Structural capabilities in small and medium-sized patient-centered medical homes.

OBJECTIVES: 1) Evaluate structural capabilities associated with the patient-centered medical home (PCMH) model in PCMH pilots in Colorado, Ohio, and Rhode Island; 2) evaluate changes in capabilities over 2 years in the Rhode Island pilot; and 3) evaluate facilitators and barriers to the adoption of capabilities.

STUDY DESIGN: We assessed structural capabilities in the 30 pilot practices using a cross-sectional study design and examined changes over 2 years in 5 Rhode Island practices using a pre/post design.

METHODS: We used National Committee for Quality Assurance's Physician Practice Connections-Patient-Centered Medical Home (PPC/PCMH) accreditation survey data to measure capabilities. We stratified by high and low performance based on total score and by practice size. We analyzed change from baseline to 24 months for the Rhode Island practices. We analyzed qualitative data from interviews with practice leaders to identify facilitators and barriers to building capabilities.

RESULTS: On average, practices scored 73 points (out of 100 points) for structural capabilities. High and low performers differed most on electronic prescribing, patient self-management, and care-management standards. Rhode Island practices averaged 42 points at baseline, and reached 90 points by the end of year 2. Some of the key facilitators that emerged were payment incentives, "transformation coaches," learning collaboratives, and data availability supporting performance management and quality improvement. Barriers to improvement included the extent of transformation required, technology shortcomings, slow cultural change, change fatigue, and lack of broader payment reform.

CONCLUSIONS: For these early adopters, prevalence of structural capabilities was high, and performance was substantially improved for practices with initially lower capabilities. We conclude that building capabilities requires payment reform, attention to implementation, and cultural change.