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Article
Supporting Primary Care Patient-Centered Medical Homes with Community Care Teams: Findings from a Pilot Study
Journal of Clinical Outcomes Management
  • Carol A Foltz, PhD, Lehigh Valley Health Network
  • Susan Lawrence, MS, CMAC, Lehigh Valley Health Network
  • Nyann Biery, MS, Lehigh Valley Health Network
  • Nancy Gratz, MPA, Lehigh Valley Health Network
  • Hannah D Paxton, RN, MPH, Lehigh Valley Health Network
  • Deborah Swavely, DNP, RN, Lehigh Valley Health Network
Publication/Presentation Date
8-1-2014
Abstract

Objective: With the growing recognition that team-based care might help meet the country’s primary care needs, this study’s objective was to evaluate the preliminary effectiveness of multidisciplinary community care teams (CCTs) deployed to primary care practices transforming into patient-centered medical homes (PCMHs). Methods: A nonrandomized longitudinal study design was used contrasting the CCT practices/patients with non-CCT comparison groups. Outcomes included utilization (ED/hospital use), quality indicators (QIs), practice joy, and patient satisfaction. Two CCTs (consisting of nurse care manager, behavioral health specialist, social worker, and pharmacist) were deployed to 6 primary care practices and provided services to 406 patients. Practice level analyses compared patients from the 6 CCT practices not receiving team services (29,881 patients) to 3 non-CCT practices (22,350 patients) that were also transforming toward PCMH. The comparison group for the patient level analyses (patients who received CCT services) was patients from the same CCT practice who did not receive CCT services. Results: At the practice level, there were significant improvements in QIs for practices both with and without CCTs. However, reductions in the probability of an admission and readmission occurred only for high-risk patients in CCT practices. At the patient level, the probability of an unplanned admission was reduced for CCT and non-CCT patients, but the probability of a readmission was only reduced in CCT patients receiving hospital discharge reconciliation calls from CCT staff. Conclusion: Preliminary results suggest possible added benefit of CCTs over PCMHs alone for reducing hospitalization.

Document Type
Article
Citation Information

Foltz, C., Lawrence, S., Biery, N., Gratz, N., Paxton, H., & Swavely, D. (2014). Supporting primary Care patient-centered medical homes with community care teams: Findings from a pilot study. Journal of Clinical Outcomes Management, 21(8), 352-361.