PCMH Implementation Strategies: Implications for Cancer Survivor Care

癌症诊断和治疗的成功导致了长- 癌症幸存者事实上，在过去的20年里，接受初级保健的患者发生了巨大的变化， 护理实践，如癌症幸存者与复杂的，共病的条件。而不是大多数访问是急性 或单一慢性病，现在大多数就诊是为有复杂病情和需要的病人。到 为了满足像癌症幸存者这样的复杂病人的需要，初级保健实践必须从根本上重新配置。 以病人为中心的医疗之家（PCMH）旨在提高初级保健的质量和安全， 通常是医疗系统改革努力的一部分。虽然有很多关于PCMH的文章，但尚不清楚PCMH 提高了癌症幸存者等复杂患者的治疗质量。事实上，PCMH属性对于满足 癌症幸存者的需求是最具挑战性的实施：重新定向到人口的角度， 发展协作团队，整合医疗保健社区和社区资源， 临床医生和工作人员的角色/身份。 复杂性科学（CS）为理解初级保健实践如何实施提供了理论基础 像PCMH这样的创新。作为复杂的适应系统，实践根据主导目标自组织 并共同进化以获得与这些目标一致的配置。如果获得NCQA认可的目标 主导，实践自我组织，以最大限度地提高这个目标。同样，如果照顾个人、家庭和 社区占主导地位，实践自我组织，以最大限度地实现这一目标。在这两种情况下，结果可能是 PCMH，但CS表明，它们可能进化成具有非常不同的能力来照顾癌症幸存者。 确定并描述PCMH如何成功实现癌症治疗所需的挑战性属性 幸存者护理，我们使用CS框架进行比较案例研究的做法，使用不同的 PCMH实施战略：一些侧重于NCQA 3级PCMH认可，另一些侧重于 关心个人、家庭和社区。我们研究创新的初级保健做法，使用混合- 方法将案例研究设计与从国家创新做法清单中选出的做法进行比较。一个 10个做法的初步样本（5个寻求NCQA三级认可，5个寻求满足个人需求， 将选择10个可复制的案例， 证实/否定假设。数据包括经验证的调查、执行和维持的费用 创新，以及对实践成员和患者的人种学观察和访谈。结果可能 对癌症幸存者护理和美国各地使用的PCMH实施策略产生了深远的影响。

Successes in diagnosis and treatment of cancer have resulted in dramatic increases in the number of long- term cancer survivors. In fact, the past 20 years has seen dramatic shifts in patients receiving care in primary care practices like cancer survivors with complex, co-morbid conditions. Instead of most visits being for acute or single chronic conditions, the majority of visits are now for patients with complex conditions and needs. To meet the needs of complex patients like cancer survivors, primary care practices must radically reconfigure. The Patient-Centered Medical Home (PCMH) is purported to enhance quality and safety in primary care and is often part of health system reform efforts. While much is written about the PCMH, it is not clear that a PCMH enhances quality for complex patients like cancer survivors. In fact, PCMH attributes critical for meeting the needs of cancer survivors are the most challenging to implement: reorienting to a population perspective, developing collaborative teams, integrating healthcare neighborhoods and community resources, and changing roles/identities of clinicians and staff. Complexity science (CS) provides a theoretical basis for understanding how primary care practices implement innovations like the PCMH. As complex adaptive systems, practices self-organize according to dominant goals and co-evolve to take on configurations consistent with those goals. If a goal of achieving NCQA recognition dominates, practices self-organize to maximize this goal. Likewise, if caring for individuals, families, and communities dominates, practices self-organize to maximize this goal. In both cases, the result may be a PCMH, but CS suggests they might evolve to have very different capacities to care for cancer survivors. To identify and describe how PCMHs successfully implement the challenging attributes needed for cancer survivor care, we use a CS framework to conduct comparative case studies of practices that used different PCMH implementation strategies: some focused on NCQA Level 3 PCMH recognition and others focused on caring for individuals, families, and communities. We examine innovative primary care practices using a mixed- methods comparative case study design with practices selected from a national list of innovative practices. An initial sample of 10 practices (5 seeking level 3 NCQA recognition and 5 seeking to meet needs of individuals, families, and communities) will be selected for comparative purposes, with 10 replicative cases selected to confirm/disconfirm hypotheses. Data include validated surveys, costs of implementing and sustaining innovations, and ethnographic observations and interviews of practice members and patients. Results could have a profound impact on cancer survivor care and PCMH implementation strategies used throughout the US.