Some TPC studies examined practices that had begun primary care transformation many years prior, while others evaluated more recent or ongoing transformation efforts. However, AHRQ specifically funded evaluations of transformation efforts that had been in process long enough to produce patient-level outcomes. The outcomes of primary care transformation reported by the investigators fell into the following categories: access, utilization, cost, quality of care, health outcomes, patient satisfaction/experience, and provider/staff satisfaction.
Access
Multiple TPC studies assessed the impact of PCMH transformation on patient access to care, including access to in-person appointments and electronic methods of communicating with clinicians and viewing health care information through online portals. Several studies also examined the relationship between access to care and other outcomes, such as health care utilization and health outcomes.
Appointment Access
Results from two studies indicated that patient access improved after PCMH transformation. At Southcentral Foundation, a large primary care system in Alaska (PI: Driscoll), patients reported that access to primary care services and same-day appointments improved following the implementation of targeted changes that included open (often same-day) scheduling, expanded office hours, designated schedulers, and options for electronic communication with providers.22 Similarly, in a study of safety net primary care clinics in Oregon, Meenan and colleagues found that practices successfully reduced wait times for appointments by implementing same-day and telephone appointment options.29
Electronic Access
In multiple studies, practices sought to improve access through online systems and patient portals that facilitated patient communication with clinicians and timely access to laboratory results and other information. Results from three studies suggest that patients welcomed and valued the enhanced access offered by these strategies. Calman and colleagues found that patients receiving care at Federally Qualified Health Centers in New York liked the ease of access offered by electronic methods of communication;17 in another study led by Magill, patients reported that an online portal that allowed them to view laboratory results and send secure email messages to their provider made them feel more empowered and engaged in their care.10 Further evidence of patient acceptance was identified by Reid and colleagues at Group Health Cooperative in Washington State, where the number of secure message threads per 1,000 patients increased by 123 percent following PCMH implementation.2
Impact of Access on Utilization and Patient Outcomes
Two studies examined the relationship between access and utilization and found mixed results. At Group Health, Reid and colleagues found that the sharp increase in secure messaging and a 20 percent increase in telephone encounters were accompanied by a 6.7 percent decrease in primary care office visits and an 18.5 percent decrease in emergency department visits.36 Among diabetes patients, however, a more modest 10 percent increase in secure message threads and phone encounters was associated with a slight increase (1.25% to 2.74%) in office visits.37 Tai-Seale and colleagues at the Palo Alto Medical Foundation in California similarly found that each new secure email thread between the patient and physician was associated with a small increase (+0.05 visits per patient year) in primary care office visits and a slight increase (+0.21 visits per patient year) in specialty care office visits, leading them to conclude that secure messaging complemented, rather than substituted for, office visits.38
Other findings from Tai-Seale and colleagues suggested a complex relationship between access and health outcomes. The research team found that increased use of personal EHRs (an electronic application patients can use to maintain and manage their own health information in a secure and confidential environment) and shorter wait times to see one’s own care provider were associated with improved chronic disease management processes and increased preventive screening, but were not consistently associated with improved clinical outcomes.39 In commenting on their findings, the researchers noted the challenges of establishing relationships between access and quality outcomes in real-world settings, suggesting this is an area in need of further study.
Quality
Many studies explored how PCMH implementation impacted aspects of the quality of care, including continuity, care coordination and teamwork, and comprehensiveness of care, as well as measures of overall quality.
Continuity
The presence and impact of continuity, in which patients consistently see the same provider, was examined in two studies. Berry and colleagues found that continuity was a key feature of small primary care practices in New York City that implemented PCMH elements. Ninety percent of the practices studied indicated that their patients usually or always saw the same clinician, and 57 percent of practices reported that all patients could identify their primary care providers by name.27 Another study, led by Magill, included 10 primary care practices in Utah and determined that continuity with the clinician and care team was associated with improved clinical quality (i.e., the provision of chronic and preventive services), greater patient satisfaction, and lower health care costs primarily among patients with chronic conditions.10 The study also noted the tension that is inherent to providing timely access and ensuring that patients consistently see the same provider and suggested that practices monitor and adjust related activities as needed to reach desired goals.
Comprehensive Care and Prevention
Multiple studies provide evidence suggesting that PCMH transformation enhances the comprehensiveness of care. Two studies highlighted efforts by small practices (i.e., ≤5 physicians) to enhance the comprehensiveness of care. One study of small practices in New York City led by Berry found that providers in a majority of the practices increased the comprehensiveness of care by usually or always discussing diet, exercise, and stress and anxiety with patients.27 In a study led by Scholle, providers from small practices in 23 States that achieved NCQA PCMH recognition reported that after becoming a PCMH, their care was more comprehensive and efficient, leading to better patient care and improved health outcomes.4 Findings from two additional studies offered further information about the relationship between PCMH transformation and comprehensive care and preventive practices. In North Carolina, Donahue and colleagues monitored key clinical processes associated with diabetes and asthma care (e.g., nephropathy screening for patients with diabetes and annual flu immunization for patients with asthma) and found that performance improved in 68 to 78 percent of practices within the first year of PCMH implementation. The researchers also found that the odds of making practice changes (i.e., performing nephropathy screening) were greater for practices with higher leadership scores.3 Practices participating in the Chronic Care Initiative in Pennsylvania studied by Gabbay and colleagues reported using protocols and practices developed for diabetes patients to manage other patients with chronic diseases and to support preventive care for their entire population.19
Coordination and Teamwork
Two studies linked increased care coordination and teamwork to improvements in clinical quality. Magill and colleagues found that multiple PCMH elements involving coordination and team function (e.g., contacting patients after hospital discharge, medication reconciliation, and implementing after-visit summaries and advance directives) were associated with improved clinical quality.10 Coordination and teamwork were also found by Calman and colleagues to be essential elements of an integrated mental health model adopted by Federally Qualified Health Centers in New York.17 The model, which involved universal depression screening and expanded access to mental health providers, was found to facilitate communication among providers and a consistent approach to care and was especially beneficial to patients with complex conditions and multiple psychosocial stressors.
Overall Quality
The relationship between PCMH implementation and overall quality was examined by Fetters and colleagues in a study of more than 2,000 primary care practices in Michigan that sought to implement a PCMH model encompassing 13 domains and 128 discrete capabilities. Quality was assessed using composite quality and preventive scores derived from individual quality and preventive measures defined by Healthcare Effectiveness Data and Information Set (HEDIS), a tool used to measure performance on important dimensions of care and service, and Blue Cross Blue Shield of Michigan.25 Based on the results of partial implementation, the study team estimated that full implementation of the PCMH model would yield a 3.5 percent increase in the quality composite score and a 5.1 percent increase in the preventive composite score for adults, and a 12.2 percent increase in the preventive composite score for pediatrics.40 Estimates indicate that incremental implementation was also associated with improved quality for both adult and pediatric populations.
Health Outcomes
The PCMH model is considered especially well-suited for patients with chronic disease, who benefit from its focus on enhanced continuity, care coordination, and comprehensive care. Five of the TPC studies examined whether the PCMH model fulfilled its promise for chronic disease patients by measuring the impact of PCMH transformation on two of the most common chronic diseases encountered in primary care, diabetes and cardiovascular disease. Results from each of the studies are summarized in Appendix B. All of the studies found improvements in the target indicators following PCMH transformation, suggesting that care practices and processes implemented as part of PCMH transformation benefited patients with chronic disease.
However, researchers from two studies offered caveats that highlight the variable performance of practices in each study. In the TransforMN Study conducted by Solberg and colleagues, PCMH practices achieved a 2.1 percent increase in the number of patients achieving optimal diabetes measures and a 4.4 percent increase in patients achieving optimal cardiovascular measures. In responding to these findings, the researchers observed, “The extensive variation among Health Care Home (HCH) clinics, their overlap with non-HCH clinics, and the small change in performance over time suggest that medical homes are not similar, that change in outcomes is slow, and that there is a continuum of transformation.”12 Variability in performance by PCMH practices was also highlighted by Gabbay and colleagues, who ranked primary care practices undergoing PCMH transformation in Pennsylvania according to their level of improvement in clinical indicators and found striking differences between the five most-improved and five least-improved practices. As noted in Appendix B, the five most-improved practices achieved noteworthy gains in each measure, while performance by the five least-improved practices declined.19 A physician champion from one of the practices in the study offered the following comment on the difficulties of achieving clinical improvement. “You have to make a lot of little incremental changes, but there are lots and lots of incremental changes, and you have to train the staff to do things to a high level of proficiency on every single one of those things and make sure they do it every single time.”19
Several of the studies linked improvements in clinical measures to specific PCMH processes such as care management, team-based care, and monitoring and outreach. For example, when comparing practices that had the greatest improvement in diabetes outcomes to those with the least improvement, Gabbay and colleagues found that the more improved practices reported more involvement of patient-centered care managers, greater integration of the care manager into the overall care team, and improved messaging and patient tracking using the electronic medical record.30 Calman and colleagues studied PCMH transformation in Federally Qualified Health Centers and highlighted the importance of population monitoring and outreach with their finding that patients whose diabetes was not well controlled at baseline (defined as a baseline hemoglobin A1c level of ≥9%) improved more than patients who were in control, linking the improvement to the Centers’ efforts to target poorly-controlled patients for enhanced services.17, 41 In a third example, Solberg and colleagues identified six factors that were most strongly associated with higher performance measures for diabetes and cardiovascular outcomes: reminders for clinicians during care about services needed for chronic conditions; registries for tracking care for patients with chronic conditions; designated primary care teams that collaborate in the care of a defined group of patients; routine use of secure email to support self-management for patients and their families; routine exchange of data and health records with patients through an EHR; and a process for systematically screening patients for depression and dementia.42
Utilization
Several studies from this initiative provided evidence suggesting that PCMH transformation can lead to reductions in health care utilization. The evidence was strongest for reductions in emergency care and primary care services, though studies also found some evidence of reduced hospitalization. Factors that contribute to utilization trends, such as the extent of PCMH transformation and differences in patient morbidity, were also noted.
Emergency Room Utilization
Three studies found evidence of reduced emergency room utilization by PCMH practices. At Southcentral Foundation in Alaska, Driscoll and colleagues found that emergency care use was increasing prior to PCMH implementation and declined significantly during and after implementation before stabilizing in the later post-implementation period.33 The trend applied to emergency care use overall and to asthma and unintentional injury specifically. Southcentral patients and primary care clinicians suggested that the decrease was a result of the improved access to primary care services that occurred with PCMH transformation. At Group Health, Reid and colleagues examined utilization data for patients who received care from a PCMH clinic to those receiving care from a (nonPCMH) community network practice. The researchers determined that compared to what would be expected with no PCMH implementation, PCMH practices had an 18.3 percent reduction in emergency room visits but a 10 percent increase in specialty care visits and no significant change in inpatient admission rates.2 In Minnesota, Solberg and colleagues found that emergency care utilization varied with the extent of PCMH implementation. Specifically, practices that adopted more PCMH processes and systems were more likely to have lower emergency care and health care utilization for the most complex patients, but not lower inpatient admissions.42
Hospitalization
In contrast to the findings of no link between PCMH transformation and hospitalization reported by Reid and Solberg, two studies found evidence that hospitalizations decreased following PCMH implementation. At Southcentral Foundation, Driscoll found trends for hospitalization similar to those for emergency care. Specifically, the percent of PCMH patients hospitalized per month (overall and for asthma and unintentional injury specifically) declined steadily immediately following PCMH implementation and then stabilized at a lower level compared to before or during PCMH implementation.43 In Oregon, Meenan and colleagues studied 12 clinics that underwent PCMH transformation and found that hospital admissions decreased more rapidly in the PCMH clinics than the nonPCMH clinics. Trend analyses predicted that the decline in hospital admissions would increase over time, from 5.39 fewer inpatient admissions per month in PCMH clinics in the first year after PCMH implementation to 16.03 fewer admissions per month 3 years after implementation.29
Primary Care and Specialty Care Visits
Several studies examined factors that influence primary care and specialty care utilization. As noted earlier, researchers at Group Health and the Palo Alto Medical Foundation examined the relationship between electronic access and primary care and specialty visits and found mixed results.36-38 Other analyses examined links between ambulatory utilization and patient morbidity and highlighted how PCMH practices tailor their services in accordance with a patient’s needs and severity of illness. For example, at Group Health, Reid and colleagues determined that patients with hypertension experienced a 4 percent decline in specialty visits and a 13 percent decline in cardiology visits in the first year after PCMH implementation. However, closer examination revealed that the decline was limited to low- and mid-morbidity patients, while high-morbidity patients experienced an increase in specialty care utilization. Based on these results, the researchers suggested that PCMHs prioritize high-morbidity, clinically complex patients when seeking to improve coordination between primary care and specialist services.44 In another study, Calman and colleagues examined utilization patterns among patients with diabetes and found that utilization varied with the patient’s baseline hemoglobin A1c level. Specifically, encounters with primary care providers remained relatively steady in patients whose baseline level was 9 percent or less. For patients whose level was greater than 9 percent, encounters with primary care providers declined, while encounters with outreach, diabetes education, and psychosocial care increased, consistent with the PCMH clinics’ efforts to target high-risk patients for enhanced services.41
Health Care Costs
Evidence from three studies suggests that improvements in continuity, teamwork, and other changes implemented as part of PCMH transformation can help lower the costs of care. At Group Health, Reid and colleagues compared a PCMH prototype clinic to 19 nonPCMH clinics and found that patients at the PCMH clinic experienced a modestly improved quality of care and a 7 percent reduction in total health care costs, largely due to reduced utilization of inpatient and emergency/urgent care.45 In Utah, Magill and colleagues found that using a care team and expanding the role of MAs allowed providers to be more efficient. While staff costs per visit increased by $8.27 because of staffing increases, staff cost per physician work relative value unit (which calculates the amount of effort expended by a physician) decreased by $6.98.10 The researchers also determined that a 10 percent increase in continuity of care was associated with a $350 decrease in annual health care spending, largely due to reductions in inpatient care for patients with chronic conditions who were commercially insured.
Cost projections by Fetters and colleagues in Michigan, who studied the impact of implementing a PCMH model that encompassed 13 domains, also linked PCMH transformation and cost savings. The researchers estimated that full implementation of the PCMH model would lower per member per month medical costs for adult patients by $26.37; however, full implementation would likely yield no reductions in costs for pediatric populations, and incremental implementation was not associated with cost savings for either population.40 The findings suggest that multiple changes and PCMH elements, rather than a single element or practice improvement, are necessary to achieve cost savings.
Provider and Patient Satisfaction
Provider and patient satisfaction was studied by multiple researchers. Overall, the evidence suggests that PCMH transformation is associated with improved satisfaction scores for both patients and providers and with lower rates of clinician burnout. As previously discussed, however, improvements in patient or provider satisfaction may involve tradeoffs because of the different ways changes in care impact the patient and provider experience.
Provider Satisfaction
For PCMH providers, improvement in the quality of care and in their ability to provide the kind of care needed by patients was a key source of satisfaction. Clinicians and care coordinators in a sample of pediatric practices studied by Cooley and McAllister described the enhanced sense of personal and professional satisfaction they obtained after PCMH transformation and identified the pediatric medical home as a more gratifying career path.46 One physician champion noted, “I love what I do, in part because of the medical home. I have more time with my patients; I earn less, but am happier.”46 A satisfaction survey completed by providers from PCMH practices in Utah (PI: Magill) revealed a similar sentiment, with results indicating that providers were most satisfied with the “quality of care” and their “interactions with patients” and least satisfied with “time spent working,” “paperwork,” and “compensation.”47 At Group Health, Reid and colleagues found that work satisfaction and burnout rates among providers and staff improved after PCMH transformation, with the percentage of staff reporting that they were “extremely” satisfied with their workplace increasing from 38.5 percent at baseline to 42.4 percent, and rates of reported burnout decreasing from 32.7 to 25.8 percent.2 Provider satisfaction was also evident in comments in which physicians and staff noted that the PCMH focus on improving primary care performance and the patient experience was the “right work” and “right thing to be doing.”2
Patient Satisfaction
Patient ratings and feedback provided important information about the impact of PCMH transformation on patients and families and suggested that PCMH practices were largely successful in improving the patient experience. At Group Health (PI: Reid), satisfaction surveys conducted before and after PCMH implementation revealed small but statistically significant improvements in four of seven areas: access, communication, followup, and knowledge of context.2 Cooley and McAllister reported that pediatric practices that transformed into medical homes scored above the mean on national Consumer Assessments of Healthcare Providers and Systems® benchmarks, and that family satisfaction appeared to stem from better access, care, and safety and having a strong relationship with their health care team.46 Improved relationships with physicians were also reported by PCMH patients receiving care at Southcentral Foundation in Alaska, who described improved communication with physicians and increased feelings of safety and trust (PI: Driscoll),22 and by patients at the Palo Alto Medical Foundation who participated in shared medical appointments and said these appointments changed the power dynamic between patients and physicians and fostered a more relaxed environment (PI: Tai-Seale).38
