The document summarizes findings from a study evaluating the impact of the Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI) on clinical quality measures at the midpoint of the initiative. The study found that three measures showed statistically significant improvement from baseline to 21 months: screening diabetic patients for depression, developing asthma action plans for children with persistent asthma, and developing care plans for highest risk patients. While other measures trended toward improvement or no change, the results indicate that primary care practice transformation takes time but processes of care are more likely to improve before outcomes. The initiative provides an example of using clinical quality measures to evaluate the impact of implementing patient-centered medical home processes and improving patient care.

1. Massachusetts Patient-Centered Medical
Home Initiative: Impact on Clinical
Quality at Midpoint
Judith Steinberg, MD, MPH
Sai Cherala, MD, MPH
Christine Johnson, PhD
Ann Lawthers, SM, ScD
Commonwealth Medicine
UMass Medical School

2. Background: Massachusetts Patient-Centered
Medical Home Initiative (MA PCMHI)
 Multi-payer, statewide initiative, sponsored by MA
Health & Human Services
 45 Participating Practices
• 35 adult practices
• 7 pediatric practices
• 3 adult and pediatric practices
 3-Year Demonstration; Start: March 29, 2011
 Vision: All MA primary care practices will be
PCMHs by 2015

3. MA PCMHI Interventions
Technical Assistance
 Three‐year Learning Collaborative
• Periodic Learning Sessions
• Monthly conference calls or webinars
• Online courses
• Monthly submission and review of
practice‐level performance data
• Support for obtaining NCQA PCMH
recognition
 Practice Facilitation

4. MA PCMHI Interventions
Financial Incentives
 31/45 practices receive incentive payments
 Incentives:
• Start-up funding, 2 prospective payment
streams, shared savings

5. Massachusetts Patient Centered
Medical Home Initiative
Inputs
Outputs
Activities Results
(1 – 2 years)
Outcomes – Impact
Short Term Long Term
(1-2 years) (3-5 years)
*Fewer ED visits
*Fewer
Hospitalizations
*Improved chronic
disease management
*Improved acute
problem management
*Improved delivery of
preventive care
*Better patient
experience
*Better practice
experience
*Slowed growth of
cost
Stakeholder Groups
· Massachusetts
Patient-Centered
Medical Home
Initiative Council
(includes multiple
stakeholders)
· EOHHS
· Residents of the
Commonwealth
of Massachusetts
Payment Reform
EVALUATION
Situation
Fragmented,
discontinuous
care that harms
patient health
status and
increases costs
Increased
prevalence
of chronic disease,
and suboptimal
management of
chronic disease
Shortage of PCPs
Priorities
Implement and
evaluate the PCMH
model as a means to
achieve accessible,
high quality primary
care
Demonstrate cost-
effectiveness to justify
and support the
sustainability and
spread of the model
Attract and retain
primary care
clinicians in
Massachusetts
Assumptions
Transformation of primary care practices will change patient
behavior (how they access care & manage their own health).
External Factors
Working relationships across state agencies.
Available resources
*Sustained reduction
in cost growth
*Improved primary
care provider
retention
Practices have
Core
Competencies in:
· Consumer
engagement
· Practice
redesign
· Clinical care
management
and
coordination
Key Activities
External to
Practice
· Learning
Collaboratives
· Practice
coaching
· Feedback of
data
Within the Practice
· Team
meetings
· Care Manager
· Registry with
reporting
capability
· Linkages to
medical
neighborhood
Payers
Providers
Patients
January 2010MA PCMHI Logic Model

6. Aim And Study Design
 Aim: To assess data trends of 12 clinical quality
measures from participating practices for first 21
months of the initiative
 Design: Quality improvement study using self-
reported monthly clinical quality measures data from
all PCMHI practices from June 2011 through February
2013

7. Clinical Quality Measures
Adult Diabetes
 HbA1c Control (<8%)
 HbA1c Control (>9%)
 BP < 140/90 mmHg
 LDL Control < 100mg/dL
 Screened for Depression
Adult Prevention
 Adult Weight Screening and
Follow-Up
 Tobacco Use Assessment
 Tobacco Cessation
Intervention
Pediatric Asthma
 Use of Appropriate Medications
for Asthma
 Persistent Asthma Patients with
Action Plan
Care Coordination/ Care
Management
 Follow-up after Hospital
Discharge
 Highest Risk Patients with Care
Plan

8.  Methods
• Linear Mixed Model
 Analysis
• Data were divided into three-month periods:
• Time 1 (2011-June, July and August)….. to Time 7 (
2012-December, 2013- January and February)
• Analysis of Change over Time: Baseline (Time 1
or Time 2) vs. Time 7
Methods And Analysis

9. Results: Study Participants
Practice Characteristics Percentage
Geography
Rural (<10,000 town population) 9%
Suburban (Between 10,000 and 50,000) 20%
Urban (>= 50,000) 71%
Practice Size (Based on Number of Full Time Practitioners)
Small (< 6 FTE practitioners) 31%
Medium (Between 6 and 11 FTE practitioners) 29%
Large (> 11 FTE practitioners) 40%
Type of Practice
Community Health Center 56%
Residency or Academic Practice 11%
Group Practice 29%
Solo Practice 4%
Payer Mix (Practices with Financial Incentives N=31)
Commercial 12%
Health Safety Net 15%
Medicaid 72%
Medicare 1%

10. Results
 3 measures showed statistically significant
improvement from Baseline to Time 7:
• Diabetic patients screened for depression
(25.8% to 42.4%, p=0.0009)
• Action plan for children diagnosed with
persistent asthma (19.6% to 50.7%, p=0.0076)
• Highest risk patients with care plan (36.5% to
54.2%, p=0.0147)
 All other measures showed a non-significant
trend towards improvement or no change

11. Adult Diabetes Measures: Change over Time
* Values met the study’s definition of statistical significance p<.05.
71.3
16.2
61.7
47.7
25.8
68.7
15.2
61.6
45.8
42.4*
0
10
20
30
40
50
60
70
80
BP < 140/90 mmHg HbA1c > 9% HbA1c < 8% LDL Control <
100mg/dL
Screened for
Depression
Percent
Measure
Baseline
Time 7

12. Adult Prevention Measures: Change over Time
* Values met the study’s definition of statistical significance p<.05.
35.1
80.9
45.1
39.2
86.3
50.1
0
10
20
30
40
50
60
70
80
90
100
Adult Weight Screening and
Follow-Up
Tobacco Use Assessment Tobacco Cessation
Intervention
Percent
Measure
Baseline
Time 7

13. Pediatric Asthma Measures: Change over Time
* Values met the study’s definition of statistical significance p<.05.
76.1
19.6
77.6
50.7*
0
10
20
30
40
50
60
70
80
90
Use of Appropriate Medications for Asthma Persistent Asthma Patients With Action Plan
Percent
Measure
Baseline
Time 7

14. Care Coordination/Care Management
Measures: Change over Time
* Values met the study’s definition of statistical significance p<.05.
66.9
36.5
70.6
54.2*
0
10
20
30
40
50
60
70
80
Hospital discharge Management of Highest-Risk Patient:
Developing Care Plan
Percent
Measure
Baseline
Time 7

15.  In the first 21 months of the MA PCMHI,
participating practices have significantly improved:
• Diabetes care delivery by more consistently
screening patients for depression
• Pediatric asthma care by more consistently
developing action plans for patients with
persistent asthma
• Care management by more consistently
developing care plans for highest risk patients
Discussion I

16. Discussion II
 Factors which may impact improvement rates:
• Payer mix
• Practice size
• Financial incentives/resources
• Practice leadership engagement
• HIT functionality and use
• Practice “adaptive reserve”
 Next steps:
• Analyze effect of factors on practice performance
• Use results in sharing best practices and addressing
barriers to change

17. Limitations
 Quality Improvement study
• Small sample size
• Short follow-up period
• No comparison group

18. Conclusion and Implications for Policy
and Practice
 Primary care practice transformation takes time
 Processes of care are more likely to improve
before outcomes are impacted
 Use of a clinical quality measures set is important
for:
• Developing practices’ skillset in QI, a PCMH
component
• Evaluating the impact of implementing PCMH
processes on patient care and outcomes

19. Acknowledgements
We would like to acknowledge the MA Executive Office of Health and Human
Services (EOHHS), the MA PCMHI Leadership and Medical Home Facilitator
Teams, as well as MA PCMHI participating practices without whom this work
would not be possible.
Contact Information:
Judith Steinberg, MD, MPH
Deputy Chief Medical Officer
Commonwealth Medicine, UMass Medical School
Judith.Steinberg@umassmed.edu