title: The facilitators and barriers associated with implementation of a patient-centered medical home in VHA.
abstract: BACKGROUND
  The patient-centered medical home (PCMH) is a team-based, comprehensive model of primary care. When effectively implemented, PCMH is associated with higher patient satisfaction, lower staff burnout, and lower hospitalization for ambulatory care-sensitive conditions. However, less is known about what factors contribute to (or hinder) PCMH implementation. We explored the associations of specific facilitators and barriers reported by primary care employees with a previously validated, clinic-level measure of PCMH implementation, the Patient Aligned Care Team Implementation Progress Index (Pi(2)).
  
  
  METHODS
  We used a 2012 survey of primary care employees in the Veterans Health Administration to perform cross-sectional, respondent-level multinomial regressions. The dependent variable was the Pi(2) categorized as high implementation (top decile, 54 clinics, 235 respondents), medium implementation (middle eight deciles, 547 clinics, 4537 respondents), and low implementation (lowest decile, 42 clinics, 297 respondents) among primary care clinics. The independent variables were ordinal survey items rating 19 barriers to patient-centered care and 10 facilitators of PCMH implementation. For facilitators, we explored clinic Pi(2) score decile both as a function of respondent-reported availability of facilitators and of rating of facilitator helpfulness.
  
  
  RESULTS
  The availability of five facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile: teamlet huddles (OR = 3.91), measurement tools (OR = 3.47), regular team meetings (OR = 2.88), information systems (OR = 2.42), and disease registries (OR = 2.01). The helpfulness of four facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile. Six barriers were associated with significantly higher odds of a respondent's clinic's Pi(2) scores being in the lowest versus highest decile, with the strongest associations for the difficulty recruiting and retaining providers (OR = 2.37) and non-provider clinicians (OR = 2.17). Results for medium versus low Pi(2) score clinics were similar, with fewer, smaller significant associations, all in the expected direction.
  
  
  CONCLUSIONS
  A number of specific barriers and facilitators were associated with PCMH implementation, notably recruitment and retention of clinicians, team huddles, and local education. These findings can guide future research, and may help healthcare policy makers and leaders decide where to focus attention and limited resources.
authors.affiliation: Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, U.S. Department of Veterans Affairs, 1660 Columbian Way, S-152, Seattle, 98108, WA, USA. christian.helfrich@va.gov.|Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA. christian.helfrich@va.gov.
authors.forename: Christian D
authors.initials: CD
authors.lastname: Helfrich
authors.affiliation: Office of Analytics and Business Intelligence, U.S. Department of Veterans Affairs, Seattle, WA, USA.
authors.forename: Philip W
authors.initials: PW
authors.lastname: Sylling
authors.affiliation: Center for Innovation to Implementation, VHA Palo Alto Healthcare System, Menlo Park, CA, USA.
authors.forename: Randall C
authors.initials: RC
authors.lastname: Gale
authors.affiliation: Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA.|Boston University School of Public Health, Boston, MA, USA.
authors.forename: David C
authors.initials: DC
authors.lastname: Mohr
authors.affiliation: HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VHA Greater Los Angeles Health Care System, North Hills, CA, USA.|Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
authors.forename: Susan E
authors.initials: SE
authors.lastname: Stockdale
authors.affiliation: Portland VHA Medical Center, VISN 20 Patient Aligned Care Team (PACT) Demonstration Laboratory, U.S. Department of Veterans Affairs, Portland, OR, USA.
authors.forename: Sandra
authors.initials: S
authors.lastname: Joos
authors.affiliation: Center for Evaluation of Patient Aligned Care Teams (CEPACT), Philadelphia Veterans Affairs Medical Center, Philadelphia, USA.|The Robert Wood Johnson Foundation Clinical Scholars Program, and the Department of Family and Community Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, USA.
authors.forename: Elizabeth J
authors.initials: EJ
authors.lastname: Brown
authors.affiliation: Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
authors.forename: David
authors.initials: D
authors.lastname: Grembowski
authors.affiliation: Center for Innovation to Implementation, VHA Palo Alto Healthcare System, Menlo Park, CA, USA.|Stanford University School of Medicine, Palo Alto, CA, USA.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
authors.affiliation: Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, U.S. Department of Veterans Affairs, 1660 Columbian Way, S-152, Seattle, 98108, WA, USA.|Office of Analytics and Business Intelligence, U.S. Department of Veterans Affairs, Seattle, WA, USA.|Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
authors.forename: Stephan D
authors.initials: SD
authors.lastname: Fihn
authors.affiliation: Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, U.S. Department of Veterans Affairs, 1660 Columbian Way, S-152, Seattle, 98108, WA, USA.|Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
authors.forename: Karin M
authors.initials: KM
authors.lastname: Nelson
authors.affiliation: RAND Corporation, Santa Monica, CA, USA.|VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA.
authors.forename: Lisa S
authors.initials: LS
authors.lastname: Meredith
mesh_terms: D000288:Administrative Personnel / Q000523:psychology; D003430:Cross-Sectional Studies; D004059:Diffusion of Innovation; D006801:Humans; D016015:Logistic Models; D018802:Patient-Centered Care; D011320:Primary Health Care; D011795:Surveys and Questionnaires; D014481:United States; D014493:United States Department of Veterans Affairs