Primary Care Delivery by Associate Care Providers in the Patient Centered Medical Home.

Abstract

INTRODUCTION: The Patient Centered Medical Home (PCMH) requires collaboration and task delegation among primary care providers (PCPs: physicians, nurse practitioners, physician assistants, and medical residents) and associate care providers (ACPs: nurses, pharmacists, social workers, dietitians, and behavioral health providers). Within PCMH, ACPs have expanded roles in clinical care delivery. However, PCMH evaluations have primarily focused on the performance of PCPs. AIMS: 1) To assess the extent to which PCMH measures encompass ACP-delivered care; 2) To determine trends in care delivery across different types of providers before and during PCMH implementation; and 3) To examine relationships between PCMH implementation, ACP care delivery, and resource utilization. METHODS: Study 1 was a systematic literature review of PCMH access and care coordination measures to assess their inclusion of ACP-delivered care. Study 2 analyzed five years of retrospective, in-person, clinical patient encounters by PCPs and ACPs among 764 Veterans Health Administration (VHA) primary care sites. Negative binomial regression estimated monthly rates of provider-delivered encounters among sites before and during PCMH implementation. Study 3 was a cross-sectional analysis of VHA primary care sites during two twelve-month periods, before (n=688) and during (n=684) PCMH implementation. Structural equation modeling tested whether the rate of nurse-delivered encounters mediated the effect of PCMH implementation on inpatient hospitalization. RESULTS: Review of 42 PCMH studies found wide variability in the inclusion of ACP care in measurement approaches, and limited information about ACP impact on outcomes. Study 2 showed that ACPs delivered 29% of in-person encounters in fiscal year (FY) 2009 (pre-PCMH), and 35% in FY2013 (during PCMH implementation). Monthly rates of PCP encounters decreased, while those for some ACPs increased during PCMH implementation. Mediation analyses demonstrated a significant positive relationship between the level of PCMH implementation and the rate of nurse-delivered encounters, and a significant negative relationship between nurse-delivered encounters and the rate of hospitalizations during PCMH. CONCLUSIONS: Findings suggest that a shift in care delivery from PCPs to some ACPs occurred in VHA primary care sites after the introduction of PCMH. ACP-delivered care may be an important mechanism of how PCMH impacts outcomes and should be included in PCMH evaluations.