Journal of General Internal Medicine

, Volume 33, Issue 11, pp 1928–1936 | Cite as

Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system

  • Anita D. Misra-Hebert
  • Adam Perzynski
  • Michael B. Rothberg
  • Jaqueline Fox
  • Mary Beth Mercer
  • Xiaobo Liu
  • Bo Hu
  • David C. Aron
  • Kurt C. Stange
Original Research



Successful implementation of new care models within a health system is likely dependent on contextual factors at the individual sites of care.


To identify practice setting components contributing to uptake of new team-based care models.


Convergent mixed-methods design.


Employees and patients of primary care practices implementing two team-based models in a large, integrated health system.

Main measures

Field observations of 9 practices and 75 interviews, provider and staff surveys to assess adaptive reserve and burnout, analysis of quality metrics, and patient panel comorbidity scores. The data were collected simultaneously, then merged, thematically analyzed, and interpreted by a multidisciplinary team.

Key results

Based on analysis of observations and interviews, the 9 practices were categorized into 3 groups—high, partial, and low uptake of new team-based models. Uptake was related to (1) practices’ responsiveness to change and (2) flexible workflow as related to team roles. Strength of local leadership and stable staffing mediated practices’ ability to achieve high performance in these two domains. Higher performance on several quality metrics was associated with high uptake practices compared to the lower uptake groups. Mean Adaptive Reserve Measure and Maslach Burnout Inventory scores did not differ significantly between higher and lower uptake practices.


Uptake of new team-based care delivery models is related to practices’ ability to respond to change and to adapt team roles in workflow, influenced by both local leadership and stable staffing. Better performance on quality metrics may identify high uptake practices. Our findings can inform expectations for operational and policy leaders seeking to implement change in primary care practices.

Key Words

Primary care redesign Health care delivery Qualitative research 



These results were presented in part at the Society of General Internal Medicine national meeting in Washington, DC in April, 2017 and in Denver, CO in May, 2018.

Funding Information

Dr. Misra-Hebert is supported by an Agency for Healthcare Research and Quality grant K08HS024128. Dr. Stange’s time was supported by a Clinical Research Professorship from the American Cancer Society.

Compliance with Ethical Standards

Conflicts of Interest

Dr. Misra-Hebert has received research funding from the Merck Investigators Studies Program and from Novo Nordisk, both unrelated to this work. Drs. Perzynski, Rothberg, Hu, Aron, and Stange, and Ms. Fox., Mercer, and Liu report no conflicts of interest.

Supplementary material

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  1. 1.
    Mitchell et al. Core Principles & Values of Effective Team-Based H.pdf. Accessed July 5, 2018.
  2. 2.
    Green LV, Savin S, Lu Y. Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication. Health Aff (Millwood) 2013;32(1):11–19. doi: CrossRefGoogle Scholar
  3. 3.
    Home|PCMH Resource Center. Accessed July 5, 2018.
  4. 4.
    Patient Aligned Care Team (PACT) - Patient Care Services. Accessed July 5, 2018.
  5. 5.
  6. 6.
    The Patient-Centered Medical Home’s Impact on Cost and Quality: Annual Review of Evidence, 2014–2015 | Patient-Centered Primary Care Collaborative. Accessed July 5, 2018.
  7. 7.
    Nelson KM, Helfrich C, Sun H, et al. Implementation of the patient-centered medical home in the veterans health administration: Associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Intern Med. 2014. PubMedCrossRefGoogle Scholar
  8. 8.
    Sylling PW, Wong ES, Liu C-F, et al. Patient-Centered Medical Home Implementation and Primary Care Provider Turnover. Med Care. 2014:1.
  9. 9.
    Wagner EH, Flinter M, Hsu C, et al. Effective team-based primary care: observations from innovative practices. BMC Fam Pract 2017;18(1):13. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Stock R, Mahoney E, Carney PA. Measuring team development in clinical care settings. Fam Med 2013;45(10):691–700.PubMedGoogle Scholar
  11. 11.
    Cronholm PF, Shea JA, Werner RM, et al. The patient centered medical home: mental models and practice culture driving the transformation process. J Gen Intern Med 2013;28(9):1195–1201. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Calman NS, Hauser D, Weiss L, et al. Becoming a patient-centered medical home: a 9-year transition for a network of Federally Qualified Health Centers. Ann Fam Med 2013;11 Suppl 1:S68–73. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Nutting PA, Crabtree BF, Miller WL, Stange KC, Stewart E, Jaén C. Transforming physician practices to patient-centered medical homes: lessons from the national demonstration project. Health Aff Proj Hope 2011;30(3):439–445. doi: CrossRefGoogle Scholar
  14. 14.
    Eubank D, Orzano J, Geffken D, Ricci R. Teaching team membership to family medicine residents: what does it take? Fam Syst Health J Collab Fam Healthc 2011;29(1):29–43. doi: CrossRefGoogle Scholar
  15. 15.
    Crabtree BF, Nutting PA, Miller WL, et al. Primary care practice transformation is hard work: insights from a 15-year developmental program of research. Med Care 2011;49 Suppl:S28–35. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Landon BE, Gill JM, Antonelli RC, Rich EC. Using evidence to inform policy: developing a policy-relevant research agenda for the patient-centered medical home. J Gen Intern Med 2010;25(6):581–583. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Chesluk BJ, Holmboe ES. How teams work--or don’t--in primary care: a field study on internal medicine practices. Health Aff Proj Hope 2010;29(5):874–879. doi: CrossRefGoogle Scholar
  18. 18.
    Miller WL, Crabtree BF, Nutting PA, Stange KC, Jaen CR. Primary Care Practice Development: A Relationship-Centered Approach. Ann Fam Med 2010;8(Suppl 1):S68-S79. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Jaen CR, Crabtree BF, Palmer RF, et al. Methods for Evaluating Practice Change Toward a Patient-Centered Medical Home. Ann Fam Med 2010;8(Suppl 1):S9-S20. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Shorter Adaptive Reserve Measures. Annals of Family Medicine Vol 10, No 3 Online Supplementary Data. Published June 2012.
  21. 21.
    Gabbay RA, Friedberg MW, Miller-Day M, Cronholm PF, Adelman A, Schneider EC. A Positive Deviance Approach to Understanding Key Features to Improving Diabetes Care in the Medical Home. Ann Fam Med 2013;11(Suppl 1):S99-S107. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Bobiak SN, Zyzanski SJ, Ruhe MC, et al. Measuring practice capacity for change: a tool for guiding quality improvement in primary care settings. Qual Manag Health Care 2009;18(4):278–284. doi: PubMedCrossRefGoogle Scholar
  23. 23.
    Helfrich CD, Simonetti JA, Clinton WL, et al. The Association of Team-Specific Workload and Staffing with Odds of Burnout Among VA Primary Care Team Members. J Gen Intern Med 2017;32(7):760–766. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Creswell J. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. Fourth. Sage Publications, Inc.; 2014. Accessed May 2, 2016.
  25. 25.
    Crabtree BF, Miller WL, eds. Miller WL, Crabtree BF.Chapter 7: The Dance of Interpretation. In: Doing Qualitative Research. Second. Thousand Oaks, CA: Sage Publications, Inc.; 1999:127–143.Google Scholar
  26. 26.
    Crabtree BF, Miller WL, eds. Addison R B. Chapter 8: A Grounded Hermeneutic Editing Approach. In: Doing Qualitative Research. Thousand Oaks, CA: Sage Publications, Inc.; 1999:145–161.Google Scholar
  27. 27.
    Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol 2013;13:117. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    NVivo Qualitative Data Analysis Software; Version 11. QSR International Pty Ltd.; 2015.Google Scholar
  29. 29.
    Maslach Burnout Inventory (MBI) - Assessments, Tests| Mind Garden-Mind Garden. Accessed July 6, 2018.
  30. 30.
    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42(2):377–381. doi: CrossRefGoogle Scholar
  31. 31.
    Medicare C for, Baltimore MS 7500 SB, Usa M. program-guidance-and-specifications. Published August 24, 2017. Accessed October 4, 2017.
  32. 32.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373–383.CrossRefGoogle Scholar
  33. 33.
    Cohen D, McDaniel RR Jr, Crabtree BF, et al. A practice change model for quality improvement in primary care practice. J Healthc Manag Am Coll Healthc Exec 2004;49(3):155–168; discussion 169-170.Google Scholar
  34. 34.
    Cohen DJ, Crabtree BF, Etz RS, et al. Fidelity versus flexibility: translating evidence-based research into practice. Am J Prev Med 2008;35(5 Suppl):S381–389. doi: PubMedCrossRefGoogle Scholar
  35. 35.
    Øvretveit J. Understanding the conditions for improvement: research to discover which context influences affect improvement success. BMJ Qual Saf 2011;20(Suppl 1):i18-i23. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Hawe P, Shiell A, Riley T, Gold L. Methods for exploring implementation variation and local context within a cluster randomised community intervention trial. J Epidemiol Community Health 2004;58(9):788–793. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Jackson GL, Williams JW. Does PCMH “Work”?—The Need to Use Implementation Science to Make Sense of Conflicting Results. JAMA Intern Med 2015;175(8):1369–1370. doi: PubMedCrossRefGoogle Scholar
  38. 38.
    Reiss-Brennan B, Brunisholz KD, Dredge C, et al. Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost. JAMA 2016;316(8):826–834. doi: PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Anita D. Misra-Hebert
    • 1
    • 2
    • 3
  • Adam Perzynski
    • 4
  • Michael B. Rothberg
    • 1
    • 2
  • Jaqueline Fox
    • 2
  • Mary Beth Mercer
    • 5
  • Xiaobo Liu
    • 3
  • Bo Hu
    • 3
  • David C. Aron
    • 6
  • Kurt C. Stange
    • 7
  1. 1.Department of Internal Medicine Cleveland ClinicClevelandUSA
  2. 2.Center for Value-Based Care ResearchCleveland ClinicClevelandUSA
  3. 3.Department of Quantitative Health SciencesCleveland ClinicClevelandUSA
  4. 4.Center for Health Care Research and PolicyCase Western Reserve University at MetroHealthClevelandUSA
  5. 5.Office of Patient ExperienceCleveland ClinicClevelandUSA
  6. 6.Louis Stokes Cleveland Veterans Affairs Medical CenterClevelandUSA
  7. 7.Center for Community Health Integration, and Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, Oncology and SociologyCase Western Reserve UniversityClevelandUSA

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