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The American Journal of Managed Care July 2018
Differences in Spending on Provider-Administered Chemotherapy by Site of Care in Medicare
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Kateryna Karimova, MSc; Lorenz Uhlmann, MSc; Marc Hammer, MPH; Corina Guethlin, PhD; Ferdinand M. Gerlach, MD, MPH; and Martin Beyer, MSc
Value-Based Health Insurance Design: How Much Does Socioeconomic Status Matter?
Bruce W. Sherman, MD, and Carol Addy, MD, MMSc
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Ammarah Mahmud, MPH; Justin W. Timbie, PhD; Rosalie Malsberger, MS; Claude M. Setodji, PhD; Amii Kress, PhD; Liisa Hiatt, MS; Peter Mendel, PhD; and Katherine L. Kahn, MD
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Julius L. Chen, PhD; Andrew L. Hicks, MS; and Michael E. Chernew, PhD
Forgotten Patients: ACO Attribution Omits Those With Low Service Use and the Dying
Mariétou H. Ouayogodé, PhD; Ellen Meara, PhD; Chiang-Hua Chang, PhD; Stephanie R. Raymond, BA; Julie P.W. Bynum, MD, MPH; Valerie A. Lewis, PhD; and Carrie H. Colla, PhD
Postdischarge Engagement Decreased Hospital Readmissions in Medicaid Populations
Wanzhen Gao, PhD; David Keleti, PhD; Thomas P. Donia, RPh; Jim Jones, MBA; Karen E. Michael, MSN, MBA, RN; and Andrea D. Gelzer, MD, MS, FACP
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Margje H. Haverkamp, MD, PhD; David Peiris, MD, PhD; Alexander J. Mainor, JD, MPH; Gert P. Westert, PhD; Meredith B. Rosenthal, PhD; Thomas D. Sequist, MD, MPH; and Carrie H. Colla, PhD
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Trends in Primary Care Encounters Across Professional Roles in PCMH
Ann M. Annis, PhD, RN; Marcelline Harris, PhD, RN; Hyungjin Myra Kim, ScD; Ann-Marie Rosland, MD, MS; and Sarah L. Krein, PhD, RN

Trends in Primary Care Encounters Across Professional Roles in PCMH

Ann M. Annis, PhD, RN; Marcelline Harris, PhD, RN; Hyungjin Myra Kim, ScD; Ann-Marie Rosland, MD, MS; and Sarah L. Krein, PhD, RN
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.

Objectives: Team-based care models, including the patient-centered medical home (PCMH), are increasingly promoted to improve the delivery of primary care. However, evaluation measures are often reported at a clinic or primary care provider (PCP) level, creating challenges in describing and analyzing the use and impact of non-PCP clinician team members. Thus, we aimed to measure clinician-specific care delivery trends and determine whether trends were responsive to systemwide PCMH implementation.

Study Design: Interrupted time-series analysis of 57 million primary care encounters among 5 million veterans at 764 Veterans Health Administration primary care clinics from 2009 to 2013.

Methods: Retrospective data identified patient encounters attributable to 12 types of clinicians, yielding an encounters-by-clinician metric. Negative binomial regression modeled the monthly clinic-level rates of encounters for each type of clinician, before and during PCMH implementation.

Results: Over 5 years, the percentage of encounters by non-PCP clinicians increased from 29% to 35%. Monthly encounter rates for nurses and social workers significantly increased by 0.5% and 1.3%, respectively, after the introduction of PCMH, whereas PCP encounter rates significantly decreased over time. Encounter trends for pharmacists, nutritionists, and behavioral health clinicians did not significantly change.

Conclusions: This study demonstrated the feasibility of capturing care delivered by a full complement of team members using routinely collected data. Findings suggest that the proportions of care delivered by non-PCP clinicians were sensitive to a change in care delivery model. As team-based care models expand, availability and use of metrics that account for care by all team members are critical for inferring clinician-related effects on outcomes.

Am J Manag Care. 2018;24(7):e222-e229
Takeaway Points

Following patient-centered medical home (PCMH) implementation in the Veterans Health Administration, we noted a shift in care delivery among clinicians, with decreased monthly patient encounters by primary care providers (PCPs) and increased encounters by nurses and social workers.
  • Interdisciplinary team-based care is foundational in high-profile care delivery models, including the PCMH, emphasizing the need to capture the work of all clinicians.
  • We demonstrated that a simple metric of encounters by clinician was responsive to change in primary care delivery model and inclusive of 12 clinician roles.
  • Care delivery by non-PCP clinicians is measurable and applicable to team-based performance and quality metrics.
Between 2008 and 2019, the nation’s annual primary care visits are expected to increase by 15 million to 24 million, in part due to changes in national healthcare policy.1,2 Increased demand for primary care, coupled with projected shortages of primary care physicians,3,4 threaten to limit patient access to primary care. In response, healthcare systems and organizations promote team-based care models, such as the patient-centered medical home (PCMH), as best practice for care delivery. The PCMH model encompasses several core principles of high-value primary care, including patient-centeredness, enhanced access, comprehensive care, and care coordination. PCMH has been widely adopted in the United States, with many varied demonstrations and evaluations.5,6

Team-based care is a collaborative process among primary care providers (PCPs) and other clinicians who deliver aspects of care but do not function as PCPs (eg, nurses, pharmacists, and social workers). Effective teams, with a mix of PCPs and non-PCP clinicians, leverage the skills and full scope of licensure of each member, allocating the most appropriate personnel to specific tasks.7-9 Expanded roles for non-PCP clinicians are essential for the delivery of high-quality primary care.10-18 Study findings suggest that a portion of PCP tasks could be reassigned to non-PCP team members19 and that non-PCPs, such as nurses, can independently meet the needs of some patients during clinic visits.20,21 Not surprisingly, the utilization of clinicians other than physicians to manage patient care appears to be more common among clinics at higher levels of PCMH functioning compared with those at lower levels,22 and underutilization of non-PCPs is an identified barrier to PCMH implementation.23 Although studies have assessed care delivery among PCP roles,24-29 less is known about non-PCP care delivery, especially in the context of the PCMH. Moreover, little is known about whether there are shifts in patterns of care delivery among members of the care team that may be attributed to systematic uptake of new care delivery models.

In April 2010, the Veterans Health Administration (VHA) introduced a PCMH initiative called Patient Aligned Care Team (PACT) to more than 900 primary care clinics nationwide.30 Under PACT, care is primarily delivered by members of a core team, including PCPs and nurses, and further supported by members of an expanded team, such as pharmacists and social workers. During the rollout of PACT, VHA increased its primary care support staff by more than 3000 full-time equivalent employees, which included the hiring of almost 1300 registered nurses (RNs).31 Rosland et al31 reported decreases in quarterly patient visits with PCPs and pharmacists from 2009 to 2012 (from 53 to 43 and from 2.6 to 2.4 per 100 patients, respectively; P <.01 for both trends), whereas visits with nurses remained unchanged. An analysis of visits by the full complement of non-PCPs was not reported.

Expanding on this initial work, we conducted a longitudinal study to examine trends in patient encounters with a full range of PCPs and non-PCP clinicians in VHA primary care clinics. The purpose was to develop an overall metric that could be sensitive to changes in care delivery models and reflect care by all clinicians. Our aims were to (1) identify and measure clinician-specific care delivery trends in primary care clinics via documented patient encounters and (2) determine whether the identified clinician-specific care delivery trends could reveal a change in care delivery model (ie, PACT implementation). This study was approved by the University of Michigan and the Veterans Affairs Ann Arbor Healthcare System Institutional Review Boards.


We analyzed retrospective data from 5 fiscal years (FYs): October 1, 2008, through September 30, 2013. Two time periods were defined: pre-PACT (October 2008-March 2010) and mid–PACT implementation (April 2010-September 2013). PACT implementation was not uniform across sites and required considerable time, and full PACT rollout was not complete during the study period. Thus, the latter period consisted of ongoing PACT transformation.

We included 609 of 797 VHA community-based (located separate from a VHA hospital) outpatient clinics, as well as 155 of 163 VHA hospital-based clinics with at least 500 documented primary care encounters per year (corresponding to VHA’s definition of a primary care site32) and at least 100 veteran patients assigned to clinic PCPs per year, for all study years. Patient assignment data were validated monthly, and assignment dates (begin and end) permitted the determination of a monthly denominator population in each clinic.

We used encounter service codes to identify primary care encounters that occurred during in-person (ie, face-to-face) visits by patients assigned to the clinics, regardless of which clinician was seen. An encounter was a documented clinical interaction between a patient and clinician. Although a patient visit may consist of more than 1 clinical encounter, we noted that few visits had multiple documented encounters. We included encounters most commonly designated as primary care, which represented 80.4% of all primary care encounters during the 5 years. We excluded the following other types of primary care encounters: specialty primary care (eg, women’s health [1.5% of encounters], mental health care [2.7%], and geriatric primary care [0.6%]), group appointments (0.5%), home-based primary care (2.3%), and telephone encounters (12.1%). The same electronic health record system was in place during the entire study period. However, there was an evident spike in phone encounters (not included in this study) across all clinicians with the introduction of PACT, as PACT processes facilitated improved documentation of non–face-to-face care.

Encounter data included the primary clinician responsible for delivering the encounter. We categorized the identified clinician as a PCP if he or she was a physician, nurse practitioner, physician assistant, or medical resident, as these are the 4 types of clinicians to whom primary care patient panels are assigned in VHA. For lack of an accepted categorical term, we refer to clinicians who did not function as PCPs and were not assigned primary care patient panels, but did provide clinical services directly to patients, as non-PCP clinician members of the care team, which included RNs, clinical nurse specialists (CNSs), licensed practical nurses (LPNs), nursing assistants (NAs) or technicians, clinical pharmacists or pharmacy technicians, social workers, dietitians or nutritionists, and behavioral health clinicians. Although some members of the expanded team may have advanced roles (eg, psychiatrists), our intent was to distinguish between PCPs (ie, primary care clinicians responsible for assigned primary care patient panels) and other types of clinicians whose documented services may fall under primary care encounter codes. We excluded encounters with clinicians other than those listed above (<1.2% of encounters each year) and those missing clinician information (<0.009% of encounters each year).

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