Title: Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI): Impact on Clinical Quality at 30 Months

1. Massachusetts Patient-Centered
Medical Home Initiative (MA PCMHI):
Impact on Clinical Quality at 30 Months
Judith Steinberg, M.D., M.P.H.
Sai Cherala, M.D., M.P.H.
Ann Lawthers, S.M., Sc.D.
Christine Johnson, Ph.D.
Commonwealth Medicine
UMass Medical School

2. Introduction
 The Patient‐Centered Medical Home (PCMH) offers an
innovative model of care: comprehensive primary care, quality
improvement, care management, and enhanced access in a
patient centered environment
 PCMH evaluations have shown variable impact
Aims:
 To assess data trends of clinical quality measures from
participating practices in the Massachusetts Patient-Centered
Medical Home Initiative
 To evaluate practice and staff level factors that may impact
clinical quality performance

3. Background: Massachusetts Patient
Centered Medical Home Initiative
 Multi-payer, statewide initiative
 Sponsored by Massachusetts Health & Human Services;
legislatively mandated
 46 participating practices
 3-year demonstration: March, 2011 − March, 2014
 Includes payment reform and technical assistance

4. MA PCMHI Evaluation Questions
Question 1:
To what extent and how do practices
become medical homes?
• Extent
• Patient-family centeredness
• Care management
• Care coordination
• Access
• Teamwork
• Information technology
• Leadership
• Barriers and Facilitators
Question 2:
To what extent do
patients become
partners in their health
care?
•Perceived self-
management efficacy
•Patient-family
centeredness by chronic
and non-chronic
Question 3:
What is the initiative’s
impact on utilization, cost,
clinical quality, patient and
provider outcomes?
•Emergency Department
use
•Hospitalizations
•Cost
•Clinical quality measures
•Staff satisfaction
•Patient satisfaction

5. Methods
 Design: Quality improvement study using practices’
self-reported monthly data on 22 clinical quality
measures from June 2011 through February 2014
 Methods
 Linear Mixed Model
 Analysis
 Data were divided into three-month periods:
 Time 1 (June – August, 2011) ... to
Time 11 (December, 2013 – February, 2014)
 Analysis of Change over Time: Baseline (Time 1 or Time
2 or Time 6) vs. Time 11

6. Clinical Quality Measures
Adult Diabetes
 HbgA1c Control (<8%)
 HbgA1c Control (>9%)
 BP < 140/90 mmHg
 LDL Control < 100mg/dL
 Screened for Depression
 Self-Management Goal
Adult Prevention
 Adult Weight Screening and
Follow-up
 Tobacco Use Assessment
 Tobacco Cessation Intervention
Other Adult Target
 Blood Pressure Control
 Hypertension with Documented
Self-Management Goal
 Depression with Documented
PHQ-9 Score
 Depression with Documented Self-
Management Goal
Childhood Prevention
 Immunization Status Multiple
vaccines
 Weight Assessment and Counseling
for Children and Adolescents
Pediatric Asthma
 Use of Appropriate Medications for
Asthma
 Persistent Asthma Patients with
Action Plan
Other Pediatric Target
 Follow-up Care for Children
Prescribed ADHD Medication
 Management Plan for Children
Prescribed ADHD Medication
Care Coordination/ Care Management
 Follow-up after Hospital Discharge
 Highest Risk Patients with Care Plan

7. 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%

8. Clinical Quality Measures that Showed Significant
Improvement in Change over Time
25.2 23.8
37.1
82.4
46.5
16.7 17.3
11.5
18.6
46.4
22.3
36.1
48.7
32.0
47.6
90.5
51.3
25.3
21.4
19.3
62.7 63.1
61.2
64.7
0
10
20
30
40
50
60
70
80
90
100
Screened for
Depression
Self-
Management
Goal
Adult Weight
Screening &
Follow-Up
Tobacco Use
Assessment
Tobacco
Cessation
Intervention
Hypertension
Self-
Management
Goal
Depression
PHQ-9 Score
Depression
Self-
Management
Goal
Patients With
Action Plan
Immunization
Status
Multiple
Vaccines 1
Immunization
Status
Multiple
Vaccines 2
Care Plans for
Highest Risk
Patients
Percent
Baseline Time 11
11 of 22 measures showed statistically significant improvement
Adult Diabetes Adult Prevention Other Adult Measures Pediatric
Asthma
Childhood
Prevention
Care
Management

9. Values met the study’s definition of statistical significance p<.05.
Care Coordination/Care Management Measures:
Change over Time
63.3
36.1
66.5 64.7
0
10
20
30
40
50
60
70
Follow-Up After Hospital Discharge Care Plans for Highest Risk Patients
AverageRate
Measures
Baseline Time 11

10. Drilling Deeper on Change:
Methods
 Correlation analysis
 Variables included: Performance on clinical measures
in the last three months, change in clinical
performance over the demonstration, practice
characteristics and staff perceptions/attitudes
towards the change
 Data sources: Clinical data submission, Medical Home
Implementation Quotient (MHIQ), staff survey

11. Results of Correlation Analysis:
Care Plan for Highest Risk Patients
Change over Three Years Performance in Last Three
Months
Leadership at Baseline
(staff survey) (r=0.42, p=0.01)
Leadership at Baseline
(staff survey) (r=0.45, p=0.009)
Strong team
(staff survey) (r=0.41, p=0.01)
Quality improvement culture
at Baseline
(staff survey) (r=0.39, p=0.02)
Quality improvement culture
at Baseline
(staff survey) (r=0.36, p=0.04)
Strong team
(staff survey) (r=0.32, p=0.05)

12. Processes and Practices Characteristics
Associated with Clinical Outcomes
HbA1c < 8% BP <140/90mm of Hg
Comfort with HIT
(staff survey) (r=0.61, p <0.0001)
Improved care planning for
high risk patients
(MHIQ) (r=0.50, p=0.005)
QI culture
(staff survey) (r=0.51, p <0012)
Strong leadership at baseline
(staff survey) (r=0.44, p=0.009)
Strong teamwork
(staff survey) (0.50, p=0.002)
Strong teamwork
(staff survey) (r=0.41, p=0.01)
Leadership
(staff survey) (r=0.48, p=0.002)
QI culture
(staff survey) (r=0.38, p=0.02)

13.  Quality Improvement Study
 No Comparison Group
 Small Sample Size
 Correlation Analysis
Limitations

14.  At the close of the MA PCMHI initiative (3 years),
11 of 22 clinical measures showed statistically significant
improvement
 Measures that showed significant improvement:
 Process measures
 New or newly documented processes
 A solid practice QI culture, leadership and strong team
functioning were positively correlated with performance
and improvement in high risk care planning
 Factors that correlated with performance on clinical
outcome measures were: QI culture, strong leadership and
teamwork, comfort with HIT
Summary

15. Conclusion and Implications for
Policy and Practice
 Quality of care in the management of chronic diseases,
prevention and screening, and high risk care
management was significantly improved in this PCMH
demonstration that had a preponderance of safety net
practices
 Implementation of foundational elements of the PCMH
− QI, leadership engagement, teamwork and HIT − may
foster improvement in clinical quality
 Understanding factors that are correlated with clinical
performance can focus transformation efforts

16. Acknowledgments
We would like to acknowledge the Massachusetts 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, M.D., M.P.H.
Deputy Chief Medical Officer
Commonwealth Medicine
UMass Medical School
Judith.Steinberg@umassmed.edu
Sai Cherala, M.D., M.P.H.
Senior Clinical Analyst
Commonwealth Medicine
UMass Medical School
Sai.Cherala@umassmed.edu