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The American Journal of Managed Care February 2013
Are Benefits From Diabetes Self-Management Education Sustained?
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Medical Homes Require More Than an EMR and Aligned Incentives
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Medical Homes Require More Than an EMR and Aligned Incentives

Samantha L. Solimeo, PhD, MPH; Michael Hein, MD, MS; Monica Paez, BA; Sarah Ono, PhD; Michelle Lampman, MA; and Greg L. Stewart, PhD
Primary care teams implementing medical homes experience professional role confusion and interpersonal conflict, and require effective administrative leadership to ensure success during this transition.
Background: The Veterans Health Administration (VHA) is changing its primary care delivery by implementing the patient-centered medical home (PCMH).

Objectives: To evaluate PCMH implementation among 22 newly formed teams working in the VHA.

Study Design: Longitudinal formative evaluation of team members’ role transformation during the first 18 months of implementation.

Methods: We used 3 sequential, semistructured focus groups to gather data from 4 different groups representing the principal team member roles: primary care providers, registered nurse care managers, licensed practical nurses, and clerical associates.

Results: Team members identified within-team role and interpersonal conflict, as well as discordant administrative leadership styles, as key implementation challenges.

Conclusions: Our results suggest that, in addition to technological and fiscal infrastructure, healthcare leaders implementing the PCMH model must take into account interprofessional issues associated with changes in leadership and the adoption of team-based structures.

(Am J Manag Care. 2013;19(2):132-140)
Primary care reform has recently focused on financial incentives and electronic medical records, but the social side of medical home and team implementation demands investment and attention. Team development is facilitated when the following occur:

  •  Extensive effort is made early in the team formation process to develop positive interpersonal and interprofessional relationships.

  • Administrative leadership champions new ideas and supports teams by providing key resources.

  •  Team members work cooperatively and democratically to determine member roles.
The US healthcare system is facing systemic change driven by urgent needs to rein in unsustainable costs and deliver higher-quality care. Successful transformation will require a robust primary care infrastructure that provides first-contact, comprehensive, coordinated, and continuous care.1 Toward that end, the patient- centered medical home (PCMH) has been proposed as a model not only for reforming healthcare delivery but also for rejuvenating primary care as a field.2-5

Building on long-standing investments in organizational, technological, and fiscal infrastructure to support integrated, team-based care,6 the Veterans Health Administration (VHA) has emerged as a champion of the PCMH model— branded the Patient Aligned Care Team (PACT). Formal adoption of the PCMH model began in 2009, when Secretary of Veterans Affairs Eric K. Shinseki initiated several large-scale transformational initiatives to position the VHA as a patient-centered, team-based, continuously improving, and data-driven organization.7,8 Foremost among these initiatives was fully implementing PACT. This included increased primary care clinic staffing, technical and interpersonal skill development, and development of highly functional interdisciplinary care teams. In-person learning collaboratives were implemented using the model of the Institute for Healthcare Improvement (IHI) Breakthrough Collaborative Series methodology,9 including training seminars, virtual communities of practice, and virtual lectures. The extensive nationwide change effort involves all 21 Veterans Integrated Service Networks (VISNs) and every VHA healthcare facility.

The VHA’s recent implementation efforts and long-standing infrastructural investments in key PCMH components such as electronic medical records are intrinsic advantages for PCMH implementation. Moreover, the VHA’s focus on providing patients with healthcare for life in the context of a limited global budget creates organizational incentives for investing in health promotion, disease prevention, and chronic disease management.10 Yet these structural advantages that on the face appear to make the VHA example unique are counterbalanced by the recognition that the VHA is implementing PCMH across the entirety of its primary care network, composed of approximately 5000 full-time-equivalent primary care providers (PCPs) who have a wide range of clinical experience and understanding of the PACT model. Accordingly, the VHA experience can inform the broader adoption of PCMH. In this study we present the results of a formative evaluation of PACT implementation in the VHA among 22 teams working to transform their interpersonal and clinical practices in the first wave of implementation. We then draw on these early findings to present a set of lessons learned.

Research Design

A qualitative observational design was used to gather experience- near data in order to understand implementation barriers and facilitators from the perspective of the teams involved in putting PACT into practice. These observations focus on the experiences of 22 primary care teams distributed across the VA Midwest Healthcare Network (VISN 23), which includes 8 hospitals and 56 outpatient clinics located throughout 6 upper Midwest states, providing care to approximately 300,000 veterans. The teams in this study were selected because they all participated in the first wave of PACT training provided in VISN 23. Individual team members were selected by administrative leadership based on perceived high performance and their expressed interest in PACT. Each team was composed of 4 distinct roles, as prescribed by the VHA model based on previous medical home transformations: a PCP, a registered nurse care manager, a licensed practical nurse, and a clerical associate. A clerical associate is similar to an administrative assistant and is typically responsible for greeting patients, telephone work, scheduling, and data entry and retrieval. These core teams were supported by closely aligned staff referred to as “neighbors” such as pharmacists, social workers, and mental health specialists.

VISN 23 leadership selected the IHI Breakthrough Series Collaborative methodology to facilitate the development of PACT teams in VISN 23 because it is designed to assist health systems with large-scale quality improvement efforts and to establish a framework for the creation of systemwide learning communities.9 The IHI framework presents a process whereby leaders and outside experts come together to develop and deliver training content that is tailored to the needs of the specific organization. To help organizations learn and deploy this methodology, IHI provides a Breakthrough Series College.11 The training delivery process guides participants to acquire knowledge, experiences, and skills via a series of didactic inperson 3-day learning sessions. Experience-based action periods occur between learning sessions, with teams engaging in implementation of self-selected rapid cycle small tests of change using “plan-do-study-act.”12 Responding to expressed needs, demonstrated knowledge gaps, and goals of the change effort, the content of the learning session and action period activities are created iteratively by faculty content experts and Collaborative leadership. In the present context, the VHA Office of Quality Safety and Value also developed and supported the VHA-wide PACT Collaborative.

Prior to the transformation reported in this study, VISN 23 leadership had used the Collaborative methodology to implement a systemwide chronic disease management program.13 Under the guidance of an expert consultant and building on the skills and knowledge from the prior Collaborative and the national PACT implementation work, VISN 23 Collaborative leadership partnered with expert faculty brought together from the 8 healthcare systems in VISN 23. Together they created the initial scope and aims, as well as the learning session content and structure. As the Collaborative progressed, content was modified, added, or deleted in response to emerging themes, identified knowledge gaps, and shared learning. The content of the training was thus tailored specifically to the VISN 23 context and is presented in Table 1.

Learning collaboratives are labor intensive and require sustained organizational commitment of resources. The VISN 23 PACT Collaborative required weekly 60-minute planning sessions; monthly team action reporting, review, and feedback for all submitted materials (eg, monthly team reports); and substantial time dedicated to logistical planning and content development for the learning sessions. The VISN 23 PACT Collaborative lasted 18 months and required 4 months of preplanning and preparation.

It was during the learning sessions that data for this study were collected via PACT teams participating in role-based focus groups that occurred approximately 6, 12, and 18 months after the VHA initiative began. These time points provided longitudinal data on the changes and challenges members encountered. Data were analyzed after each focus group to inform discussion prompts for subsequent sessions. The focu group discussions were loosely framed around the given topic, but participants were otherwise naïve to the data collection purpose. The Figure describes the specific domains addressed in the focus groups.

Focus groups were facilitated by 5 social scientists who took handwritten notes that were elaborated into longer typewritten field notes for content analysis. To maximize participants’ comfort with speaking freely, discussions were not audio-recorded and no identifiable data were collected. Focus group field notes were reviewed by 2 members of our research team, who identified role-specific and cross-cutting themes. These themes were then validated by group discussion using an iterative, constant comparative approach14 within the study team and through feedback mechanisms such as telephone conferences with VISN leadership and inperson presentations at learning sessions. Reports summarizing the discussion findings were distributed electronically to all Collaborative participants, and in-person presentations were conducted at subsequent learning sessions to foster dissemination and interprofessional understanding. These techniques not only strengthened rapport between the study team and the PACT team members, but also provided a mechanism for assessing the face validity of the findings. Barriers to and facilitators of PCMH implementation among the 22 pilot PACT teams were derived from these themes and are reported in a temporal fashion. This study was approved by the Iowa City VA Healthcare System Institutional Review Board and Research and Development Committee.


Participation in the focus groups was voluntary, but a majority of learning session participants attended (Table 2). As expected, focus group participants’ concerns changed over time. Analysis of focus group field notes produced 3 overarching trends, moving from (1) an emphasis on establishing teams and negotiating tasks to (2) the importance of clarifying identity and sharing responsibility to (3) an increased understanding of both internal and external supportive leadership roles (Table 3). Discussion of these 3 phases follows.

Phase 1: Establish Teams and Negotiate Tasks

During the first 6 months of implementation, teams reported widely varying degrees of cohesion and success. The variation was traced to differences in team composition. Some teams were fully staffed, whereas others, primarily rural clinics, were not. Some teams consisted of colleagues who had long-standing relationships; others consisted of new employees. Primary care providers (physician, nurse practitioner, physician assistant), the de facto team leaders, also had widely varying degrees of experience in the VHA. Teams with stable membership, particularly members with experience working together, were able to develop and advance more quickly than those teams with new employees.

Early-phase development challenges focused on the equitable and practical within-team distribution of tasks. Teams experienced a lack of role clarity regarding scope of practice and performance expectations. Team members viewed their roles as sets of tasks and invested substantial effort in determining who on the team should do what. This process of role negotiation was especially difficult for nursing staff. They were subject to multiple lines of guidance concerning scope of practice, facility policies, and PCP preferences for the specific responsibilities nurses should assume.

Every team member perceived an increase in workload associated with pressure to achieve same-day access for patients and improve care coordination. For teams with a preexisting perception of being overworked, the increased expectations with PACT were at the crux of early-adoption challenges.

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