title: Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics.
abstract: BACKGROUND
  Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care.
  
  
  METHODS
  We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity.
  
  
  RESULTS
  4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (β=32, P<0.0001) and history of change in the clinic (β=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (β=0.16-0.34, P=<0.0001), and lower improvements in patient-centered care (β=-0.19, P=0.001).
  
  
  CONCLUSIONS
  Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures.
  
  
  CONCLUSIONS
  Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics.
authors.affiliation: VA Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, WA, USA; Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA. Electronic address: Christian.Helfrich@va.gov.
authors.forename: Christian D
authors.initials: CD
authors.lastname: Helfrich
authors.affiliation: VA Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, WA, USA.
authors.forename: Emily D
authors.initials: ED
authors.lastname: Dolan
authors.affiliation: Office of Analytics and Business Intelligence, US Department of Veterans Affairs, Seattle, WA, USA.
authors.forename: Stephan D
authors.initials: SD
authors.lastname: Fihn
authors.affiliation: Division of Health Policy and Management, School of Public Health, University of California, Berkeley, CA, USA.
authors.forename: Hector P
authors.initials: HP
authors.lastname: Rodriguez
authors.affiliation: RAND Corporation, Santa Monica, CA, USA; Veterans Health Administration Health Services Research & Development Center of Excellence, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA.
authors.forename: Lisa S
authors.initials: LS
authors.lastname: Meredith
authors.affiliation: VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA; University of Michigan Medical School, Department of Internal Medicine, USA.
authors.forename: Ann-Marie
authors.initials: AM
authors.lastname: Rosland
authors.affiliation: Philadelphia VA Medical Center, US Department of Veterans Affairs, Philadelphia, PA, USA.
authors.forename: Michele
authors.initials: M
authors.lastname: Lempa
authors.affiliation: VA Iowa City Health Services Research & Development Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City, IA, USA.
authors.forename: Bonnie J
authors.initials: BJ
authors.lastname: Wakefield
authors.affiliation: Portland VA Medical Center, VISN 20 PACT Demonstration Laboratory, US Department of Veterans Affairs, Portland, OR, USA.
authors.forename: Sandra
authors.initials: S
authors.lastname: Joos
authors.affiliation: Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
authors.forename: Lauren H
authors.initials: LH
authors.lastname: Lawler
authors.affiliation: Office of Analytics and Business Intelligence, US Department of Veterans Affairs, Seattle, WA, USA.
authors.forename: Henry B
authors.initials: HB
authors.lastname: Harvey
authors.affiliation: VA Office of Clinical Operations, Washington, DC, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Stark
authors.affiliation: VA Office of Patient Care Services, Washington, DC, USA.
authors.forename: Gordon
authors.initials: G
authors.lastname: Schectman
authors.affiliation: VA Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, WA, USA.
authors.forename: Karin M
authors.initials: KM
authors.lastname: Nelson
keywords: Evaluation; Patient care team; Patient-centered care; Patient-centered medical home (PCMH); Team-based care