Study Finds PCMH Model with Diabetes Focus Works

Philadelphia—Because a majority of diabetes patients are treated in the primary care setting, this has been a focus for diabetes improvement efforts. The patient-centered medical home (PCMH) model has gained national attention as an opportunity to reorganize primary care to improve clinical quality and health outcomes and has exhibited positive results in enhancing diabetes care.

Pennsylvania has had a large, multipayer supported state-led PCMH initiative involving 152 primary care practices in 7 regions throughout the state. Care has improved through the initiative, although some participating practices have better results in diabetes care than others. A mixed methods study, presented in an ADA poster session, used a positive deviance approach to identify the characteristics and behaviors that distinguish the most improved practices from the lowest improved practices. The poster was titled A Medical Home Initiative Targeting Diabetes Care: A Positive Deviance Approach to Understanding What Works.

For the study, the researchers looked at 25 heterogeneous adult medicine practices with 143 participating providers in southeast Pennsylvania. All focused initially on improving diabetes care and all participated in the first regional rollout of the statewide PCMH initiative starting in May 2008. A majority of the practices (36%) were family medicine and 76% of the practices had 100 to 500 diabetes patients. Practices were ranked into improvement quintiles calculated according to average absolute percentage change from baseline to 18 months in 3 practice-reported evidence-based diabetes measures for hemoglobin A1c (HbA1c), blood pressure (BP), and low-density lipoprotein (LDL) cholesterol.

Participating practices were sampled for in-depth interviews based on their improvement ranking. The interviews (n=55) were conducted with providers, office managers, and staff in all 10 of the most- and least-improved practices. Within each of the 10 practices, individuals (n=215) were surveyed to evaluate practice-level adaptive reserve (defined as a practice’s ability to make and sustain change) and professional burnout. The survey response rate was 52%, ranging from 12% to 100% across the 10 practices.

The results showed the most-improved practices had better diabetes care across all 3 diabetes measures at 18 months compared with the least-improved practices: 8.8% versus −11.8% change in HbA1c <7%, 19.5% versus −8.3% change in BP <130/80 mm Hg, and 14.9% versus −13.2% change in LDL cholesterol <100 mg/dL. The average improvement index of the most-improved practices was significantly greater than that of the least-improved practices (+14.4% vs −11.1%).

The investigators also analyzed the practices’ abilities to buffer stress related to change. The most-improved practices had greater shared vision, better planning and decision-making, stronger teamwork and development of staff, and better communication on expectations and performance. For example, the most-improved practices articulate and reinforce how PCMH will help patients and the practice increase knowledge and motivation of the staff regarding the PCMH model and the need for changes. The least-improved practices, however, are confused about changing roles and uncertain about processes and expected outcomes.

In conclusion, the researchers stated that “facilitative leadership seems to be a key ingredient to successful change management leading to clinical diabetes improvement. Provider and administrative practice leaders need greater training in skills to promote buy-in for changes, plan and coordinate change, cultivate a culture of team-based care, and solicit feedback in a systematic manner.”

This study was supported by the Agency for Healthcare Research and Quality.