In 2008, the Indian Health Service (IHS) launched a patient-centered medical home (PCMH) initiative to improve the quality of care for patients who seek care at its clinics. To assist IHS facilities on the path to PCMH recognition, RAND researchers examined common strategies and identified barriers to implementation, key lessons from PCMH-recognized clinics, and possible strategies for facilities that are not yet PCMH-recognized.
Patient-Centered Medical Home Implementation in Indian Health Service Direct Service Facilities
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Research Questions
- According to the peer-reviewed and grey literature, what strategies and challenges do clinics face when implementing the PCMH model?
- How have components of the PCMH model been implemented at IHS clinics that have received PCMH recognition?
- What are the challenges associated with PCMH implementation at IHS clinics that have received PCMH recognition?
- What key lessons and recommendations could benefit other IHS clinics that have not yet received PCMH recognition?
In an effort to provide care that is more accessible, team-based, coordinated, and patient-focused, primary care practices are increasingly adopting patient-centered medical home (PCMH) models of care. In 2008, the Indian Health Service (IHS) launched its own PCMH initiative, Improving Patient Care (IPC), to improve the quality of care for American Indians and Alaska Natives (AI/ANs) who seek care in its clinics. The IHS provides comprehensive health care services to roughly 2.2 million AI/ANs from more than 567 federally recognized tribes across the United States.
In this report, RAND researchers examine the peer-reviewed and grey literature and identify common PCMH implementation strategies and challenges to better understand the kinds of methods used by clinics across the United States — particularly small clinics and those located in rural or remote locations. The research team then held telephone discussions with representatives from seven IHS clinics that had received PCMH recognition as of July 2017. The discussions with clinic leaders sought to identify how components of the PCMH model had been implemented at their clinics; challenges associated with PCMH implementation; and key lessons and recommendations that could benefit clinics that have not yet received PCMH recognition.
Key Findings
Leadership Facilitates Implementation
- Strong leaders successfully oversaw the implementation of cultural and process changes while ensuring that patient needs guided their efforts.
A Dedicated Team Is Essential
- A team spanning multiple disciplines, including senior staff, and working to secure staff buy-in for proposed changes can guide the effort to a successful result.
- Staff shortages limited the ability to expand access and use empanelment and multidisciplinary care teams. A dedicated implementation team that provides consistent messaging can help maintain forward progress.
Consistent Communication Can Secure Buy-In
- Engaging staff, sharing data, and communicating successes can encourage staff to pursue continuous process improvements.
- Working with tribal leaders and the community can secure buy-in for major changes, leverage community assets, and build trust.
Program Tools Are Valuable
- The IPC tools were appreciated, but support from IHS Area Offices varied. Some clinics reported that their area-level improvement support teams were not able to consistently provide the level of assistance needed.
Assessing Needs Focuses Efforts
- Knowing a clinic's population was essential in meeting their needs.
- Analyzing clinic expenditures and other providers' availability could determine ways to spend resources more efficiently.
Smaller Clinics May Need More Assistance
- Smaller clinics suffered disproportionately from staff turnover, reported a limited ability to apply for grants, and described shortages of staff with expertise in quality improvement, data analytics, or use of the iCare system.
Third-Party Revenue Is Critical
- Additional revenue, particularly from Medicaid reimbursements, helped clinics hire more staff, expand access, and invest in improvements.
The Overall Impact Is Positive
- The clinics reported positive feedback from staff, high performance on quality measures, and improvements in patient satisfaction and access to care.
Recommendations
- As the IHS reflects on its ongoing efforts to support clinics on the path toward PCMH recognition, it might consider several suggestions offered by clinics. Among these suggestions are the need for expediting clearance and approval processes for hiring new staff, providing additional resources for clinic expansion and modernization to support the implementation and sustainability of medical homes, ensuring the adequacy of technical assistance across areas, and facilitating additional opportunities for collaborative learning.
- Successful clinics urged others to "start small" and pursue a few "easy wins" to avoid being overwhelmed when implementing multiple process changes simultaneously. Clinics described failing numerous times before successfully implementing a new process, and noted that incremental changes take time and require persistence.
- Shifting to team-based care and continuous quality improvement models represent large cultural shifts that can initially engender resistance from staff. Patients may become frustrated with new scheduling systems or by new staffing models in which they receive care from lower-level staff.
- Successful clinics did not exhibit symptoms of "change fatigue," but rather embraced the concept of continuous process improvement and allowed their staff to guide practice changes using a "bottom-up" model rather than a "top-down" approach.
- Clinics that were able to meet face-to-face with other clinics and their improvement teams, share best practices, and, in some cases, shadow one another found those experiences to be particularly helpful and motivating.
Table of Contents
Chapter One
Introduction
Chapter Two
PCMH-Recognized Clinics Participating in the Study
Chapter Three
PCMH Implementation Strategies and Challenges
Chapter Four
Lessons Learned and Recommendations for Clinics in Pursuit of PCMH Recognition
Chapter Five
Conclusion
Appendix A
Implementation and Impact of Patient-Centered Medical Homes: Literature Review
Appendix B
Discussion Guide
The research described in this report was sponsored by the Office of the Assistant Secretary for Planning and Evaluation and conducted by RAND Health.
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