Social side of PCMH implementation requires study

Many view the patient-centered medical home (PCMH) model as the new wave in healthcare delivery, but getting there requires overcoming significant implementation challenges, according to an American Journal of Managed Care study published in February.

A recent longitudinal and qualitative evaluation of team experience implementing PCMH--branded the Patient Aligned Care Team (PACT)--found that even when there is buy-in for the new model and strong technological and fiscal systems to support it, interpersonal challenges impeded progress.

“Primary care reform has recently focused on financial incentives and electronic medical records, but the social side of medical home and team implementation demands investment and attention,” author Samantha L. Solimeo, PhD, MPH, et al stated.

Over an 18-month period, Solimeo and colleagues studied PACT implementation among 22 newly formed teams at the Veterans Health Administration, which is in the process of adopting PCMH across its entire primary care network. Each team included a PCP, a registered nurse care manager, a licensed practical nurse and a clerical associate.

The researchers found that within-team and interpersonal conflict, as well as discordant administrative leadership abilities, hampered implementation. These challenges occurred even though the VHA has the organizational, technological and fiscal infrastructure to support integrated, team-based care, according to the study. Moreover, the teams all were trained in the IHI Breakthrough Series Collaborative methodology and received support from team coaches.

Teams achieved varying degrees of cohesion and success based on team composition and pre-existing relationships between members, the study found. PCPs felt uncomfortable enacting a leadership role, and others felt as if they lacked authority to lead. Licensed practical nurses and clerical associates were least likely to report participation as intra-team leaders, the report stated.

In addition to interpersonal challenges that members encountered as they adopted new roles, the resource commitments required to implement PACT frustrated team members who already felt overworked.

Other challenges reported include tension between the team and overall clinic. “In some instances, the disparity between PACT team needs and broader clinic interests amplified leadership resistance to change,” the authors found, adding “participants made it clear that PACT implementation was highly disruptive to traditional hierarchies.”

After the 18-month study, researchers offered the recommendations for future implementation: extensive effort during team formation to develop positive interpersonal and interprofessional relationship; administrative leadership support, the ability of team members to cooperatively and democratically determine tasks and responsibilities.