What Do Patient-Centered Medical Home (PCMH) Teams Need to Improve Care for Primary Care Patients with Complex Needs?



Intensive primary care (IPC) programs for patients with complex needs do not generate cost savings in most settings. Strengthening existing patient-centered medical homes (PCMH) to address the needs of these patients in primary care is a potential high-value alternative.


Explore PCMH team functioning and characteristics that may impact their ability to perform IPC tasks; identify the IPC components that could be incorporated into PCMH teams’ workflow; and identify additional resources, trainings, and staff needed to better manage patients with complex needs in primary care.


We interviewed 44 primary care leaders, PCMH team members (providers, nurses, social workers), and IPC program leaders at 5 VA IPC sites and analyzed a priori themes using a matrix analysis approach.


Higher-functioning PCMH teams were described as already performing most IPC tasks, including panel management and care coordination. All sites reported that PCMH teams had the knowledge and skills to perform IPC tasks, but not with the same intensity as specialized IPC teams. Home visits/assessments and co-attending appointments were perceived as not feasible to perform. Key stakeholders identified 6 categories of supports and capabilities that PCMH teams would need to better manage complex patients, with care coordination/management and fully staffed teams as the most frequently mentioned. Many thought that PCMH teams could make better use of existing VA and non-VA resources, but might need training in identifying and using those resources.


PCMH teams can potentially offer certain clinic-based services associated with IPC programs, but tasks that are time intensive or require physical absence from clinic might require collaboration with community service providers and better use of internal and external healthcare system resources. Future studies should explore the feasibility of PCMH adoption of IPC tasks and the impact on patient outcomes.

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  1. 1.

    McWilliams JM, Schwartz AL. Focusing on high-cost patients - the key to addressing high costs? N Engl J Med. 2017;376(9):807-809.

    Article  Google Scholar 

  2. 2.

    Peikes D, Anglin G, Dale S, et al. Evaluation of the comprehensive primary care initiative: fourth annual report. Mathematica Policy Research;2018.

  3. 3.

    Swanson J, Weissert WG. Case managers for high-risk, high-cost patients as agents and street-level bureaucrats. Med Care Res Rev. 2018;75(5):527-561.

    Article  Google Scholar 

  4. 4.

    Finkelstein A, Zhou A, Taubman S, Doyle J. Health care hotspotting - a randomized controlled trial, N Engl J Med. 2020;382(2):152-162.

    Article  Google Scholar 

  5. 5.

    Edwards ST, Peterson K, Chan B, Anderson J, Helfand M. Effectiveness of intensive primary care interventions: a systematic review. J Gen Intern Med. 2017;32(12):1377-1386.

    Article  Google Scholar 

  6. 6.

    Yee T, Lechner A, Carrier E. High-intensity primary care: lessons for physician and patient engagement. National Institute for Health Care Reform. 2012;9:1-7.

    Google Scholar 

  7. 7.

    Boult C, Green AF, Boult LB, Pacala JT, Snyder C, Leff B. Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine’s “retooling for an aging America” report. J Am Geriatr Soc. 2009;57(12):2328-2337.

    Article  Google Scholar 

  8. 8.

    Chang ET, Raja PV, Stockdale SE, et al. What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study. Paper presented at: Healthcare2018.

  9. 9.

    Bodenheimer T, Berry-Millett R. Care management of patients with complex health care needs. Princeton, NJ: Robert Wood Johnson Foundation;2009. 19.

  10. 10.

    de Bruin SR, Versnel N, Lemmens LC, et al. Comprehensive care programs for patients with multiple chronic conditions: a systematic literature review. Health policy. 2012;107(2-3):108-145.

    Article  Google Scholar 

  11. 11.

    McCarthy D, Ryan J, Klein S. Models of care for high-need, high-cost patients: an evidence synthesis. Issue Brief (Commonw Fund). 2015;31:1-19.

    PubMed  Google Scholar 

  12. 12.

    Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. Bmj. 2012;345:e5205.

    Article  Google Scholar 

  13. 13.

    Stokes J, Panagioti M, Alam R, Checkland K, Cheraghi-Sohi S, Bower P. Effectiveness of case management for ‘at risk’ patients in primary care: a systematic review and meta-analysis. PLoS One. 2015;10(7):e0132340.

  14. 14.

    Lipson D, Rich E, Libersky J, Parchman M. Ensuring that patient-centered medical homes effectively serve patients with complex health needs. In. Rockville, MD: Agency for Healthcare Research and Quality; 2011.

  15. 15.

    Veet CA, Radomski TR, D'Avella C, et al. Impact of healthcare delivery system type on clinical, utilization, and cost outcomes of patient-centered medical homes: a systematic review. J Gen Intern Med. 2020;35(4):1276-1284.

    Article  Google Scholar 

  16. 16.

    Hong C, Siegel A, Ferris T. Caring for high-need, high-cost patients: what makes for a successful care management program? New York, NY2014.

  17. 17.

    Hudon C, Chouinard MC, Lambert M, Diadiou F, Bouliane D, Beaudin J. Key factors of case management interventions for frequent users of healthcare services: a thematic analysis review. BMJ Open. 2017;7(10):e017762.

    Article  Google Scholar 

  18. 18.

    Hudon C, Chouinard MC, Aubrey-Bassler K, et al. Case management in primary care for frequent users of health care services: a realist synthesis. Ann Fam Med. 2020;18(3):218-226.

    Article  Google Scholar 

  19. 19.

    Rosland AM, Wong E, Maciejewski M, et al. Patient-centered medical home implementation and improved chronic disease quality: a longitudinal observational study. Health Serv Res. 2018;53(4):2503-2522.

    Article  Google Scholar 

  20. 20.

    Zulman DM, Pal Chee C, Ezeji-Okoye SC, et al. Effect of an intensive outpatient program to augment primary care for high-need veterans affairs patients: a randomized clinical trial. JAMA Intern Med. 2017;177(2):166-175.

    Article  Google Scholar 

  21. 21.

    Dorr DA, Wilcox A, Burns L, Brunker CP, Narus SP, Clayton PD. Implementing a multidisease chronic care model in primary care using people and technology. Dis Manag. 2006;9(1):1-15.

    Article  Google Scholar 

  22. 22.

    Breland JY, Asch SM, Slightam C, Wong A, Zulman DM. Key ingredients for implementing intensive outpatient programs within patient-centered medical homes: a literature review and qualitative analysis. Healthc (Amst). 2016;4(1):22-29.

    Article  Google Scholar 

  23. 23.

    Blumenthal D, Chernof B, Fulmer T, Lumpkin J, Selberg J. Caring for high-need, high-cost patients - an urgent priority. N Engl J Med. 2016;375(10):909-911.

    Article  Google Scholar 

  24. 24.

    Rosland A, Nelson K, Sun H, et al. The patient-centered medical home in the Veterans Health Administration. American Journal of Managed Care. 2013;19(7):e263-272.

    Google Scholar 

  25. 25.

    Nelson KM, Helfrich C, Sun H, et al. Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Intern Med. 2014;174(8):1350-1358.

    Article  Google Scholar 

  26. 26.

    Chang ET, Zulman DM, Asch SM, et al. An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation. Contemp Clin Trials. 2018;69:65-75.

    Article  Google Scholar 

  27. 27.

    Atlas.ti 8 Windows User Manual [computer program]. Berlin, Germany: Scientific Software Development GmbH; 2018.

  28. 28.

    Averill J. Matrix analysis as a complementary analytic strategy in qualitative inquiry. Qualitative Health Research. 2002;12(6):855-866.

    Article  Google Scholar 

  29. 29.

    Miles MB, Huberman AM. Qualitative Data Analysis: an Expanded Sourcebook. Thousand Oaks, CA: Sage; 1994.

    Google Scholar 

  30. 30.

    Hayes SL, Salzberg CA, McCarthy D, et al. High-need, high-cost patients: who are they and how do they use health care? A population-based comparison of demographics, health care use, and expenditures. Issue Brief (Commonw Fund). 2016;26:1-14.

    Google Scholar 

  31. 31.

    Hasselman D. Super-Utilizer Summit: common themes from innovative complex care management programs. Hamilton, NJ: Center for Health Care Strategies. 2013;2013:1-37.

    Google Scholar 

  32. 32.

    Tinetti ME, Fried TR, Boyd CM. Designing health care for the most common chronic condition--multimorbidity. JAMA. 2012;307(23):2493-2494.

    CAS  Article  Google Scholar 

  33. 33.

    Long P, Abrams M, Milstein A, Anderson G, Apton KL, Dahlberg M. Effective care for high-need patients. Washington, DC. 2017.

    Google Scholar 

  34. 34.

    Bodenheimer T. Strategies to reduce costs and improve care for high-utilizing Medicaid patients: reflections on pioneering programs. Center for Health Care Strategies, Inc. 2013.

    Google Scholar 

  35. 35.

    Kizer KW, Demakis JG, Feussner JR. Reinventing VA health care: systematizing quality improvement and quality innovation. Med Care. 2000;38(6 Suppl 1):I7-16.

    CAS  PubMed  Google Scholar 

  36. 36.

    McFarland MS, Lamb K, Hughes J, Thomas A, Gatwood J, Hathaway J. Perceptions of integration of the clinical pharmacist into the patient care medical home model. J Healthc Qual. 2018;40(5):265-273.

    Article  Google Scholar 

  37. 37.

    Nigro S, Garwood C, Berlie H, et al. Clinical pharmacists as key members of the patient-centered medical home: an opinion statement of the Ambulatory Care Practice and Research Network of the American College of Clinical Pharmacy. Pharmacotherapy. 2014;34:96-108.

    Article  Google Scholar 

  38. 38.

    Scott MA, Hitch B, Ray L, Colvin G. Integration of pharmacists into a patient-centered medical home. J Am Pharm Assoc (2003). 2011;51(2):161-166.

  39. 39.

    Affairs UDoV. Connected care. https://connectedcare.va.gov/. Published 2020. Accessed March 12, 2020.

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Contributors: The authors would like to acknowledge Emily Wong, MPH, for assistance with coding qualitative interview data; Steven M. Asch, MD, MPH, and Jeffrey E. Rollman for reviewing and commenting on previous versions of the manuscript; and Michelle Wong, PhD, Tana Luger, PhD, and Karleen Giannitrapani, PhD, for feedback on the “RESULTS” section. Funders: This study was conducted as part of the PACT Intensive Management evaluation, funded by VA Office of Primary Care, XVA 65-054. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, or the US government, or other affiliated institutions. Prior presentations: VA HSRD/QUERI Research Meeting, Washington, D.C., 2019; Society for General Internal Medicine Annual Meeting, Washington, D.C., 2019; AcademyHealth Annual Research Meeting, Washington, D.C., 2019.

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Correspondence to Susan E. Stockdale PhD.

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Stockdale, S.E., Katz, M.L., Bergman, A.A. et al. What Do Patient-Centered Medical Home (PCMH) Teams Need to Improve Care for Primary Care Patients with Complex Needs?. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-020-06563-x

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  • patient-centered medical home
  • intensive primary care
  • qualitative interviews