Overviewc
A patient-centered medical home (PCMH), as defined by the Agency for Healthcare Research and Quality, is an organizational model of primary care with the following functions and attributes: comprehensive, patient centered, coordinated, accessible, high quality,24 and safe. Achieving these functions and attributes requires a complex set of changes and innovations that go well beyond the boundaries of the practice setting and include provider and hospital networks, insurers, and Federal agencies. Examples of PCMH interventions within the practice setting include team-based care, the use of facilitation and coaching to develop skills, and disease registries that allow the provider to see patients not just as individuals but as part of a larger population with common needs and concerns.
The purpose of the PCMH Framework is to guide research and evaluation of PCMH implementation within a broad range of organizational settings. The primary users of this framework are investigators and practitioners who wish to understand why PCMH implementation succeeds or fails and whether the PCMH intervention or its components can be replicated and scaled to other settings. The PCMH Framework is intended to guide users in the design of a study or evaluation project. Some practitioners, because of the comprehensiveness of the PCMH Framework, may also find it useful for intervention design and continuous quality improvement. Investigators can apply the PCMH Framework to a whole intervention with various distinct parts or to one or more of those parts.
This chapter is organized into six sections. The first section briefly describes the domains of the PCMH Framework. It is followed by a discussion of the most noteworthy changes we made. The PCMH Framework is next presented in two forms, a graphic followed by a full explication of the domains, constructs, and subconstructs in Tables 10 through 16. The How To Use section gives users a step-by-step roadmap for approaching the multiple and complex dimensions of the PCMH Framework. This chapter concludes with an application of the roadmap to a PCMH case study. See the Glossary for important terms.
Organization of the Patient-Centered Medical Home Framework
Tables 10 through 16 show the PCMH Framework. The content is organized into seven domains and further subdivided into precise categories of constructs and subconstructs. The elements are summarized with their definitions in the first two columns of the tables; those elements labeled “new” were not part of the original Consolidated Framework for Implementation Research (CFIR).3 The PCMH Framework domains, adapted from CFIR, are—
Intervention Characteristics: The characteristics and features of the intervention being implemented into a particular organization or organizations, including core components (the essential and indispensable elements of the intervention itself). These may be fixed or mutable attributes; they are considered and assessed prior to implementation and influence adoption decisions.
Outer Setting: The economic, political, and social context within which an organization resides.
Inner Setting: Tangible and intangible manifestations of characteristics of the organizations involved in the intervention, including structural characteristics, networks and communications, culture, climate, and readiness, which all interrelate and influence implementation.
Characteristics of Individuals and Teams: The individuals (as carriers of cultural, organizational, professional, and individual mindsets, norms, interests, and affiliations) involved with the intervention and/or implementation process. Includes patients and caregivers.
Process of Implementation: Refers here to the course of actions (e.g., planning, engaging, and reflecting) to achieve individual- and organizational-level use of the intervention as designed.
Measures of Implementation: Refer to what Proctor et al.5 call “implementation outcomes”; they are intermediary outcomes that describe how well the implementation was carried out and prospects for sustainability.
Outcomes: The results of the PCMH implementation, defined as the targets of the PCMH intervention.
Users of the framework may find it helpful to refine these subconstructs even further for specific research purposes. Researchers could use these frameworks to define and review the range of potentially relevant concepts and variables as they prepare an implementation study. Additionally, they may engage in prestudy to determine which constructs are likely to be most useful. During their research, they may refine their selection of constructs and their specifications of them in response to data that emerge from the field or in response to changes in the intervention process and context that take place during the life course of the intervention.
Modifications in the Patient-Centered Medical Home Framework
The CFIR served as the foundation for the PCMH Framework. In addition, the PR and PCMH Frameworks were developed simultaneously, and therefore additions to one framework resulted in similar additions to the other when appropriate. All construct and subconstruct additions are noted in Table B in the Executive Summary and Table 25 in the Discussion. Below, we briefly list by domain the constructs added to the PCMH Framework as a result of the adaptation work (i.e., not present in the original CFIR or in the PR Framework). For definitions of these constructs, we direct the reader to the PCMH Framework tables, which begin with Table 10.
Table 10
Patient-Centered Medical Home Framework—Intervention Characteristics.
Intervention Characteristics: Some models of PCMH rely extensively on vendors and consultants to carry out PCMH activities such as case management or outreach. Thus, the location of the intervention may be partially outside the practice setting. The practice's history with similar PCMH interventions was deemed a potentially important factor in seeking to engage in these activities and ease of implementation.
Outer Setting: A new construct, population needs and resources, was added because these needs may influence the kinds of services and care innovations the practice may pursue.
Inner Setting: Patient-centeredness was added to capture the degree to which the practice is aware of patient needs and seeks to addresses them. Patient self-management infrastructure represents the resources made available to patients in the PCMH. The construct human factor that was added in the PR Framework was renamed HIT/IT (health information technology/information technology) accessibility to better resonate with PCMH users.
Characteristics of Individuals and Teams: The new construct socioeconomic demographics provides a place for users to capture important information on patient groups. Role, authority, and collective efficacy are elements important to teaming and collaboration.
Process of Implementation: We expanded on the planning construct and added the subconstruct assessing to cover activities designed to identify needs and barriers. Acquiring and allocating resources is typically a part of the process of implementation. To practice roles, we added organizational leaders, frontline staff, facilitator, and patients and other stakeholders to better articulate the focus on patients. Under execution, we added decisionmaking.
Measures of Implementation: This is a new domain. The PCMH Framework does not contain any new constructs in this domain in addition to those described in the PR Framework.
Outcomes: This is a new domain. The PCMH Framework added a number of PCMH-specific outcomes that the interventions seek to achieve for patients, providers, and health care utilization. These outcomes include process of care (further subdivided by six subconstructs: patient-centered, coordinated, comprehensive, accessible, quality, and safety), patient/caregiver experience, clinical outcomes, and health care utilization. The Technical Expert Panel raised the issue of the high burden of PCMH implementation, which provided the rationale for adding provider experience.
Graphic Representation of the Patient-Centered Medical Home Framework
Figure 4 is a graphic representation of the PCMH Framework. It shows the relationships of five of the domains to measures of implementation success and various PCMH outcomes. On the left side of the figure is an inner circle with four domains: Intervention Characteristics, Individual/Team Characteristics, Inner Setting, and Process of Implementation. Surrounding this inner circle is an outer ring named the Outer Setting that may influence these four domains. An arrow to the right of the inner and outer circles points to the Measures of Implementation, which influence Outcomes.
Figure 4
Framework for Implementation Research on Patient-Centered Medical Homes.
How To Use the Patient-Centered Medical Home Framework
The evolving nature of PCMH interventions and the heterogeneity of the settings in which the PCMH model may be applied are such that the details of implementation will vary from one setting to another. Therefore, the PCMH Framework does not prescribe a set of normative constructs that must be considered; rather, it provides a large set of potential constructs within major domains, from which investigators can choose those constructs relevant to their particular intervention and goals, questions, theory, or model guiding the research or evaluation.
The flowchart in Figure 5 presents step-by-step guidance on how this framework may be used. The flowchart presents a series of questions, and each set of questions is tied to a particular domain in the framework (Tables 10 through 16). As these questions are considered, the user should refer to the appropriate domain in the framework table to see which constructs are relevant. For example, Step 1 corresponds to the Intervention Characteristics domain; as users consider the various issues related to this domain, they should refer to the framework to choose those constructs relevant to them.
Figure 5
How to use the Patient-Centered Medical Home Framework. Abbreviations: PCMH = Patient-Centered Medical Home.
As mentioned previously, the framework does not prescribe which constructs must be selected due to the diversity of research objectives and to variations between different PCMH interventions. The frameworks are designed to be a practical tool for research and evaluation, and it would be unfeasible to include all or even most of the constructs described. While following this step-by-step process of using the framework, we recommend that users of the framework select qualities, features, or characteristics that are closely tied to intervention outcomes and aligned to the goal, questions, theory, or model guiding the research or evaluation. Doing so will help the user prioritize the constructs, remain focused on the essential aims of the investigation, and keep the number of constructs to a manageable size.
Content of the Patient-Centered Medical Home Framework
We present the PCMH Framework in Tables 10 through 16 with brief definitions of the constructs and subconstructs, and examples. Constructs labeled “new” are additions to the original CFIR.3 Based on Technical Expert Panel input, we added clarifying examples and comments for those constructs and subconstructs that were unclear or complex. Each construct or subconstruct is independent and should be applied as appropriate to the research questions and objectives.
Applying the Patient-Centered Medical Home Framework: A Case Study
To illustrate how the PCMH Framework may be applied, we present below a brief case study based on Driscoll et al., “Process and outcomes of patient-centered medical care with Alaska Native people at Southcentral Foundation.”28
Alaska Southcentral Foundation Case Study
The Southcentral Foundation (SCF) provides health care services to nearly 60,000 Alaska Native and American Indian people living in south-central Alaska, including Anchorage and 50 rural villages. SCF was formerly managed by the Indian Health Service. In 1997, SCF assumed responsibility for the primary care services at the Alaska Native Medical Center. Two years later the SCF began implementing key components of the PCMH model. The tailored model is based on several key characteristics of a PCMH. These are described below:
Team-based care. Coordinated care is delivered by multidisciplinary teams rather than by individual clinicians. These teams include primary care physicians or physician assistants, nurses, certified medical assistants, and other clinicians. Over time, behavioral health consultants, nutritionists, and appointment schedulers were added.
Empanelment. Patients are matched, either by self-selection or assignment, to an integrated and comprehensive care team. Patients schedule primary care appointments with their team members.
Open access. To the extent possible, patients' barriers to access are mitigated through open scheduling, expanded office hours, and increased availability of electronic communication between patients and team members.
In the remainder of the case study, we will use the example of SCF to demonstrate how the PCMH Framework may be used to evaluate this intervention.
Applying the Patient-Centered Medical Home Framework
Below, we walk through the how-to-use flowchart detailed in Figure 5. For illustrative purposes we have used a brief case study and examine this study at a high level. In real-world implementations, the level of detail will be significantly greater. For each step, we have selected a few constructs as examples.
Step 1. Define the Intervention
In this step, the user of the framework examines the first major domain in the PCMH Framework, Intervention Characteristics.
What is the intervention designed to achieve?
The goal of the PCMH intervention is to improve access to and coordination of care among patients served by SCF's primary care services.
What are the features of the intervention?
Here, the user considers the details of the various intervention components specified above, which have three main components: empanelment, open access, and team-based care. In this case, we address all three, but another option is to limit the focus to only one of these components. The user may consider evidence strength and quality as a potential construct to include (e.g., perceptions of the quality and validity of the three components selected among key stakeholders at SCF; whether there are existing standards and/or publications that can provide supporting evidence).
Who is the intended target group?
Relevant constructs that may be used include targeted groups and workflows. See Table 10.
Step 2. Define the Outer Setting
What components of the environment will impact the implementation?
These may include political context, social context (including Native American subcultures), economic context, and population needs and resources (e.g., the specific health needs, if any, of the local Alaskan population and how the PCMH intervention will ensure that these needs are well served). See Table 11.
Table 11
Patient-Centered Medical Home Framework—Outer Setting.
Step 3. Define the Inner Setting
What components of structure and process within the inner setting will impact the implementation?
These may be networks and communications, culture, climate, readiness, and so on. Relevant constructs here include structural characteristics (e.g., how many physicians are employed by the SCF; in how many buildings services are provided) and provider culture (e.g., how staff will adapt to the concept of team-based care, which will include more frequent communication and coordination between individuals; how comfortable physicians are with increased communications and how the transitions can be made smoother). See Table 12.
Table 12
Patient-Centered Medical Home Framework—Inner Setting.
Step 4. Define the Characteristics of the Individuals/Teams Involved
What are the characteristics of individuals (or teams) that will help in making the PCMH intervention and/or implementation successful?
Here, the user could examine patient needs and resources (e.g., whether patients are able to schedule appointments during various hours when they need to do so; whether they can make appointments online or by email). Other relevant constructs here include skills and competences (e.g., whether staff members have the skills needed to successfully form integrated and comprehensive care teams; whether staff members require training); role (who is responsible for which tasks under the new team-based care); and authority (which physicians have override authority if there are multiple physicians involved in care for a patient). See Table 13.
Table 13
Patient-Centered Medical Home Framework—Characteristics of Individuals and Teams.
Step 5. Define the Processes Required To Achieve Desired Level of Use
What are the implementation processes that are required to achieve individual- and organizational-level use of the intervention?
Relevant constructs to consider may include planning (e.g., whether the PCMH intervention has clear milestones, timelines, and dedicated staff accountable for actions) and staff time (e.g., whether staff are given sufficient time to implement various changes, while not compromising the various functions they are currently responsible for). See Table 14. This step does not cover how completely an intervention was used; this concept is covered under the Measures of Implementation domain.
Table 14
Patient-Centered Medical Home Framework—Process of Implementation.
Step 6. Define Measures of Implementation
What are the attributes of the implementation process that demonstrate it was carried out well and can be replicated, scaled, and sustained?
Relevant constructs here may include acceptability (e.g., the degree to which stakeholders find SCF's PCMH implementation agreeable and satisfactory), intervention cost (e.g., the total cost of implementing the three components of PCMH, and whether this stays within a set budget), and reach within the organization (e.g., the number of units within SCF where empanelment is functioning as expected 6 months after completion of intervention). See Table 15.
Table 15
Patient-Centered Medical Home Framework—Measures of Implementation (new domain).
Step 7. Define the Outcomes
What are the specific measurable outcomes that will result from the intervention?
Relevant constructs, representing outcomes, may include process of care (e.g., whether the SCF is able to provide care that satisfies relevant defining attributes of PCMH, such as being coordinated, accessible, and patient centered). The user is encouraged to revisit previous domains to ensure that the outcomes selected in this step are logically supported by the intervention. In particular, the user would tie these outcomes back to the goals of the intervention (improving access and coordination of care) listed under the first step. See Table 16.
Table 16
Patient-Centered Medical Home Framework—Outcomes (new domain).
Note: The constructs in the PCMH Framework, because they represent components of a complex system intervention, can be explored at multiple levels (i.e., at the individual, team, or organizational level). The number of levels and their definitions will vary based on the specific scenario. In Table 17, we show how a handful of constructs applicable to this case study are relevant across multiple organizational levels. For brevity, we show only three levels, but other levels may be relevant, depending on the scenario. For example, in some cases, a “unit” might be a level composed of groups of “teams.” However the levels may be defined, the important aspect is to ensure that users of the framework appreciate that each construct may (and in most cases should) be applied at various levels, and not just at one.
Table 17
Example of application of Patient-Centered Medical Home Framework constructs to diverse levels of analysis by organizational level.
- c
Because the three frameworks are described in stand-alone chapters, the Overview and Organization sections are similar across the chapters.
