Shift to medical home may not increase patient satisfaction

If the challenges facing individual practices moving toward the patient-centered medical home concept were not already daunting enough, a study published in June presents a new wrinkle: Patients may not like the new approach to care.

Researchers asked 393 physician practices whether they implemented medical-home elements such as team-based care, electronic health records, disease registries, clinical decision support, quality measurement, patient reminders, email access and group visits. Then they surveyed 1,304 patients who received care at those clinics about their experience during the last six months. The study, published online June 7 in the journal Health Services Research, found no association between a clinic’s use of patient-centered medical home processes and patients’ satisfaction with care.

The results came as a surprise to researchers, who hypothesized that practices with more medical-home elements would have happier patients.

Patients were asked about their communication with physicians and other health professionals at the clinics — whether things were explained in a way they understood, for example. They also answered questions about goal-setting with these professionals on diet, exercise and disease-monitoring, as well as whether they received phone or mail reminders about care. The lack of improvement in patient experience remained even after controlling for characteristics of the clinics and patients that might have affected the results, the study said.

It may be that the shift to a patient-centered medical home disrupts patients’ experience of care, said Grant R. Martsolf, RN, MPH, lead author of the study. Changes in workflow resulting from new electronic systems and changes to how appointments are set, how patients are counseled and how they are reminded to take their medicine could worsen their satisfaction over the short term. Meanwhile, elements such as disease registries that help ensure patients with chronic conditions get the right care may not make much impact on patients’ perception of quality.

“One thing to really think hard about in talking about the patient-centered medical home — this is back-office stuff,” said Martsolf, who led the project as a health-services researcher at Penn State University. “It may lead to better care for the patient, but some of these things maybe turn these places into factories. & Potentially, maybe there are these back-office things that make the practice efficient, but don’t make the experience of the patient any better.”

The respondents were randomly sampled from 14 communities originally involved in the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative. However, the study is not an evaluation of that project’s effectiveness, as only about one in eight physicians in each community is participating in the initiative.

Outcomes of the medical home

Patients’ experience of care might suffer in the transition to a medical home, said Katherine Browne, deputy director of Aligning Forces for Quality.

“The workflow, processes and all that don’t change overnight,” she said. “It’s not as though one day they’re not a patient-centered medical home and the next day they are, and instantaneously all the care has changed. The effects of the redesign of care and the changing of those processes and changes in culture may not have been felt by patients. There’s a little bit of that dynamic going on here.”

The study is the largest yet to examine the link between medical-home elements and patient experience, said Robin Clarke, MD, assistant clinical professor at the David Geffen School of Medicine at the University of California, Los Angeles.

In a Feb. 13 Health Affairs study of 40 Los Angeles-area community health centers, Dr. Clarke and his colleagues found that those that had implemented more medical-home processes did not fare better on quality metrics in caring for patients with diabetes. Meanwhile, a February Agency for Healthcare Research and Quality review of early evidence on medical-home outcomes found mixed results and said more research is needed to refine the care model and ensure it is cost-effective.

In 2008, the American Medical Association adopted policy supporting medical-home principles consistent with those adopted by the American Academy of Pediatrics, American College of Physicians and American Osteopathic Assn.

The Centers for Medicare & Medicaid Services, the Dept. of Veterans Affairs and other federal agencies are testing the model, and it will be years before results of these demonstration projects are available.

Patient experience is an important part of quality care and ought to be part of how the medical-home concept is implemented and evaluated, Dr. Clarke said.

“We have spent a lot of time developing the patient-centered medical home model,” he said. “Most of that process has been focused on talking with researchers and with academics and with clinic executives, and looking to see what makes a clinic effective, what makes the processes efficient and what makes them better able to track patients. We haven’t spent a lot of time talking to patients about what they perceive to be patient-centered care and what they want to see in a primary care practice.”