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Which facilitators and barriers have the strongest correlations with implementation of a patient-centered medical home in VA?

Helfrich CD, Gale RC, Sylling PW, Mohr DC, Stockdale SE, Brown EJ, Asch SM, Nelson KM, Fihn SD, Meredith LS. Which facilitators and barriers have the strongest correlations with implementation of a patient-centered medical home in VA? Presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.


The Patient Aligned Care Teams (PACT) initiative, the VA patient-centered medical home model, is designed to improve clinical continuity, coordination, and patient-centeredness. Early evaluations of PACT have found a clinic-level association of PACT implementation with better patient satisfaction, lower provider burnout and lower hospitalization for ambulatory care-sensitive conditions and lower emergency department use. However, there have also been significant challenges to implementing PACT, and the conditions and resources that foster or hinder PACT implementation are less clear. To better understand how to disseminate PCMH, we assessed the associations of employee ratings of facilitators and barriers with extent of PACT implementation. Methods: We performed a cross-sectional, respondent-level analysis of the odds of respondents from high and medium-implementation PACT clinics relative to low-implementation clinics reporting specific barriers and facilitators. PACT implementation was assessed the 2012 PACT Implementation Progress Index, a previously validated, clinic-level index covering 8 domains and incorporating administrative, clinical, patient survey and employee survey data. Consistent with prior analyses, clinics were categorized as high (n = 77), medium (n = 749) and low (n = 87). Independent variables were 2012 national primary-care employee survey data (n = 4,819) from structured measures of the availability and helpfulness of 10 facilitators of PACT implementation and limitations created by 19 barriers to patient-centered care. We adjusted for respondent characteristics previously found associated with facilitator use, and clinic-level workload and staffing measures. Findings: The most prevalent barrier to PACT implementation was volume of electronic clinical reminders (54% reported "limits a great deal") and the highest rated facilitator was team huddles (51% reported "very helpful"). In adjusted analyses, respondents at high-implementation clinics, relative to low-implementation clinics, had significantly higher odds of reporting the presence of 5 facilitators, with the strongest association for involvement in teamlet huddles (OR = 3.75, p = .01), while respondents at medium-implementation facilities had higher odds of reporting the presence of 3 facilitators with the strongest association the availability of disease registries (OR = 1.59, p = .04). Respondents at high-implementation clinics had significantly higher odds of rating 4 facilitators as very helpful, with the strongest association for local education sessions (OR = 1.99, p = .02), while there was no difference in ratings of facilitator helpfulness between medium and low-implementation clinics. Relative to high and medium-implementation clinics, respondents at low-implementation clinics had significantly higher odds of rating 9 and 7 barriers, respectively, as limiting patient-centered care a great deal. The strongest association for high-implementation clinics was recruiting and retaining providers (OR = .41, p < .01), and the strongest for medium-implementation clinics was recruiting and retaining non-provider clinicians (OR = .59, p = .01). .

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