Implementation and Impact of VA Patient-Centered Medical Home

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PROJECT BACKGROUND/RATIONALE: Primary care delivery is at a crossroads. Pundits point to a "perfect storm" and the impending "collapse of primary care" given how few medical trainees are moving into primary care, while others are leaving practice thanks to dwindling reimbursements, leaving the future of primary care uncertain. Patient-centered medical homes (PCMH) represent an updated primary care model that recognizes and rewards, through appropriate payment, the diverse but necessary activities of a primary care home base for a population of patients.4,5 Most major medical societies, and many public and private health care funders currently endorse some version of this concept. While extensive evidence documents the relationships between primary care and outcomes, there is remarkably little information on relationships between specific PCMH features and outcomes. In addition, there is almost no information on characteristics of sites that promote adoption of PCMH features. This proposal aims to use data from a 2007 all-VA survey of over 200 VA primary care practices to assess links between PCMH features and quality of care in VA, and understand which types of VA practices are most likely to adopt PCMH features. PROJECT OBJECTIVES: We propose to: Aim #1: Evaluate the impacts of existing VA patient-centered medical home models on quality of care, including which elements are most effective; Aim #2: Determine the factors related to successful site adoption of patient-centered medical home models and features in VA; Aim #3: Use expert panel methods to integrate and apply findings from Aims #1 and #2 to develop practice and policy recommendations on evidence-based primary care delivery models. PROJECT METHODS: For Aim #1, we will merge data from the VA Clinical Practice Organizational Survey (CPOS) on PCMH features with existing VA quality data on preventive practice (e.g., flu shots), chronic disease processes (e.g., diabetic retinal exams) and intermediate outcomes (e.g., HbA1c), and patient ratings of care (e.g., access, continuity, coordination). We will use multi-level models to examine contributions of PCMH features to quality, adjusting for patient-level covariates. For Aim #2, we will analyze practice environment measures (from CPOS and administrative data) and area characteristics chiefly from the Area Resource File linked to CPOS practice data. For Aim #3, we will use expert panel methods to engage VA and non-VA national leaders in primary care and PCMH to develop practice/policy recommendations based on evidence generated from Aims #1 and #2.