Evaluating the ability of patient-centered medical homes to improve clinical outcomes

By | August 24, 2016

Support for patient-centered medical homes (PCMH) has been growing in recent years.  A typical PCMH model includes a primary care physician supported by a multidisciplinary team, coordinated care, measurements of quality and safety, and enhanced access to same-day appointments. Preliminary program evaluations have shown that PCMHs can improve access and quality, but to date, there has been little evidence that the model improves clinical outcomes.  A new Medical Care paper by Shi and colleagues is one of the first to evaluate the relationship between PCMH model adoption in health centers and clinical process and outcome measures.

Using health center-level data from HRSA’s 2009 Uniform Data System (UDS) and the 2009 Commonwealth Fund National Survey of Federally Qualified Health Centers, researchers generated an analytic sample of 795 health centers, each serving an average of more than 18,000 patients. The population served included minority patients (49%), uninsured patients (40%), Medicaid patients (32%), managed-care patients (17%), and patients with chronic conditions (24%).

Clinical performance measures generated from UDS included two process outcomes: children receiving required vaccines by their 2nd birthday, and females between the ages of 24-64 receiving a Pap test in the last 3 years.  The outcome measures were the percent of adult patients with Type 1 or Type 2 diabetes who had their blood sugar levels under control and percent of adult patients with hypertension who had their blood pressure under control.

The results were mixed. As shown in the figure below, total PCMH score was associated with an increase in the percentage of diabetics with HbA1c of 7% or less. Improvements in access and communication were associated with increases in the percentage of diabetics with HbA1c of 7% or less and HbA1c of 9% or less. Improvements in care management led to improvements in the percent of women receiving Pap tests. Improvements in coordination of care were associated with improvements in the percent of children receiving immunizations. None of the PCMH improvements were associated with improvements in hypertension (HTN) control.

BarrLines fig 1

Oddly, in multivariate analyses, practices that increased their use of patient tracking and registries had significantly worse results on three of the outcome measures – a discouraging finding for proponents of health IT. Less surprisingly, practices with larger proportions of uninsured patients, Medicaid patients, and patients with chronic conditions had worse results on some of the performance measures, highlighting the need for risk adjustment in performance measurement.

The authors point to the findings related to access and communication on influencing clinical outcomes to highlight importance of keeping the focus on the patient and the need for improved targeting of important subpopulations.

A key limitation of this study is data.  The study used 2009 data, when there were fewer PCMHs in the US.  The limited findings may suggest that more time is needed to assess the impact of PCMH on performance. Unfortunately, the Commonwealth Fund survey provides only cross-sectional data. Future evidence from ongoing efforts, such as theMulti-payer Advanced Primary Care Practicedemonstration, will allow researchers to track the longitudinal effects of primary care improvements on clinical outcomes.

This study provides new evidence about PCMHs, highlighting both the difficulty of practice transformation and the promise of better approaches to primary care. Read the full article to learn more about the methods, results, and future research needs.

Damika Barr

Damika Barr

Manager, Public Policy at AmeriHealth Caritas
Damika W. Barr is always looking for the policy solution in healthcare challenges. Damika is a Public Policy Manager at AmeriHealth Caritas, where she evaluates legislative, regulatory and public policy activities related to Medicaid and Medicare. Before joining, AmeriHealth Caritas, Damika served as the Policy Surveillance Director at Public Health Law Research at Temple University. Ms. Barr has a Juris Doctor from Thomas Jefferson School of Law, a graduate certificate in Public Health from the University of North Carolina, Chapel Hill, and a Bachelor of Science from George Mason University. The views expressed are those of the author and do not necessarily reflect the views of AmeriHealth Caritas. The views expressed are those of the author and do not necessarily reflect the views of AmeriHealth Caritas.
Lisa M. Lines

Lisa M. Lines

Senior health services researcher at RTI International
Lisa M. Lines, PhD, MPH is a senior health services researcher at RTI International, an independent, non-profit research institute. She is also an Assistant Professor in Population and Quantitative Health Sciences at the University of Massachusetts Chan Medical School. Her research focuses on social drivers of health, quality of care, care experiences, and health outcomes, particularly among people with chronic or serious illnesses. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She has served as chair of the APHA Medical Care Section's Health Equity Committee from 2014 to date. Views expressed are the author's and do not necessarily reflect those of RTI or UMass Chan Medical School.
Lisa M. Lines
Lisa M. Lines

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About Damika Barr and Lisa Lines

Damika W. Barr is always looking for the policy solution in healthcare challenges. Damika is a Public Policy Manager at AmeriHealth Caritas, where she evaluates legislative, regulatory and public policy activities related to Medicaid and Medicare. Before joining, AmeriHealth Caritas, Damika served as the Policy Surveillance Director at Public Health Law Research at Temple University. Ms. Barr has a Juris Doctor from Thomas Jefferson School of Law, a graduate certificate in Public Health from the University of North Carolina, Chapel Hill, and a Bachelor of Science from George Mason University. The views expressed are those of the author and do not necessarily reflect the views of AmeriHealth Caritas. The views expressed are those of the author and do not necessarily reflect the views of AmeriHealth Caritas.