Major Finding: At 7 months, 17 of 18 supported practices met NCQA patient-centered medical home criteria. One practice did not report data at follow-up.

Data Source: Randomized, controlled trial of a 2-year medical home demonstration project.

Disclosures: The medical home demonstration was funded by insurer EmblemHealth. The outside evaluation was funded by the Commonwealth Fund. No other disclosures were reported.

TORONTO — Small and solo practices can successfully transition to a patient-centered medical home model, but the change requires intensive outside support, according to early findings released at the annual meeting of the American College of Physicians.

In the first randomized, controlled trial evaluating the transition to the medical home, small practices that received hands-on support and financial incentives were able to rapidly transform to meet the National Committee for Quality Assurance (NCQA) criteria for a patient-centered medical home, according to Judith Fifield, Ph.D., who performed the external evaluation of the medical home project.

Dr. Fifield and her team at the Ethel Donaghue Center for Translating Research into Practice and Policy at the University of Connecticut, Farmington, are still evaluating data from the medical home project, but the initial findings show that, with proper support, the transition can happen in just over 6 months, even in very small practices.

The demonstration project involved 38 primary care practices in the New York City area. Half of the practices were randomized to receive intensive, in-person support and pay-for-performance incentive payments. The other 19 practices were given a $5,000 annual stipend and asked to make the transition to the medical home on their own.

Of the initial 19 supported practices, 1 practice withdrew. In the control arm, four practices withdrew before the study's end. At baseline, there were no significant differences between the supported and control arms of the study. Overall, about 40% of the participating practices were solo and 60% were small. About half of the practices had electronic health record (EHR) systems or were under contract to purchase one at baseline. The evaluation of the study was funded by the Commonwealth Fund.

Those practices in the supported group received on-site help from trained facilitators and nurse care managers. The facilitators provided guidance and training on how to use an EHR for patient communication, care coordination, and practice management. The practices without an EHR were given guidance on how to use their existing technology and paper-based systems to increase efficiency.

The nurse care managers, who were on site in the practices about once a week, helped staff members identify high-risk patients, assisted with care planning, and conducted group visits for patients with newly diagnosed diabetes. The nurses were often matched to the ethnicity and language of patients at the site, Dr. Fifield said.

The support teams “really became a big part of the care at the site,” she said.

The supported practices also were eligible to receive up to $5 per member per month in addition to their regular fee for service payments. The incentives were based on meeting the NCQA criteria for the medical home, as well as meeting clinical quality and patient experience benchmarks.

Preliminary data from the first year of the project show that supported practices earned between $3,300 and $55,000 in total pay-for-performance incentives.

Of the 18 supported practices that completed the project, only 1 practice could meet NCQA criteria at baseline. After 7 months, 17 of the supported practices met the criteria and 10 qualified for the highest level of NCQA recognition. One supported practice did not report data at the 7-month follow-up.

Dr. Fifield did not discuss outcomes for the control group during her review of the study's preliminary results.

Conversations with study participants also revealed that providers and staff were happy with the transition to the medical home, she said. Although there was some frustration at the beginning of the project, that quickly changed. Physicians reported that they were excited to learn how to do more with their EHRs, and staff members said that the process to convert to a medical home gave them new skills and made them feel like a more valued part of the care team.

The biggest concern, Dr. Fifield said, is the sustainability of the change, since so much of it depended on assistance from outside contractors.

“It requires a great deal of support,” she said. “It is a very high-touch operation, especially to do it this quickly”.

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'It requires a great deal of support. It is a very high-touch operation, especially to do it this quickly.'

Source DR. FIFIELD

Small Practices Can Become Medical Homes