1. 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

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

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

4. 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.

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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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?

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

14. 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

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

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

18. Conclusion PCMHI Mixed-methods for complex evaluations
Innovative approaches

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

20. 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?

21. Enhanced access is the availability of easy and flexible access to the primary care team, including alternatives to face-to-face visits, such as and telephone.

22. 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

23. Time 1 Data Collection

24. MHIQ Time 1 Results

25. MHIQ Time 1 Results

26. 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?

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

28. 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.

29. 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

30. Time 2 Data Collection

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

32. 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?

33. 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

34. 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.

36. 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

37. 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

38. Contact Information