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The Patient Centered Medical Home: Mental Models and Practice Culture Driving the Transformation Process

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ABSTRACT

BACKGROUND

The Patient-Centered Medical Home (PCMH) has become a dominant model of primary care re-design. The PCMH model is a departure from more traditional models of healthcare delivery and requires significant transformation to be realized.

OBJECTIVE

To describe factors shaping mental models and practice culture driving the PCMH transformation process in a large multi-payer PCMH demonstration project.

DESIGN

Individual interviews were conducted at 17 primary care practices in South Eastern Pennsylvania.

PARTICIPANTS

A total of 118 individual interviews were conducted with clinicians (N = 47), patient educators (N = 4), office administrators (N = 12), medical assistants (N = 26), front office staff (N = 7), nurses (N = 4), care managers (N = 11), social workers (N = 4), and other stakeholders (N = 3). A multi-disciplinary research team used a grounded theory approach to develop the key constructs describing factors shaping successful practice transformation.

KEY RESULTS

Three central themes emerged from the data related to changes in practice culture and mental models necessary for PCMH practice transformation: 1) shifting practice perspectives towards proactive, population-oriented care based in practice–patient partnerships; 2) creating a culture of self-examination; and 3) challenges to developing new roles within the practice through distribution of responsibilities and team-based care. The most tension in shifting the required mental models was displayed between clinician and medical assistant participants, revealing significant barriers towards moving away from clinician-centric care.

CONCLUSIONS

Key factors driving the PCMH transformation process require shifting mental models at the individual level and culture change at the practice level. Transformation is based upon structural and process changes that support orientation of practice mental models towards perceptions of population health, self-assessment, and the development of shared decision-making. Staff buy-in to the new roles and responsibilities driving PCMH transformation was described as central to making sustainable change at the practice level; however, key barriers related to clinician autonomy appeared to interfere with the formation of team-based care.

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Acknowledgements

The authors wish to thank Katherine Kellom and Shimrit Keddem from the University of Pennsylvania’s Department of Family Medicine and Community Health’s Mixed Methods Research Lab (http://www.med.upenn.edu/mmrl/), Patricia L. Bricker from the Penn State Hershey Diabetes Institute, and Dana Naughton Pennsylvania State University, Department of Communication Arts and Sciences for their contributions to program coordination, data collection and data management.

Funders

This project was supported by a grant from the Agency for Healthcare Research and Quality (5R18HS019150) and funds from Aetna Foundation.

Prior Presentations

These data were submitted for as an abstract for presentation at the 2012 North American Primary Care Research Group (NAPCRG). The submission is pending review.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Author information

Authors and Affiliations

  1. Department of Family Medicine and Community Health, The University of Pennsylvania, 141 Anatomy & Chemistry Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA

    Peter F. Cronholm MD, MSCE, FAAFP

  2. Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA, USA

    Peter F. Cronholm MD, MSCE, FAAFP

  3. Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA

    Peter F. Cronholm MD, MSCE, FAAFP

  4. Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Judy A. Shea PhD & Rachel M. Werner MD, PhD

  5. Philadelphia VA Medical Center, Philadelphia, PA, USA

    Rachel M. Werner MD, PhD

  6. Department of Communication Studies, Chapman University, Orange, CA, USA

    Michelle Miller-Day PhD

  7. Department of Biomedical Informatics & Medical Education, University of Washington School of Medicine, Seattle, WA, USA

    Jim Tufano PhD, MHA

  8. Department of Family Medicine and Community Health, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ, USA

    Benjamin F. Crabtree PhD

  9. Penn State Hershey Diabetes Institute, Penn State College of Medicine, Diabetes Program, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA

    Robert Gabbay MD, PhD

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  1. Peter F. Cronholm MD, MSCE, FAAFP
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  2. Judy A. Shea PhD
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Correspondence to Peter F. Cronholm MD, MSCE, FAAFP.

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Cronholm, P.F., Shea, J.A., Werner, R.M. et al. The Patient Centered Medical Home: Mental Models and Practice Culture Driving the Transformation Process. J GEN INTERN MED 28, 1195–1201 (2013). https://doi.org/10.1007/s11606-013-2415-3

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  • DOI: https://doi.org/10.1007/s11606-013-2415-3

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