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Core Functions and Forms of Complex Health Interventions: a Patient-Centered Medical Home Illustration

  • Mónica Perez Jolles
  • Rebecca Lengnick-Hall
  • Brian S. Mittman
Perspective

Abstract

Despite policy and practice support to develop and test interventions designed to increase access to quality care among high-need patients, many of these interventions fail to meet expectations once deployed in real-life clinical settings. One example is the Patient-Centered Medical Home (PCMH) model, designed to deliver coordinated care. A meta-analysis of PCMH initiatives found mixed evidence of impacts on service access, quality, and costs. Conceptualizing PCMH as a complex health intervention can generate insights into the mechanisms by which this model achieves its effects. It can also address heterogeneity by distinguishing PCMH core functions (the intervention’s basic purposes) from forms (the strategies used to meet each function). We conducted a scoping review to identify core functions and forms documented in published PCMH models from 2007 to 2017. We analyzed and summarized the data to develop a PCMH Function and Form Matrix. The matrix contributes to the development of an explicit theory-based depiction of how an intervention achieves its effects, and can guide decision-support tools in the field. This innovative approach can support transformations of clinical settings and implementation efforts by building on a clear understanding of the intervention’s standard core functions and the forms adapted to local contexts’ characteristics.

KEY WORDS

complex health interventions core functions and forms patient-centered care medical home primary care 

Notes

Acknowledgments

Ms. Crystal Villalpando made valuable contributions to the literature searches and initial classification of the literature. We would also like to thank Laura Esmail, PhD, MSc, and Barbara J. Turner, MD, for reviewing drafts of this manuscript.

Funding Information

This project was in part funded by an internal grant from the Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

References

  1. 1.
    Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. In: Committee on Quality of Health Care in America, ed. Washington, DC: National Academy Press; 2001.Google Scholar
  2. 2.
    The Commonwealth Fund. Primary Care: Our First Line of Defense. 2013; http://www.commonwealthfund.org/publications/health-reform-and-you/primary-care-our-first-line-of-defense. Accessed November 21, 2018.
  3. 3.
    Katon, Wayne J., Jürgen Unützer, Simon, Gregory. Treatment of depression in primary care: where we are, where we can go. Medical Care 2004;42(12):1153–1115.Google Scholar
  4. 4.
    Solberg LI, Trangle MA, Wineman AP. Follow-up and follow-through of depressed patients in primary care: the critical missing components of quality care. Journal of American Board of Family Practice. 2005;18(6):520–525.Google Scholar
  5. 5.
    Litaker D, Tomolo A, Liberatore V, Stange KC, Aron D. Using complexity theory to build interventions that improve health care delivery in primary care. Journal of General Internal Medicine 2006;21(S30–34).Google Scholar
  6. 6.
    AHRQ. The Patient-Centered Medical Home: Strategies to put patients at the center of primary care. 2017; https://pcmh.ahrq.gov/page/patient-centered-medical-home-strategies-put-patients-center-primary-care. Accessed November 21, 2018.
  7. 7.
    Farmer JE, Clark MJ, Drewel EH, Swenson TM, Ge B. Consultative care coordination through the medical home for CSHCN: a randomized controlled trial. Maternal and Child Health Journal. 2011;15(7):1110–1118.CrossRefGoogle Scholar
  8. 8.
    Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815–825.CrossRefGoogle Scholar
  9. 9.
    McMillan SS, Kendall E, Sav A, King MA, Whitty JA, Kelly F, Wheeler AJ. Patient-centered approaches to health care: a systematic review of randomized controlled trials. Medical Care Research and Review. 2013;70(6):567–596.Google Scholar
  10. 10.
    Mosquera RA, Avritscher EB, Samuels CL, et al. Effect of an enhanced medical home on serious illness and cost of care among high-risk children with chronic illness: a randomized clinical trial. JAMA. 2014;312(24):2640–2648.CrossRefGoogle Scholar
  11. 11.
    CMS. Multi-payer advanced primary care practice. 2018; https://innovation.cms.gov/initiatives/Multi-Payer-Advanced-Primary-Care-Practice/. Accessed November 21, 2018.
  12. 12.
    Sinaiko AD, Landrum MB, Meyers DJ, et al. Synthesis of research on patient-centered medical homes brings systematic differences into relief. Health Affairs. 2017;36(3):500–508.CrossRefGoogle Scholar
  13. 13.
    Aysola J, Bitton A, Zaslavsky AM, Ayanian JZ. Quality and equity of primary care with patient-centered medical homes: results from a national survey. Med Care. 2013;51(1):68–77.CrossRefGoogle Scholar
  14. 14.
    Butcher J, Wolraich M, Gillaspy S, Martin V, Wild R. The impact of a Medical Home for children with developmental disability within a pediatric resident continuity clinic. The Journal of the Oklahoma State Medical Association. 2014;107(12):632–638.PubMedGoogle Scholar
  15. 15.
    Harder VS, Krulewitz J, Jones C, Wasserman RC, Shaw JS. Effects of patient-centered medical home transformation on child patient experience. The Journal of the American Board of Family Medicine. 2016;29(1):60–68.CrossRefGoogle Scholar
  16. 16.
    Domino ME, Humble C, Lawrence Jr WW, Wegner S. Enhancing the medical homes model for children with asthma. Med Care. 2009;47(11):1113–1120.CrossRefGoogle Scholar
  17. 17.
    Golnik A, Scal P, Wey A, Gaillard P. Autism-specific primary care medical home intervention. J Autism Dev Disord. 2012;42(6):1087–1093.CrossRefGoogle Scholar
  18. 18.
    Han B, Yu H, Friedberg MW. Evaluating the impact of parent-reported medical home status on children's health care utilization, expenditures, and quality: A difference-in-differences analysis with causal inference methods. Health Serv Res. 2017;52(2):786–806.CrossRefGoogle Scholar
  19. 19.
    Jackson GL, Powers BJ, Chatterjee R, Bettger JP, Kemper AR, Hasselblad V, Dolor RJ, Irvine RJ, Heidenfelder BL, Kendrick AS, Gray R. et al. The patient-centered medical home: a systematic review. Annals of Internal Medicine. 2013;158(3):169–178.Google Scholar
  20. 20.
    Peikes D, Zutshi A, Genevro J, Smith K, Parchman M, Meyers D. Early evidence on the patient-centered medical home. American Journal of Managed Care. 2012;18:105–6.Google Scholar
  21. 21.
    Berman S, Rannie M, Moore L, Elias E, Dryer LJ, Jones MD. Utilization and costs for children who have special health care needs and are enrolled in a hospital-based comprehensive primary care clinic. Pediatrics. 2005;115(6):e637-e642.CrossRefGoogle Scholar
  22. 22.
    Cooley WC, McAllister JW, Sherrieb K, Kuhlthau K. Improved outcomes associated with medical home implementation in pediatric primary care. Pediatrics. 2009;124(1):358–364.CrossRefGoogle Scholar
  23. 23.
    Hawe P, Shiell A, Riley T. Complex interventions: how “out of control” can a randomised controlled trial be? BMJ: British Medical Journal. 2004;328(7455):1561.CrossRefGoogle Scholar
  24. 24.
    Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655.CrossRefGoogle Scholar
  25. 25.
    Leykum LK, Pugh J, Lawrence V, et al. Organizational interventions employing principles of complexity science have improved outcomes for patients with Type II diabetes. Implementation Science. 2007;2(1):28.CrossRefGoogle Scholar
  26. 26.
    Schwenk TL. The patient-centered medical home: one size does not fit all. JAMA. 2014;311(8):802–803.CrossRefGoogle Scholar
  27. 27.
    Petticrew M. When are complex interventions ‘complex’? When are simple interventions ‘simple’? European Journal of Public Health. 2011;21(4):3970–3398.CrossRefGoogle Scholar
  28. 28.
    Guise JM, Chang C, Viswanathan M, et al. Systematic Reviews of Complex Multicomponent Health Care Interventions [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2014; https://www.ncbi.nlm.nih.gov/books/NBK194846/. Accessed 21 November 2018.
  29. 29.
    Shiell A, Hawe P, Gold L. Complex interventions or complex systems? Implications for health economic evaluation BMJ: British Medical Journal. 2008;336(7656):1281–1283.CrossRefGoogle Scholar
  30. 30.
    PCORI. Standards for Studies of Complex Interventions (SCI). 2017; https://www.pcori.org/engagement/engage-us/provide-input/comment-proposed-new-pcori-methodology-standards-2017. Accessed November 21, 2018.
  31. 31.
    Oregon Health Authority. Patient-Centered Primary Care Home Program: 2017 Recognition Criteria, technical specifications and reporting guide. 2017;2:1–144. https://www.oregon.gov/oha/HPA/dsi-pcpch/Documents/TA-Guide.pdf. Accessed November 21, 2018.
  32. 32.
    Ackroyd SA, Wexler DJ. Effectiveness of diabetes interventions in the patient-centered medical home. Current Diabetes Reports. 2014;14(3):471–480.Google Scholar
  33. 33.
    Chaumont VM. Patient-Centered Medical Home Pilot: Final Report. 2013, November. :215. https://www.pcpcc.org/resource/final-report-patient-centered-medical-home-pilot. Accessed November 21, 2018.
  34. 34.
    Maine PCMH Pilot. PCMH 2013 core expectations: Minimum Requirements. 2013:4. https://www.mainequalitycounts.org/image_upload/Maine_PCMH_Pilot_MAPCP_Extension_MOA_Appdx_C_Reporting_Expectations_Nov2014.pdf Accessed November 21, 2018.
  35. 35.
    NCQA. PCMH Reconition Process: Becoming a PCMH. Patient Centered Medical Home PCMH 2017; http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/get-started/process-becoming-a-pcmh. Accessed November 21, 2018.
  36. 36.
    Alexander JA, Paustian M, Wise CG, et al. Assessment and measurement of patient-centered medical home implementation: the BCBSM experience. The Annals of Family Medicine. 2013;11(Suppl 1):S74-S81.CrossRefGoogle Scholar
  37. 37.
    Fix GM, Asch SM, Saifu HN, Fletcher MD, Gifford AL, Bokhour BG. Delivering PACT-principled care: are specialty care patients being left behind? Journal of General Internal Medicine. 2014;29(2):695–702.CrossRefGoogle Scholar
  38. 38.
    Chang A, Bowen JL, Buranosky RA, Frankel RM, Ghosh N, Rosenblum MJ, Thompson S, Green ML. Transforming primary care training—patient-centered medical home entrustable professional activities for internal medicine residents. Journal of General Internal Medicine. 2013;28(6):801–809.Google Scholar
  39. 39.
    Paustian ML, Alexander JA, El Reda DK, Wise CG, Green LA, Fetters MD. Partial and incremental PCMH practice transformation: implications for quality and costs. Health Services Research. 2014;49(1):52–74.Google Scholar
  40. 40.
    New York State Department of Health. NYS health home provider qualification standards for chronic medical and behavioral health patient populations. September, 2017:1. https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/provider_qualification_standards.htm. Accessed November 21, 2018.
  41. 41.
    Detmer D, Bloomrosen M, Raymond B, Tang P. Integrated personal health records: transformative tools for consumer-centric care. BMC Medical Informatics and Decision Making. 2008;8(1):45.Google Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Mónica Perez Jolles
    • 1
  • Rebecca Lengnick-Hall
    • 1
  • Brian S. Mittman
    • 2
  1. 1.Suzanne Dworak-Peck School of Social WorkUniversity of Southern CaliforniaLos AngelesUSA
  2. 2.Health Services Research & Implementation Science, Department of Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaUSA

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