RESUMEN
This study examined how aspects of quality improvement (QI) culture changed during the introduction of the Veterans Health Administration (VHA) patient-centered medical home initiative and how they were influenced by existing organizational factors, including VHA facility complexity and practice location. A voluntary survey, measuring primary care providers' (PCPs') perspectives on QI culture at their primary care clinics, was administered in 2010 and 2012. Participants were 320 PCPs from hospital- and community-based primary care practices in Pennsylvania, West Virginia, Delaware, New Jersey, New York, and Ohio. PCPs in community-based outpatient clinics reported an improvement in established processes for QI, and communication and cooperation from 2010 to 2012. However, their peers in hospital-based clinics did not report any significant improvements in QI culture. In both years, compared with high-complexity facilities, medium- and low-complexity facilities had better scores on the scales assessing established processes for QI, and communication and cooperation.
Asunto(s)
Cultura Organizacional , Percepción , Atención Primaria de Salud/organización & administración , Mejoramiento de la Calidad/organización & administración , United States Department of Veterans Affairs/organización & administración , Comunicación , Centros Comunitarios de Salud/organización & administración , Conducta Cooperativa , Liderazgo , Servicio Ambulatorio en Hospital/organización & administración , Atención Dirigida al Paciente/organización & administración , Admisión y Programación de Personal , Estados Unidos , United States Department of Veterans Affairs/normasRESUMEN
OBJECTIVE: To evaluate the effect of medical home implementation on primary care delivery in the Veterans Health Administration (VHA). DATA SOURCES/STUDY SETTING/STUDY DESIGN: We link interview-based qualitative data on medical home implementation to quantitative outcomes from VHA clinical encounter data. We use a longitudinal analysis with provider fixed effects (taking advantage of variation in timing of implementation and allowing each provider to serve as a control for him or herself) to test whether patient-aligned care team (PACT) implementation was associated with changes in organizational processes and patient outcomes. PRINCIPAL FINDINGS: Among 683 PCPs, caring for 321,295 patients, the uptake of eight of nine PACT structural changes significantly increased from July 2010 to June 2012 as did the percentage of primary care appointments occurring by telephone and hospital discharges contacted within 2 days of discharge. We found that PACT implementation was associated with significant improvements in 2-day post-hospital discharge contact, but not primary care visits occurring by telephone or within 3 days of the requested date. We found no association between medical home implementation and rates of emergency department use by patients. CONCLUSIONS: Medical home implementation at the VHA resulted in large changes in the structure of care but few changes in patient-level outcomes. These results highlight both the complexity of studying the effect of the medical home as well as implementing this model to change primary care delivery.