Patient-Centered Medical Homes

An enhanced way to deliver primary care that provides ongoing, team-based, and coordinated care.  PCMHs are now being tested for their ability to improve outcomes and limit costs growth. 

Practices To Support Relational Coordination In Care Transitions: Observations From The VA Rural Transitions Nurse Program

Robert Burke, MD, University of Pennsylvania
Nov. 11, 2020

Heather M. Gilmartin, Catherine Battaglia, Theodore Warsavage, Brigid Connelly, Robert E. Burke

Abstract [from journal]

Background: Ensuring safe transitions of care around hospital discharge requires effective relationships and communication between health care teams. Relational coordination (RC) is a process of communicating and relating for the purpose of task integration that predicts desirable outcomes for patients and providers. RC can be measured using a validated survey.

Purpose: The aim of the study was to demonstrate the application of RC practices within the rural Transitions Nurse Program (TNP), a


Supportive Clinical Practice Environments Associated With Patient-Centered Care

Sep. 1, 2020

J. Margo Brooks CarthonHeather Brom, Lusine Poghosyan, Marguerite Daus, Barbara Todd, Linda Aiken

Abstract [from journal]

A lack of organizational supports in clinical settings may prevent nurse practitioners from providing patient centered care. Using a cross sectional survey design, data were collected from NPs in 1,571 practices across four states to investigate clinical practice environments and the extent to which they are associated with NP integration of patient preferences. Three-quarters of NPs reported frequent integration of patient preferences into clinical care. Overall, 371 practices (23.6%) were classified as good practice environments;


Problem Solving Therapy For Home-Hospice Caregivers: A Pilot Study

Zvi D. Gellis, PhD
Aug. 30, 2020

Christin Gregory and Zvi Gellis

Abstract [from journal]

This pilot study examined the effects of Brief Problem-Solving Therapy on caregiver quality of life, depression, and problem-solving in family caregivers of hospice patients. Thirty-seven family caregivers to home-based hospice patients (mean age 62.8 [SD = 12.32]) were randomized to the study group (PST-Hospice), for a 45 minute per week/5 week intervention or comparison group of usual care plus caregiver education (UC + CE). The severity of depressive symptoms, caregiver quality of life and problem-solving functioning were assessed


Utilization And Cost Effects Of The VHA Caring For Older Adults And Caregivers At Home (COACH) Program

Bruce Kinosian, MD
Jul. 9, 2020

Wei Song, Orna Intrator, Jack Twersky, Judith Davagnino, Bruce Kinosian, Darryl Wieland

Abstract [from journal]

Since 2010, the Veterans Health Administration has initiated a home-based Caring for Older Adults and Caregivers at Home (COACH) program to provide clinical support to dementia patients and family caregivers. But its impact on health care utilization and costs is unknown. We compared 354 COACH care recipients with a propensity score weighted comparison group of 9,857 community-dwelling Veterans during fiscal years 2010-2015. In 1-year follow-up, COACH program was associated with a lower rate of long-term nursing home placement (


Predictors Of Change Over Time In Subjective Daytime Sleepiness Among Older Adult Recipients Of Long-Term Services And Supports

Jun. 11, 2020

Darina V. PetrovskyKaren B. Hirschman, Miranda Varrasse McPhillips, Justine S. Sefcik, Alexandra L. Hanlon, Liming Huang, Glenna S. Brewster, Nancy A. HodgsonMary D. Naylor

Abstract [from journal]

Objectives: Daytime sleepiness is associated with multiple negative outcomes in older adults receiving long-term services and supports (LTSS) including reduced cognitive performance, need for greater assistance with activities of daily living and decreased social engagement. The purpose of this study was to identify predictors of change in subjective daytime sleepiness among older adults during their first 2 years of receiving LTSS.

Design and setting: Secondary analysis of data from a


Factors Associated With Perceived Worsened Physical Health Among Older Adults Who Are Newly Enrolled Long-term Services and Supports Recipients

Jan. 2, 2020

Jasmine L. TraversKaren B. Hirschman, Alexandra L. Hanlon, Liming Huang, Mary D. Naylor

Abstract [from journal]

Limited information exists on the perceived health of older adults new to receiving long-term services and supports (LTSS) compared with the year prior, posing challenges to the anticipation of health care need and optimization of wellness efforts for this growing population. In response, we sought to identify differences in perceived worsened physical health across three LTSS types (nursing home, assisted living, and home and community-based services) along with health-related quality of life (HRQoL) characteristics associated with older adults'


Factors Affecting Patient Prioritization Decisions at Admission to Home Healthcare: A Predictive Study to Develop a Risk Screening Tool

Nov. 21, 2019

Maxim Topaz, Mary Naylor, John Holmes, Kathryn Bowles

Abstract [from journal]

There is a lack of evidence on how to identify high-risk patients admitted to home healthcare. This study aimed (1) to identify which disease characteristics, medications, patient needs, social support characteristics, and other factors are associated with patient priority for the first home health nursing visit; and (2) to construct and validate a predictive model of patient priority for the first home health nursing visit. This was a predictive study of home health visit priority decisions made by 20 nurses for 519 older adults. The study found that


Health Care Safety-Net Programs After The Affordable Care Act

Issue Brief
Oct. 1, 2019

Prior to the Affordable Care Act (ACA), health care safety-net programs were the primary source of care for over 44 million uninsured people. While the ACA cut the number of uninsured substantially, about 30 million people remain uninsured, and many millions more are vulnerable to out-of-pocket costs beyond their resources. The need for the safety net remains, even as the distribution and types of need have shifted. This brief reviews the effects of the ACA on the funding and operation of safety-net institutions. It highlights the challenges and opportunities that health care reform presents to safety-net programs, and how they have adapted and evolved to continue to serve our most vulnerable residents.

Inside the Black Box of Patient-Centered Medical Homes

Aug. 2, 2018

The concept of a patient-centered medical home (PCMH) holds intuitive appeal, with its emphasis on coordination of care, improved patient-provider communication and patient engagement, use of health information technology, and expanded practice hours.

Organizational Processes and Patient Experiences in the Patient-Centered Medical Home

May. 10, 2018

Abstract [from journal]

Background: There is increasing emphasis on the use of patient-reported experience data to assess practice performance, particularly in the setting of patient-centered medical homes. Yet we lack understanding of what organizational processes relate to patient experiences.

Objective: Examine associations between organizational processes practices adopt to become PCMH and patient experiences with care.

Research Design: We analyzed visit data from patients (n=8356) at adult primary care practices...

System Redesign and the Health Care Workforce

Oct. 19, 2017

An interdisciplinary panel of experts from health care management, economics, and nursing came together at LDI’s 50th Anniversary Symposium to discuss their perspectives on how “organizational innovation” can be used to redesign health care systems and care delivery.

Linda Aiken, PhD, RN, University of Pennsylvania

Continuity of Care in Infancy and Early Childhood Health Outcomes

Jul. 14, 2017

Elizabeth Enlow, Molly Passarella, Scott A. Lorch

In Pediatrics, Elizabeth Enlow and colleagues, including Scott Lorch, assess the relationship between provider continuity in infancy, and use of both urgent and preventative health services. Continuity of care is a key aspect of the patient-centered medical home and has been shown to improve pediatric outcomes. The authors hypothesize that increased provider continuity in infancy decreases urgent health care use and increases preventative services use in early childhood. They measured continuity across all primary care encounters during the first year of life for 17,773 infants...