Journey to the patient-centered medical home: a qualitative analysis of the experiences of practices in the National Demonstration Project.
OBJECTIVE
We describe the experience of practices in transitioning toward patient-centered medical homes (PCMHs) in the National Demonstration Project (NDP).


METHODS
The NDP was launched in June 2006 as the first national test of a model of the PCMH in a diverse sample of 36 family practices, randomized to facilitated and self-directed intervention groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical records, and patient and practice surveys. The evaluation team reviewed data from all practices as they became available and produced interim summaries. Four 2- to 3-day evaluation team retreats were held during which case summaries of all practices were discussed and patterns were described.


RESULTS
The 6 themes that emerged from the data reflect major shifts in individual and practice roles and identities, as well as changes in practices' management strategies. The themes are (1) practice adaptive reserve is critical to managing change, (2) developmental pathways to success vary considerably by practice, (3) motivation of key practice members is critical, (4) the larger system can help or hinder, (5) practice transformation is more than a series of changes and requires shifts in roles and mental models, and (6) practice change is enabled by the multiple roles that facilitators play.


CONCLUSIONS
Transformation to a PCMH requires more than a sequence of discrete changes. The practice transformation process may be fostered by promoting adaptive reserve and local control of the developmental pathway.
Nutting
Paul A
PA
Center for Research Strategies, 225 East 16th Avenue, Denver, CO 80203, USA. Paul.Nutting@CRSLLC.org
Crabtree
Benjamin F
BF
Miller
William L
WL
Stewart
Elizabeth E
EE
Stange
Kurt C
KC
Jaén
Carlos Roberto
CR
D001291:Attitude of Health Personnel; D055317:Evidence-Based Practice; D005194:Family Practice / Q000379:methods / Q000458:organization & administration* / Q000639:trends; D006801:Humans; D017146:Models, Organizational; D009936:Organizational Innovation; D018802:Patient-Centered Care / Q000379:methods / Q000458:organization & administration* / Q000639:trends; D036301:Qualitative Research; D011785:Quality Assurance, Health Care / Q000379:methods / Q000458:organization & administration / Q000639:trends; D014481:United States