Ann-Marie Rosland, MD, MS

Family support with medication management and recent urgent self-management concerns are 2 novel factors, among others, that predict completion of diabetes telehealth calls.

Data-driven segmentation of high-risk patient populations may inform health system interventions, but results are dependent on the data sources and methods applied.

Most patients in a large integrated healthcare system who were high-risk for hospitalization were at substantially lower risk within 2 years.

A metric of primary care delivery by non–primary care provider clinicians demonstrated increasing trends in patient encounters by nurses and social workers and was responsive to patient-centered medical home implementation.

The characteristics of patients who visit practices that are ready versus unready for the patient-centered medical home differ in important ways.

Commonly used measures of performance for assessing patient access do not reflect PCMH-encouraged strategies to improve access that may be preferentially used by part-time physicians.

We describe the Veterans Health Administration's nationwide patient-centered medical home (PCMH) initiative and evaluate interim changes in PCMH-related patient care processes.