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Background: Patient- and family-centered care (PFCC) is increasingly linked to improved communication, care quality, and patient decision making. However, in order to consistently implement and study PFCC, health care systems and researchers need a solid evidentiary base. Most current definitions and models of PFCC are broad and conceptual, and difficult to translate into measurable behaviors and actions. This paper provides a brief overview of all actions that focus group respondents associated with PFCC in ambulatory (outpatient) care settings and then explores actions associated with the concept of "dignity and respect" in greater detail., Methods: We conducted nine focus groups with patients, family members, and physicians in three metropolitan regions across the United States. Group discussions were transcribed and analyzed using a thematic analysis approach., Results: We identified 14 domains and 47 specific actions that patients, family members, and physicians associate with PFCC. In addition to providing a detailed matrix of these domains and actions, this paper details the actions associated with the "dignity and respect" concept. Key domains identified under "dignity and respect" include: 1) building relationships, 2) providing individualized care, and 3) respecting patients' time. Within these domains we identified specific actions that break down these abstract ideas into explicit and measurable units such as taking time, listening, including family, and minimizing wait times. We identified 9, 6, and 3 specific actions associated, respectively, with building relationships, providing individualized care, and respecting patients' time., Conclusions: Our work fills a critical gap in our ability to understand and measure PFCC in ambulatory care settings by breaking down abstract concepts about PFCC into specific measurable actions. Our findings can be used to support research on how PFCC affects clinical outcomes and develop innovative tools and policies to support PFCC.

Context: Patient- and family-centered care (PFCC) literature is growing, but few reports present patient, caregiver, and practitioner perspectives about care coordination in a team-based model., Objective: To understand the patient's, caregiver's, and physician's ideal forms of PFCC, we investigated the function of the medical team quarterback, who coordinates and advocates for appropriate care, and probed to understand how the quarterback works with a team to contribute to ideal PFCC., Design and Main Outcome Measures: Nine focus groups with 92 participants were held in 3 major cities. Patients (n = 35) and family members (n = 36) were recruited through market research groups. Physicians (n = 21) were recruited by the American College of Physicians. Focus group transcripts were analyzed and coded using inductive analysis., Results: The quarterback emerged as an important function for addressing care gaps and improving the care experience. We identified 6 themes articulated by participants that defined the role of a medical team quarterback: Overseeing care; coordinating diagnoses, tests, and treatments; advocating for patients; identifying and respecting patient values; proactively communicating; and solving problems. Patients and family members in our sample were open to different members of the care team acting as quarterback in coordination with the physician., Conclusion: Medical team quarterbacks were perceived as enhancing team-based care by facilitating the coordination/communication that is critical to PFCC. Patients and family members acknowledged that PFCC can be delivered by different members of the medical team if the care felt organized and coordinated with the primary care physician.

Purpose: The patient-centered medical home (PCMH) is being rapidly deployed in many settings to strengthen US primary care, improve quality, and control costs; however, evidence supporting this transformation is still lacking. We describe the Group Health experience in attempting to replicate the effects on health care use seen in a PCMH prototype clinic via a systemwide spread using Lean as the change strategy., Methods: We used an interrupted time series analysis with a patient-month unit of analysis over a 4-year period that included baseline, implementation, and stabilization periods for 412,943 patients. To account for secular trends across these periods, we compared changes in use of face-to-face primary care visits, emergency department visits, and inpatient admissions with those of a nonequivalent comparison group of patients served by community network practices., Results: After accounting for secular trends among network patients, patients empaneled to the PCMH clinics had 5.1% and 6.7% declines in primary care office visits in early and later stabilization years, respectively, after the implementation year. This trend was accompanied by a 123% increase in the use of secure electronic message threads and a 20% increase in telephone encounters. Declines were also seen in emergency department visits at 1 and 2 years (13.7% and 18.5%) compared with what would be expected based on secular trends in network practices. No statistically significant changes were found for hospital admissions., Conclusions: The Group Health experience shows it is possible to reduce emergency department use with PCMH transformation across a diverse set of clinics using a clear change strategy (Lean) and sufficient resources and supports.

Purpose: To assess the impact on health care cost and quality among seniors of a patient-centered medical home (PCMH) pilot at Group Health Cooperative, an integrated health care system in Washington State., Design and Methods: A prospective before-and-after evaluation of the experience of seniors receiving primary care services at 1 pilot clinic compared with seniors enrolled at the remaining 19 primary care clinics owned and operated by Group Health. Analyses of secondary data on quality and cost were conducted for 1,947 seniors in the PCMH clinic and 39,396 seniors in the 19 control clinics. Patient experience with care was based on survey data collected from 487 seniors in the PCMH clinic and of 668 in 2 specific control clinics that were selected for their similarities in organization and patient composition to the pilot clinic., Results: After adjusting for baseline, seniors in the PCMH clinic reported higher ratings than controls on 3 of 7 patient experience scales. Seniors in the PCMH clinic had significantly greater quality outcomes over time, but this difference was not significant relative to control. PCMH patients used more e-mail, phone, and specialist visits but fewer emergency services and inpatient admissions for ambulatory care sensitive conditions. At 1 and 2 years, the PCMH and control clinics did not differ significantly in overall costs., Implications: A PCMH redesign can be associated with improvements in patient experience and quality without increasing overall cost.

Health care leaders and policymakers are turning to the patient-centered medical home (PCMH) model to contain costs, improve the quality of care, and create a more positive primary care work environment. We describe how Group Health, an integrated delivery system, developed and implemented a PCMH intervention that included standardized structural and practice level changes. This intervention was spread to a diverse set of 26 primary care practices in 14 months using Lean Management principles. Group Health's experience provides valuable insights that can be used to improve the design and implementation of future PCMH models.

Purpose: Improving patient-doctor continuity is one goal of the medical home, but achieving this goal may require physicians to reduce panel size. This article examines the impact on patient experience and utilization of Group Health Cooperative's process of reassigning patients to new physicians as part of their medical home demonstration project., Methods: This work represents a subanalysis of the Group Health medical home pilot evaluation. Study participants include 8,005 adults who received primary care in 2006 and 2007 at an urban practice owned and operated by a not-for-profit integrated delivery system. Approximately one-quarter of patients were selected to be reassigned to a new physician. Primary care, emergency department, secure messaging, and telephone utilization were captured through automated sources. Patients' experience was measured before and after implementation of the medical home for a subset of 1,098 patients., Results: Patients who were retained by their existing physicians were older, sicker, and had longer preexisting patient-doctor relationships. After reassignment, reassigned patients were less likely to use primary care services but equally likely to use the emergency department. They were no less satisfied with their care experience., Conclusions: Informational and managerial continuity may mitigate deleterious effects of reassignment, but more must be done to actively bind reassigned patients to the medical home to improve relational continuity with younger, healthier patients.

As the patient-centered medical home model emerges as a key vehicle to improve the quality of health care and to control costs, the experience of Seattle-based Group Health Cooperative with its medical home pilot takes on added importance. This paper examines the effects of the medical home prototype on patients' experiences, quality, burnout of clinicians, and total costs at twenty-one to twenty-four months after implementation. The results show improvements in patients' experiences, quality, and clinician burnout through two years. Compared to other Group Health clinics, patients in the medical home experienced 29 percent fewer emergency visits and 6 percent fewer hospitalizations. We estimate total savings of $10.3 per patient per month twenty-one months into the pilot. We offer an operational blueprint and policy recommendations for adoption in other health care settings.

OBJECTIVE: Children with low income and minority race and ethnicity have worse hospital outcomes due partly to systemic and interpersonal racism causing communication and system barriers. We tested the feasibility and acceptability of a novel inpatient communication-focused navigation program. METHODS: Multilingual design workshops with parents, providers, and staff created the Family Bridge Program. Delivered by a trained navigator, it included 1) hospital orientation; 2) social needs screening and response; 3) communication preference assessment; 4) communication coaching; 5) emotional support; and 6) a post-discharge phone call. We enrolled families of hospitalized children with public or no insurance, minority race or ethnicity, and preferred language of English, Spanish, or Somali in a single-arm trial. We surveyed parents at enrollment and 2 to 4 weeks post-discharge, and providers 2 to 3 days post-discharge. Survey measures were analyzed with paired t tests. RESULTS: Of 60 families enrolled, 57 (95%) completed the follow-up survey. Most parents were born outside the United States (60%) with a high school degree or less (60%). Also, 63% preferred English, 33% Spanish, and 3% Somali. The program was feasible: families received an average of 5.3 of 6 components; all received > 2. Most caregivers (92%) and providers (81% [30/37]) were "very satisfied." Parent-reported system navigation improved from enrollment to follow-up (+8.2 [95% confidence interval 2.9, 13.6], P = .003; scale 0-100). Spanish-speaking parents reported decreased skills-related barriers (-18.4 [95% confidence interval -1.8, -34.9], P = .03; scale 0-100). CONCLUSIONS: The Family Bridge Program was feasible, acceptable, and may have potential for overcoming barriers for hospitalized children at risk for disparities. [ABSTRACT FROM AUTHOR]

Objective: Recognition is growing that to create truly patient‐centred care, health‐care organizations need to partner with patients around care design. More research into the benefits of engaging patients and the most effective ways of partnering with them is needed. Methods: This study assessed the process and impact of a collaborative effort to design a new clinic service that balanced the number of patient and clinical provider/staff codesigners involved and recruited patients to represent diverse perspectives. Data sources included interviews with participants, event observation and participant surveys. Results: Our evaluation found that including patients as equal partners improved the design process by infusing a real‐world, patient perspective. The pre‐event orientation and interactive methods used in the event fostered positive collaboration, as well as personal growth for the patient codesigners. Conclusion: This study demonstrated the feasibility and benefits of including a roughly equal number of patients and clinical providers/staff in design events and ensuring that the patients represent diverse perspectives. [ABSTRACT FROM AUTHOR]

Background: Team-based care is now recognized as an essential feature of high quality primary care, but there is limited empiric evidence to guide practice transformation. The purpose of this paper is to describe advances in the configuration and deployment of practice teams based on in-depth study of 30 primary care practices viewed as innovators in team-based care. Methods: As part of LEAP, a national program of the Robert Wood Johnson Foundation, primary care experts nominated 227 innovative primary care practices. We selected 30 practices for intensive study through review of practice descriptive and performance data. Each practice hosted a 3-day site visit between August, 2012 and September, 2013, where specific advances in team configuration and roles were noted. Advances were identified by site visitors and confirmed at a meeting involving representatives from each of the 30 practices. Results: LEAP practices have expanded the roles of existing staff and added new personnel to provide the person power and skills needed to perform the tasks and functions expected of a patient-centered medical home (PCMH). LEAP practice teams generally include a rich array of staff, especially registered nurses (RNs), behavioral health specialists, and lay health workers. Most LEAP practices organize their staff into core teams, which are built around partnerships between providers and specific Medical Assistants (MAs), and often include registered nurses (RNs) and others such as health coaches or receptionists. MAs, RNs, and other staff are heavily involved in the planning and delivery of preventive and chronic illness care. The care of more complex patients is supported by behavioral health specialists, RN care managers, and pharmacists. Standing orders and protocols enable staff to act independently. Conclusions: The 30 LEAP practices engage health professional and lay staff in patient care to the maximum extent, which enables the practices to meet the expectations of a PCMH and helps free up providers to focus on tasks that only they can perform. [ABSTRACT FROM AUTHOR]

The patient-centered medical home model relies on team-based care for meaningful practice transformation. This article adds to the literature on the importance of teams in primary care by exploring the barriers and facilitators to establishing high functioning teams during a patient-centered medical home transformation process. [ABSTRACT FROM AUTHOR]