Martsolf Grant R, Kandrack Ryan, Schneider Eric C, Friedberg Mark W
RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA, 15213, USA,
J Gen Intern Med. 2015 Jun;30(6):817-23. doi: 10.1007/s11606-014-3176-3. Epub 2015 Feb 11.
Healthcare purchasers have created financial incentives for primary care practices to achieve medical home recognition. Little is known about how changes in practice structure vary across practices or relate to medical home recognition.
We aimed to characterize patterns of structural change among primary care practices participating in a statewide medical home pilot.
We surveyed practices at baseline and year 3 of the pilot, measured associations between changes in structural capabilities and National Committee for Quality Assurance (NCQA) medical home recognition levels, and used latent class analysis to identify distinct classes of structural transformation.
Eighty-one practices that completed surveys at baseline and year 3 participated in the study.
Study measures included overall structural capability score (mean of 69 capabilities); eight structural subscale scores; and NCQA recognition levels.
Practices achieving higher year-3 NCQA recognition levels had higher overall structural capability scores at baseline (Level 1: 28.4 % of surveyed capabilities, Level 2: 40.9 %, Level 3: 48.7 %; p value = 0.001). We found no association between NCQA recognition level and change in structural capability scores (Level 1: 33.2 % increase, Level 2: 30.8 %, Level 3: 33.7 %; p value = 0.88). There were four classes of practice transformation: 27 % of practices underwent "minimal" transformation (changing little on any scale); 20 % underwent "provider-facing" transformation (adopting electronic health records, patient registries, and care reminders); 26 % underwent "patient-facing" transformation (adopting shared systems for communicating with patients, care managers, referral to community resources, and after-hours care); and 26 % underwent "broad" transformation (highest or second-highest levels of transformation on each subscale).
In a large, state-based medical home pilot, multiple types of practice transformation could be distinguished, and higher levels of medical home recognition were associated with practices' capabilities at baseline, rather than transformation over time. By identifying and explicitly incentivizing the most effective types of transformation, program designers may improve the effectiveness of medical home interventions.
医疗保健购买者为初级保健机构创造了经济激励措施，以促使其获得医疗之家认证。对于实践结构的变化在不同机构之间如何不同，或者与医疗之家认证有何关联，人们了解甚少。
我们旨在描述参与全州医疗之家试点的初级保健机构的结构变化模式。
我们在试点的基线期和第3年对各机构进行了调查，测量了结构能力变化与美国国家质量保证委员会（NCQA）医疗之家认证水平之间的关联，并使用潜在类别分析来识别不同的结构转变类别。
81家在基线期和第3年完成调查的机构参与了该研究。
研究测量指标包括总体结构能力得分（69项能力的平均值）；8个结构子量表得分；以及NCQA认证水平。
在第3年获得更高NCQA认证水平的机构在基线期具有更高的总体结构能力得分（1级：调查能力的28.4%，2级：40.9%，3级：48.7%；p值 = 0.001）。我们发现NCQA认证水平与结构能力得分的变化之间没有关联（1级：增加33.2%，2级：30.8%，3级：33.7%；p值 = 0.88）。有四类机构转变：27%的机构经历了“最小”转变（在任何规模上变化都很小）；20%的机构经历了“面向提供者”的转变（采用电子健康记录、患者登记册和护理提醒）；26%的机构经历了“面向患者”的转变（采用与患者沟通、护理经理、转介到社区资源以及非工作时间护理的共享系统）；26%的机构经历了“广泛”转变（在每个子量表上处于最高或第二高的转变水平）。
在一个基于州的大型医疗之家试点中，可以区分多种类型的机构转变，更高水平的医疗之家认证与机构在基线期的能力相关，而非随时间的转变。通过识别并明确激励最有效的转变类型，项目设计者可能会提高医疗之家干预措施的有效性。
