Journal of General Internal Medicine

, Volume 35, Issue 1, pp 119–125 | Cite as

Association of the Implementation of the Patient-Centered Medical Home with Quality of Life in Patients with Multimorbidity

  • Linnaea SchuttnerEmail author
  • Ashok Reddy
  • Ann-Marie Rosland
  • Karin Nelson
  • Edwin S. Wong
Original Research



The patient-centered medical home (PCMH) has clinical benefits for chronic disease care, but the association with patient-reported outcomes such as health-related quality of life (HRQoL) is unexplored in patients with multimorbidity (two or more chronic diseases).


To examine if greater clinic-level PCMH implementation was associated with higher HRQoL in multimorbid adults.


A retrospective cohort study.


Twenty-two thousand ninety-five multimorbid patients who received primary care at 944 Veterans Health Administration (VHA) clinics.

Main Measures

Our exposure was the Patient Aligned Care Team Implementation Progress Index (PI2) for the clinic in 2012, a previously validated composite measure of PCMH implementation. Higher PI2 scores indicate better performance within eight PCMH domains. Outcomes were patient-reported HRQoL measured by the physical and mental component scores (PCS and MCS) from the Short Form-12 patient experiences survey in 2013–2014. Interaction of the outcomes with total hospitalizations and primary care visit count was also examined. Generalized estimating equations were used for main models after adjusting for patient and clinic characteristics.


The cohort average age was 68 years, mostly male (96%), and had an average of 4.4 chronic diagnoses. Compared with patients seen at the lowest scoring clinics for PCMH implementation, care in the highest scoring clinics was associated with a higher adjusted marginal mean PCS (42.3 (95% CI 41.3–43.4) versus 40.3 (95% CI 39.1–41.5), P = 0.01), but a lower MCS (35.2 (95% CI 34.4–36.1) versus 36.0 (95% CI 35.3–36.8), P = 0.17). Patients with prior hospitalizations seen in clinics with higher compared with lower PI2 scores had a 2.7 point greater MCS (95% CI 0.6–4.8; P = 0.01).


Multimorbid patients seen in clinics with greater PCMH implementation reported higher physical HRQoL, but lower mental HRQoL. The association between PCMH implementation and mental HRQoL may depend on complex interactions with disease severity and prior hospitalizations.


vulnerable populations quality of life primary care patient-centered outcomes research comorbidity 



Our thanks to the Office of Reporting, Analytics, Performance, Improvement, and Deployment (RAPID) within the Veterans Health Administration for the access to the SHEP data. Additional thanks to Evelyn Chang, Matt Maciejewski, Lisa Rubenstein, Donna Zulman, Paul Hebert, and members of the VHA Primary Care Analytics Team and High-Risk Investigator Network for the insights and comments on the manuscript. Leslie Taylor and Philip Sylling provided invaluable statistical and coding assistance. This work was undertaken as part of the national evaluation of PACT funded by the VHA Office of Primary Care. Support for the primary author was from a VHA HSR&D Advanced Physician Fellowship. ES Wong was supported by a VHA HSR&D Career Development Award (No. 13-024).

Compliance with Ethical Standards

Conflict of Interest

The authors have no additional conflicts of interest, financial or otherwise, to disclose.


Funding agencies had no role in the study’s design, conduct, or reporting. The views expressed are those of the authors and do not necessarily reflect the position of the affiliated institutions.

Supplementary material

11606_2019_5429_MOESM1_ESM.docx (20 kb)
ESM 1 (DOCX 20 kb)


  1. 1.
    Cassell A, Edwards D, Harshfield A, et al. The epidemiology of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pr 2018;68(669):e245-e251. CrossRefGoogle Scholar
  2. 2.
    Nunes BP, Flores TR, Mielke GI, Thumé E, Facchini LA. Multimorbidity and mortality in older adults: a systematic review and meta-analysis. Arch Gerontol Geriatr 2016;67:130-138. CrossRefPubMedGoogle Scholar
  3. 3.
    Zulman DM, Chee CP, Wagner TH, et al. Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System. BMJ Open 2015;5(4):e007771. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37-43. CrossRefPubMedGoogle Scholar
  5. 5.
    Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract 1998;1(1):2-4.PubMedGoogle Scholar
  6. 6.
    Rosland A-M, Wong E, Maciejewski M, et al. Patient-centered medical home implementation and improved chronic disease quality: a longitudinal observational study. Health Serv Res 2018;53(4):2503-2522. CrossRefPubMedGoogle Scholar
  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;174(8):1350. CrossRefPubMedGoogle Scholar
  8. 8.
    Nelson K, Sylling PW, Taylor L, Rose D, Mori A, Fihn SD. Clinical quality and the patient-centered medical home. JAMA Intern Med 2017;177(7):1042. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Zullig LL, Whitson HE, Hastings SN, et al. A systematic review of conceptual frameworks of medical complexity and new model development. J Gen Intern Med 2016;31(3):329-337. CrossRefPubMedGoogle Scholar
  10. 10.
    Kastner M, Hayden L, Wong G, et al. Underlying mechanisms of complex interventions addressing the care of older adults with multimorbidity: a realist review. BMJ Open. 2019;9(4):e025009. CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Wagner EH. The role of patient care teams in chronic disease management. BMJ. 2000;320(7234):569-572.CrossRefGoogle Scholar
  12. 12.
    Chi WC, Wolff J, Greer R, Dy S. Multimorbidity and decision-making preferences among older adults. Ann Fam Med 2017;15(6):546-551. CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Tinetti ME, Fried TR, Boyd CM. Designing health care for the most common chronic condition—multimorbidity. JAMA. 2012;307(23):2493-2494. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    U.S. Department of Health & Human Services. Health-related quality of life & well-being. Heal 2020 Top Object. Accessed 27 August 2019.
  15. 15.
    Smith SM, Wallace E, Salisbury C, Sasseville M, Bayliss E, Fortin M. A core outcome set for multimorbidity research (COSmm). Ann Fam Med 2018;16(2):132-138. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Maly RC, Liu Y, Liang L-J, Ganz PA. Quality of life over 5 years after a breast cancer diagnosis among low-income women: effects of race/ethnicity and patient-physician communication. Cancer. 2015;121(6):916-926. CrossRefPubMedGoogle Scholar
  17. 17.
    Jonkman NH, Schuurmans MJ, Groenwold RHH, Hoes AW, Trappenburg JCA. Identifying components of self-management interventions that improve health-related quality of life in chronically ill patients: Systematic review and meta-regression analysis. Patient Educ Couns 2016;99(7):1087-1098. CrossRefPubMedGoogle Scholar
  18. 18.
    Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010;363(27):2611-2620. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Wong ES, Rosland A-M, Fihn SD, Nelson KM. Patient-centered medical home implementation in the Veterans Health Administration and primary care use: differences by patient comorbidity burden. J Gen Intern Med 2016;31(12):1467-1474. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    U.S. Department of Veterans Affairs. Health benefits: family members of Veterans. Accessed 27 August 2019.
  21. 21.
    Fortin M, Stewart M, Poitras M-E, Almirall J, Maddocks H. A systematic review of prevalence studies on multimorbidity: toward a more uniform methodology. Ann Fam Med 2012;10(2):142-151. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    HCUP-US Tools & Software Page. Accessed 27 August 2019.
  23. 23.
    Wright SM, Craig T, Campbell S, Schaefer J, Humble C. Patient satisfaction of female and male users of Veterans Health Administration services. J Gen Intern Med 2006;21(Suppl 3):S26-S32. CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Kazis LE, Miller DR, Skinner KM, et al. Applications of methodologies of the Veterans Health Study in the VA healthcare system: conclusions and summary. J Ambul Care Manage 2006;29(2):182-188.CrossRefGoogle Scholar
  25. 25.
    Hays RD, Morales LS. The RAND-36 measure of health-related quality of life. Ann Med 2001;33(5):350-357. CrossRefPubMedGoogle Scholar
  26. 26.
    Ware JE, Kosinski M, Keller SD. A 12-Item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996;34(3):220.CrossRefGoogle Scholar
  27. 27.
    Samsa G, Edelman D, Rothman ML, Williams GR, Lipscomb J, Matchar D. Determining clinically important differences in health status measures: a general approach with illustration to the Health Utilities Index Mark II. PharmacoEconomics. 1999;15(2):141-155. CrossRefPubMedGoogle Scholar
  28. 28.
    Spiro A, Rogers W, Qian S, Kazis L. Imputing Physical and Mental Summary Scores (PCS and MCS) for the Veterans SF-12 Health Survey in the Context of Missing Data. Boston, MA; Bedford, MA: Health Services Department, Boston University School of Public Health; Center for Health Quality, Outcomes and Economic Research, Veterans Affairs Medical Center; 2004:62.Google Scholar
  29. 29.
    U.S. Department of Veterans Affairs. 172VA10P2: VHA Corporate Data Warehouse – VA. 79 FR 4377. September 2014.Google Scholar
  30. 30.
    Heinze G, Wallisch C, Dunkler D. Variable selection - a review and recommendations for the practicing statistician. Biom J 2018;60(3):431-449. CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Fihn SD, Francis J, Clancy C, et al. Insights from advanced analytics at the Veterans Health Administration. Health Aff (Millwood) 2014;33(7):1203-1211. CrossRefGoogle Scholar
  32. 32.
    Payne RA, Abel GA, Guthrie B, Mercer SW. The effect of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study. Can Med Assoc J 2013;185(5):E221-E228. CrossRefGoogle Scholar
  33. 33.
    Counsell SR, Callahan CM, Clark DO, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623. CrossRefPubMedGoogle Scholar
  34. 34.
    Stock R, Mahoney ER, Reece D, Cesario L. Developing a senior healthcare practice using the chronic care model: effect on physical function and health-related quality of life. J Am Geriatr Soc 2008;56(7):1342-1348. CrossRefPubMedGoogle Scholar
  35. 35.
    Stevens GD, Shi L, Vane C, Nie X, Peters AL. Primary care medical home experience and health-related quality of life among adult Medicaid patients with type 2 diabetes. J Gen Intern Med 2015;30(2):161-168. CrossRefPubMedGoogle Scholar
  36. 36.
    Freund T, Peters-Klimm F, Boyd CM, et al. Medical assistant-based care management for high-risk patients in small primary care practices: a cluster randomized clinical trial. Ann Intern Med 2016;164(5):323-330. CrossRefPubMedGoogle Scholar
  37. 37.
    Wilson SR, Strub P, Buist AS, et al. Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med 2010;181(6):566-577. CrossRefPubMedGoogle Scholar
  38. 38.
    Coulter A, Entwistle VA, Eccles A, Ryan S, Shepperd S, Perera R. Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database Syst Rev. 2015;(3):CD010523. CrossRefGoogle Scholar
  39. 39.
    Weeger S, Farin E. The effect of the patient–physician relationship on health-related quality of life after cardiac rehabilitation. Disabil Rehabil 2017;39(5):468-476. CrossRefPubMedGoogle Scholar
  40. 40.
    Reddy A, Pollack CE, Asch DA, Canamucio A, Werner RM. The effect of primary care provider turnover on patient experience of care and ambulatory quality of care. JAMA Intern Med 2015;175(7):1157-1162. CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Lauffenburger JC, Shrank WH, Bitton A, et al. Association between patient-centered medical homes and adherence to chronic disease medications: a cohort study. Ann Intern Med 2017;166(2):81-88. CrossRefPubMedGoogle Scholar
  42. 42.
    Slazak EM, Kozakiewicz JT, Winters NS, Smith JR, Monte SV. Statin adherence rates in patients utilizing a patient-centered medical home-based pharmacy. J Pharm Pract 2017;30(5):516-520. CrossRefPubMedGoogle Scholar
  43. 43.
    Lindenauer PK, Lagu T, Shieh M-S, Pekow PS, Rothberg MB. Association of diagnostic coding with trends in hospitalizations and mortality of patients with pneumonia, 2003-2009. JAMA. 2012;307(13):1405-1413. CrossRefPubMedGoogle Scholar
  44. 44.
    Mielck A, Vogelmann M, Leidl R. Health-related quality of life and socioeconomic status: inequalities among adults with a chronic disease. Health Qual Life Outcomes 2014;12:58. CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Jones AL, Mor MK, Cashy JP, et al. Racial/ethnic differences in primary care experiences in patient-centered medical homes among Veterans with mental health and substance use disorders. J Gen Intern Med 2016;31(12):1435-1443. CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    HIPxChange. Area Deprivation Index. Accessed 27 August 2019.
  47. 47.
    Fleishman JA, Selim AJ, Kazis LE. Deriving SF-12v2 physical and mental health summary scores: a comparison of different scoring algorithms. Qual Life Res 2010;19(2):231-241. CrossRefPubMedGoogle Scholar
  48. 48.
    U.S. Department of Veterans Affairs. Department of Veterans Affairs FY 2018-2024 strategic plan. Accessed 27 August 2019.

Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  • Linnaea Schuttner
    • 1
    • 2
    Email author
  • Ashok Reddy
    • 1
    • 2
  • Ann-Marie Rosland
    • 3
    • 4
  • Karin Nelson
    • 1
    • 2
  • Edwin S. Wong
    • 1
    • 5
  1. 1.Health Services Research & DevelopmentVA Puget Sound Health Care SystemSeattleUSA
  2. 2.Department of MedicineUniversity of WashingtonSeattleUSA
  3. 3.VA Center for Health Equity Research and PromotionVA Pittsburgh Healthcare SystemPittsburghUSA
  4. 4.Department of Internal MedicineUniversity of Pittsburgh School of MedicinePittsburghUSA
  5. 5.Department of Health ServicesUniversity of Washington School of Public HealthSeattleUSA

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