of quality or cost/utilization measures.
Study Limitations - TBD
Merrithew Page | 7
PAH 660
Draft Research Proposal