A First Look at PCMH for Minority Veterans: Implementation and Utilization

描述（由申请人提供）：背景：2010年，退伍军人事务部开始实施以患者为中心的护理团队（PACT），这是一种全国性的以患者为中心的医疗之家（PCMH）模式，旨在将900多家初级保健诊所的初级保健转变为基于团队的护理。PACT的重点是通过使用由初级保健提供者、RN病例管理者、临床和行政人员以及患者组成的跨学科团队，改善初级和专科保健之间的护理和协调。具体目标：目标1将调查PACT是否由设施根据在设施服务的少数族裔退伍军人的百分比以不同的方式实施。目标2将调查PACT对医疗保健利用的影响是否因种族/少数民族而异。研究方法：对于目标1，诊所将根据少数民族患者在其患者人群中的百分比分为低（<5%）、中（5%-15%）和高（>15%）。我们将使用多元线性回归测试服务于较高比例少数族裔退伍军人的设施是否具有较低的PACT实施领域分数，并对其他协变量进行调整。对于目标2，使用年龄分层（65岁以上和65岁以下）中断时间序列设计，本研究将评价在调整潜在混杂因素后，与白色退伍军人相比，种族/少数民族群体的个体是否具有与PACT相关的不同季度利用率（门诊访视、专科护理、心理健康和门诊护理敏感状况）。将使用2003-2012年患者和诊所随机截距的混合效应负二项模型进行估计。影响：拟议的研究将作出独特的和关键的贡献，AHRQ的研究组合的质量和有效性，重点放在种族/少数民族成年人的优先人口。本研究将确定特定PCMH域（它们的域得分较低）是否存在实施挑战。如果拟议的研究表明，为高比例少数族裔退伍军人服务的设施在PACT实施方面得分较低，则可以针对特定设施进行干预（目标1）。未来的研究可以评估PCMH实施的趋势是否因少数族裔退伍军人的比例而不同。此外，这项研究是第一个描述医疗保健趋势的研究。 利用少数民族退伍军人，并测试是否少数民族退伍军人的医疗保健利用差异影响以病人为中心的医疗家庭模式的初级保健（目标2）。如果发现对利用率的影响存在差异，未来的研究可以评估它们是否保持，关闭或扩大。

DESCRIPTION (provided by applicant): Background: In 2010 the VA began implementing Patient Aligned Care Teams (PACT), a nationwide patient- centered medical home (PCMH) model, designed to transform primary care into team-based care in over 900 primary care clinics. PACT is focused on improving access to care and coordination between primary and specialty care through the use of interdisciplinary teams composed of primary care providers, RN case managers, clinical and administrative staff, and patients. Specific Aims: Aim 1 will investigate whether PACT is implemented differently by facilities in relation to the percent of minority Veterans served at a facility. Aim 2 will investigate whether the effects of PACT on healthcare utilization differ by racial/ethnic minority group. Methods: For Aim 1, clinics will be categorized as low (<5%), medium (5%-15%), and high (>15%) based on the percent of minority patients comprising their patient population. We will test whether facilities serving higher proportions of minority Veterans have lower PACT implementation domain scores adjusting for other covariates using multivariate linear regression. For Aim 2, using an age stratified (above and below 65) interrupted time series design this study will evaluate whether compared to white veterans, individuals of racial/ethnic minority groups have differential quarterly utilization (outpatient visits, specialty care, mental health, and ambulatory care sensitive conditions) associated with PACT after adjusting for potential confounders. It will be estimated using mixed effects negative binomial models with random intercepts for patient and clinic for 2003-2012. Impact: The proposed research will make a unique and critical contribution to AHRQ's research portfolio in quality and effectiveness with a significant focus on the priority population of racial/ethnic minority adults. This study will determine whether implementation challenges exist of particular PCMH domains (they have lower domain scores). If the proposed research demonstrates facilities serving high proportions of minority Veterans have lower scores in PACT implementation, the particular facilities can be targeted for intervention (Aim 1). Future research could evaluate whether trends in PCMH implementation differ by the percentage of minority Veterans served. In addition, this study is the first to characterize trends in healthcare utilization for minority Veterans and to test whether minority Veterans' healthcare utilization is differentially affected by a patient- centered medical home model of primary care (Aim 2). If differences in effects on utilization are found, future research could evaluate whether they are maintained, closed, or widened.