title: Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use.
abstract: OBJECTIVE
  In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation.
  
  
  OBJECTIVE
  To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes.
  
  
  METHODS
  We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care.
  
  
  METHODS
  Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout.
  
  
  RESULTS
  Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001).
  
  
  CONCLUSIONS
  The extent of PCMH implementation, as measured by the Pi2, was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.
authors: Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington2General Internal Medicine Service, VA Puget Sound Health Care System, Seattle, Washington 3Department of Medicine, University o.
authors: Karin M
authors: KM
authors: Nelson
authors: Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle.
authors: Christian
authors: C
authors: Helfrich
authors: Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle.
authors: Haili
authors: H
authors: Sun
authors: Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle.
authors: Paul L
authors: PL
authors: Hebert
authors: Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle.
authors: Chuan-Fen
authors: CF
authors: Liu
authors: Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.
authors: Emily
authors: E
authors: Dolan
authors: Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.
authors: Leslie
authors: L
authors: Taylor
authors: Department of Health Services, University of Washington School of Public Health, Seattle.
authors: Edwin
authors: E
authors: Wong
authors: Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle.
authors: Charles
authors: C
authors: Maynard
authors: Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle.
authors: Susan E
authors: SE
authors: Hernandez
authors: Office of Analytics and Business Intelligence, Veterans Health Administration, Washington, DC.
authors: William
authors: W
authors: Sanders
authors: Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle.
authors: Ian
authors: I
authors: Randall
authors: Office of Analytics and Business Intelligence, Veterans Health Administration, Washington, DC.
authors: Idamay
authors: I
authors: Curtis
authors: Office of Patient Care Services, US Department of Veterans Affairs, Washington, DC.
authors: Gordon
authors: G
authors: Schectman
authors: Office of Clinical Operations, US Department of Veterans Affairs, Washington, DC.
authors: Richard
authors: R
authors: Stark
authors: General Internal Medicine Service, VA Puget Sound Health Care System, Seattle, Washington 3Department of Medicine, University of Washington School of Medicine, Seattle5Office of Analytics and Business Intelligence, Veterans Health Administration, Washingt.
authors: Stephan D
authors: SD
authors: Fihn
mesh_terms: D000368:Aged; D002055:Burnout, Professional; D003695:Delivery of Health Care; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008503:Medical Staff; D008875:Middle Aged; D017060:Patient Satisfaction; D018802:Patient-Centered Care / Q000379:methods / Q000458:organization & administration*; D011320:Primary Health Care / Q000379:methods / Q000458:organization & administration*; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D014481:United States; D014493:United States Department of Veterans Affairs / Q000458:organization & administration*