Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use.
JAMA Intern Med. 2014 Aug; 174(8):1350-8.JIM

Abstract

IMPORTANCE

In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation.

OBJECTIVES

To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes.

DESIGN, SETTING, AND PARTICIPANTS

We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care.

MAIN OUTCOMES AND MEASURES

Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout.

RESULTS

Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001).

CONCLUSIONS AND RELEVANCE

The extent of PCMH implementation, as measured by the Pi2, was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.

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Publisher Full Text (DOI)

Authors+Show Affiliations

Nelson KM

Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington2General Internal Medicine Service, VA Puget Sound Health Care System, Seattle, Washington 3Department of Medicine, University o.

Helfrich C

Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle.

Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.

Taylor L

Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.

Wong E

Department of Health Services, University of Washington School of Public Health, Seattle.

Maynard C

Hernandez SE

Sanders W

Office of Analytics and Business Intelligence, Veterans Health Administration, Washington, DC.

Randall I

Curtis I

Office of Analytics and Business Intelligence, Veterans Health Administration, Washington, DC.

Schectman G

Office of Patient Care Services, US Department of Veterans Affairs, Washington, DC.

Stark R

Office of Clinical Operations, US Department of Veterans Affairs, Washington, DC.

Fihn SD

General Internal Medicine Service, VA Puget Sound Health Care System, Seattle, Washington 3Department of Medicine, University of Washington School of Medicine, Seattle5Office of Analytics and Business Intelligence, Veterans Health Administration, Washingt.

MeSH

AgedBurnout, ProfessionalDelivery of Health CareEmergency Service, HospitalFemaleHospitalizationHospitalsHumansMaleMedical StaffMiddle AgedPatient SatisfactionPatient-Centered CarePrimary Health CareQuality of Health CareUnited StatesUnited States Department of Veterans Affairs

Pub Type(s)

Journal Article

Research Support, U.S. Gov't, Non-P.H.S.

Language

eng

PubMed ID

25055197

Clinical Trial Links

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Citation

Nelson, Karin M., et al. "Implementation of the Patient-centered Medical Home in the Veterans Health Administration: Associations With Patient Satisfaction, Quality of Care, Staff Burnout, and Hospital and Emergency Department Use." JAMA Internal Medicine, vol. 174, no. 8, 2014, pp. 1350-8.

Nelson KM, Helfrich C, Sun H, et al. Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Intern Med. 2014;174(8):1350-8.

Nelson, K. M., Helfrich, C., Sun, H., Hebert, P. L., Liu, C. F., Dolan, E., Taylor, L., Wong, E., Maynard, C., Hernandez, S. E., Sanders, W., Randall, I., Curtis, I., Schectman, G., Stark, R., & Fihn, S. D. (2014). Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Internal Medicine, 174(8), 1350-8. https://doi.org/10.1001/jamainternmed.2014.2488

Nelson KM, et al. Implementation of the Patient-centered Medical Home in the Veterans Health Administration: Associations With Patient Satisfaction, Quality of Care, Staff Burnout, and Hospital and Emergency Department Use. JAMA Intern Med. 2014;174(8):1350-8. PubMed PMID: 25055197.

* Article titles in AMA citation format should be in sentence-case

TY - JOUR T1 - Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. AU - Nelson,Karin M, AU - Helfrich,Christian, AU - Sun,Haili, AU - Hebert,Paul L, AU - Liu,Chuan-Fen, AU - Dolan,Emily, AU - Taylor,Leslie, AU - Wong,Edwin, AU - Maynard,Charles, AU - Hernandez,Susan E, AU - Sanders,William, AU - Randall,Ian, AU - Curtis,Idamay, AU - Schectman,Gordon, AU - Stark,Richard, AU - Fihn,Stephan D, PY - 2014/7/24/entrez PY - 2014/7/24/pubmed PY - 2014/12/15/medline SP - 1350 EP - 8 JF - JAMA internal medicine JO - JAMA Intern Med VL - 174 IS - 8 N2 - IMPORTANCE: In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation. OBJECTIVES: To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. DESIGN, SETTING, AND PARTICIPANTS: We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care. MAIN OUTCOMES AND MEASURES: Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. RESULTS: Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001). CONCLUSIONS AND RELEVANCE: The extent of PCMH implementation, as measured by the Pi2, was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes. SN - 2168-6114 UR - https://www.unboundmedicine.com/medline/citation/25055197/Implementation_of_the_patient_centered_medical_home_in_the_Veterans_Health_Administration:_associations_with_patient_satisfaction_quality_of_care_staff_burnout_and_hospital_and_emergency_department_use_ DB - PRIME DP - Unbound Medicine ER -

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Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use.JAMA Intern Med. 2014 Aug; 174(8):1350-8.JIM