How Healthcare Systems Conceptualize and Manage Complex Interventions Using the Patient-Centered Coordinated Care As Illustration

Background/Purpose. Complex interventions are defined as multi-level, characterized by interdependent dynamics and delivered within dynamic settings. Despite support for complex interventions to increase quality healthcare, their evaluation and implementation in local settings has been limited. This study fills this gap by: 1) conceptualizing the patient-centered coordinated care model (PCMH) as a complex health intervention, and 2) gathering rich interview data from diverse clinical settings to explore the process of how PCMH care is delivered and adapted according to the needs and preferences of local communities. PCMH transforms the way health care is coordinated across health and safety net agencies and how care is delivered.

Methods. In-depth interview data (n=31) using a purposive and a randomly selected sample of healthcare managers, individuals from quality assurance/research department, service providers and staff (i.e., participants) from seven Federally Qualified Health Centers (FQHCs) located in Southern California. The sample was mostly female (64%), and 36% were service providers, 29% care coordinators, 21% managers and 14% quality assurance/research. Interviews lasted 35-45 min and each participant received an incentive. Interview data addressed how stakeholders meet, struggle or adapt to the national expectations of PCMH based on local characteristics as well as describing PCMH in terms of mechanisms of change (i.e., Functions defined as PCMH core purposes/goals and forms defined as local activities to carry out those goals). Data was de-identified and text analyzed using NVivo software. Data coding used a codebook with primary categories informed by the complex intervention and implementation science frameworks. Open coding was used to identify themes within those three categories. We used an iterative comparative coding process and member checking to increase validity of results.

Results. Conceptually, participants endorsed PCMH care as a care model that improves access to and delivery of quality of care. However, in practice respondents expressed that the model presents implementation challenges including meeting the needs of a patient populations with complex health care needs and the need for comprehensive resources to the care model work locally. Participants were keenly aware of the complexity of the PCMH care model and perceived it to stem in great part from the social, economic and individual characteristics and needs of their patients. Complexity was related to performance indicators (e.g., ED visits, no-shows) and to the multiple and evolving needs of the health centers and safety net agencies involved. Variations emerged by professional role on how participants conceptualized their work in terms of functions versus forms in their daily routine.

Conclusions and Implications. FQHCs were driven by a need to innovate as a way to meet the complex health and social needs of their patients. Flexibility in the implementation and evaluation of PCMH to reflect impact of this care model according to the needs and characteristics of the local communities was highlighted as an important factor needed to increase the likelihood of success in implementing complex interventions. We can increase successful implementation of complex interventions by uncovering local service arrangements and gaining a better understanding of how local systems handle organizational complexity.