Humberto Reynoso-Vallejo, PhD Linda Cabral, MM Transformation towards becoming a Patient-Centered Medical Home – A mixed methods approach to measuring system change American Evaluation Association Conference October 2012 Humberto Reynoso-Vallejo, PhD Linda Cabral, MM

Project Team Ann Lawthers, Principal Investigator Terri Anderson Humberto Reynoso-Vallejo Linda Cabral Laura Sefton Bruce Barton Various Others – Thank you!

Today’s Session Overall study design Assessing one Primary Care Medical Home (PCMH) Core Competency Enhanced Access

Mixed-Methods Evaluation Design of the PCMHI in MA Humberto Reynoso-Vallejo, PhD Center for Health Policy and Research UMass Medical School Panel Abstract: The Patient-Centered Medical Home (PCMH) has been identified as a model of high-quality primary care and is being gradually adopted by practices nationwide. In Massachusetts, the PCMH has been in process of implementation in 46 primary care practices. Our team at the Center for Health Policy and Research (University of Massachusetts Medical School) is currently evaluating this initiative. A central question of the evaluation is “How and to what extent do practices become medical home”? This evaluation utilizes a multi-level mixed methods design to answer this question. This panel will present how the evaluators are collecting and analyzing both qualitative and quantitative data. Information will be shared about how data from various sources, including surveys, interviews and focus groups, and various stakeholders, such as Medical Home Facilitators and practice staff, are being integrated to answer this evaluation question.

Overview Patient Centered Medical Homes and the MA -PCMHI 46 Practices (+ 19 Comparison) Total n=65 Mixed-Methods Design

There are medical home demonstrations in almost every state of the country, many of them multipayer

States with dedicated resources to advance Medical Homes From: BUILDING MEDICAL HOMES: LESSONS FROM EIGHT STATES WITH EMERGING PROGRAMS Neva Kaye, Jason Buxbaum, and Mary Takach National Academy for State Health Policy Source: The Commonwealth Fund and the National Academy for State Health Policy, December 2011

MA Patient-Centered Medical Home Initiative Statewide Initiative Sponsored by MA EOHHS Multi-payer 46 Participating Practices + 19 Comparison 3 year Demonstration Start Date: March 29, 2011 Vision: All MA primary care practices will be PCMHs by 2015

MA PCMHI: Objectives To implement and evaluate the PCMH model as a means to achieve accessible, high quality primary care To demonstrate cost-effectiveness in order to justify and support the sustainability and spread of the model To attract and retain primary care clinicians into practice in Massachusetts by increasing resources available to practices and improving their quality of work life   To improve the quality of primary care To demonstrate cost effectiveness with the aim of sustainability and spread of the model To help address the issue of primary care clinician shortage

MA PCMHI: Practice Redesign 12 Core Competencies Patient/family centeredness Team based care Planned visits & follow-up care Registry use for population and patient management Care coordination Care management for high risk patients Self management support Patient and family education Shared decision making, patient action plans Evidence based care Integration of QI Enhanced access High Priority competency by the PCMH council

Practice Groups Technical Assistance plus Payment (TA+P) n=18 Technical Assistance Only (TAO) n=14 Technical Assistance plus Payment + Qualis (TA+P+Q) n=14 Comparison n=19 Total Practice Groups n= 65

MA PCMHI: Evaluation Questions To what extent do practices become medical homes? To what extent and in what ways do patients become active partners in their health care? What is the initiative’s impact on service use, costs, clinical quality, patient and provider outcomes?

Evaluation Methods Design Mixed–Methods Descriptive, Pre-Post with Comparison Group

Evaluation Methods Design Qualitative Data Sources: Interviews and focus groups Participant observation at Learning Sessions Site Visits Quantitative Data Sources: Medical Home Quotient Index (MHIQ) Staff Member Satisfaction Patient Experience Survey (CAHPS) Claims data, clinical quality measures

Qualitative Analysis In-depth semi-structured individual interviews and focus groups with MHF’s Atlas ti Summative Analysis Participation in Learning Sessions Site Visits

Quantitative Analysis MHIQ TransforMed© instrument Patient Experience Survey (CAHPS) Staff Member Satisfaction Survey Claims data, clinical quality measures Include domains for each instrument

Conclusion PCMHI Mixed-methods for complex evaluations Innovative approaches

Examining Enhanced Access in the Implementation of a Medical Home Linda Cabral, MM Center for Health Policy and Research UMass Medical School

Overview What is enhanced access? Why is it of interest? How is it measured? How did we use qualitative and quantitative data to better under how practices are enhancing access to care for their patients?

Enhanced access is the availability of easy and flexible access to the primary care team, including alternatives to face-to-face visits, such as e-mail and telephone. http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/pcmhi/about/core-competencies.html

PCMHI Core Competency: Enhanced Access MHIQ Questions Access to Care and Information (9 questions) Same-Day Appointments After-Hours Access Coverage Accessible Patient and Lab Information Online Patient Services Electronic Visits Group Visits

Time 1 Data Collection

MHIQ Time 1 Results

MHIQ Time 1 Results

Baseline Qualitative Data on Access Focus Group We’d like to understand how you work with the practices to address the PCMHI initiative’s core competencies. What types of activities do you conduct with the practices? Do practices view some competencies as more important than others? If so, which ones?

Baseline Qualitative Data on Access Individual Interviews Among the practices with whom you work, what are sites doing to enhance patient access to care?

Time 1 Qualitative Results Competency in enhanced access depends: Empanelment Teamwork/collaboration across the practice staff Managing patient flow within the office One way that practices strived to meet this core competency was to introduce open access. This was met with varying levels of satisfaction among providers and patients.

Time 1 Qualitative Results New positions such as “Access Facilitator” and “Patient Navigator” are being introduced in some practices. Some practices feel that they have no access issues

Time 2 Data Collection

Mean TransforMED© Scores for MHF 2 Practices - Access to Care Module Percent TransforMED Maximum Score

Time 2 Qualitative Data Collection Q: We have a chart here which shows the TransforMED© survey scores which your practices achieved as well as the total for all practices for Access Domain. These data reflect the practice responses from March. From your knowledge, how do these scores reflect these practices?

Time 2 Qualitative Results Practices are working on enhancing access by working in teams to increase chances of being able to be seen by team member, better utilizing their MA being smarter about scheduling, and hiring LPNs to offload RNs to offload NPs to offload MDs Challenges arise when a practice has many part time providers, a residency program, or has a lot of turnover

Time 2 Qualitative Results Access and continuity are intertwined; one can affect the other. Team-based care, where the patient is familiar with more than one provider, can mitigate potential problems. Practices are working on Access and Empanelment at the same time. In order to ensure that visit time is adequate, the panels need to be the appropriate size.

Reactions Thoughtful insights provided Gained much more practice-specific information However, the more practices a MHF had, the less practice-specific data we were able to gather

Using this Mixed Methods Approach… Assumes participants have a certain comfort level with quantitative data Allows for unique insights of the quantitative data Generates a better understanding among participants of how quantitative data is being used

Contact Information Humberto.Reynoso@umassmed.edu 508-856-1531 Linda.Cabral@umassmed.edu 508-856-8423