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Original Investigation |

Patient-Centered Medical Home Intervention at an Internal Medicine Resident Safety-Net Clinic

Michael E. Hochman, MD, MPH1,2,3,7; Steven Asch, MD, MPH4; Arek Jibilian, MD3; Bharat Chaudry, MD3; Ron Ben-Ari, MD3; Eric Hsieh, MD3; Margaret Berumen, MS5; Shahrod Mokhtari, MD6; Mohamad Raad, MD6; Elisabeth Hicks, MA3; Crystal Sanford, BA3; Norma Aguirre3; Chi-hong Tseng, PhD7,8; Sitaram Vangala, MS7; Carol M. Mangione, MD, MSPH7,8,9; David A. Goldstein, MD3,4
[+] Author Affiliations
1AltaMed Health Services Corporation, Los Angeles, California
2Department of Veterans Affairs, Greater Los Angeles, Los Angeles, California
3Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles
4Department of Veterans Affairs, Palo Alto Healthcare System, and Department of Medicine, Stanford School of Medicine, Palo Alto, California
5Administration, Los Angeles County + University of Southern California (LAC + USC) Medical Center, Los Angeles
6Department of Medicine, LAC + USC Medical Center, Los Angeles
7Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles (UCLA)
8Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles
9Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, UCLA
JAMA Intern Med. 2013;173(18):1694-1701. doi:10.1001/jamainternmed.2013.9241.
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Importance  The patient-centered medical home (PCMH) model holds promise for improving primary care delivery, but it has not been adequately tested in teaching settings.

Design, Setting, and Participants  We implemented an intervention guided by PCMH principles at a safety-net teaching clinic with resident physician providers. Two similar clinics served as controls.

Main Outcomes and Measures  Using a cross-sectional design, we measured the effect on patient and resident satisfaction using the Consumer Assessment of Healthcare Providers and Systems survey and a validated teaching clinic survey, respectively. Both surveys were conducted at baseline and 1 year after the intervention. We also measured the effect on emergency department and hospital utilization.

Results  Following implementation of our intervention, the clinic’s score on the National Committee for Quality Assurance’s PCMH certification tool improved from 35 to 53 of 100 possible points, although our clinic did not achieve all must-pass elements to qualify as a PCMH. During the 1-year study period, 4676 patients were exposed to the intervention; 39.9% of these used at least 1 program component. Compared with baseline, patient-reported access and overall satisfaction improved to a greater extent in the intervention clinic, and the composite satisfaction rating increased from 48% to 65% in the intervention clinic vs from 50% to 59% in the control sites (P = .04). The improvements were particularly notable for questions relating to access. For example, satisfaction with urgent appointment scheduling increased from 12% to 53% in the intervention clinic vs from 14% to 18% in the control clinics (P < .001). Resident satisfaction also improved in the intervention clinic: the composite satisfaction score increased from 39% to 51% in the intervention clinic vs a decrease from 46% to 42% in the control clinics (P = .01). Emergency department utilization did not differ significantly between the intervention and control clinics, and hospitalizations increased from 26 to 27 visits per 1000 patients per month in the intervention clinic vs a decrease from 28 to 25 in the control clinics (P = .02).

Conclusions and Relevance  Our PCMH-guided intervention, which represented a modest but substantive step toward the PCMH vision, had favorable effects on patient and resident satisfaction at a safety-net teaching clinic but did not reduce emergency department or hospital utilization in the first year. Our experience may provide lessons for other teaching clinics in safety-net settings hoping to implement PCMH-guided reforms.

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