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Association of the Patient-Centered Medical Home Implementation with Chronic Disease Quality in Patients with Multimorbidity

Linnaea Schuttner, Edwin S Wong, Ann-Marie Rosland, Karin Nelson, Ashok Reddy

Background: The patient-centered medical home (PCMH) was established in part to improve chronic disease management, yet evidence is limited for effects on patients with multimorbidity.

Objective: To examine the association of Patient-Aligned Care Team (PACT) implementation, the Veterans Health Administration (VA) PCMH model, and care quality for multimorbid patients enrolled in VA primary care from 2012 to 2014.

Design: Retrospective cohort.

Patients: 318,764 multimorbid (> 3 chronic diseases) patients receiving care in 917 clinics.

Main measures: PCMH implementation was measured using the PACT Implementation Progress Index (PI²) for clinics in 2012. The PI² is a validated composite measure of administrative and survey data with higher scores associated with greater care quality. Quality outcomes from 2013 to 2014 were assessed from External Peer Review Program (EPRP) metrics. Outcomes included preventative care, chronic disease management, and mental health and substance use metrics. We used generalized estimating equations to model associations adjusting for patient and clinic characteristics. We also examined associations for a subgroup with > 5 chronic diseases.

Key results: For one-third of metrics (5/15), greater implementation of PACT in 2012 was associated with higher predicted probability of meeting the quality metric in 2013-2014. This association persisted for only two metrics (diabetic glycemic control, P < 0.001; lipid control in ischemic heart disease, P = 0.02) among patients with > 5 chronic diseases.

Conclusions: Multimorbid patients engaged in care from clinics with higher PCMH implementation received higher quality care across several quality domains, but this association was reduced in patients with > 5 chronic diseases.