Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics.

Helfrich CD, Dolan ED, Fihn SD, Rodriguez HP, Meredith LS, Rosland AM, Lempa M, Wakefield BJ, Joos S, Lawler LH, Harvey HB, Stark R, Schectman G, Nelson KM. Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics. Healthcare (Amsterdam, Netherlands). 2014 Dec 1; 2(4):238-44.

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Abstract:

INTRODUCTION: Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams? abilities to deliver patient-centered care. MATERIAL AND METHODS: We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity. RESULTS: 4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (ß = 32, P < 0.0001) and history of change in the clinic (ß = 18, P = 0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (ß = 0.16-0.34, P = < 0.0001), and lower improvements in patient-centered care (ß = -0.19, P = 0.001). CONCLUSIONS: Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures. IMPLICATIONS: Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics.