A randomized, controlled trial of implementing the patient-centered medical home model in solo and small practices

Abstract

Background: Transition to a Patient-Centered Medical Home (PCMH) is challenging in primary care, especially for smaller practices.

Objective: To test the effectiveness of providing external supports, including practice redesign, care management and revised payment, compared to no support in transition to PCMH among solo and small (<2-10 providers) primary care practices over 2 years.

Design: Randomized Controlled Trial.

Participants: Eighteen supported practices (intervention) and 14 control practices (controls).

Interventions: Intervention practices received 6 months of intensive, and 12 months of less intensive, practice redesign support; 2 years of revised payment, including cost of National Council for Quality Assurance's (NCQA) Physician Practice Connections(®)-Patient-Centered Medical Home™ (PPC(®)-PCMH™) submissions; and 18 months of care management support. Controls received yearly participation payments plus cost of PPC(®)-PCMH™.

Main measures: PPC(®)-PCMH™ at baseline and 18 months, plus intervention at 7 months.

Key results: At 18 months, 5 % of intervention practices and 79% of control practices were not recognized by NCQA; 10% of intervention practices and 7% of controls achieved PPC(®)-PCMH™ Level 1; 5% of intervention practices and 0% of controls achieved PPC(®)-PCMH™ Level 2; and 80% of intervention practices and 14% of controls achieved PPC(®)-PCMH™ Level 3. Intervention practices were 27 times more likely to improve PPC(®)-PCMH™ by one level, irrespective of practice size (p < 0.001) 95% CI (5-157). Among intervention practices, a multilevel ordinal piecewise model of change showed a significant and rapid 7-month effect (p(time7) = 0.01), which was twice as large as the sustained effect over subsequent 12 months (p(time18) = 0.02). Doubly multivariate analysis of variance showed significant differential change by condition across PPC(®)-PCMH™ standards over time (p(time x group)=0.03). Intervention practices improved eight of nine standards, controls improved three of nine (p(PPC1) = 0.009; p(PPC2) = 0.005; p(PPC3) = 0.007).

Conclusions: Irrespective of size, practices can make rapid and sustained transition to a PCMH when provided external supports, including practice redesign, care management and payment reform. Without such supports, change is slow and limited in scope.

Figure 1.

Enrollment and retention of practices.

Figure 2.

Distribution of PPC^®-PCMH™ levels at 18-month follow-up by study condition. * Zero values represent practices that did not achieve NCQA recognition. ^† Number of practices at each PPC^®-PCMH™ level at 18-month follow-up. ^‡ Kolmogorov–Smirnov (K–S) statistic p-value of significant differences in distributions.

Figure 3.

Observed proportion of practices reaching PPC^®-PCMH™ Level 3 by 18-months follow-up, and piecewise ordinal multilevel model predicted slope estimates and P-values. * Piecewise ordinal multilevel model coefficients and p-values for intervention practices. ^† PPC^®-PCMH™ level.