As mentioned previously, the 14 TPC grants varied widely in terms of the size, type, number, and geographic location of the practices included in the studies. For example, one study examined PCMH transformation efforts across a single integrated health care system located in the Pacific Northwest,2 another looked at the 76 practices that participated in a statewide quality improvement initiative in North Carolina,3 while a third study investigated the PCMH transformation efforts of 249 small practices across the country that had achieved PCMH recognition by the National Committee for Quality Assurance (NCQA).4 The number of practices evaluated by each study ranged from five to 2,432, and the types of practices ran the gamut, including Federally Qualified Health Centers and Community Health Centers; large, multisite health systems; small, independent group practices; and solo practices. Appendix A provides details on key characteristics of each study, and short profiles of each study are available at www.ahrq.gov//ncepcr/research-transform-primary-care/transform/profile/index.html.
Approaches to Transformation
The practice transformation efforts studied by the TPC investigators also differed in terms of the types of changes they made toward becoming a PCMH and the processes they used to implement these changes.
We collected information about what types of changes were implemented by the practices being studied and mapped these to the five PCMH attributes, as defined by AHRQ (i.e., comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety), as well as health IT. Overall, we found that almost all of the practices implemented changes related to at least four of the five PCMH attributes. Only one of the 14 studies reported that practices implemented changes to fewer than four of the five attributes, and only three studies did not report efforts to improve health IT. More specifically, we found the following:
- The practices studied by all 14 grants reported practice changes aimed at improving quality and safety, including implementing evidence-based medicine and clinical decision-support tools, engaging in performance measurement and quality improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management.
- Thirteen of the grants reported that practices engaged in practice changes related to providing coordinated care, including coordinating care across health care settings (e.g., specialty care, hospitals, emergency and urgent care, behavioral health care services, case management, pharmacy, and home health care), providing extra services to assist with transitions between care settings, and coordination with community services and support services.
- Practices studied by 12 of the grants made efforts to provide more comprehensive care, including implementing team-based care models (including shifting tasks from physicians and nurses to medical assistants (MAs) or other clinic staff); providing chronic, acute, and preventive care services to patients; and integrating behavioral health services into primary care.
- Eleven studies reported efforts by practices to provide more accessible services, including offering same-day visits or shorter waiting times for urgent needs; additional in-person hours or evening appointments; secure messaging or email and telephone visits; online patient services; group visits; and redistributing physician panel sizes.
- A different subset of 11 studies reported efforts to provide more patient-centered care, including a focus on the whole person and considering contextual issues that can affect health; self-management support and self-care support; shared decisionmaking; and involving the family in care and care planning.
- Finally, yet another subset of 11 studies reported enhancements to health IT, including implementing or improving an electronic health record (EHR) system, health registries, a patient portal, electronic orders and e-prescribing, and health information exchanges.
In addition, some of the practices studied made efforts to improve continuity of care, where a patient is seen by the same clinicians at each visit.
A variety of processes were used by practices to implement continuous quality improvement as a part of practice change efforts. For example, five of the TPC grants reported that the primary care transformation efforts they studied used learning collaboratives. In these learning collaboratives, teams from multiple practices met together as a group to learn from each other and work on quality improvement activities. Practices also used plan-do-study-act (or plan-do-check-act) cycles for quality improvement efforts. Four grants reported the use of practice facilitation, where an outside expert or team of experts (sometimes called a practice coach, quality improvement coach, or process improvement coach) is brought in to assist with the implementation of practice changes and to help build the internal capacity to engage in quality improvement activities.5 A study by Scholle and colleagues found that 64 percent of the of 249 small practices they studied received practice-specific consultation to help with practice change efforts, and 59 percent had access to a learning collaborative.6 Other quality improvement–related processes employed by the practices included sponsoring trainings, implementing a steering committee to lead efforts, developing systems for care, conducting regular clinical performance quality reporting and review, and quality goal setting.
A few of the health systems being evaluated by TPC studies developed and used models for practice transformation. For example, the Southcentral Foundation in Alaska implemented the Nuka System of Care, which was developed with input from patients (referred to as “customer-owners” by Southcentral Foundation) and aims to help patients achieve “physical, mental, emotional and spiritual wellness.”7 Another notable example is the Group Health Cooperative, which applied the Lean (also called Toyota Production System) methodology to primary care transformation, which aims to maximize quality and value while minimizing waste.8
Methods Used to Study Transformation
Almost all of the studies used a mixed methods approach to study the primary care transformation efforts, incorporating both quantitative and qualitative analyses. Scammon et al found that mixed methods were particularly useful for understanding the complex phenomena involved in primary care transformation.9 The authors reported that “each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others…Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change.”9
However, the specific data collected and analyzed by the TPC investigators and the analytical techniques they used varied widely. Quantitative assessments included analysis of operational and administrative data (such as claims data) and surveys. Qualitative assessments included analysis of interviews; focus groups; and survey data collected from the individuals involved in planning and implementing the practice changes, the providers and staff adjusting to the changes, and patients receiving care within the new model. For example, a study of 10 clinics at the University of Utah led by Magill used both existing operations data and newly collected quantitative and qualitative data. The investigators assessed the level of implementation achieved by the practices using an internally developed 28-measure tool; reviewed archived documents to understand the sequence and management of change; examined experiences with change through surveys, interviews, and focus groups of systems administrators, clinicians, and patients; assessed the impact of practice changes on quality measures, patient and provider satisfaction, and clinic operations using operational data; and assessed cost and utilization for individual patients through an analysis of claims data from the Centers for Medicare & Medicaid Services and Utah’s All Payer Claims Database.10
