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The American Journal of Managed Care August 2016
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The Impact of Patient-Centered Medical Homes on Safety Net Clinics
Li-Hao Chu, PhD; Michael Tu, MS; Yuan-Chi Lee, MS; Jennifer N. Sayles, MD; and Neeraj Sood, PhD
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Steven M. Kymes, PhD; Richard L. Pierce, PhD; Charmaine Girdish, MPH; Olga S. Matlin, PhD; Troyen Brennan, MD, JD, MPH; and William H. Shrank, MD, MSHS

The Impact of Patient-Centered Medical Homes on Safety Net Clinics

Li-Hao Chu, PhD; Michael Tu, MS; Yuan-Chi Lee, MS; Jennifer N. Sayles, MD; and Neeraj Sood, PhD
Adopting a patient-centered medical home model in safety net practices can effectively reduce emergency department use and increase the use of office visits among Medicaid patients.

To evaluate the impact of moving to a patient-centered medical home (PCMH) model in safety net clinics in a managed Medicaid plan.

Study Design: Quasi-experimental, difference-in-differences design.

Methods: The study examined whether the PCMH model reduced emergency department (ED) use and whether the growth in the seniors and people with disabilities (SPDs) population crowds out lower-cost populations. The study compared 7 PCMH safety net clinics (22,870 members) in late 2011 in the greater Los Angeles area with 110 general safety net clinics (143,530 members) between January 2011 and December 2013. During the time from 2011 to 2012, California began transitioning SPDs from fee-for-service Medicaid into managed care systems under a federal waiver.

Results: Among clinics with less than 10% SPD membership, a PCMH model was associated with more office visits and less ED use. In particular, PCMH clinics—relative to non-PCMH clinics—reduced ED visits by an average of 70 visits per 1000 members per year (PTMPY) and reduced avoidable ED visits by 20 visits PTMPY. Neither the change in office visits nor ED visits was evident in clinics with SPD membership greater than 10%.

Conclusions: Adopting a PCMH model in safety net practices can effectively reduce ED use and increase the use of office visits among Medicaid patients. However, the beneficial effects of the PCMH model can be muted by a sudden influx of high-need users.    

Am J Manag Care. 2016;22(8):532-538
Take-Away Points

This study shows that implementing the patient-centered medical home (PCMH) model in safety net clinics can have a meaningful impact on reducing the use of emergency departments (EDs). However, the extent to which a PCMH can successfully reduce ED visits may depend on the capacity of clinics to increase access to primary care. We found that the effects of PCMHs on reducing ED visits were smaller in clinics that experienced a greater increase in seniors and individuals with disabilities.
Safety net clinics play a pivotal role in delivering both primary and specialty care to millions of low-income Californians.1 These clinics comprise licensed primary care clinics, clinics operated by government entities (eg, counties and cities), and clinics operated by federally recognized Indian tribes or tribal organizations. Safety net clinics provide care to medically underserved populations, regardless of their ability to pay. In 2011, the State of California authorized a section 1115 Medicaid waiver that mandated enrollment of seniors and people with disabilities (SPD) in managed Medicaid plans, which, in turn, led to an influx of patients with chronic conditions into safety net clinics.
The California Medicaid population is associated with frequent hospital admissions and heavy reliance on the emergency department (ED).2 Medicaid provides insurance to underserved, minority, and low-income patients—the populations most susceptible to fragmented and uncoordinated care. In light of this knowledge, a Los Angeles local health plan initiated a pilot program to transform selected safety net clinics into patient-centered medical homes (PCMHs) in the hopes of improving patient care and alleviating the impact of the SPD influx. Specifically, the intervention of this program focused on providing implementation services on: 1) on-site and virtual technical assistance on topics like optimizing team-based care, patient experience, population health management, care coordination, and patient access to care; 2) workflow analysis and process improvement support; 3) access to subject matter experts on key topics like care coordination; 4) provision of customized coaching training; and 5) administration of the PCMH Assessment.
In a PCMH, each patient has an ongoing relationship with a primary care physician who leads a team that takes collective responsibility for the patient’s care. A PCMH model emphasizes enhanced care through open scheduling, expanded hours, and communication among patients, providers, and staff. Care is facilitated by disease registries, health information technology (IT), the exchange of health information among providers, and other means to ensure that patients receive proper care in a culturally and linguistically appropriate manner.3 PCMH pilot programs in integrated delivery systems and multi-payer–sponsored initiatives have shown promise in improving the quality of patient care, reducing hospitalization and ED visits, and lowering Medicaid costs.4-8 More than half of US states have implemented a variety of payment policy changes and other reforms to Medicaid to help primary care providers function as PCMHs.4,9 Thus far, among those states, Colorado, Minnesota, New York, North Carolina, Oklahoma, South Carolina, and Vermont have reported fewer ED visits, hospitalizations, and costs.10
Our research focuses on the impact of PCMHs on a previously untested population: safety net clinics serving the greater Los Angeles area. Los Angles is the largest urban area in California, with approximately half of its population of Hispanic descent. The transition to the PCMH model coincided with the state-mandated switch of SPDs from fee-for-service to a managed Medicaid plan (MMP). This switch created a potential complication: the new, high-use SPD members—with their demand on health services being much higher than regular Medicaid members—could crowd out or delay routine medical services for all other Medicaid recipients at safety net clinics.11 Therefore, our second research question asks whether the PCMH model was less effective in clinics that experienced a larger influx of heavy users.

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