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The Missed Opportunity of Patient-Centered Medical Homes to Thrive in an Asian Context.

ABSTRACT: In recent years, there is growing interest internationally to implement patient-centered medical homes (PCMHs), and Singapore is no exception. However, studies understanding the influence of contextual policy factors on the implementation of PCMHs are limited. We conducted 10 semi-structured in-depth interviews with general practitioners working in seven out of the nine PCMHs. Audio recordings were transcribed and analyzed by two study team members in NVivo 12 Software using grounded theory techniques. Power dynamics between the stakeholders and lack of shared decision-making among them in selecting the locale of the PCMH and formulating the practice fee and pharmacy structure were the key factors which negatively affected the implementation of PCMHs on a larger scale. Over time, lack of funding to hire dedicated staff to transfer patients and misalignment of various stakeholders' interest to other right-siting programs also resulted in low number of patients with chronic conditions and revenue. Countries seeking to implement a successful PCMH may benefit from building trust and relationship between stakeholders, engaging in shared decision-making, ongoing cost-efficiency efforts, and formulating a clear delineation of responsibilities between stakeholders. For a healthcare delivery model to succeed in the primary care landscape, policies should be developed keeping mind the realities of primary care practice.

SUBMITTER: Surendran S

PROVIDER: S-EPMC7917999 | biostudies-literature | 2021 Feb

REPOSITORIES: biostudies-literature

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The Missed Opportunity of Patient-Centered Medical Homes to Thrive in an Asian Context.

Surendran Shilpa S Foo Chuan De C Tam Chen Hee CH Ho Elaine Qiao Ying EQY Matchar David Bruce DB Car Josip J Koh Gerald Choon Huat GCH

International journal of environmental research and public health 20210213 4

In recent years, there is growing interest internationally to implement patient-centered medical homes (PCMHs), and Singapore is no exception. However, studies understanding the influence of contextual policy factors on the implementation of PCMHs are limited. We conducted 10 semi-structured in-depth interviews with general practitioners working in seven out of the nine PCMHs. Audio recordings were transcribed and analyzed by two study team members in NVivo 12 Software using grounded theory tech ...[more]

PMID: 33668610

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Project description:BackgroundThere is growing evidence that even small and solo primary care practices can successfully transition to full Patient Centered Medical Home (PCMH) status when provided with support, including practice redesign, care managers, and a revised payment plan. Less is known about the quality and efficiency outcomes associated with this transition.ObjectiveTest quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices.DesignRandomized Controlled Trial.ParticipantsEighteen intervention practices with 43 physicians and 14 control practices with 24 physicians; all from adult primary care practices.InterventionsModeled on 2008 NCQA PPC®-PCMH™, intervention practices received 18 months of tailored practice redesign support; 2 years of revised payment, including up to $2.50 per member per month (PMPM) for achieving quality targets and up to $2.50 PMPM for PPC-PCMH recognition; and 18 months of embedded care management support. Controls received yearly participation payments.Main measuresEleven clinical quality indicators from the 2009 HEDIS process and health outcomes measures derived from patient claims data; Ten efficiency indicators based on Thomson Reuter efficiency indexes and Emergency Department (ED) Visit Ratios; and a panel of costs of care measures.Key resultsCompared to control physicians, intervention physicians significantly improved TWO of 11 quality indicators: hypertensive blood pressure control over 2 years (intervention +23 percentage points, control -2 percentage points, p =0.02) and breast cancer screening over 3 years (intervention +3.5 percentage points, control -0.4 percentage points, p =0.03). Compared to control physicians, intervention physicians significantly improved ONE of ten efficiency indicators: number of care episodes resulting in ED visits was reduced (intervention -0.7 percentage points, control + 0.5 percentage points, p = 0.002), with 3.8 fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year. There were no significant cost-savings on any of the pre-specified costs of care measures.ConclusionsIn a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.

Project description:BackgroundFor more than a decade, the Patient-Centered Medical Home model has been a guiding vision for the modernization of primary care systems. In Canada, Ontario's Family Health Teams (FHTs) were designed in the mid-2000s with the medical home model in mind. These primary care clinics aim to provide accessible, comprehensive, and person-centered primary care services to communities across Ontario. Their services typically include mental health care for people experiencing common mental disorders, such as depression and anxiety disorders. It remains unclear, however, whether the mental health care delivered within FHTs is consistent with person-centered care approaches. In the current study, we aimed to explore the perspectives of FHT providers on the care delivered to people with common mental disorders to determine whether, and to what extent, they believed this care was person-centered.MethodsWe conducted a qualitative grounded theory study involving interviews with 65 health professionals and administrators from 18 FHTs across Ontario. Transcripts were coded using a three-step process of initial, focused, and axial coding that mixed inductive and deductive approaches informed by sensitizing concepts on person-centeredness.ResultsPractices and challenges associated with the delivery of mental health care in a person-centered way were captured by several themes regrouped into five domains: (1) patient as unique person, (2) patient-provider relationship, (3) sharing power and responsibility, (4) connecting to family and community, and (5) creating person-centered care environments. FHT providers perceived that they delivered person-centered care by delivering mental health care that was responsive, flexible, and consistent with biopsychosocial approaches. They emphasized the importance of creating long-lasting relationships with patients grounded in empathy and trust. Their challenges included being able to ensure continuity of care, adequately prioritizing patients' mental health issues, and meaningfully engaging patients and families as partners in care.ConclusionsOur findings suggest that FHT providers have adopted a range of person-centered practices for people with common mental disorders. However, greater attention to practices such as shared decision making, supporting self-management, and involving families in care would strengthen person-centeredness and bring teams closer to the Patient-Centered Medical Home vision.

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The Missed Opportunity of Patient-Centered Medical Homes to Thrive in an Asian Context.

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The Missed Opportunity of Patient-Centered Medical Homes to Thrive in an Asian Context.

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