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The American Journal of Managed Care December 2013
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Implementing Effective Care Management in the Patient-Centered Medical Home
Catherine A. Taliani, BS; Patricia L. Bricker, MBA; Alan M. Adelman, MD, MS; Peter F. Cronholm, MD, MSCE, FAAFP; and Robert A. Gabbay, MD, PhD
Generic Initiation and Antidepressant Therapy Adherence Under Medicare Part D
Yuhua Bao, PhD; Andrew M. Ryan, PhD; Huibo Shao, MS; Harold Alan Pincus, MD; and Julie M. Donohue, PhD
Economics of Genomic Testing for Women With Breast Cancer
Robert D. Lieberthal, PhD
Impact of Electronic Prescribing on Medication Use in Ambulatory Care
Ashley R. Bergeron, MPH; Jennifer R. Webb, MA; Marina Serper, MD; Alex D. Federman, MD, MPH; William H. Shrank, MD, MSHS; Allison L. Russell, BA; and Michael S. Wolf, PhD, MPH
Medication Utilization and Adherence in a Health Savings Account-Eligible Plan
Paul Fronstin, PhD; Martin-J. Sepulveda, MD; and M. Christopher Roebuck, PhD, MBA
Characteristics of Low-Severity Emergency Department Use Among CHIP Enrollees
Justin Blackburn, PhD; David J. Becker, PhD; Bisakha Sen, PhD; Michael A. Morrisey, PhD; Cathy Caldwell, MPH; and Nir Menachemi, PhD, MPH
Collection of Data on Race/Ethnicity and Language Proficiency of Providers
David R. Nerenz, PhD; Rita Carreón, BS; and German Veselovskiy, MS
Dietary Diversity Predicts Type of Medical Expenditure in Elders
Yuan-Ting Lo, PhD; Mark L. Wahlqvist, MD; Yu-Hung Chang, PhD; Senyeong Kao, PhD; and Meei-Shyuan Lee, DPH

Implementing Effective Care Management in the Patient-Centered Medical Home

Catherine A. Taliani, BS; Patricia L. Bricker, MBA; Alan M. Adelman, MD, MS; Peter F. Cronholm, MD, MSCE, FAAFP; and Robert A. Gabbay, MD, PhD
A positive deviance approach was used to identify best practices in embedding care management in patient-centered medical home team-based care processes.
Background: There is growing evidence that practice-based care management can improve clinical quality and reduce costly healthcare utilization.

Objectives: To explore how a disparate group of patient-centered medical homes (PCMHs) embedded care management in their team care environment to identify best practices.

Study Design: A positive deviance approach was used to contrast care management implementation in practices having the greatest and least improvement on clinical measures of diabetes, the initial target disease for a multipayer-supported statewide initiative involving 25 National Committee on Quality Assurance–recognized PCMH practices participating in a regional learning collaborative.

Methods: Practices were ranked according to their average absolute percentage point increase from baseline to 18 months on 3 diabetes quality measures. Semistructured interviews were conducted with 136 individuals in 21 of the 25 practices. Interview data were analyzed using grounded theory with NVivo 9.0 software. To develop hypotheses related to care management best practices, we compared and contrasted emerging themes across clinical performance tertiles.

Results: Practices with the greatest diabetes improvement described (1) more patient-centered care manager duties, (2) better use of the  electronic medical record (EMR) for messaging and patient tracking, and (3) stronger integration of the care manager into the care team compared with practices with the least diabetes improvement.

Conclusions: PCMHs may want to ensure that care managers are available to meet with patients during visits, support patient self-management, fully leverage the EMR for team messaging and patient tracking, and ensure integration into the care team with office huddles and ongoing communication.

Am J Manag Care. 2013;19(12):957-964
This study used a positive deviance approach to explore how 25 patient-centered medical homes (PCMHs) embedded care management within the PCMH team.
  • Practices with the greatest reported improvement on diabetes quality measures described more patient-centered care manager duties, more effective electronic capabilities, and stronger integration of the care manager into the team than practices with the least improvement on those measures.

  • Results suggest PCMHs should ensure care managers are available to meet with patients during visits, fully leverage the electronic medical record for messaging and patient tracking, and maintain ongoing communication with providers and other team members.
The patient-centered medical home (PCMH) is a new and increasingly widespread1 model of healthcare delivery that shows significant promise for improving patient care. The PCMH emphasizes team-based care, coordinated and integrated care, and whole-person care,2,3 and has been associated with improved measures of quality care and cost reduction.4,5 The process of becoming a PCMH involves practice transformation often centered on the development of a care management plan and infrastructure.6-9

Care management involves more intensely caring for high-risk patients through the establishment and monitoring of care plans, more frequent follow-up visits, regular outreach between office visits to assess health status, extensive support for disease management  and self-care, tracking and coordination of specialty and other services, and linkages with community resources.10,11

Care management has traditionally been conducted by insurer-based nurses providing telephonic outreach to patients identified as  either high cost or high risk by claims-based predictive modeling software. However, this method has provided inconsistent care improvement results.12,13 Some successful models of care management include community-based care managers,14,15 health plan care managers embedded in primary care practices,16 and health system–based nurse teams working with primary care practices.17,18

This study examined the development of care management within 25 heterogeneous primary care practices in southeastern  Pennsylvania implementing the PCMH focused initially on improving diabetes care. Diabetes is a common chronic disease used as a starting point for many PCMH initiatives.19 A recent review described team-based care and care management as critical components in improving the care of patients with chronic conditions such as diabetes.20 With care management and team-based care both representing key elements of the PCMH3 and growing evidence that practice-based care management is highly effective in improving clinical quality and reducing costly healthcare utilization,21,22 it is important to better understand the implementation of care management in primary care practices. Although care management is an important addition to primary care, there is tremendous variation in the definition and implementation of the role at the practice level, making the implementation of care management an important research topic. This is one of the first studies to explore how a disparate group of unaffiliated primary  care practices embedded care management within the team care environment of a PCMH. We used a positive deviance approach   contrasting care management implementation in higher- and lower-performing practices to identify a collection of potential best practices synthesized from individual higherperforming practices.

The practices studied were part of the first regional rollout of a statewide, multipayer PCMH initiative consisting of regional learning collaborative meetings, practice facilitation support, and monthly clinical data and narrative reports describing PCMH and care management implementation. All 25 practices were recognized PCMHs by the National Committee on Quality Assurance (NCQA), and 6 regional payers provided pro rata payments to the practices to support PCMH and care management implementation. Practices were expected to take an all-payer approach to population management, including planned chronic and preventive care for all patients and, specific to this study, care management for the highest risk patients. Using a positive deviance method, performed by calculating high and low performance on standard measures of diabetes management and developing hypotheses related to the description of top-performing practices,23,24 we analyzed and characterized care management implementation in the PCMH setting. We aimed to identify best practices for primary care sites seeking to develop embedded care management services.


This mixed-methods study involved (1) rank-ordering the sites based on practice-reported diabetes data to determine the highest and lowest performing practices and (2) analyzing qualitative data collected from interviews to contrast care management implementation in high- and low-performing practices.

Positive Deviance Stratification

The highest and lowest performing practices were identified using practice-reported diabetes data, the initial clinical focus of the statewide initiative. The 25 practices participating in the collaborative were ranked according to their improvement from baseline to 18 months across 3 diabetes performance measures most closely associated with minimizing morbidity and mortality: the percentage of diabetes patients (1) whose latest glycated hemoglobin (A1C) result was less than 7%, (2) whose blood pressure was less than 130/80 mm Hg, and (3) whose low-density lipoprotein cholesterol was less than 100 mg/dL. The resulting improvement index was calculated as the arithmetic mean of the absolute percentage improvement in the 3 clinical diabetes measures. Practices were divided into performance tertiles based on their calculated improvement index. The improvement indexes were statistically significantly different between performance tertiles (1-way analysis of variance P <.001).

Qualitative Interviews

Semistructured interviews were conducted with 136 individuals, including clinicians (n = 56), practice managers (n = 15), care managers (n = 13), and other staff (n = 52), in 21 of the 25 practices. Interviews were framed by interview guides with extra questions related to finances for practice leaders and office administrators. Interviews were conducted by 2 teams of 2 trained researchers, with 1 person asking questions and the other taking notes. Both teams followed the same semistructured interview guide and recorded notes from the interviews that were used to assess and ensure inter-observer consistency within and across the interviewer teams. In addition, members of the 2 interviewer teams each observed 1 of the other team’s on-site interview sessions to identify and address any differences in interviewer style or delivery of the questions. Members of both interviewer teams also participated in weekly team meetings to review discrepancies and reach consensus. Most interviews were conducted on-site, during office hours, in private locations. Additional interviews were conducted through focus groups or phone calls if key personnel were not available in person. Participants were not compensated for their interview time.

Participants were asked to describe their  understanding of the PCMH and their experiences with implementing the PCMH, including their role, level of adoption across the practice, key leadership, accountability, surprises, and lessons learned. Interviews ranged from 15 to 120 minutes and were audio-recorded and professionally transcribed.

Data Analysis

Transcripts were entered into NVivo version 9, a software package for qualitative analysis.25 Using grounded-theory methods, individual interviews were analyzed for themes and patterns.26,27 Grounded theory is a methodology that involves iterative development of theories about what is occurring in the data as they are collected.28 The process develops themes that emerge  “from the ground” based on responses to the open-ended questions developed for this study.26 Broad codes reflecting stakeholder  responses to questions about the PCMH were created by a multidisciplinary team of investigators from primary care and  communication that coded and analyzed the transcripts. Discrepancies in coding were resolved by group consensus. Keyword  searches were run of all interviews identifying use of the terms “care manager,” “care management,” and “high risk.” Topics  developed from care manager interviews were used to create further nodes and searches identifying care management mentioned in  relation to payment incentives, team-based care, hiring and firing, technology, and roles and responsibilities. In order to develop hypotheses around best practices related to care management, emergent themes were compared between higher- and  lowerperforming tertile practices. Emerging themes clustered in 3 clear categories that correlated with tertiles of practice performance measures.


Practices included in the study included 4 solo/partner, 8 small, 10 medium, and 3 large practices (Table 1). These included private practices, residencies, systems, and federally qualified health centers. Within the first year, 8 practices had level 3 PCMH   recognition from the NCQA, 3 practices had level 2, and 14 practices had level 1. No direct correlation was seen between diabetes   care improvement measured by the improvement index and any practice demographics, including NCQA recognition levels. The   study was not powered to detect differences between diabetes improvement and the educational background of care managers,   including registered nurses, social workers, and medical assistants.

We determined the mean baseline for all 3 practice tertiles in regard to the percentage of patients achieving A1C levels less than 7%, blood pressure less than 130 mm Hg, and low-density lipoprotein cholesterol less than 100 mg/dL. The most improved practices reported 41.8%, 40.8%, and 36.4%, respectively. The middle-performing practices reported 38.9%, 40.7%, and 38.0%, respectively. The least improved practices reported 44.4%, 42.9%, and 44.8%, respectively.

Comparing interviews of care managers in the upper and lower tertiles, 3 topics were most salient for implementing successful care management. Practices with the greatest improvement indices described (1) patient-centered care manager duties, (2) using the electronic medical record (EMR) system to its fullest patient-tracking capabilities, and (3) stronger integration of the care manager in the care team as evidenced by extensive information sharing. In contrast, the practices with the lowest improvement indices described more administrative care manager duties, little EMR use, and minimal integration of care management and information sharing.

Care Manager Duties

Care managers in the upper-tertile practices described performing duties best characterized as patient centered, including focusing specifically on diabetic and high-risk patients, following up with patients after visits, providing self-management health coaching and patient education, and providing care for their own roster of patients (Table 2). A care manager from a practice in the upper tertile described her duties:

I do all the phone calls with the patients. I remind [them of] their appointments … all the high-risk patients … I follow the dialysis roster. I look for the missing things, like they need labs, they need appointments, and I bring them back.

Care managers in the lower-tertile practices did not describe having a roster of high-risk patients and described doing mostly telephonic follow-up with patients, managing other staff, and delegating patient follow-up to others, suggesting they serve in more of an administrative role instead  of providing direct patient care. A lower-tertile care manager described her position as:

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