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Does PCMH Work?

Does PCMH Work?. Perspectives from the research literature. Goals. Does empirical research support the PCMH Model? Critical perspective on PCMH Research Modest proposal for advancing the usefullness of PCMH research. Background. Embracing PCMH values is not equivalent to empirical support

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Does PCMH Work?

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  1. Does PCMH Work? Perspectives from the research literature

  2. Goals • Does empirical research support the PCMH Model? • Critical perspective on PCMH Research • Modest proposal for advancing the usefullness of PCMH research

  3. Background • Embracing PCMH values is not equivalent to empirical support • Many practices have expressed reluctance to take on PCMH until it is clear whether or not "it works” • Relatively few attempts to examine the empirical evidence about the effects of PCMH on quality, cost, and access related outcomes.

  4. PCMH- Key Questions • Can it work? • Will it work? • When will it work (for which patients and settings)? • What is necessary for it to work? • Is it worth it? • value • How can we put it into practice? • Implementation research

  5. Methods • Included: articles treating medical home as a holistic, multi-dimensional model of care and assessing patient related outcomes • Excluded: articles examining implementation of PCMH, evaluating tools used to assess the medical home, predicting medical home adoption, etc. • 49 research articles met inclusion criteria

  6. Classifying PCMH Research • Focus on patient-related outcomes of PCMH • Access • Service utilization • Patient Satisfaction/quality • Multiple outcomes • Costs of care

  7. Access • 15 studies examining access to PCMH for different population groups • 13 studies focus on access for children • 50 percent of children with special health care needs have access to a medical home • Certain combinations of risk factors resulted in larger deficits in having a medical home

  8. Service Utilization • 18 empirical studies examining the relationship of PCMH and service utilization • 9 studies focused on use of preventive services or immunization rates, 7 examined inappropriate service use • All but 3 indicated greater use of appropriate services or decreased use of inappropriate services for PCMH patients relative to comparison patients.

  9. Patient Satisfaction/Quality • 6 studies examining satisfaction and/or quality/lifestyle related outcomes • Patients satisfied with the care they receive and perceive positive health care interactions • Relatively lower satisfaction with coordination of referrals, connection with outside resources, wait times, and cultural sensitivity • Mixed findings on quality and lifestyle outcomes

  10. Multiple Outcome Studies • 8 studies included multiple outcomes • All but one included patient satisfaction or care experience • Other outcomes- HEDIS quality measures, condition specific outcomes, service utilization, costs and measures of access • Study findings indicate that PCMH is associated with higher or improved outcomes compared to non-PCMH comparison groups. • Improvements were generally noted for multiple outcomes

  11. Costs • Only 2 studies focused on association between PCMH and cost savings • Outpatient costs and ED charges

  12. Summary of PCMH Research Findings • Considerable support for appropriate service utilization and patient satisfaction • Mixed support for cost savings and higher quality • Weak support for PCMH access by special populations

  13. Bottom line on PCMH Preliminary research evidence is encouraging, but it may be too early to declare “victory”

  14. Not so fast…. • Sample and external validity issues • Measurement issues • Research design issues • Asking the right questions

  15. 1. Sample and External Validity Issues • Samples drawn from small demonstration projects or large surveys of individual patients • Not representative (location, subpopulations) • Insufficient consideration of practice context

  16. 2. PCMH Measurement Issues • PCMH is not directly or independently measured in many studies • PCMH measured by patients’ perceptions of exposure to aspects of care related to PCMH • Significant variation in how PCMH components are defined and operationalized • Measures tend to be linear and additive

  17. 3. Research design issues • Little assessment of synergistic effects of components of the PCMH model • Selection bias • Most PCMH studies are cross sectional • Short study duration • Unit of analysis

  18. 4. Framing PCMH Effectiveness in a Broader Context

  19. From Model to Practice GOAL: To increase the adoption, reach and impact of PCMH Science Push Investigation, Improvement and communication of PCMH for widespread use Delivery Capacity Building the capacity of relevant systems to deliver PCMH Market Pull/Demand Building a market and demand for PCMH Increase the number of systems providing evidence-based PCMH Increase the number of practitioners providing evidence-based PCMH Increase the number of individuals receiving evidence-based PCMH ULTIMATE GOAL: Improve patient health and well being

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