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

Abstract

Background

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.

Objectives

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.

Methods

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.

Results

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.

Conclusions

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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Acknowledgments

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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KEY WORDS

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