Expanding Patient-Centered Medical Home Teams in Primary Care: Qualitative Evaluation of Implementation Experiences from a Multi-site Pilot Within the VA Healthcare System.

Abstract

Background: More than a decade ago, the Veterans Health Administration (VA) implemented the Patient-Centered Medical Home (PCMH) model in primary care (PC) to improve healthcare access, care coordination, and patient outcomes. In 2021, VA's Office of Primary Care piloted three new PCMH models that aimed to improve provider efficiency and patient healthcare access by adding new team roles and increasing panel sizes.

Objective: To describe frontline staff experiences and lessons learned during implementation of expanded PCMH team models.

Design: Qualitative, semi-structured interviews of 25 frontline staff at 6 VA sites participating in the PCMH Modernization pilot conducted between March and August 2022.

Participants: Interview participants included physicians, nurses, physical therapists, high-risk care managers, and other staff.

Approach: We used a rapid analysis approach that included creating and validating interview summaries, developing a matrix of interview domains to identify common themes, and iterative discussion among the research team to build consensus and interpret findings.

Key results: We found that when the basic PCMH structure and processes (e.g., staffing, huddling, pre-visit planning) were not in place, it was challenging to integrate new team members and to increase panel sizes. Role clarity challenges were also introduced by adding certain roles to PCMH teams. The physical therapist and high-risk care manager roles were seen as positive additions to PCMH models. Lastly, matching panel size expansion with staffing capacity was crucial to optimizing team efficiency while increasing patient healthcare access.

Conclusions: Healthcare administrators considering expanding PCMH team models may need to thoroughly assess and address site readiness (e.g., adherence to foundational PCMH model, staffing, and practices) prior to implementation. Role clarity challenges should also be anticipated when adding new team roles. Physical therapists and high-risk care managers could be important contributions to existing PCMH models for offloading provider workload and improving population health management.