title: A randomized, controlled trial of implementing the patient-centered medical home model in solo and small practices.
abstract: BACKGROUND
  Transition to a Patient-Centered Medical Home (PCMH) is challenging in primary care, especially for smaller practices.
  
  
  OBJECTIVE
  To test the effectiveness of providing external supports, including practice redesign, care management and revised payment, compared to no support in transition to PCMH among solo and small (<2-10 providers) primary care practices over 2 years.
  
  
  METHODS
  Randomized Controlled Trial.
  
  
  METHODS
  Eighteen supported practices (intervention) and 14 control practices (controls).
  
  
  METHODS
  Intervention practices received 6 months of intensive, and 12 months of less intensive, practice redesign support; 2 years of revised payment, including cost of National Council for Quality Assurance's (NCQA) Physician Practice Connections(®)-Patient-Centered Medical Home™ (PPC(®)-PCMH™) submissions; and 18 months of care management support. Controls received yearly participation payments plus cost of PPC(®)-PCMH™.
  
  
  METHODS
  PPC(®)-PCMH™ at baseline and 18 months, plus intervention at 7 months.
  
  
  RESULTS
  At 18 months, 5 % of intervention practices and 79% of control practices were not recognized by NCQA; 10% of intervention practices and 7% of controls achieved PPC(®)-PCMH™ Level 1; 5% of intervention practices and 0% of controls achieved PPC(®)-PCMH™ Level 2; and 80% of intervention practices and 14% of controls achieved PPC(®)-PCMH™ Level 3. Intervention practices were 27 times more likely to improve PPC(®)-PCMH™ by one level, irrespective of practice size (p < 0.001) 95% CI (5-157). Among intervention practices, a multilevel ordinal piecewise model of change showed a significant and rapid 7-month effect (p(time7) = 0.01), which was twice as large as the sustained effect over subsequent 12 months (p(time18) = 0.02). Doubly multivariate analysis of variance showed significant differential change by condition across PPC(®)-PCMH™ standards over time (p(time x group)=0.03). Intervention practices improved eight of nine standards, controls improved three of nine (p(PPC1) = 0.009; p(PPC2) = 0.005; p(PPC3) = 0.007).
  
  
  CONCLUSIONS
  Irrespective of size, practices can make rapid and sustained transition to a PCMH when provided external supports, including practice redesign, care management and payment reform. Without such supports, change is slow and limited in scope.
authors.affiliation: University of Connecticut Health Center, Farmington, CT, USA. fifield@nso1.uchc.edu
authors.forename: Judith
authors.initials: J
authors.lastname: Fifield
authors.forename: Deborah Dauser
authors.initials: DD
authors.lastname: Forrest
authors.forename: Melanie
authors.initials: M
authors.lastname: Martin-Peele
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Burleson
authors.forename: Jeanette
authors.initials: J
authors.lastname: Goyzueta
authors.forename: Marco
authors.initials: M
authors.lastname: Fujimoto
authors.forename: William
authors.initials: W
authors.lastname: Gillespie
mesh_terms: D003695:Delivery of Health Care / Q000191:economics / Q000458:organization & administration; D018166:Health Care Reform / Q000458:organization & administration*; D006276:Health Facility Size; D006302:Health Services Research / Q000379:methods; D006801:Humans; D008137:Longitudinal Studies; D008611:Mentors; D009519:New York City; D009936:Organizational Innovation; D017063:Outcome Assessment, Health Care / Q000379:methods; D018802:Patient-Centered Care / Q000191:economics / Q000458:organization & administration*; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration*; D012051:Reimbursement Mechanisms / Q000458:organization & administration; D013997:Time Factors