| PI Name: Project Title | Unique Element | # of Practices | Practice Type | Practice Size | Location |
|---|---|---|---|---|---|
| Carolyn Berry, PhD; Health Care Transformation Among Small Urban Practices Serving the Underserved | Small, urban primary care practices participating in the New York City Department of Health and Mental Hygiene's Primary Care Information Project | 83 | Primarily solo and independent primary care practices serving racially diverse and predominantly low-income adults | Very small; all had 5 or fewer physicians, two thirds were solo practices | New York City |
| Neil Calman, MD; A Study of the PCMH: Lessons From a New York State Community Health Center Network | Federally Qualified Health Centers in the Institute for Family Health Network | 14 | Federally Qualified Health Centers | Varied; majority were small— between 4 and 8 primary care clinicians (although some included large sites) | Medically underserved communities in New York State, including the Bronx, Manhattan, and the Mid-Hudson Valley |
| Carl Cooley, MD; Medical Home Transformation in Pediatric Primary Care: What Drives Change? | The top performing pediatric primary care practices that participated in the Medical Home Learning Collaborative | 12 | Mix of types, including independent and hospital-owned practices, an academic clinic, and a Federally Qualified Health Center | Varied in size, with between 528 and 27,597 patients | Connecticut, Pennsylvania, Ohio, Michigan, Minnesota, North Carolina, Utah, Texas, and Illinois |
| Katrina Donahue, MD, MPH; Transforming Primary Care Practices in North Carolina | Practices participating in a statewide QI initiative in North Carolina | 76 | 42% family medicine, 13% internal medicine, and 26% pediatric practices. Range of structure types, but mostly independent. | 32 practices with seven or more clinicians, 26 practices with four to six clinicians, and 18 practices with three or fewer clinicians | North Carolina (49% rural) |
| David Driscoll, MPH, MA; Transforming Primary Care Practice | A tribally owned and managed primary care system serving primarily American Indian and Alaskan Native patients | Not applicable; not structured as discrete practices | Tribally owned and managed primary care system | 48,000 adult and pediatric patients in 2009 across system | Southcentral Alaska |
| Michael Fetters, MD, MPH, MA; Multimethod Evaluation of Physician Group Incentive Programs for PCMH Transformation | Practices enrolled in Blue Cross Blue Shield of Michigan Physician Group Incentive Program | 2,432 | Varied; includes adult and pediatric practices and 60% solo practices | Varied in size | Michigan (including urban, suburban, and rural areas) |
| Robert Gabbay, MD, PhD; A Multipayer Patient-Centered Medical Home Initiative in Pennsylvania | Adult primary care practices participating in the first regional rollout of Pennsylvania's statewide Chronic Care Initiative | 25 | Varied; includes private practices, Federally Qualified Health Centers, and practices belonging to health systems | Practices varied in size from two to 25 providers; including some nurse practitioner–led practices and Federally Qualified Health Centers | Southeast Pennsylvania (including inner-city, suburban, almost-rural, and underserved communities) |
| Michael Magill, MD; Transformed Primary Care by Design™ | Clinics run by the University of Utah and implemented Care by Design™ | 10 | University-owned family medicine and pediatrics clinics | 70 primary care providers and 100,000 patients across all 10 clinics, between three and nine primary care providers per clinic | Utah |
| Richard Meenan, PhD, MPH, MBA; Transformation to Patient-Centered Medical Home in CareOregon Clinics | Selected safety net primary care practices that implemented the Primary Care Renewal project, supported by CareOregon, a large nonprofit Medicaid managed care plan | 17 | Safety net primary care practices; mixed type of ownership, all with large percentage of Medicaid patients | Ranging in size from 630 to 8,000 or more CareOregon (Medicaid) patients per clinic | Portland, Oregon |
| Robert Reid. MD, PhD, MPH; Transforming Primary Care: Evaluating the Spread of Group Health Medical Home | Group Health owned and operated clinics | 26 | Integrated health system (nonprofit, consumer-governed) | Practices ranged in size from about 5,000 to more than 20,000 patients | Washington (Puget Sound and Spokane regions) and northern Idaho |
| Diane Rittenhouse, MD; Transforming Primary Care Practice: Lessons From the New Orleans Safety Net | Safety net clinics in New Orleans serving predominately African American, low-income, and uninsured patients | 5 | Three nonprofit clinics (one of which is faith-based) and two university-owned clinics | 10 or fewer clinicians | New Orleans, LA |
| Sarah Hudson Scholle, DrPH; Understanding the Transformation Experiences of Small Practices With NCQA's Medical Home Recognition | Small practices that achieved NCQA PCMH recognition prior to 2011 | 249 | Varied; includes Federally Qualified Health Centers and/or Community Health Centers; independent, physician-owned practices; and practices affiliated with larger groups or owned by a hospital/health system |
Very small; fewer than five physicians per clinic. One third were solo practices. | Across 23 States representing all major U.S. regions |
| Leif Solberg, MN; TransforMN Study | Primary care clinics certified as health care homes by the Minnesota Department of Health | 132 | 75% of the health care homes were part of large medical groups with 20 or more clinics, nearly all were owned by a medical system | 77% of the clinics had one to 10 primary care physicians, and nearly all had nurse practitioners or physician assistants | Minnesota |
| Ming Tai-Seale, PhD, MPH; Primary Care Transformation in a NCQA Certified Patient-Centered Medical Home | Clinics at Palo Alto Medical Foundation | 13 | Large, nonprofit multispecialty medical group that serves about 850,000 patients | Practice size ranges from three to 300 physicians | Northern California |
(continued)
| PI Name: Project Title | EHR Status | Transformation Efforts | Recognition Status/Type |
|---|---|---|---|
| Carolyn Berry, PhD; Health Care Transformation Among Small Urban Practices Serving the Underserved | 21% of practices had EHRs before participating in the project; all practices used EHR system provided through project for at least 1 year | 73% of practices implemented processes to remind patients of appointments, follow up on missed appointments, and monitor patients with chronic conditions. Close to half of the practices reported having informal care teams and monthly or more frequent meetings to discuss patient care, while 40% began using staff at the top of their skill set (e.g., engaging nurses or medical assistants in patient education, taking histories, or chronic disease screening). More than half of the practices implemented QI efforts to improve patient satisfaction and reported using data to assess the impact of QI efforts. | 47 practices applied for NCQA PCMH recognition and either achieved recognition (Level 1) or were awaiting notification when the study ended. The remaining practices did not pursue recognition. |
| Neil Calman, MD; A Study of the PCMH: Lessons From a New York State Community Health Center Network | Implemented in 2002 (just prior to when PCMH transformation began); enhancements added as part of transformation | Central elements included: developing patient registries and reports using the EHR to support outreach, monitoring, and management of patient populations (focusing on patients at highest risk of poor outcomes); implementing workflow changes (e.g., shifting some screening and educational tasks to nurses); and introducing online tools, including clinical decision supports, a visit summary for patients, and a patient portal | All of the Community Health Centers achieved Level 3 NCQA PCMH certification in 2009 |
| Carl Cooley, MD; Medical Home Transformation in Pediatric Primary Care: What Drives Change? | Practices did not have an EHR in place before redesign. EHR implementation occurred in parallel with PCMH transformation. By the end, most had some EHRs in place. | Practices used QI techniques and other strategies to enhance care coordination and facilitate family-centered, team-based care. Practices partnered with patients and families to incorporate goals and care strategies into individualized care plans. Practices strengthened their linkages with community resources and partners and implemented strategies to enhance access to care (e.g., by responding to patient concerns by phone). All but the smallest practice introduced care coordinators. | One practice attained Level 3 NCQA PCMH recognition; one practice attained PCMH recognition from a State program; and the remaining 10 practices opted not to pursue PCMH recognition |
| Katrina Donahue, MD, MPH; Transforming Primary Care Practices in North Carolina | 50% of practices had an EHR prior to the initiative | Onsite Quality Improvement Consultants were provided through the North Carolina Area Health Education Centers to serve as practice coaches and assist with practice change. They helped set goals for practice improvement, trained staff on QI methodology, and assisted in the creation of patient data registries to track clinical outcomes for asthma or diabetes; they also provided practices with monthly practice change and leadership ratings to track implementation and use of disease registries, planned care templates, care protocols, and patient self-management support tools. | At the time of the study, 22 had NCQA recognition, and 17 were actively working on attaining recognition |
| David Driscoll, MPH, MA; Transforming Primary Care Practice | Had a pre-existing EHR system commonly used by Indian Health Service | Introduced the Southcentral Foundation Nuka System of Care, a PCMH model developed with input from patients. The model emphasizes enhanced access; team-based care and care coordination; and patient empanelment. | Recognized as a NCQA PCMH Level 3 in 2010. Also earned the Malcolm Baldrige Award for quality excellence in 2011. |
| Michael Fetters, MD, MPH, MA; Multimethod Evaluation of Physician Group Incentive Programs for PCMH Transformation | Some, but not all practices had EHR in place | Practices implemented a PCMH model defined by Blue Cross Blue Shield of Michigan and encompassing 13 domains: patient-provider partnership, patient registry, performance reporting, individual care management, extended access, test results tracking and followup, e-prescribing, preventive services, linkage to community services, self-management support, patient web portal, coordination of care, and specialist referral process | No information available |
| Robert Gabbay, MD, PhD; A Multipayer Patient-Centered Medical Home Initiative in Pennsylvania | Not all practices had an EHR at baseline, some implemented it over the course of the project; some only used a registry provided by the State | Practices varied in their approaches to PCMH transformation. Some practices regularly shared performance data with staff, while others did not. All practices enhanced care management capabilities for high-risk patients, but differed in how they defined the role of care managers and how they incorporated them into the care team. Many practices trained medical assistants to serve as health coaches and/or outreach workers or engaged them in population management activities. | All of the practices achieved NCQA PCMH recognition in the first year of the initiative |
| Michael Magill, MD; Transformed Primary Care by Design™ | Implemented EHR prior to this initiative | Implementation initially focused on improving access through same-day appointments. By 2006, the model incorporated team-based care and more comprehensive planned care. Care teams were used to enhance efficiency through better use of support staff time and skills. Medical assistants assumed increased responsibilities. Planned care included creating registries of chronic care patients and introducing reminders for preventive services to enhance continuity and integration of care. Standardized order sets were included in the EHR to improve follow-through on recommended care. | Did not apply for PCMH recognition |
| Richard Meenan, PhD, MPH, MBA; Transformation to Patient-Centered Medical Home in CareOregon Clinics | Varied; some but not all practices had EHR in place. Many of those who had it were in the early stages (i.e., not ready for PCMH QI and population management). | Included team-based and customer-driven care, barrier-free access through same-day and telephone appointments, proactive panel health improvement, and onsite or otherwise integrated behavioral health | All PCR clinics achieved the highest level of certification in Oregon's Patient-Centered Primary Care Home Program |
| Robert Reid. MD, PhD, MPH; Transforming Primary Care: Evaluating the Spread of Group Health Medical Home | Well established | Implemented reduced patient panel size, longer patient visits, and reduced the number of face-to-face visits per day; increased care team staffing. Implemented virtual visits through nurse call line and secure emailing, chronic disease management, previsit preparation, and outreach. | Level 3 NCQA recognition was achieved at all 26 practices |
| Diane Rittenhouse, MD; Transforming Primary Care Practice: Lessons From the New Orleans Safety Net | Statewide QI program included minimum quality standards, such as establishing a quality assurance program, 24-hour phone urgent access, same-day appointments, and implementing and assessing the use of clinical evidence-based guidelines | All five clinics achieved NCQA PCMH recognition | |
| Sarah Hudson Scholle, DrPH; Understanding the Transformation Experiences of Small Practices With NCQA's Medical Home Recognition | 77% of practices had EHRs at time of evaluation | Strategies implemented by more than 80% of practices included working with patients to develop care plans, reconcile medications, address barriers to self-care, and review progress between visits; referring patients to community programs; and providing evidence-based patient education. More than 60% of practices delegated some aspects of self-management support or other elements of patient care to nonclinicians. | All had NCQA recognition prior to participation. 33 of the surveyed practices (13%) changed from NCQA Level 1 recognition to Level 3 during the survey period. |
| Leif Solberg, MN; TransforMN Study | All practices had EHRs in place | Continuous access and communication between health care homes and the patient and family; electronic searchable registry to identify gaps in care and manage services; care coordination for more patient- and family-centered care; care plans for patients with chronic or complex conditions and their family; and continuous improvement in experience, health outcomes, and cost-effectiveness. | All 132 practices in this study were certified as health care homes by the Minnesota Department of Health |
| Ming Tai-Seale, PhD, MPH; Primary Care Transformation in a NCQA Certified Patient-Centered Medical Home | Well established | Enhancements to patient access and outreach; shared medical appointments; team-based care and cross-trained staff; bringing best evidence to the point of care through use of self-management protocols, EHR alerts, and linked orders; encouraging shared decisionmaking and family involvement in care; coordination of care throughout system and with community resources; new methods of measuring and improving quality and safety; innovations in practice management; advanced information systems and technology; and changes to physician reimbursements | In 2007, four primary care practices were recognized by the NCQA as Level 3 PCMHs, five were recognized as Level 2, and four did not seek recognition. In 2009, PCMH recognition was allowed to lapse. |
Abbreviations: EHRs = electronic health records; QI= quality improvement; NCQA = National Committee for Quality Assurance; PCMH = patient-centered medical home.
