title: Implementation and Sequencing of Practice Transformation in Urban Practices with Underserved Patients.
abstract: Patient-centered medical home (PCMH) has gained momentum as a model for primary-care health services reform.
  
  
  
  We conducted interviews at 14 primary care practices undergoing PCMH transformation in a large urban federally qualified health center in California and used grounded theory to identify common themes and patterns.
  
  
  
  We found clinics pursued a common sequence of changes in PCMH transformation: Clinics began with National Committee for Quality Assurance (NCQA) level 3 recognition, adding care coordination staff, reorganizing data flow among teams, and integrating with a centralized quality improvement and accountability infrastructure. Next, they realigned to support continuity of care. Then, clinics improved access by adding urgent care, patient portals, or extending hours. Most then improved planning and management of patient visits. Only a handful worked explicitly on improving access with same day slots, scheduling processes, and test result communication. The clinics' changes align with specific NCQA PCMH standards but also include adding physicians and services, culture changes, and improved communication with patients.
  
  
  
  NCQA PCMH level 3 recognition is only the beginning of a continuous improvement process to become patient centered. Full PCMH transformation took time and effort and relied on a sequential approach, with an early focus on foundational changes that included use of a robust quality improvement strategy before changes to delivery of and access to care.
authors.affiliation: RAND Corporation, Santa Monica, California (Dr Quigley); RAND Corporation, Boston, Massachusetts (Mr Predmore); AltaMed Health Services Corporation, Los Angeles, California (Dr Chen); and UCLA, Division of General Internal Medicine & Health Services Research, Los Angeles, California (Dr Hays).
authors.forename: Denise D
authors.initials: DD
authors.lastname: Quigley
authors.forename: Zachary S
authors.initials: ZS
authors.lastname: Predmore
authors.forename: Alex Y
authors.initials: AY
authors.lastname: Chen
authors.forename: Ron D
authors.initials: RD
authors.lastname: Hays
mesh_terms: D000328:Adult; D002140:California; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D009936:Organizational Innovation; D009937:Organizational Objectives; D010348:Patient Care Team / Q000458:organization & administration*; D018802:Patient-Centered Care / Q000458:organization & administration*; D011320:Primary Health Care / Q000458:organization & administration*; D058996:Quality Improvement / Q000458:organization & administration*; D011787:Quality of Health Care / Q000458:organization & administration*; D014505:Urban Population; D035862:Vulnerable Populations