Readiness for the Patient-Centered Medical Home: structural capabilities of Massachusetts primary care practices

Abstract

Background: The Patient-Centered Medical Home (PCMH), a popular model for primary care reorganization, includes several structural capabilities intended to enhance quality of care. The extent to which different types of primary care practices have adopted these capabilities has not been previously studied.

Objective: To measure the prevalence of recommended structural capabilities among primary care practices and to determine whether prevalence varies among practices of different size (number of physicians) and administrative affiliation with networks of practices.

Design: Cross-sectional analysis.

Participants: One physician chosen at random from each of 412 primary care practices in Massachusetts was surveyed about practice capabilities during 2007. Practice size and network affiliation were obtained from an existing database.

Measurements: Presence of 13 structural capabilities representing 4 domains relevant to quality: patient assistance and reminders, culture of quality, enhanced access, and electronic health records (EHRs).

Main results: Three hundred eight (75%) physicians responded, representing practices with a median size of 4 physicians (range 2-74). Among these practices, 64% were affiliated with 1 of 9 networks. The prevalence of surveyed capabilities ranged from 24% to 88%. Larger practice size was associated with higher prevalence for 9 of the 13 capabilities spanning all 4 domains (P < 0.05). Network affiliation was associated with higher prevalence of 5 capabilities (P < 0.05) in 3 domains. Associations were not substantively altered by statistical adjustment for other practice characteristics.

Conclusions: Larger and network-affiliated primary care practices are more likely than smaller, non-affiliated practices to have adopted several recommended capabilities. In order to achieve PCMH designation, smaller non-affiliated practices may require the greatest investments.

Figure 1

Derivation of study sample.

Figure 2

Adjusted network-by-network prevalences of capabilities associating with network affiliation. For all 3 panels, P<0.001 for variation among networks. Point estimates and 95% CI's (represented by error bars) are calculated using multivariable logistic models that include a dummy variable for each network, and adjust for practice size, multi-specialty status, and teaching status. In panel A, Networks A, B, and C were excluded from logistic modeling because 100% of respondents reported awareness of patient experience ratings. The median number of responding practices per network was 16 (range, 7-72). There were no significant relationships between the number of practices in a network and capability prevalence. In Panel C, Network A was excluded from the logistic model because none of its practices had frequently used, multi-functional EHRs.