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The Patient-Centered Medical Home (PCMH) model has been touted as one of the most promising reform efforts of the largely inefficient U.S. healthcare system. In comparison to the current primary care system, the PCMH is a care delivery model that is based on the principles of care-coordination, enhanced access, and team-based collaboration as a means of providing comprehensive, patient-centered medical care. The current literature contains a limited number of review articles synthesizing the data of numerous PCMH outcome studies. Even a smaller number draws definitive conclusions as to whether PCMH is a viable model upon which to reform the US healthcare system. This literature review will examine the available results of PCMH studies in light of their ability to 1) decrease the overall cost of healthcare 2) increase the efficiency of the continuity of care and 3) to increase positive patient outcomes through proactive patient care. Additionally, these results will be examined in regard to their longevity as a viable model of reform and specifically as it compares to the current US healthcare system. This review will determine whether there is statistical evidence that the Patient-Centered Medical Home is a successful model to decrease healthcare costs, increase healthcare efficiency as well as increasing positive patient outcomes. In addition, this review hopes to point to ways in which the model could be improved in order to more completely achieve the goals listed above.

Thesis (Ph.D.)--University of Missouri-Columbia, 2000. / Typescript. Vita. Includes bibliographical references (leaves 321-333). Also available on the Internet.

Thesis (Ph. D.)--University of Missouri-Columbia, 2000. / Typescript. Vita. Includes bibliographical references (leaves 321-333). Also available on the Internet.

A frequently cited reason for poor quality of care in the ambulatory care setting is the lack of optimally designed systems to address care for those with preventive or chronic care needs. Organizational theory suggests that culture plays an important role in the shaping of these types of programs. The purpose of this cross-sectional study is to understand through descriptive and regression analysis of secondary data, the relationship between the existence of cultural characteristics such as collegiality, quality emphasis and autonomy, and the systems employed to improve quality of care within primary care practices. The study uses an integrated theoretical framework consisting of organizational culture, social network and organizational learning theories to better understand the rationale for the relationships. The analysis is an outgrowth of a previous National Committee for Quality Assurance (NCQA) project conducted in Minnesota where 300 staff across 42 office practices were asked to answer questions on a self-report survey to assess the presence and function of clinical practice systems. To evaluate organizational culture, validated questions from the work of Kralewski and colleagues were also asked. Descriptive analysis results showed a large range in consistency of practice system use, with clinical information systems as most used and care management systems as least used. Results of the multivariate analysis showed collegiality and quality emphasis as significantly related to the use of practice systems. More specifically, both collegiality and quality emphasis were seen to positively influence the use of clinical quality evaluation and improvement systems and an emphasis of quality was seen to positively influence the use of clinician reminders and clinical information systems. A statistically significant relationship between autonomy and practice systems use was not seen. As the study shows that culture does influence the use of certain systems for care improvement, it provides an increased understanding and avenue for intervention/change in the continued quest for improved quality of care. Policymakers and practice leadership may want to focus energy on understanding primarily whether the culture of practices places an emphasis on quality and collegiality. Ultimately it may foster the use of practice systems for quality of care improvement.

The Patient-Centered Medical Home (PCMH) is an emerging model of health care designed to provide a simpler, more effective health care experience. The model places heavy emphasis on the concept of every patient having a "personal physician" who is the point of access for all health care needs and concerns. The personal physician integrates all relevant health care information to provide the patient with a holistic picture of his health. The supposed benefits of the PCMH model include an improved patient experience, increased effectiveness of care, increased efficiency of care, greater access to care, among others. Only now is evidence beginning to emerge to substantiate those clams. As evidence continues to emerge supporting the PCMH model, one area that warrants further study is how those directly involved in health care perceive this model. Here, a survey was developed to assess the following information among a population of pediatric physicians: understanding of the PCMH model, agreement with PCMH principles, interest in moving to a PCMH-based practice, and what issues are perceived as barriers to PCMH integration. Results suggest that there is a high degree of familiarity with the PCMH model and a high level of agreement with PCMH principles in this population, but that agreement does not correlate with interest in moving one’s practice toward the PCMH model. Data further indicate that issues regarding payment and associated expenses for PCMH integration are universally perceived barriers. On the other hand, a lack of evidentiary support and compatibility issues with HIPAA are not perceived as barriers. Other issues, such as human resource needs, were more likely to be perceived as barriers in one subpopulation versus another. These data suggest a disconnect between PCMH familiarity and PCMH interest in pediatric physicians. Further, while some issues are perceived as barriers to all pediatric physicians, some issues are more likely to be perceived as barriers in one physician subpopulation versus another, and these differences must be recognized and addressed to help ensure success of the PCMH movement.

This dissertation proposal seeks to understand if the increasingnumbers (density) of recognized PCMH practices incommunities affect avoidable hospitalizations related toambulatory care sensitive conditions (ACSC), as measured bythe AHRQ Composite Prevention Quality Indicators (PQI). Theresearch has two purposes: 1. Establish constructs and hypotheses to measurethe effect of the increasing numbers of NCQA-Recognized PCMH practices in communities(counties). 2. Using an outcomes-based measurement approach,investigate the relationship between growingdensities of NCQA-Recognized PCMH practicedoctors among all primary care doctors (PCD) ina community and the associated impact on theutilization of inpatient care, specifically related toACSCs, as measured by the AHRQ CompositePQIs. The research is quasi-experimental in design and is based on aretrospective (2008–2011) analysis of existing data from theNCQA PCMH program, the AHRQ Composite PQI and theCenters for Medicare & Medicaid Services (CMS) NationalProvider Identification (NPI) databases. Analysis will linkNCQA-Recognized PCMH practices (independent variable),AHRQ Risk Adjusted Composite PQIs (dependent variable),and the CMS NPI (total PCDs) on Federal InformationProcessing Standard (FIPS) identifiers across 114 state andcounty-level geographical areas in Vermont and North Carolina.

Health care today harms too frequently and routinely fails to deliver its potential benefits. Significant evidence suggests that high quality primary care can positively affect health outcomes. I explored three related topics mentioned frequently in current United States health reform €“ Electronic Health Records (EHR), physician profiling and Medical Home. An investment in these areas is expected to significantly improve quality of care and efficiency; however, there is only a patchwork of evidence supporting such claims. To achieve EHR promises, my research employed a standardization lens to study the dynamics between EHR embedded structures and primary care processes. Using grounded theory, a standardization dynamics model was created describing the influencers, conditions and consequences of the process state. A matrix of two conditions, information exchange and patient complexity, identified four distinct pathways that require a different balance between standardization and flexibility. The value of such pathways is that they frame choices about how to use embedded IT structures to support effective delivery processes. Physician profiling is an emerging methodology used in health care quality improvement programs. Efforts to measure performance at the individual physician level face a number of challenges, including the need for sufficient sample size to support reliable measurement. A process for creating a physician profiling model was developed, and a model designed for a case study site. Results indicate that reliable physician profiling is possible across care domains using a hierarchical composite model. Patient-Centered Medical Home (PCMH) is a new care delivery approach for providing comprehensive primary care that seeks to strengthen the physician-patient relationship. This exploratory study utilizes Pearson correlation coefficients to test four hypotheses about relationships between two sources of data: (1) PPC-PCMH Survey results that measure adoption of PCMH structures and (2) patient experience data from Massachusetts Health Quality Partners (MHQP). The results showed that the PPC-PCMH structures of access and communication were negatively correlated with the related patient experience measure. This study contributes to the literature by addressing deficiencies in how EHR-enabled processes, physician profiling models and Medical Home constructs are measured, to support improved outcomes.

This study explored how being enrolled in a program that both coordinates patient care and provides a medical home changes health care utilization for uninsured patients, more specifically those persons with chronic conditions, through the use of the Chronic Care Model and Andersen and Aday’s Behavioral Model for Access to Health Care. Uninsured patients typically seek out care in a fragmented manner, which may lead to ineffective and inefficient care, especially for conditions that may require ongoing treatment and monitoring such as chronic conditions. The methodology used to examine the relationship between the interaction of enrollment and chronic condition status and health care utilization was multivariate linear regression. The results of this study show that enrollment in a coordinated care program does have an impact on health care utilization, and that the impact differs for patients with no chronic conditions, a single chronic condition, and multiple chronic conditions. These results point to the effectiveness of implementing the Chronic Care Model to improve access to health care for patients with chronic conditions.

Families of children with special health care needs (CSHCN) and disabilities who lived in rural communities faced a variety of economic, social, and environmental challenges. Bronfenbrenner (1979, 2005) in his Bioecological Theory of Human Development offered an insightful lens for understanding the nested environments in which these families interact. This model was used as the overarching framework for this dissertation. The three manuscripts contained in this dissertation have included analyses of the involvement and participation of families of CSHCN and disabilities in the creation of a medical home located in a rural southwestern border community. These studies were critical for the medical home professionals - family involvement was at the core of the medical home philosophy. The overarching purpose of this dissertation was to set the foundation for successful family participation and feedback in the medical home. Within the first manuscript, I used the Medical Home Family Index to discover families’ (a) perceptions of interactions with medical professionals and (b) ratings of the quality of care within the medical home. Families of CSHCN (N = 92) completed the Medical Home Family Index and descriptive statistics as well as Chi-Square analyses were completed. Significant associations between families’ home languages and the amount of time the CSHCN had been receiving services at the medical home and the families’ responses were found. No associations between the children’s ages and the families’ responses were found. Recommendations for medical home professionals to complete the partner index, the Medical Home Index, were included. The purpose of the second manuscript was to examine the support needs of families of CSHCN and disabilities. Relationships between the severity of the children’s special health care needs and disabilities and the potential services they required were explored. For this study, a small sample (N = 25) of families of CSHCN completed the Family Needs section of the Center for Medical Home Improvement Family Survey, an in-depth, five-part survey designed to have families report on the services and supports that their CSHCN actually received. Families of CSHCN identified the need for therapies to be provided within the community. Findings from this study supported the creation of a pilot program in which parents were active participants in an intensive summer program designed to address the language and communication needs of their children. The purposes of the third manuscript were to (a) conduct research in two settings - a rural medical home and the families’ natural environments, (b) identify families’ perceptions of a targeted summer language intervention program, and (c) determine what changes in young children’s communication skills could be measured when parents were active members in a targeted summer language intervention program. For the third study, fourteen children with language delays and their families participated. Children were assessed using the Battelle Developmental Inventory-2nd Edition or the Preschool Language Scale-4th Edition. Intervention was conducted within a pediatric medical home and families continued the intervention at home. For both test results, the treatment had a significant effect. All families indicated a strong desire to continue the program and families who were most concerned with their children’s language were most satisfied with the program. This pilot program model was an example of ways that interventions could be extended successfully beyond traditional settings.