Challenges facing primary care practices aiming to implement patient-centered medical homes.
BACKGROUND
While the potential of patient-centered medical homes (PCMH) is promising, little is known empirically about the frontline challenges that primary care (PC) leaders face before making the decision to implement PCMH, let alone in making it a reality.


OBJECTIVE
Prior to the design and implementation of the Veterans Health Administration's (VA) national PCMH model--Patient Aligned Care Teams (PACT)--we identified the top challenges faced by PC directors and examined the organizational and area level factors that influenced those challenges.


METHODS
A national cross-sectional key informant organizational survey was fielded to the census of PC directors at VA medical centers and large community-based outpatient clinics (final sample n = 229 sites).


METHODS
PC directors were asked to rate the degree to which they faced 48 management challenges in eight PCMH-related domains (access, preventive care, chronic diseases requiring care in PC, challenging medical conditions, mental health/substance abuse, special populations, PC coordination of care, and clinical informatics). Responses were dichotomized as moderately-to-extremely challenging versus somewhat-slightly-not at all challenging. Items were rank ordered; chi square or regression techniques were used to examine variations in facility size, type, urban/rural location, and region.


RESULTS
On average, VA PC directors reported 16 moderate-to-extreme challenges, and the top 20 challenges spanned all eight PCMH domains. Four of the top 20 challenges, including the top two challenges, were from the clinical informatics domain. Management of chronic non-malignant pain requiring opiate therapy was the third most reported challenge nationwide. Significant organizational and area level variations in reported challenges were found especially for care coordination.


CONCLUSIONS
Better understanding of PC challenges ahead of PCMH implementation provides important context for strategic planning and redesign efforts. As a national healthcare system, the VA provides a unique opportunity to examine organizational and area determinants relevant to other PCMH models.
VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Sepulveda Campus (Mailcode 152), 16111 Plummer Street, Sepulveda, CA, 91343, USA, Melissa.Farmer@va.gov.
Melissa M
MM
Farmer
Danielle E
DE
Rose
Lisa V
LV
Rubenstein
Ismelda A
IA
Canelo
Gordon
G
Schectman
Richard
R
Stark
Elizabeth M
EM
Yano
D003430:Cross-Sectional Studies; D006801:Humans; D018802:Patient-Centered Care / Q000379:methods / Q000639:trends*; D008486:Physician Executives / Q000639:trends*; D058007:Physicians, Primary Care / Q000639:trends*; D011320:Primary Health Care / Q000379:methods / Q000639:trends*; D014481:United States; D014493:United States Department of Veterans Affairs / Q000639:trends*