Categories of Practice Transformation in a Statewide Medical Home Pilot and Their Association with Medical Home Recognition

Published in: Journal of General Internal Medicine, v. 30, no. 6, June 2015, p. 817-823

Posted on RAND.org on February 25, 2015

by Grant R. Martsolf, Ryan Kandrack, Eric C. Schneider, Mark W. Friedberg

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Research Questions

  1. In what ways did primary care practices transform their structural capabilities—for example, by adopting electronic health records or increasing patients' access to after-hours care—during a three-year medical home pilot in Pennsylvania?
  2. What was the relationship between practice transformation and gaining recognition as a medical home?

BACKGROUND: Healthcare purchasers have created financial incentives for primary care practices to achieve medical home recognition. Little is known about how changes in practice structure vary across practices or relate to medical home recognition. OBJECTIVE: We aimed to characterize patterns of structural change among primary care practices participating in a statewide medical home pilot. DESIGN: We surveyed practices at baseline and year 3 of the pilot, measured associations between changes in structural capabilities and National Committee for Quality Assurance (NCQA) medical home recognition levels, and used latent class analysis to identify distinct classes of structural transformation. PARTICIPANTS: Eighty-one practices that completed surveys at baseline and year 3 participated in the study. MAIN MEASURES: Study measures included overall structural capability score (mean of 69 capabilities); eight structural subscale scores; and NCQA recognition levels. RESULTS: Practices achieving higher year-3 NCQA recognition levels had higher overall structural capability scores at baseline (Level 1: 28.4 % of surveyed capabilities, Level 2: 40.9 %, Level 3: 48.7 %; p value = 0.001). We found no association between NCQA recognition level and change in structural capability scores (Level 1: 33.2 % increase, Level 2: 30.8 %, Level 3: 33.7 %; p value = 0.88). There were four classes of practice transformation: 27 % of practices underwent "minimal" transformation (changing little on any scale); 20 % underwent "provider-facing" transformation (adopting electronic health records, patient registries, and care reminders); 26 % underwent "patient-facing" transformation (adopting shared systems for communicating with patients, care managers, referral to community resources, and after-hours care); and 26 % underwent "broad" transformation (highest or second-highest levels of transformation on each subscale). CONCLUSIONS AND RELEVANCE: In a large, state-based medical home pilot, multiple types of practice transformation could be distinguished, and higher levels of medical home recognition were associated with practices' capabilities at baseline, rather than transformation over time. By identifying and explicitly incentivizing the most effective types of transformation, program designers may improve the effectiveness of medical home interventions.

Key Findings

  • Practices transformed their structural capabilities in different ways: some made few changes, some made extensive changes, some focused on "provider-facing" changes, such as care reminders, and some focused on "patient-facing" changes, such as care managers.
  • Of the 81 practices surveyed for this study, all but one achieved recognition as a medical home. Yet there was no association between the amount or the type of transformation a practice made and the level of medical home recognition (on a scale from 1-3) a practice achieved.
  • The biggest factor in determining medical home recognition was the pre-existence of structural capabilities: practices with one or more capabilities in place at the outset of the pilot achieved the highest levels of recognition.

Recommendation

More dynamic and detailed measures of practice transformation may help payers, policy makers, and other stakeholders identify the most effective types of medical home transformation and tailor medical home incentives for greater precision and impact.

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