Practices I work with are extremely hard working, thorough, and dedicated. They want what is best for their patients and their practice. They have found the PCMH model is the best way to improve their practice to better serve not only their patients but also the overall community. Developing practices into PCMHs is a complex endeavor that requires substantial time, energy, and attention.
Earlier studies suggest the context in which a PCMH is implemented and the process of implementation is critical to achieving the desired impact on primary care. For example, choosing to emphasize efforts to increase patient access to care would likely result in changes in utilization that are different than if a PCMH practice instead emphasized care coordination efforts. Facilitated practices adopted new components more than self-directed practices. Adoption of the PCMH model components was associated with improved access, better prevention scores, and chronic care scores.
Another study that was implemented on 36 family practices across the U.S. (picked randomly, Rural and Urban) found that implementation of PCMH components, whether by facilitation or practice self-direction, was associated with small improvements in condition-specific quality of care but not patient experience. PCMH models that call for practice change without altering the broader delivery system may not achieve their intended results, at least in the short term.
Evaluation of the PCMH model is now under way across the U.S. Within the PCMH model, Coordination of Care linked to primary care practices is substantially reducing overall costs while increasing the quality of care for patients with severe chronic illness. Better outcomes at lower cost were noted after a large integrated delivery system reduced its primary care clinicians’ panel size, lengthened visits, and embedded care management in its electronic medical record. The cost savings in several of these projects exceeds the added investment in primary care services. Evaluations of this type will help us understand not just if, but how the PCMH model could be an effective intervention in a larger tool kit of delivery system innovation.
Currently, the rationale for the PCMH model is drawn mainly from studies of single attributes of primary care, such as continuous relationships; early evidence suggests that more global measures of PCMH attainment are also associated with outcomes. In separate studies, two different PCMH measures were associated with fewer hospitalizations and emergency department visits and less disparity in access.
Patient-level outcomes included a broad and deep array of measures including ratings of the primary care experience, health care quality (medical record measures), patient empowerment, health status, and well-validated measures of primary care’s core attributes. Below are some comments from established patients from before the PCMH model implementation to after implementation.
“Keeps track of all my health care; follows up on a problem I’ve had, either at the next visit or by mail, e-mail, or telephone; follows up on my visit to other health care professionals; helps me interpret my laboratory tests, x-rays, or visits to other doctors; communicates with other health professionals I see.”
“Knows a lot about my family medical history; have been through a lot together; understands what is important to me regarding my health; knows my medical history very well; takes my beliefs and wishes into account in caring for me; knows whether or not I exercise, eat right, smoke, or drink alcohol; knows me well as a person (such as hobbies, job, etc.)”
Practices that adopted more PCMH model components achieved better quality of care scores for chronic disease management, Accountable Cost & Quality Arrangement (ACQA) measures, and prevention services.
Without fundamental transformation of the health care landscape that promotes coordination, close ties to community resources, payment reform, and other support for the PCMH model, practices going it alone will face a daunting uphill climb.