Effect of facilitation on practice outcomes in the National Demonstration Project model of the patient-centered medical home.
OBJECTIVE
The objective of this study was to elucidate the effect of facilitation on practice outcomes in the 2-year patient-centered medical home (PCMH) National Demonstration Project (NDP) intervention, and to describe practices' experience in implementing different components of the NDP model of the PCMH.


METHODS
Thirty-six family practices were randomized to a facilitated intervention group or a self-directed intervention group. We measured 3 practice-level outcomes: (1) the proportion of 39 components of the NDP model that practices implemented, (2) the aggregate patient rating of the practices' PCMH attributes, and (3) the practices' ability to make and sustain change, which we term adaptive reserve. We used a repeated-measures analysis of variance to test the intervention effects.


RESULTS
By the end of the 2 years of the NDP, practices in both facilitated and self-directed groups had at least 70% of the NDP model components in place. Implementation was relatively harder if the model component affected multiple roles and processes, required coordination across work units, necessitated additional resources and expertise, or challenged the traditional model of primary care. Electronic visits, group visits, team-based care, wellness promotion, and proactive population management presented the greatest challenges. Controlling for baseline differences and practice size, facilitated practices had greater increases in adaptive reserve (group difference by time, P = .005) and the proportion of NDP model components implemented (group difference by time, P=.02); the latter increased from 42% to 72% in the facilitated group and from 54% to 70% in the self-directed group. Patient ratings of the practices' PCMH attributes did not differ between groups and, in fact, diminished in both of them.


CONCLUSIONS
Highly motivated practices can implement many components of the PCMH in 2 years, but apparently at a cost of diminishing the patient's experience of care. Intense facilitation increases the number of components implemented and improves practices' adaptive reserve. Longer follow-up is needed to assess the sustained and evolving effects of moving independent practices toward PCMHs.
Nutting
Paul A
PA
Center for Research Strategies, 225 East 16th Avenue, Denver, CO 80203, USA. Paul.Nutting@CRSLLC.org
Crabtree
Benjamin F
BF
Stewart
Elizabeth E
EE
Miller
William L
WL
Palmer
Raymond F
RF
Stange
Kurt C
KC
Jaén
Carlos Roberto
CR
D055317:Evidence-Based Practice; D005194:Family Practice / Q000379:methods / Q000458:organization & administration* / Q000639:trends; D006801:Humans; D017146:Models, Organizational; D009936:Organizational Innovation; D017063:Outcome Assessment, Health Care; D017060:Patient Satisfaction; D018802:Patient-Centered Care / Q000379:methods / Q000458:organization & administration* / Q000639:trends; D016032:Randomized Controlled Trials as Topic; D014481:United States