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Transforming Primary Care Practice

Award Recipients

In the summer of 2010, the Agency for Healthcare Research and Quality (AHRQ) awarded 14 transforming primary care grants totaling more than $4.1 million each year for 2 years through RFA HS-10-002. The purpose of these grants is to understand the "natural experiments" that primary care practices undergo as they transform into Patient-Centered Medical Homes (PCMHs).

These grants support AHRQ's goal of supporting the evidence base for and implementation of activities to improve primary care and clinical outcomes through: health care redesign, clinical-community linkages, self-management support, integration of health information technology, and care coordination.

The following applicants demonstrated that their primary care practices underwent transformation to PCMHs for at least 1 year and have documented evidence that the transformation was successful (e.g., improved health outcomes, operational efficiency). Lessons learned from the transformation process, including understanding the barriers and costs involved and the impact on staff, providers, and patients, will be informative to other primary care settings undergoing or considering undergoing transformation to PCMHs.

Project Title: Transformed Primary Care by Design
Principal Investigator: Michael K. Magill, MD
Organization: University of Utah Community Clinics
Grant Number: R18 HS019136
Project Period: 7/1/10 to 6/30/12
AHRQ Funding Amount: $269,615 (year 1), $285,678 (year 2)
Current Status: Funded

Summary: This project will investigate the transformation of university-owned primary care practices in Utah into PCMHs through a process called "Care by Design" (CBD). CBD is organized around the principles of appropriate access, care teams, and planned care, all of which are supported by a robust electronic medical record that has been in place since the start of the transformation. A newly available Utah All Payer Database for patients younger than 65 and Medicare data for patients older than 65 will be used to examine the total cost of care. CBD implementation; satisfaction of staff, providers, and patients; and clinical health outcomes such as diabetes, coronary heart disease, and asthma will also be studied.

Specific Aims:

Aim 1: Document and measure the transformation of the University of Utah Community Clinics to PCMHs using the CBD process, and the impact of this transformation on the quality of patient care delivery.
Aim 2: Determine the effect of the transformation on costs to the clinics and overall costs of health care services at the patient level for health insurance carriers and patients.
Aim 3: Determine the impact of practice transformation on the experiences and satisfaction of providers, staff, and patients.
Aim 4: Collect and analyze information related to organizational and contextual factors within the clinics that could have influenced the success of the transformation.
Aim 5: Assess in depth how the transformation was implemented, including the modifications, adaptations, and refinements to the PCMH model that were required to accommodate local context, and how obstacles and other challenges were overcome.

Project Title: Evaluating Statewide Transformation of Primary Care to Medical Homes
Principal Investigator: Leif I. Solberg, MD
Organization: Health Partners Research Foundation
Grant Number: R18 HS019161
Project Period: 9/30/10 to 8/31/12
AHRQ Funding Amount: $299,749 (year 1), $296,378 (year 2)
Current Status: Funded

Summary: This study is an evaluation in the context of a legislative initiative in Minnesota to transform primary care practices into PCMHs. Using matched controls, this study will look at increases in quality of care measures for diabetes and cardiovascular disease, the effect of reimbursement policy on practices, and the effect of transformation on staff, providers, and patients.

Specific Aims:

Aim 1: Test whether change in clinic scores for practice systems is correlated with change in clinic scores for quality measures for patients with diabetes or cardiovascular disease.
Aim 2: Identify the transformation priorities, strategies, care process changes, and context that distinguish transformed clinics from comparison clinics that have not achieved transformation.
Aim 3: Evaluate the impact of PCMH transformation on health care costs and utilization, clinic operating costs, and the satisfaction of patients and health care personnel by comparing data from transformed and comparison clinics.
Aim 4: Implement the lessons learned from this study throughout Minnesota and disseminate them nationally.

Project Title: Transforming Primary Care Practices in North Carolina
Principal Investigator: Katrina E. Donahue, MD, MPH
Organization: University of North Carolina at Chapel Hill
Grant Number: R18 HS019131
Project Period: 8/1/10 to 7/31/12
AHRQ Funding Amount: $299,109 (year 1), $299,107 (year 2)
Current Status: Funded

Summary: This project is a study of practices in the North Carolina Improving Performance in Practice (IPIP) Program. IPIP is a national quality improvement program that provides clinicians and their health care teams with the tools, systems, and support needed to transform their practices in ways that lead to improved care quality. IPIP also has built-in data collection systems that monitor at the practice level both the transformation process itself and changes in clinical outcomes for specific disease conditions (in this case, diabetes and asthma). This study will use longitudinal data from 40 clinics and examine the transformation efforts of 12 selected practices to provide an in-depth assessment of transformation efforts.

Specific Aims:

Aim 1: Confirm the transformational change process that has occurred within the 40 selected practices in the North Carolina IPIP.
Aim 2: Evaluate which components of change are most linked with improvement in the quality care indicators for diabetes (29 practices) and asthma (11 practices).
Aim 3: Utilize quantitative and qualitative methods in a subset of 12 practices that demonstrate varying degrees of success in implementing transformational change to:
- 3a: Obtain a better understanding of the change process, by conducting detailed in-person interviews that will address key findings from Aim 1, such as which elements of change were made more readily and why, how practice characteristics (e.g., size, geography, insurance mix) might have affected the change process, and challenges and solutions perceived by the practices and QICs.
- 3b: Examine the effect of environmental conditions, organizational characteristics, and financial resources on the change process.
- 3c: Describe the direct personnel and nonpersonnel costs involved in transformational change at the practice level.
Aim 4: Provide recommendations that can be applied at the individual practice level and the health care organization level to assist in the PCMH transformation process.

Project Title: Transforming Primary Care: Evaluating the Spread of Group Health's Medical Home
Principal Investigator: Robert J. Reid, MD, PhD, MPH
Organization: Group Health Cooperative
Grant Number: R18 HS019129
Project Period: 7/1/10 to 6/30/12
AHRQ Funding Amount: $299,938 (year 1), $297,583 (year 2)
Current Status: Funded

Summary: This study is an evaluation of the transformation of primary care clinics into PCMHs in Group Health Cooperative, a large, vertically integrated group health system. Group Health has a diverse network of over 600,000 patients and practice types, including those with five or fewer providers. Group Health will use an interrupted time series design, focus groups with patients, staff interviews, a robust cost analysis, and site visits with ethnographic observation to assess transformation across a large health care system.

Specific Aims:

Aim 1: Assess PCMH effects on efficiency and quality of patient care.
Aim 2: Examine PCMH effects on patient and staff experience.
Aim 3: Describe and assess the PCMH transformation process.

Project Title: Primary Care Transformation in a NCQA Certified Patient-Centered Home
Principal Investigator: Ming Tai-Seale, PhD, MPH
Organization: Palo Alto Medical Foundation Research Institute
Grant Number: R18 HS019167
Project Period: 8/10/10 to 7/31/12
AHRQ Funding Amount: $300,000 (year 1), $300,000 (year 2)
Current Status: Funded

Summary: Palo Alto Medical Foundation is a diverse, physician-led, nonprofit multispecialty ambulatory care system in northern California. This study will look at the transformation efforts of the Foundation's practices (ranging from three to 300 providers each) into PCMHs. The aims of this project are to describe the transformation process; determine the effect of the transformation on health outcomes, organizational processes, and practice costs; and determine the impact of transformation on staff, providers, and patients.

Specific Aims:

Aim 1: Describe how the transformation was implemented, with attention to the organizational context and practice culture and conditions within which the change occurred.
Aim 2: Determine the effect of the transformation on processes (e.g., same-day appointments, shared medical appointment, alerts, "in-box" latency), intermediate clinical outcomes (e.g., blood pressure, glucose, lipids, and weight for patients with diabetes), and costs and efficiency of care (e.g., out-of-pocket costs, inpatient readmissions within 30 days of discharge, emergency department visits).
Aim 3: Determine the impact on the actual experiences and satisfaction of physicians, staff, and patients by using routinely collected past and ongoing surveys within the organization and prospective qualitative research using key informant interviews and patient focus groups.

Project Title: Transforming Primary Care Practice: Lessons from the New Orleans Safety Net
Principal Investigator: Diane R. Rittenhouse, MD, MPH
Organization: University of California, San Francisco
Grant Number: R18 HS019139
Project Period: 8/16/10 to 7/31/12
AHRQ Funding Amount: 299,365 (year 1), $296,982 (year 2)
Current Status: Funded

Summary: This study will look at primary care transformation into PCMHs in post-Hurricane Katrina New Orleans using a focused case study approach. The study includes diverse practice settings (faith-based, university-owned, nonprofit) with 10 or fewer providers.

Specific Aims:

Aim 1: Validate implementation of the PCMH model within each of five National Committee for Quality Assurance-recognized primary care practices over 3 years using quantitative data on process changes within each practice and trends in patient outcome and costs.
Aim 2: Better understand barriers to implementing the PCMH model, particularly in the health care safety net, and how successful practices overcome those barriers through qualitative case studies.
Aim 3: Disseminate lessons learned from exemplary primary care practices in New Orleans about how to successfully adopt the PCMH model, and what changes can be expected for patients and providers as a result.

Project Title: Transformation to Patient-Centered Medical Home in CareOregon Clinics
Principal Investigator: Richard T. Meenan, PhD, MPH, MBA
Organization: Kaiser Foundation Research Institute
Grant Number: R18 HS019146
Project Period: 7/1/10 to 6/30/12
AHRQ Funding Amount: $284,455 (year 1), $299,999 (year 2)
Current Status: Funded

Summary: The setting for this study is CareOregon, a Medicaid managed health care plan, which implemented a PCMH model called "Primary Care Renewal" (PCR). PCR provides reimbursement and other support to encourage practices to provide multidisciplinary, coordinated, and comprehensive care. The evaluation design uses two principles from Linstone's multiple perspective framework: 1) technical perspective and 2) organizational and personal perspectives.

Specific Aims:

Aim 1: Using Linstone's technical perspective as a framework, identify quantitative metrics of health care quality and cost relevant to PCR practices and evaluate PCR's degree of success in improving these metrics. The study will focus on the direct health care cost and utilization implications of the PCR program from its inception through the most recent date available (at least through 12/31/09).
Aim 2: Using Linstone's organizational and personal perspectives as a framework, describe the process of PCR transformation, identify barriers and facilitators for successful PCR transformation, and identify strategies that clinics have used to strengthen the facilitators and lessen the barriers to PCR transformation.
Aim 3: Develop and implement a plan to disseminate the quantitative and qualitative results from Aims 1 and 2 to a potentially national audience of providers and organizations interested in implementing the medical home concept.

Project Title: Medical Home Transformation in Pediatric Primary Care: What Drives Change?
Principal Investigator: William C. Cooley, MD
Organization: Crotched Mountain Foundation, Inc.
Grant Number: R18 HS019157
Project Period: 7/1/10 to 6/30/12
AHRQ Funding Amount: $278,485 (year 1), $278,727 (year 2)
Current Status: Funded

Summary: This study will identify the drivers and obstacles to medical home transformation and the sustainability of change in 10 transformed primary care pediatric and family-centered medical homes (FCMHs). The 10 transformed pediatric practices and three alternates were identified from among the highest performing practices taking part in two separate yearlong national medical home learning collaboratives between 2003 and 2006, based on improvements between their pre- and post-collaborative Medical Home Index scores.

Specific Aims:

Aim 1: Identify key internal and external factors affecting successful transformation of traditional pediatric primary care models into FCMHs.
Aim 2: Describe the business case or financial modeling used by practices to achieve and sustain transformation, including billing or coding enhancements, capitated administrative reimbursements, pay-for-performance incentives, startup grants, and shared resources.
Aim 3: Evaluate the role of facilitation, technical assistance, and other supports to quality improvement and change in successful transformation.
Aim 4: Assess the impact of medical home transformation on staff and patient/family satisfaction with providing or receiving pediatric primary care.
Aim 5: Identify characteristics that distinguish the pediatric PCMH from the adult PCMH model, along with any factors unique to pediatric primary care transformation.
Aim 6: Communicate findings to key primary care professional organizations, policymakers, payers, purchasers, medical schools and residency training programs, parent and family organizations, and other stakeholders to ensure that national and State, public and private PCMH initiatives include, support, incentivize, study, and teach the pediatric FCMH.

Project Title: Health Care Transformation Among Small Urban Practices Serving the Underserved
Principal Investigator: Carolyn A. Berry, PhD, MA
Organization: Center for Healthcare Strategies, Inc.
Grant Number: R18 HS019164
Project Period: 9/30/10 to 9/29/12
AHRQ Funding Amount: $271,410 (year 1), $272,723 (year 2)
Current Status: Funded

Summary: The focus of this study is 105 small, urban primary care practices with fewer than five providers in New York City. Transformation to a PCMH is supported by the city of New York. Secondary data on the 105 practices will be analyzed and an in-depth quantitative and qualitative transformation analysis will be conducted on a subset of practices.

Specific Aims:

Aim 1: Utilize secondary data for a large number (105) of small, urban primary care practices that have undergone transformation processes for at least 1 year to understand changes in management/transformation processes, status and changes in health care processes, status and changes in patient outcomes, and the interrelationships among these variables.
Aim 2: Utilize mixed methods, including a provider survey and key informant interviews with patients, to assess the effects of practice transformation activities on health care providers and their patients.
Aim 3: Use a detailed practice assessment, site visits, and key informant interviews to examine in depth the implementation of transformation components, with attention to the organizational and contextual factors that affected implementation and success in 40 selected practices.
Aim 4: Disseminate widely the findings from this study through presentations at conferences and meetings of professional organizations and medical societies, a Web-based toolkit of best practices, and peer-reviewed journal articles.

Project Title: A Multipayer Patient-Centered Medical Home Initiative in Pennsylvania
Principal Investigator: Robert A. Gabbay, MD, PhD
Organization: Hershey Medical Center, Pennsylvania State University
Grant Number: R18 HS019150
Project Period: 9/1/10 to 7/31/12
AHRQ Funding Amount: $295,409 (year 1), $294,704 (year 2)
Current Status: Funded

Summary: This study will involve the evaluation of primary care practices that underwent transformation to a PCMH in the context of a statewide initiative. The initiative, facilitated by the Pennsylvania Governor's Office for Healthcare Reform, includes a learning collaborative, Improving Performance in Practice coaches, and required monthly registry and narrative reports. Financial incentives are paid to providers by health insurers and are guaranteed by the Governor's Office.

Specific Aims:

Aim 1: Evaluate the clinical and proximal outcomes of the PCMH intervention.
Aim 2: Evaluate the effects of the PCMH intervention on resource utilization and costs.
Aim 3: Evaluate patient and provider satisfaction and experience with the PCMH intervention.
Aim 4: Identify and describe PCMH transformations.

Project Title: Understanding the Transformation Experiences of Small Practices with NCQA's Medical Home Recognition
Principal Investigator: Sarah H. Scholle, DrPH, MPH
Organization: National Committee for Quality Assurance
Grant Number: R18 HS019162
Project Period: 8/1/10 to 7/31/12
AHRQ Funding Amount: $299,924 (year 1), $299,878 (year 2)
Current Status: Funded

Summary: The National Committee for Quality Assurance's (NCQA's) Physician Practice Connections® Patient-Centered Medical Home (PPC-PCMH) Program has become the de facto standard for primary care transformation. This study looks at 300 small practices in 14 different States that have achieved NCQA PCMH status. A case study approach will also be used to study transformation efforts on a subset of practices.

Specific Aims:

Aim 1: Detail the transformation process among small physician practices that have successfully implemented the PCMH model (based on achievement of Level 3 PPC-PCMH recognition) and that represent diverse States, organizational characteristics, PCMH demonstration programs, and patient populations.
Aim 2: Identify organizational and contextual factors that distinguish practices with a higher level of PCMH implementation (based on Level 3 recognition) compared with those with lower levels of implementation (Level 1 or 2) among 300 small practices representing diverse States, organizational characteristics, PCMH demonstration programs, and patient populations.
Aim 3: Compare physician work experiences among small practices with higher level versus lower levels of PCMH implementation.
Aim 4: Compare operational costs and revenue among small practices with higher level versus lower levels of PCMH implementation.

Project Title: Multimethod Evaluation of Physician Group Incentive Programs for PCMH Transition
Principal Investigator: Christopher G. Wise, PhD, MHA
Organization: University of Michigan
Grant Number: R18 HS019147
Project Period: 7/15/10 to 12/31/11
AHRQ Funding Amount: $477,496
Current Status: Funded

Summary: This study will obtain information on the issues related to implementing aspects of PCMH within the primary care clinics that participate in Blue Cross/Blue Shield of Michigan's (BCBSM's) Physician Group Incentive Program (PGIP). The BCBSM PGIP supports PCMH implementation for physicians throughout Michigan, and encourages collaboration and information sharing in order to measure and monitor the quality of care, improve systems of care, and effectively manage patients.

Specific Aims:

Aim 1: Quantify PGIP member practices' progress toward PCMH goals.
Aim 2: Investigate how practices have succeeded in PCMH transformation, using combined qualitative and quantitative inquiry to discover the processes and tools that have worked well, the resources that have been important, and the key organizational and leadership attributes supporting their success.

Project Title: Transforming Primary Care Practice
Principal Investigator: David L. Driscoll, PhD, MPH, MA
Organization: University of Alaska Anchorage
Grant Number: R18 HS019154
Project Period: 7/1/10 to 6/30/12
AHRQ Funding Amount: $291,281 (year 1), $279,735 (year 2)
Current Status: Funded

Summary: The focus of this study is Southcentral Foundation's transformation to a PCMH. The Foundation is a tribally-owned organization providing primary care services for American Indian and Alaska Native people in Anchorage, Alaska. Its PCMH model has three key characteristics: patient-selected family matching to a primary care team, patient-driven care, and advanced access. The Foundation's transformation has been studied and modeled by other primary care practice groups.

Specific Aims:

Aim 1: Determine the impact of the PCMH transformation on the characteristics and quality of patient care delivery.
Aim 2: Assess changes in health care delivery, such as quality and safety efforts, efforts to bring evidence to the point of care, use of information systems, and costs.

Project Title: A Study of the Patient-Centered Medical Home: Lessons from a New York State Community Health Center Network
Principal Investigator: Neil S. Calman, MD, MA
Organization: Institute for Urban Family Health
Grant Number: R18 HS019176
Project Period: 7/1/10 to 6/30/12
AHRQ Funding Amount: $298,194 (year 1), $100,000 (year 2)
Current Status: Funded

Summary: This study will evaluate the transformation efforts of 16 federally-qualified community health centers in the State of New York. The overarching goal for this study is to inform the efforts of primary care practices in general and, more specifically, other federally-qualified community health centers, as they strive to adopt the PCMH model.

Specific Aims:

Aim 1: Identify and describe discrete and specific changes in processes of care, including financial costs and other resource requirements.
Aim 2: Examine and validate changes in health service utilization and outcomes among patients (with a focus on diabetes, depression, and hyperlipidemia) that resulted from the implementation of the PCMH model in the Institute for Urban Family Health's network of community health centers.
Aim 3: Explicate the organizational, contextual, procedural, and other variables within the Institute and its individual health centers that had an impact on the implementation of the PCMH model and improvements in care.

More Information

Commentary: Health Information Technology: Turning the Patient-Centered Medical Home From Concept to Reality

For more information about these grants, please contact Dr. Joseph Clift at Joseph.Clift@ahrq.hhs.gov or (301) 427-1566.

Current as of June 2011

Internet Citation:

Transforming Primary Care Practice: Award Recipients. June 2011. Agency for Healthcare Research and Quality. http://www.ahrq.gov/research/transpcaw.htm