The most used and most helpful facilitators for patient-centered medical home implementation

Implementing a PCMH is a fundamental redesign of primary care, and we know of few efforts to systematically rate the use and utility of the implementation resources. As this model continues to spread, health systems can benefit from knowing how to package and deliver implementation-support resources to members of PCMH teams [24-26], something relatively little is known about [27].

Teamlet huddles were the most used and most helpful resource. These brief meetings allow PCMH team members to talk about and plan for the daily management of patient demands and clinic workflow, address specific patients’ needs and preferences, and improve the delivery of preventive services [28]. In at least one other study, huddles have been found to be associated with better teamwork and an improved practice environment [28]. The informal nature of these meetings and the fact that they are temporally connected to the day’s workflow may make this especially salient to busy primary care staff.

Quality-improvement methods to conduct small tests of change were the least used, although over 40% of the respondents reported using QI methods, and two-thirds of the users found them to be helpful. PCMH measurement tools were widely used but less often rated as helpful. These findings are striking in light of the centrality of Plan-Do-Study-Act (PDSA) and related quality measurement approaches in many primary care systems and PCMH models. It may be that greater training and/or experience is needed before PDSA and similar approaches are useful. Although not part of this analysis, some VHA regional networks did provide internal coaches. Internal coaches may have been especially helpful in assisting staff on the use of quality-improvement tools and methods and in helping staff see the applied value. We also did not assess the use of more comprehensive approaches to PACT implementation, such as practice facilitation, which has been found to be effective for guideline implementation in other settings [29]. In general, PCMH-implementation leaders may want to consider training and dissemination strategies that emphasize the linkage between measurement activities and PCMH effectiveness to boost uptake. Regular teamlet meetings to discuss improvement were also widely used and perceived as helpful, but patterns of use and utility were less clear than for other resources. Although the online toolkit of care delivery and organization tools was not as widely used or highly rated as the other resources, it represents a relatively inexpensive and “on-demand” resource to facilitate the sharing of best practices across disparate sites [30]. PCMH leaders should consider how to best disseminate online toolkits in the context of their own health system.

Individuals working in administrative roles were more likely than providers to have used or participated in activities intended to improve clinic access (e.g., through proactive scheduling) and quality-improvement methods to conduct small tests of change. However, they were less likely to rate those resources as being helpful than providers. If, in fact, administrative staff is the most appropriate audience for those particular resources, our data suggests there may be a need to revise their content, format, or delivery. On the other hand, if administrative staff is not the intended audience, it may be helpful to clarify for those working in primary care the purpose and intended audience of these resources. Although supervisors were more likely to have used or participated in the various PACT-related activities or resources than non-supervisors, they were less likely to rate them “helpful.” There are several possible reasons for that, including the fact that supervisors may not actually have been learning anything new or that the resources were not optimized to their job functions. Those working in supervisory roles may not have had the ability to “opt out” of participation in certain activities, making them more likely to be exposed regardless of how helpful they found the activities to be. In contrast, support staff may have self-selected those activities and resources they found most appealing. Supervisors may also be more comfortable than non-supervisors in giving a frank appraisal of resources or may simply have more time to devote to exploring new resources than front-line staff.

Although individuals working in nursing roles were consistently more likely to have used the resources or participated in the activities than providers, they were less likely to rate them as being “helpful.” The fact that providers who rated the resources and activities were consistently more likely to rate them as “useful” than other users suggests that there may be a need for additional customization of the intervention-boosting resources if we intend for them to appeal to a more diverse group of individuals.

Depending on roles and responsibilities, individuals may engage differently during the implementation of complex interventions like PCMH. In their analysis of survey data from primary care staff who participated in a virtual learning collaborative, Butler et al. found that those who benefited most from the collaborative were those with prior PCMH training and those who fully engaged in collaborative activities though non-providers and newcomers to the PCMH model found the collaboratives to be less helpful [31]. Similarly, in their qualitative analysis of interviews on PCMH implementation among staff delivering care to older adults, Hoff et al. found that a single, across-the-board implementation approach may not be effective [32]. Having a cadre of implementation resources may be valuable, and knowing what resources to make available when selectively targeting certain groups of individuals may be a more efficient and effective means of ensuring uptake. Our data provides a framework for guiding those decisions.

Facility complexity was of limited predictive utility, which may indicate that more person and workgroup targeted implementation-boosting efforts is warranted.

There are limitations to our cross-sectional study. First, there are important limitations to the generalizability of our findings. The VHA’s highly integrated structure may have contributed to the ease with which a PCMH model could be implemented. Similarly, this may have made it easier to disseminate the resources. Outside the VHA, economic incentives, competition, and other external forces may serve to facilitate PCMH uptake [4], which could not be assessed in this study. Second, there is potential measurement bias related to the survey items which were developed for the PCMH evaluation. A number of the resources identified in the survey had similar sounding names. Respondents may not have been able to accurately differentiate between them resulting in some inaccurate ratings or measurement errors. For example, “Teamlet huddles” versus “Regular (non-huddles) teamlet meetings.” Third, there is potential selection bias. This survey was distributed through clinical leadership and was anonymous and voluntary; therefore, we do not have a defined sample from which to derive a response rate or detect response bias. However, we were able to compare our respondent demographics to primary care respondents to a separate survey fielded annually to all VHA employees, which in 2012 achieved a 62% response rate, and our respondents’ demographics were very similar; our sample had a higher proportion of supervisors and fewer African-Americans, among the four occupations comprising PACTs [21]. Our sample was also representative of primary care clinics, with 69% of VHA primary care sites nationally being represented in our findings. Future research correlating timing of the availability of activities and resources with the larger implementation efforts and outcomes would add value to these types of evaluations.

Future assessments of the use and uptake of implementation-boosting resources would be enhanced by examining trends in use over time. For example, some activities and resources may be most valuable when implementation is beginning while others are important to the long-term sustainability of whatever is being implemented. This information could help inform the allocation of financial and personnel resources needed at the onset to support implementation versus resources needed several weeks or months down the line. Additionally, knowing where the system is most likely to face challenges in adopting new care delivery models or quality programs will inform the customization, timing, and marketing of these types of resources.