Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system
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.
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.
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 WordsPrimary 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.
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.
- 1.Mitchell et al. Core Principles & Values of Effective Team-Based H.pdf. https://www.nationalahec.org/pdfs/vsrt-team-based-care-principles-values.pdf. Accessed July 5, 2018.
- 3.Home|PCMH Resource Center. https://pcmh.ahrq.gov/. Accessed July 5, 2018.
- 4.Patient Aligned Care Team (PACT) - Patient Care Services. https://www.patientcare.va.gov/primarycare/PACT.asp. Accessed July 5, 2018.
- 5.Joint Principles of the Patient-Centered Medical Home. https://www.aap.org/en-us/professional-resources/quality-improvement/Pages/Joint-Principles-of-the-Patient-Centered-Medical-Home.aspx. Accessed July 5, 2018.
- 6.The Patient-Centered Medical Home’s Impact on Cost and Quality: Annual Review of Evidence, 2014–2015 | Patient-Centered Primary Care Collaborative. https://www.pcpcc.org/resource/patient-centered-medical-homes-impact-cost-and-quality-2014-2015. Accessed July 5, 2018.
- 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. https://doi.org/10.1001/jamainternmed.2014.2488
- 8.Sylling PW, Wong ES, Liu C-F, et al. Patient-Centered Medical Home Implementation and Primary Care Provider Turnover. Med Care. 2014:1. https://doi.org/10.1097/MLR.0000000000000230
- 20.Shorter Adaptive Reserve Measures. Annals of Family Medicine Vol 10, No 3 Online Supplementary Data. http://www.annfammed.org/content/suppl/2012/04/13/8.Suppl_1.S9.DC2/Shorter_Adaptive_Reserve_Measures.pdf. Published June 2012.
- 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: https://doi.org/10.1370/afm.1473 CrossRefPubMedPubMedCentralGoogle Scholar
- 24.Creswell J. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. Fourth. Sage Publications, Inc.; 2014. https://us.sagepub.com/en-us/nam/research-design/book237357. Accessed May 2, 2016.
- 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.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
- 28.NVivo Qualitative Data Analysis Software; Version 11. QSR International Pty Ltd.; 2015.Google Scholar
- 29.Maslach Burnout Inventory (MBI) - Assessments, Tests| Mind Garden-Mind Garden. https://www.mindgarden.com/117-maslach-burnout-inventory. Accessed July 6, 2018.
- 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: https://doi.org/10.1016/j.jbi.2008.08.010 CrossRefPubMedGoogle Scholar
- 31.Medicare C for, Baltimore MS 7500 SB, Usa M. program-guidance-and-specifications. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/program-guidance-and-specifications.html. Published August 24, 2017. Accessed October 4, 2017.
- 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