title: Contrasting trajectories of change in primary care clinics: lessons from New Orleans safety net.
abstract: OBJECTIVE
  We sought to compare and contrast patterns of change toward patient-centered medical homes (PCMHs) in 5 New Orleans primary care safety net clinics in the aftermath of Hurricane Katrina. We assessed the general direction of change in practice to discover possible reasons for differences in patterns of change, and to identify impediments to change.
  
  
  METHODS
  Data collection consisted of 5 semiannual telephone interviews with clinic leadership over 2.5 years supplemented by administrative audits. We used standard survey indexes of PCMH to monitor practice change. We conducted site visits and unstructured in-person interviews with clinicians and staff of the 5 clinics.
  
  
  RESULTS
  PCMH index scores improved during the observation period with variations in rates of change and initial levels of PCMH. Qualitative analysis suggested possible explanations for this differential success: (1) early vs later starts in practice change, (2) funding based on patient outcomes, (3) demands that compete with practice change, (4) qualities of clinic leadership, and (5) relations with the communities where patients live. Barriers to practice change included high demand for services, deficient linkages between hospital and specialty care, lack of staff resources, and a need to focus on clinic finances.
  
  
  CONCLUSIONS
  The PCMH model can successfully address the needs of safety net populations. Stable leadership committed to serving safety net patients via the PCMH model is important for successful practice transformation. Beyond clinic walls, cultivating deep ties to the communities that clinics serve also supports the PCMH model.
authors.affiliation: Department of Family and Community Medicine, Philip R. Lee Institute for Health, Policy Studies, University of California, San Francisco, San Francisco, California 94143, USA. rittenhouse@fcm.ucsf.edu
authors.forename: Diane R
authors.initials: DR
authors.lastname: Rittenhouse
authors.forename: Laura
authors.initials: L
authors.lastname: Schmidt
authors.forename: Kevin
authors.initials: K
authors.lastname: Wu
authors.forename: James
authors.initials: J
authors.lastname: Wiley
mesh_terms: D019058:Community Networks / Q000458:organization & administration*; D055867:Cyclonic Storms; D003695:Delivery of Health Care / Q000458:organization & administration*; D018166:Health Care Reform; D006297:Health Services Accessibility; D006801:Humans; D008484:Medicaid; D017057:Medically Uninsured; D055820:New Orleans; D009936:Organizational Innovation; D018802:Patient-Centered Care / Q000458:organization & administration*; D020399:Practice Management / Q000458:organization & administration; D011320:Primary Health Care / Q000458:organization & administration*; D011787:Quality of Health Care; D014481:United States
keywords: organizational change; patient-centered medical home; practice-based research; primary care; safety nets; vulnerable populations