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Ann Fam Med. May 2010; 8(Suppl 1): S80–S90.
PMCID: PMC2885727

Summary of the National Demonstration Project and Recommendations for the Patient-Centered Medical Home

Abstract

This article summarizes findings from the National Demonstration Project (NDP) and makes recommendations for policy makers and those implementing patient-centered medical homes (PCMHs) based on these findings and an understanding of diverse efforts to transform primary care.

The NDP was launched in June 2006 as the first national test of a particular PCMH model in a diverse sample of 36 family practices, randomized to facilitated or self-directed groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical record audits, and patient and clinical staff surveys. Peer-reviewed manuscripts from the NDP provide answers to 4 key questions: (1) Can the NDP model be built? (2) What does it take to build the NDP model? (3) Does the NDP model make a difference in quality of care? and (4) Can the NDP model be widely disseminated?

We find that although it is feasible to transform independent practices into the NDP conceptualization of a PCMH, this transformation requires tremendous effort and motivation, and benefits from external support. Most practices will need additional resources for this magnitude of transformation.

Recommendations focus on the need for the PCMH model to continue to evolve, for delivery system reform, and for sufficient resources for implementing personal and practice development plans. In the meantime, we find that much can be done before larger health system reform.

Keywords: Primary care, family practice, organizational change, quality improvement, National Demonstration Project, patient-centered medical home, patient-centered care, practice-based research

INTRODUCTION

Emerging consensus among policy makers, professional organizations, clinicians, and payers bears witness that health care in the United States has reached a defining moment.1 The landmark 2001 Institute of Medicine report Crossing the Quality Chasm called for extensive overhaul and redesign of US health care.2 The patient-centered medical home (PCMH) is a popular model that proponents hope addresses many of the concerns raised in that report.37 The PCMH concept is endorsed by the major primary care professional organizations, who issued a joint statement on principles of the PCMH in 2007, emphasizing patients’ ongoing relationship with a personal physician; team approaches to care; a whole-person orientation; mechanisms to support care integration, quality, safety and access; and payment for added value.8

During the past several years, a growing number of PCMH demonstration projects have been undertaken.9 Some of these focus on chronic care.911 Most are regional in scope9,10,12 or are conducted within a particular integrated health care system.9,1315 Relatively few both are comprehensive in scope and include diverse, especially small, independent practices.9,16 The National Demonstration Project (NDP) launched by the American Academy of Family Physicians (AAFP) in 2006 is the first demonstration project on a national sample of practices designed to test a comprehensive model of the PCMH envisioned by the Future of Family Medicine report.17 In this article, we refer to it as the NDP model.

The NDP was launched as a 2-year intervention in June 2006. A diverse sample of 36 family practices was randomly assigned to an intense facilitation group or a self-directed group. All practices attempted to implement components of the NDP model, but the facilitated practices received intense support from a facilitator. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical record audits, and patient and clinical staff questionnaires. Details of the background leading to the creation of the new model of practice and the NDP,18 as well as the intervention itself19 and multi-method evaluation,20 can be found elsewhere in this supplement. The independent evaluators of the NDP also report on the impact of the project on patient outcomes21 and practice outcomes22 (Table 1[triangle]). In addition, an article in this supplement provides a qualitative analysis of the practices’ experiences in the project,23 while another steps back to consider larger perspectives on practice development.24

Table 1.
Summary of Main Findings From National Demonstration Project Articles

Appendix 1 depicts a typical experience of a practice participating in the NDP. After all this work, is this practice a PCMH? What does the experience of this practice and the other NDP practices tell us about what PCMH implementations needs to consider? In this article, we summarize critical insights from the NDP by answering 4 key questions: (1) Can the NDP model be built? (2) What does it take to build the NDP model? (3) Does the NDP model make a difference in quality of care? and (4) Can the NDP model be widely disseminated? We then present recommendations based on the answers to these questions and the growing literature on the larger context of efforts to transform primary care in the United States.

KEY QUESTIONS AND SOME ANSWERS FROM THE NDP

Can the NDP Model Be Built?

The NDP model incorporates most of the currently accepted basic PCMH characteristics and components.8,25 Nevertheless, it is readily apparent there are diverse ways for implementing the PCMH concept as seen in the articles in this supplement1824 and a growing number of recent articles elsewhere.14,2633 The NDP and most of the initial PCMH efforts focus on implementing technological components, particularly more widely measured attributes such as use of electronic information technology or patient registries.5,34,35 More recently, the PCMH is also seen as including the harder-to-measure so-called 4 pillars of primary care (easy access to first-contact care, comprehensive care, coordination of care, personal relationship over time),3538 plus attention to reform in the areas of payment, delivery systems, and what is referred to as the medical neighborhood (a practice’s local environment).8,3944 The NDP results underscore that the PCMH needs to consider technological components, clinician and staff competencies, and patient experiences, and that focusing on one does not automatically enhance the others.21,22

The NDP experience suggests it is possible to build a PCMH even as the diverse, locally adapted meaning of a PCMH evolves. It further suggests that the work required in the field to define what a PCMH is in different contexts takes great effort and support not readily available to most independent practices.24,45 The NDP evaluation found that with enough support, motivation, or both, many practices can make multiple changes that move them meaningfully toward a PCMH.2123 When considering just the NDP-defined set of components, significant improvements were seen in both facilitated and self-directed practices.22 These changes were accomplished despite the fact that much of the technology was not really ready for full-scale rollout and there were no financial incentives.23,45 Only a handful of practices transitioned to relatively high levels of use of the NDP model’s predominantly technological components while also having high patient ratings of the practice as being a PCMH (see Jaén et al,21 Figure 1). Nevertheless, as described by Nutting et al,23 this achievement required exceptional effort, and practices took different developmental pathways getting there.

In summary, the NDP demonstrates it is possible to implement the NDP model in highly motivated practices, but in most, doing so may slightly worsen patients’ perception of care,21 at least in the short term. In facilitating such change, one challenge is paying attention to implementing components while also ensuring that patients’ experiences are not negatively affected. Amidst the substantial practice, personal, and financial challenges practices face, it is easy to lose the patient at the center of the PCMH.

What Does It Take to Build the NDP Model?

Both facilitated and self-directed NDP practices made substantial progress toward implementing the predominantly technological components of the NDP model as illustrated in the case summary in Appendix 1 and elsewhere in this supplement.22,23 Nevertheless, TransforMED, the organization designing and implementing the NDP, provided tremendous support to the facilitated practices,19 which helped them implement more technological components, maintain motivation, and develop their adaptive reserve (capacity for organizational learning and development) so they could better evolve without burning out.23,24 The NDP also showed that roles and identities need to change if a practice is to get beyond incremental change and actually transform23,45; however, such change may require personal transformation, and there was little evidence that practices actually altered their work relationships. This lack of change may partially explain the disturbing finding that in both the facilitated and self-directed practices, patient ratings of their practice as a PCMH actually significantly declined.22 For this measure, patients rated their practice both on the 4 pillars of primary care (easy access to first-contact care, comprehensive care, coordination of care, and personal relationship over time) and on global practice experience (details are shown in Table 1[triangle] and described by Nutting et al22).

Overall, the NDP experience suggests that for most practices, it will take much more time than anyone imagined to transform into a PCMH, although it is difficult to know just how much more given that so few NDP practices completed the transition in 2 years even with intense facilitation. It is apparent that for most practices, the process will take a high degree of motivation, communication, and leadership; considerable time and resources; and probably some outside facilitation.

Does the NDP Model Make a Difference in Quality of Care?

The NDP focused on a wide range of practice structures and processes19; however, the jury is still out on the actual impact on quality of care and patient outcomes. To improve patient outcomes, not only do these structures and processes need to be in place, but they also need to be fully integrated into the day-to-day delivery of care. Realistically, it may require reform of the larger delivery system, integrating primary care with the larger health care system, for the full impact of a PCMH implementation to result in statistically significant enhancements to most patient quality-of-care outcomes. It is encouraging that the adoption of more NDP components was moderately associated with improvement on all 3 outcomes assessed in the medical record audit (Ambulatory Care Quality Alliance measures, prevention, and chronic disease care) in the facilitated group at the 26-month follow-up.21 As noted above, however, the ratings that patients gave to their practice in terms of having PCMH attributes actually declined in both facilitated and self-directed practices.22

Can the NDP Model Be Widely Disseminated?

The NDP practices were highly motivated and self-selected,19 and were still working feverishly after 2 years.45 The NDP highlights that transforming to a PCMH is more than a series of incremental changes. Numerous technological components must be implemented and coordinated, and many of these components are not adequately tested as part of interoperable systems, so ongoing problem solving is necessary. The multiple important concepts for creating a PCMH, including the 4 pillars of primary care, are easy to overlook among the large number of more technological components.19 In addition, the NDP further revealed that the PCMH is not just the combination of 4 pillars and technological components, but also an organization requiring a strong core (eg, material and human resources, organizational structure, clinical process), an adaptive reserve (eg, healthy relationship infrastructure, an aligned management model, facilitative leadership), and attention to the local environment.23,24

The NDP experience suggests that most primary care practices in the United States will need external resources to successfully undertake the magnitude of redesign envisioned in the PCMH. Given the need for continual change, it is particularly important that practices identify resources for developing their adaptive reserve.24 The NDP data indicate that facilitation can enhance adaptive reserve and also suggest that having a strong adaptive reserve can lead to increases in implementing model components.22 Practices that are part of integrated systems may already have such resources14; however, most do not, and independent practices will require strategies for leveraging resources.4649 The NDP model can thus probably be disseminated, but only if sufficient time and resources are made available.

RECOMMENDATIONS

The following recommendations integrate the insights from the NDP with an understanding of the current health care context and the large emerging literature on the PCMH. For our purposes, we conceptualize the PCMH as an integration of both PCMH model components and the patient-centered 4 pillars of primary care, with an emphasis on the latter. Both the NDP and recent literature suggest that transitioning current practice configurations into such an integrated PCMH model is daunting. Recent articles3,5,37,38,5057 and books58,59 on health care redesign provide valuable insights. Our experience in evaluating the NDP and a review of the larger literature lead us to 3 overarching recommendations for moving forward in redesigning primary care and medical neighborhoods. These recommendations (summarized in Table 2[triangle]) recognize that the PCMH must continue to evolve and acknowledge that practice redesign ultimately requires health system reform, while emphasizing that much can be done in the meantime.

Table 2.
Summary of Recommendations

The PCMH Model Must Continue To Evolve

The PCMH is a political construct whose principles were defined by 4 physician professional organizations with a major stake in the status quo.8 As Christensen et al59 note, “those within a business model cannot disrupt themselves.” Consequently, the 7 principles that underlie the PCMH conceptualization result in a model representing the lowest common denominator of a physician-oriented consensus ( Supplemental Appendix in the article in this supplement by Stange et al,18 available at http://annfammed.org/cgi/content/full/8/suppl_1/s2/DC1.) Not surprisingly, this PCMH concept protects the centrality of the physician and constrains other disruptive options, for example, those involving on-site collaborative care teams using advanced practice clinicians or relationships with retail clinics.60 One of the challenges for practices attempting transformation to a PCMH is to make changes, such as the development of care teams, that are desirable in the long-term, while also maintaining personal relationships with patients and other functions already providing good value. The difficulties in moving away from physician-centeredness without meaningful tort reform is also noteworthy.

PCMH transformation will be accomplished not by making incremental changes to the existing way of doing things, but by encouraging disruptive innovation that alters the fundamental ways health care is delivered.59,6164 For example, the fragmentation of physical from mental health is not well addressed in most PCMH models despite strong evidence that this separation undermines core values, such as comprehensive care and coordination of care, and leads to poorer patient outcomes.6567 There also needs to be local control of the transformation process so that practices proceed thoughtfully toward the principles of the PCMH and develop variations on the model depending on the context of their local environment, recently referred to as the medical neighborhood.40 This step requires involvement of a wider range of stakeholders beyond the primary care professional organizations. For example, recent publications report on primary care efforts within integrated systems, whereby practices succeeded in improving measures of patient experience, medical record audits, and work satisfaction.14,33,68

As the PCMH concept continues to evolve, the NDP experience reminds us that practice redesign requires a systems perspective. Although limiting the scope or focus of an intervention is attractive from a project management perspective, those contemplating PCMH interventions should be aware of the limitations of underfunded pilot projects that focus only on parts of the PCMH, overemphasize measures for managing chronic disease, or run for less than 2 years. These limited pilot projects, including the NDP, are often initially motivating for our currently disheartened primary care workforce, but they ultimately frustrate and discourage because they do not really address the fundamental flaws in the health care delivery and payment system that block effective generalist primary care. As a result, the clinicians remain on the quickening treadmill of piecemeal, episodic, office-based encounters.

Delivery System Reform and Resources Must Be in Place for Implementing PCMH Development

Changing the way primary care practices are paid may be as important as paying them more in relation to other medical practices.5,39,42,69,70 A relationship-centered approach to practice development suggests some useful parameters for health policy. Documentation-based billing illustrates some key points. The current system of billing from documentation and the associated use of work-related value units as a basis for compensation is a major impediment to primary care practice development. It reinforces the current management models; prioritizes finance over clinical processes; blocks teamwork within clinical care processes, such as group visits, asynchronous visits, and efforts to implement the expanded chronic care model; and hinders the generation of an integrated clinical information system. Capitation and bundling reimbursement schemes and some forms of direct care models create a healthier policy landscape for primary care practice development.39,42,59,69

The success of integrated systems in adopting PCMH model components strongly suggests that integrated models of health care, such as the accountable care organization (ACO), may be fruitful for leveraging adequate resources for practices if they sufficiently value the contribution of primary care to a high-value health care system.14,44,47 New business models are needed that are appropriate to primary care and that foster integration across the whole health system.40,58,59 Changes cannot be made just in the primary care model, but must also be made in specialty care models and hospitals.40 Fixing primary care in the midst of a still-broken system will not be sufficient or possible.17,44 There must be simultaneous changes in an integrated model in what has been referred to as an optimal healing landscape.71

An immediate need is to evolve the PCMH model and to test it in the context of medical neighborhoods (not just isolated demonstration projects) that are supported for 3 to 5 years. Professional organizations must seek larger system reform and actively pursue and test medical neighborhoods and healing landscapes. Adaptation of concepts from the ACO may be an opportunity to do this.44

Much progress has been made in health information technology (HIT) in the relatively short time since the NDP kickoff in June 2006. This progress is especially seen in areas such as health information exchange (HIE), physician dashboards, patient Web portals, and electronic registries. As noted elsewhere, however, “the health care industry is awash with new technologies—but the inherent nature of most is to sustain the current way of practicing medicine.”59 David Kibbe, a long-time advocate of HIT, notes that practices need to carefully choose individual components, particularly since so many vendors have not perfected a comprehensive product.72 Despite the efforts of the Certification Commission for Health Information Technology (CCHIT), an independent 501(c)3 nonprofit organization recognized as a certification body for electronic medical records (EMRs), a fully operational and interoperable HIT system still does not exist. All of the practices in the NDP were hindered by the absence of a nationally shared online platform for communication and coordination of care.

Many of the current EMRs were designed by and for large hospital systems and not for small practices and not to support the PCMH and primary care functions.73 The EMR was designed to enhance billing documentation and not to provide population metrics or support for care programs.74 The EMR also does not provide the level of integration needed to help with a smooth transition to a collaborative care model. Additionally, most of the HIT found in primary care practices is not interoperable and continues to be a variety of point solutions that do not talk to each other, hindering collaboration. Without better regulation and coordination of the HIT industry and more emphasis on clinical information, and without more capital, operational, and educational resources, primary care practices will not move quickly toward meaningful implementation.

Articles on the NDP in this supplement2224 and other literature7585 underscore the necessity to work on learning culture, leadership, relationships, and conversations (eg, teamwork) as the building blocks for a transformed practice. Nevertheless, most practices lack the resources or financial capacity to develop these skills. The recent literature provides a sobering assessment of the ability of private independent practices to transform.16,30,31,44,46,8688 Adaptation of extension agent models and the use of learning collaboratives have been suggested as strategies for leveraging resources.89,90

In the Meantime, Much Can Be Done

The long-term success of any PCMH implementation depends on practices’ ability to manage the relentless grind of constant change. This ability requires a strong practice core and development of an adequate adaptive reserve. When a practice or other entity initiates a strategy for transforming into a PCMH, its adaptive reserve should be assessed and steps should be taken to strengthen it. As noted elsewhere in this supplement, there are measures of the core concepts of the adaptive reserve,20,22,24 and there are useful strategies for strengthening the capability of practices to evolve and sustain changes, including paying better attention to the local environment.24 For example, it is particularly helpful to create regular opportunities for sharing, learning, and reflecting that involve a diversity of practice participants.7678,91,92

The NDP experience underscores the need for flexible, regularly updated 3- to 6-year developmental plans of individuals, practices, and their partner organizations.24 The sheer number and diversity of technological components and patient-centered features that are part of the PCMH necessitate a coherent implementation strategy that includes ways to ensure practices are capable of making and sustaining change and able to prioritize the order in which technological components are adopted, ensure adherence to the 4 pillars of primary care, and integrate the whole practice as a team. The National Committee for Quality Assurance (NCQA) has 3 levels in their recognition process that are to be accomplished over 3 years.34 For the most part, these are technological components, such as disease registries, systems for tracking referrals and laboratory results, and plans for improving access to care. We recommend lengthening the time allowed for the NCQA recognition process to 5 to 6 years, during which practices should demonstrate steady development but will have more time to actually succeed depending on their initial conditions, especially their adaptive reserve.

The NDP model did not anticipate or define radical changes in roles and mental models of practice participants. Nevertheless, as the NDP unfolded, it was observed that the effective integration of NDP model components required roles of practice participants to transition in ways that met unexpected resistance.23,45 Becoming a PCMH requires more than just implementing sophisticated office systems: it involves adopting substantially different approaches to patient care that requires moving away from a physician-centered approach and toward a team approach shared with prepared office staff. Accomplishing this goal requires new leadership skills that are more facilitative than authoritative. Clinical focus needs to change from episodic care of 1 patient at a time to a proactive population-based approach that considers the health of a defined population/community. The physician-patient relationship must also shift toward more emphasis on partnership to achieve patients’ goals. Although these suggestions might seem straightforward, implementing them requires profound changes in the current mental models of everyone in the practice.

A major barrier may have inadvertently been created by the primary care professional organizations’ strong commitment to traditional roles whereby the physician continues doing everything for everyone. The PCMH envisions collaborative team care, yet its first 2 guiding principles—that each patient have a personal physician and that the physician direct the medical practice8—are potentially problematic and constrain a range of options that do not rely on the physician at the center of the team. For example, there have long been challenges to integrating enhanced roles for nurse practitioners in primary care practices in part due to real and perceived resistance from physicians and physician organizations.9397 The role of the primary care physician in the context of the practice and the larger health care system will continue to be important but needs to be encouraged to evolve in new and innovative ways.98100 Perhaps from the patient’s perspective, there will need to be a physician-led team, but from the practice’s perspective, this concept needs to transform into one wherein the physician is part of a team, and not even necessarily the team leader.

A substantial barrier to conversion to a PCMH is the need for most individual physicians to change their professional identity and the ways in which they deliver primary care. Training programs are not set up for future practice models as they are currently envisioned101; however, given that the models of the future will continue to change, these programs need to carefully pay attention to the changing landscape and regularly adapt. This adaptation will be a challenge unless accrediting bodies, such as the Residency Review Committee (RRC), are more flexible; while ensuring quality of education, they also need to allow programs to innovate.101 A first step is the Preparing the Personal Physician for Practice (P4) initiative, which focuses on family medicine residency training.29,101 Nevertheless, the P4 initiative still emphasizes the training of physicians and needs to go further to include more collaborative team-based educational models with nurse practitioners, physician assistants, nursing staff, and other health care professionals. Future physicians need to learn how to help the practices they join make transformational changes. In addition, we recommend changes in medical school admission and education. For example, Bohmer58 points out that “medical schools not only continue to select students trained in organic chemistry and physics, but few teach the basics of leadership, teamwork, operations management, or organizational behavior.”

Given the changes in roles and identities required in the PCMH, and the critical need for practice models to continually evolve and adapt, future training will need to include educational strategies that foster and enhance organizational learning. Professional organizations need to understand their role as much more than advocating for a new reimbursement structure, that is, as also embracing the need to promote new approaches to doctoring and managing practices and transformation. Accomplishing this objective requires new tools, workshops, and other learning and personal development formats to help physicians transform within themselves and in their relationships with their practice partners, patients, health care systems, and communities. For example, some of the new skills required for the PCMH include working in practice teams, integrating behavioral and mental health, thinking in terms of proactive population management, using evidence at the point of care, having facilitative leadership skills, understanding change management, training staff as peers (ie, providing adult learning), partnering with patients, and thinking outside the examination room.

In the meantime, there is an abundance of urgent research needs. The evaluation of the NDP and recently completed PCMH pilot projects demonstrate how little is really known about the practice development process and how to guide transformation in the face of great uncertainty. How do we change the paradigm (mental models) in which physicians have been socialized, but that may not work if the practice is transformed? How do we teach leadership skills and which ones, particularly to the existing workforce? What is the optimal adaptive reserve and how do we develop it? What is optimal staffing and how do we develop the levels of trust, communication, and teamwork to make this work? How do we integrate mental health, and how are these collaborative care models different from the original ones conceptualized at the start of the discipline of family medicine? How do we develop and understand an effective health care neighborhood?

There is a particularly pressing need for pilot projects that take on the entire health care neighborhood to identify and test possible linkages between the PCMH and ACO models.44 We strongly encourage the use of rigorous mixed-method evaluation for all pilot projects. Ideally, the qualitative component will include observation strategies and depth interviews over time that capture the lived experiences of transformation at the personal and organizational levels. This knowledge will be critical for designing educational programs and next steps in redesigning health care. We also urge acceleration of efforts to improve current measures of the core attributes of primary care. Improved measures are essential for assessing the success of becoming a PCMH. Developing better measures for whole-person health within a community context and for assessing healing relationships is necessary to ensure appropriate outcome measures for primary care.

CONCLUSIONS

Primary care transformation is more about learning how to become a learning organization that creates an emergent future than it is about learning from experts on how to build something already known. The level of change needed is daunting and requires tremendous motivation of all practice participants, defining new roles, understanding the local landscape, and paying attention to multiple relationships. Future PCMH recognition and certification processes should focus more on patient-centered attributes and the proven, valuable key features of primary care than on the features of disease management and information technology. The PCMH represents the essentials for better primary care, the improved delivery of chronic care, and active partnership with informed patients synergized by appropriate use of information and communication technology. Nevertheless, the PCMH model is still evolving and will need adequate capital funding from a combination of federal, state, local, insurance industry, and health system sources. Expecting practices to front the cost of transformation with the hope of more appropriate reimbursement in the future is unlikely to succeed. Ultimately, for the PCMH to spread and become the norm, the delivery system must be reformed to support this approach to care.44

Acknowledgments

The NDP was designed and implemented by TransforMED, LLC, a wholly owned subsidiary of the AAFP. We are indebted to the participants in the National Demonstration Project and to TransforMED for their tireless work.

Appendix 1. A Typical Practice Story From the National Demonstration Project (NDP)

Even before applying to the National Demonstration Project (NDP), the lead physician at Typical Family Practice was functioning well on the so-called 4 pillars of primary care, and the practice maintained high patient ratings throughout the NDP. But everything did not go smoothly in the practice’s journey through the NDP and even by the end, the practice had implemented only about 70% of the components offered in the NDP model. In fact, the facilitator had to constantly intervene with the practice champion, who often had second thoughts about participating in the NDP. During the 2 years of the NDP, the practice was plagued with the departure of junior physicians and key personnel, as well as a lack of buy-in by most other clinicians and staff in the practice. The practice did not have an enhanced model of payments for their clinical services. After intense behind-the-scenes counseling, the practice ultimately selected a new physician champion. Throughout the NDP, the facilitator used e-mail, site visits, and telephone calls to coordinate meetings; sent out articles and Web resources; connected and coordinated consultants; requested updates; stimulated conversation and reflection; counseled the physicians and staff; and encouraged, motivated, and reminded. Through this hard work, the practice now sees itself in a much better place and is grateful for having participated. As one of the physicians noted in a post-NDP interview, “The NDP really hit home with the teamwork concept.” He said it was not anything specific, but just hearing over and over again from both the facilitator and all the other participating practices the value of communication and teamwork. One of the initially skeptical physicians grudgingly admitted that the NDP was a good experience and that “Advanced Access [same-day appointments] was about the best thing to ever happen at the practice.” He further noted that having a facilitator was actually very helpful and provided focused direction and greatly streamlined the process, and it was especially helpful to have the model to look at and think about. He commented, “The NDP provided great accountability to this practice, otherwise, I wouldn’t have done anything. The facilitator was like a personal trainer—someone to answer to.”

Notes

Disclaimer: Drs Stange and Nutting, who are editors of the Annals, were not involved in the editorial evaluation of or decision to publish this article.

Funding support: The independent evaluation of the National Demonstration Project (NDP) practices was supported by the American Academy of Family Physicians (AAFP) and The Commonwealth Fund. The Commonwealth Fund is a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy.

Publication of the journal supplement is supported by the American Academy of Family Physicians Foundation, the Society of Teachers of Family Medicine Foundation, the American Board of Family Medicine Foundation, and The Commonwealth Fund.

Dr Stange’s time was supported in part by a Clinical Research Professorship from the American Cancer Society.

Disclaimer: The views presented here are those of the authors and not necessarily those of The Commonwealth Fund, its directors, officers, or staff.

Conflicts of interest: The authors’ funding partially supports their time devoted to the evaluation, but they have no financial stake in the outcome. The authors’ agreement with the funders gives them complete independence in conducting the evaluation and allows them to publish the findings without prior review by the funders. The authors have full access to and control of study data. The funders had no role in writing or submitting the manuscript.

REFERENCES

1. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348 (26):2635–2645. [PubMed]
2. Institute of Medicine. Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
3. Arrow K, Auerbach A, Bertko J, et al. Toward a 21st-century health care system: recommendations for health care reform. Ann Intern Med. 2009;150(7):493–495. [PubMed]
4. Berenson RA, Hammons T, Gans DN, et al. A house is not a home: keeping patients at the center of practice redesign. Health Aff (Millwood). 2008;27(5):1219–1230. [PubMed]
5. Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient-centered primary care. J Gen Intern Med. 2005;20(10):953–957. [PMC free article] [PubMed]
6. Task Force 1 Writing Group, Green LA, Graham R, Bagley B, Kilo CM, Spann SJ, Bogdewic SP. Task Force 1. Report of the Task Force on Patient Experience, Core Values, Reintegration, and the New Model of Family Medicine. Ann Fam Med. 2004;2(Suppl 1):S33–S50. http://www.annfammed.org/cgi/content/abstract/2/suppl_1/s33. Accessed Mar 10, 2010.
7. The Robert Graham Center. The patient centered medical home: history, seven core features, evidence and transformational change. 2007. http://www.graham-center.org/online/graham/home/publications/monographs-books/2007/rgcmo-medical-home.html. Accessed Nov 8, 2009.
8. American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA). Joint Principles of the Patient-Centered Medical Home. February 2007. http://www.aafp.org/pcmh/principles.pdf. Accessed Oct 7, 2009.
9. Patient-Centered Primary Care Collaborative. Proof in practice: a compilation of patient-centered medical home pilot and demonstration projects. http://www.pcpcc.net/content/2009-pcpcc-pilot-guide-0. Accessed Oct 30, 2009.
10. Pennsylvania kicks off medical home project. Dis Manag Advis. 2008;14(7):3–5. [PubMed]
11. DuBard CA, Cockerham J. Community Care of North Carolina and the medical home approach to chronic kidney disease. N C Med J. 2008;69(3):229–232. [PubMed]
12. Steiner BD, Denham AC, Ashkin E, Newton WP, Wroth T, Dobson LA Jr. Community Care of North Carolina: improving care through community health networks. Ann Fam Med. 2008;6(4):361–367. [PMC free article] [PubMed]
13. Blue Cross/Blue Shield promotes medical home demonstrations. Dis Manag Advis. 2008;14(1 Suppl 1–4):1. [PubMed]
14. Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009;15(9):e71–e87. [PubMed]
15. Soman M. A primary-care pilot. The medical home passes a test in the West. Mod Healthc. 2008;38(22):25. [PubMed]
16. Mitka M. Large group practices lag in adopting patient-centered “medical home” model. JAMA. 2008;300(16):1875. [PubMed]
17. Martin JC, Avant RF, Bowman MA, et al; Future of Family Medicine Project Leadership Committee. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2(Suppl 1):S3–S32. [PMC free article] [PubMed]
18. Stange KC, Miller WL, Nutting PA, Crabtree BF, Stewart EE, Jaén CR. Context for understanding the National Demonstration Project and the patient-centered medical home. Ann Fam Med. 2010;8(Suppl 1):s2–s8. [PMC free article] [PubMed]
19. Stewart EE, Nutting PA, Crabtree BF, Stange KC, Miller WL, Jaén CR. Implementing the patient-centered medical home: observation and description of the National Demonstration Project. Ann Fam Med. 2010;8(Suppl 1):s21–s32. [PMC free article] [PubMed]
20. Jaén CR, Crabtree BF, Palmer R, et al. Methods for evaluating practice change toward a patient-centered medical home. Ann Fam Med. 2010;8(Suppl 1):s9–s20. [PMC free article] [PubMed]
21. Jaén CR, Ferrer RL, Miller WL, et al. Patient outcomes at 26 months in the patient-centered medical home National Demonstration Project. Ann Fam Med. 2010;8(Suppl 1):s57–s67. [PMC free article] [PubMed]
22. Nutting PA, Crabtree BF, Stewart EE, et al. Effects of facilitation on practice outcomes in the National Demonstration Project model of the patient-centered medical home. Ann Fam Med. 2010;8(Suppl 1):s33–s44. [PMC free article] [PubMed]
23. Nutting PA, Crabtree BF, Miller WL, Stewart EE, Stange KC, Jaén CR. Journey to the patient-centered medical home: a qualitative analysis of the experiences of practices in the National Demonstration Project. Ann Fam Med. 2010;8(Suppl 1):s45–s57. [PMC free article] [PubMed]
24. Miller WL, Crabtree BF, Nutting PA, Stange KC, Jaén CR. Primary care practice development: a relationship-centered approach. Ann Fam Med. 2010;8(Suppl 1):s68–s79. [PMC free article] [PubMed]
25. TransforMED. The TransforMED Patient-Centered Model. 2010. http://www.transformed.com/transformed.cfm. Accessed Jan 26, 2010.
26. Backer LA. Building the case for the patient-centered medical home. Fam Pract Manag. 2009;16(1):14–18. [PubMed]
27. Barr MS. The need to test the patient-centered medical home. JAMA. 2008;300(7):834–835. [PubMed]
28. Berwick DM. What ‘patient-centered’ should mean: confessions of an extremist. Health Aff (Millwood). 2009;28(4):w555–w565. [PubMed]
29. Carney PA, Eiff MP, Saultz JW, et al. Aspects of the patient-centered medical home currently in place: initial findings from preparing the personal physician for practice. Fam Med. 2009;41(9):632–639. [PubMed]
30. Friedberg MW, Safran DG, Coltin KL, Dresser M, Schneider EC. Readiness for the Patient-Centered Medical Home: structural capabilities of Massachusetts primary care practices. J Gen Intern Med. 2009;24(2):162–169. [PMC free article] [PubMed]
31. Goldberg DG, Kuzel AJ. Elements of the patient-centered medical home in family practices in Virginia. Ann Fam Med. 2009;7(4): 301–308. [PMC free article] [PubMed]
32. Gottlieb LM. Learning from Alma Ata: the medical home and comprehensive primary health care. J Am Board Fam Med. 2009; 22(3):242–246. [PubMed]
33. Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Aff (Millwood). 2008;27(5):1235–1245. [PubMed]
34. National Committee for Quality Assurance [Web site]. http://www.ncqa.org/home.aspx. Accessed Oct 16, 2009.
35. Stange KC, Nutting PA, Miller WL, et al. Defining and measuring the Patient-Centered Medical Home. J Gen Intern Med. 2010;25(6):601–612. [PMC free article] [PubMed]
36. Starfield B. Primary Care: Concept, Evaluation, and Policy. New York, NY: Oxford University Press; 1992.
37. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502. [PMC free article] [PubMed]
38. Rosenthal TC. The medical home: growing evidence to support a new approach to primary care. J Am Board Fam Med. 2008;21(5): 427–440. [PubMed]
39. Davis K. Paying for care episodes and care coordination. N Engl J Med. 2007;356(11):1166–1168. [PubMed]
40. Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med. 2008;359(12):1202–1205. [PMC free article] [PubMed]
41. Goroll AH. The future of primary care: reforming physician payment. N Engl J Med. 2008;359(20):2087, 2090. [PubMed]
42. Goroll AH, Berenson RA, Schoenbaum SC, Gardner LB. Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care. J Gen Intern Med. 2007;22(3):410–415. [PMC free article] [PubMed]
43. Schoenbaum SC, Berenson RA, Gardner LB, Goroll AH. Commentary on Goldfield et al’s “reforming the primary care physician payment system.” J Ambul Care Manage. 2008;31(2):151–153. [PubMed]
44. Rittenhouse DR, Shortell SM, Fisher ES. Primary care and accountable care—two essential elements of delivery-system reform. N Engl J Med. 2009;361(24):2301–2303. [PubMed]
45. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7(3):254–260. [PMC free article] [PubMed]
46. Tollen L. Physician organization in relation to quality and efficiency of care: a synthesis of recent literature. 2008. http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2008/Apr/Physician-Organization-in-Relation-to-Quality-and-Efficiency-of-Care--A-Synthesis-of-Recent-Literatu.aspx. Accessed Mar 10, 2010.
47. Miller HD, Center for Healthcare Quality & Payment Reform. How to Create Accountable Care Organizations. 2009. http://www.chqpr.org/downloads/HowtoCreateAccountableCareOrganizations.pdf. Accessed Oct 22, 2009.
48. Solberg LI, Hroscikoski MC, Sperl-Hillen JM, O’Connor PJ, Crabtree BF. Key issues in transforming health care organizations for quality: the case of advanced access. Jt Comm J Qual Saf. 2004;30(1):15–24. [PubMed]
49. Hing E, Burt CW. Characteristics of office-based physicians and their medical practices: United States, 2005–2006. Vital Health Stat 13. 2008;(166):1–34. [PubMed]
50. Bohmer RM, Lee TH. The shifting mission of health care delivery organizations. N Engl J Med. 2009;361(6):551–553. [PubMed]
51. Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA. 2009;301(19): 2038–2040. [PubMed]
52. Rogers JC. The patient-centered medical home movement—promise and peril for family medicine. J Am Board Fam Med. 2008;21(5): 370–374. [PubMed]
53. Shortell SM, Casalino LP. Health care reform requires accountable care systems. JAMA. 2008;300(1):95–97. [PubMed]
54. Sia C, Tonniges TF, Osterhus E, Taba S. History of the medical home concept. Pediatrics. 2004;113(5 Suppl):1473–1478. [PubMed]
55. Starfield B. The future of primary care: refocusing the system. N Engl J Med. 2008;359(20):2087, 2091. [PubMed]
56. Starfield B. Family medicine should shape reform, not vice versa. Fam Pract Manag. 2009;16(4):6–7. [PubMed]
57. Toussaint J. Writing the new playbook for U.S. health care: lessons from Wisconsin. Health Aff (Millwood). 2009;28(5):1343–1350. [PubMed]
58. Bohmer RMJ. Designing Care: Aligning the Nature and Management of Health Care. Boston, MA: Harvard Business Press; 2009.
59. Christensen CM, Grossman JH, Hwang J. The Innovator’s Prescription: A Disruptive Solution for Health Care. New York, NY: McGraw-Hill; 2009.
60. Evans SW. Convenient care clinics: making a positive change in health care. J Am Acad Nurse Pract. 2010;22(1):23–26. [PubMed]
61. Christensen CM. Disruptive innovation: can health care learn from other industries? A conversation with Clayton M. Christensen. Interview by Mark D. Smith. Health Aff (Millwood). 2007;26(3): w288–w295. [PubMed]
62. Christensen CM, Baumann H, Ruggles R, Sadtler TM. Disruptive innovation for social change. Harv Bus Rev. 2006;84(12):94–101, 163. [PubMed]
63. Christensen CM, Bohmer R, Kenagy J. Will disruptive innovations cure health care? Harv Bus Rev. 2000;78(5):102–112, 199. [PubMed]
64. Christensen CM, Marx M, Stevenson HH. The tools of cooperation and change. Harv Bus Rev. 2006;84(10):72–80, 148. [PubMed]
65. Green LA, Cifuentes M, Glasgow RE, Stange KC. Redesigning primary care practice to incorporate health behavior change: prescription for health round-2 results. Am J Prev Med. 2008;35(5 Suppl): S347–S349. [PubMed]
66. Merikangas KR, Ames M, Cui L, et al. The impact of comorbidity of mental and physical conditions on role disability in the US adult household population. Arch Gen Psychiatry. 2007;64(10):1180–1188. [PMC free article] [PubMed]
67. Petterson SM, Phillips RL Jr, Bazemore AW, Dodoo MS, Zhang X, Green LA. Why there must be room for mental health in the medical home. Am Fam Physician. 2008;77(6):757. [PubMed]
68. Crosson FJ. 21st–century health care—the case for integrated delivery systems. N Engl J Med. 2009;361(14):1324–1325. [PubMed]
69. Davis K. Investing in health care reform. N Engl J Med. 2009;360 (9):852–855. [PubMed]
70. Chokshi DA. Ensuring progress in primary care—what can health care reform realistically accomplish? N Engl J Med. 2009;(20):e43. [PubMed]
71. Miller WL, Crabtree BF. Healing landscapes: patients, relationships, and creating optimal healing places. J Altern Complement Med. 2005;11(Suppl 1):S41–S49. [PubMed]
72. Kibbe DC. Toward a modular EHR. Fam Pract Manag. 2009;16 (4):8–9. [PubMed]
73. Carrier E, Gourevitch MN, Shah NR. Medical homes: challenges in translating theory into practice. Med Care. 2009;47(7):714–722. [PMC free article] [PubMed]
74. Baron RJ. Quality improvement with an electronic health record: achievable, but not automatic. Ann Intern Med. 2007;147(8):549–552. [PubMed]
75. Bohmer RM, Edmondson AC. Organizational learning in health care. Health Forum J. 2001;44(2):32–35. [PubMed]
76. Crabtree BF, Miller WL, McDaniel RR, Strange KC, Nutting PA, Jaén CR. A survivor’s guide for primary care physicians. J Fam Pract. 2009;58(8):E1. [PMC free article] [PubMed]
77. Jordan ME, Lanham HJ, Crabtree BF, et al. The role of conversation in health care interventions: enabling sensemaking and learning. Implement Sci. 2009;4:15. [PMC free article] [PubMed]
78. Lanham HJ, McDaniel RR Jr, Crabtree BF, et al. How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. Jt Comm J Qual Patient Saf. 2009; 35(9):457–466. [PMC free article] [PubMed]
79. Lencioni P. Overcoming the Five Dysfunctions of a Team: A Field Guide For Leaders, Managers, and Facilitators. San Francisco, CA: Jossey-Bass; 2005.
80. Lukas CV, Mohr DC, Meterko M. Team effectiveness and organizational context in the implementation of a clinical innovation. Qual Manag Health Care. 2009;18(1):25–39. [PubMed]
81. Miller WL, McDaniel RR Jr, Crabtree BF, Stange KC. Practice jazz: understanding variation in family practices using complexity science. J Fam Pract. 2001;50(10):872–878. [PubMed]
82. Perkins DN. King Arthur’s Table: How Collaborative Conversations Create Smart Organizations. New York, NY; Wiley; 2003.
83. Rodriguez HP, Rogers WH, Marshall RE, Safran DG. Multidisciplinary primary care teams: effects on the quality of clinician-patient interactions and organizational features of care. Med Care. 2007;45(1):19–27. [PubMed]
84. Safran DG, Miller W, Beckman H. Organizational dimensions of relationship-centered care. Theory, evidence, and practice. J Gen Intern Med. 2006;21(Suppl 1):S9–S15. [PMC free article] [PubMed]
85. Tallia AF, Lanham HJ, McDaniel RR Jr, Crabtree BF. 7 characteristics of successful work relationships. Fam Pract Manag. 2006;13(1): 47–50. [PubMed]
86. Kuzel AJ, Skoch EM. Achieving a patient-centered medical home as determined by the NCQA—at what cost, and to what purpose? Ann Fam Med. 2009;7(1):85–86. [PMC free article] [PubMed]
87. Rittenhouse DR, Casalino LP, Gillies RR, Shortell SM, Lau B. Measuring the medical home infrastructure in large medical groups. Health Aff (Millwood). 2008;27(5):1246–1258. [PubMed]
88. DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care—a national survey of physicians. N Engl J Med. 2008;359(1):50–60. [PubMed]
89. Grumbach K, Mold JW. A health care cooperative extension service: transforming primary care and community health. JAMA. 2009;301(24):2589–2591. [PubMed]
90. Jaen CR, Palmer R, Wood R, et al. The effect of facilitation in fostering practice change. 2009. http://www.graham-center.org/online/graham/home/publications/onepagers/2009/op60-effect-facilitation.html. Accessed Nov 8, 2009.
91. Chase SM, Nutting PA, Crabtree BF. Can your practice RAP? Using the reflective adaptive process to reach the next level in primary care. Fam Pract Manag. 2010;17(2):31–34. [PMC free article] [PubMed]
92. Stroebel CK, McDaniel RR Jr, Crabtree BF, Miller WL, Nutting PA, Stange KC. How complexity science can inform a reflective process for improvement in primary care practices. Jt Comm J Qual Patient Saf. 2005;31(8):438–446. [PubMed]
93. American Academy of Family Physicians. Nurse Practitioners. 1984; reaffirmed 2009. http://www.aafp.org/online/en/home/policy/policies/n/nursepractitioners.html. Accessed Jan 28, 2010.
94. Bohmer R. The rise of in-store clinics—threat or opportunity? N Engl J Med. 2007;356(8):765–768. [PubMed]
95. Flanagan L. Nursing practitioners: growing competition for family physicians? Fam Pract Manag. 1998;5(9):34–36, 41–43. [PubMed]
96. Phillips RL, Green LA, Fryer GE, Dovey SM. Uncoordinated growth of the primary care work force. Am Fam Physician. 2001;64(9):1498. [PubMed]
97. Phillips RL Jr, Harper DC, Wakefield M, Green LA, Fryer GE Jr. Can nurse practitioners and physicians beat parochialism into plowshares? Health Aff (Millwood). 2002;21(5):133–142. [PubMed]
98. Bodenheimer T, Chen E, Bennett HD. Confronting the growing burden of chronic disease: can the U.S. health care workforce do the job? Health Aff (Millwood). 2009;28(1):64–74. [PubMed]
99. Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med. 2007;5(5):457–461. [PMC free article] [PubMed]
100. Bodenheimer T, MacGregor K, Stothart N. Nurses as leaders in chronic care. BMJ. 2005;330(7492):612–613. [PMC free article] [PubMed]
101. Green LA, Jones SM, Fetter G Jr, Pugno PA. Preparing the personal physician for practice: changing family medicine residency training to enable new model practice. Acad Med. 2007;82(12):1220–1227. [PubMed]

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