Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics
Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams? abilities to deliver patient-centered care. We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity. 4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (?=32, P<0.0001) and history of change in the clinic (?=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (?=0.160.34, P=<0.0001), and lower improvements in patient-centered care (?=?0.19, P=0.001). Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures. Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics.
dcg diagnostic cost group fte full-time employee pact patient-aligned care team pcmh patient-centered medical home pcp primary care provider soap-c survey of organizational attributes of primary care va department of veterans affairs vamc veterans affairs medical center vha veterans health administration