Understanding the Local Context As the Missing Link in Evaluating Patient Center Medical Homes: A Qualitative Study

Background and Purpose: As health care services shift towards a team-based model of care delivery, the Patient-Centered Medical Home (PCMH) care model is a viable intervention that aims to be patient-centered, quality focused and coordinated. While a team-based and comprehensive approach to care are notable characteristics of the model, the challenges with on-the-ground PCMH implementation are not well understood, particularly those pertaining to how local context impacts the process and evaluation of the model. Since it has long been established that the cultural context in which an activity, project, or program operates impacts the planning, design, execution, and reporting of an evaluation it becomes imperative to explore the challenges experienced on the ground to inform future PCMH implementation and evaluation efforts. The purpose of the study was to understand the participant’s perceptions of: 1) the local contextual factors that hinder or facilitate PCMH implementation and evaluation.   

Methods: Semi-structured interviews (n=14) were conducted with a purposive sample of service providers, care coordinators, clinic managers, and quality improvement and evaluation personnel employed at one of four community-based FQHCs operating in Southern California serving under resourced communities. The interview guide included questions about the challenges and facilitators in implementing medical home care, and participants’ priorities on how medical homes can be best evaluated according to the needs of the service provider, the patients, and of the local community. Interviews were transcribed using pseudonyms and text analyzed using excel tables and NVivo software 12.

Findings: Results revealed that conceptually participants viewed the PCMH model of care as a promising framework that outlines a team-based and comprehensive approach to care. However, in practice, participants shared concerns with the complexity that emerges with PCMH implementation and evaluation. Participants expressed that contextual factors unique to a provider’s operational environment (i.e., population and community needs, organizational capabilities) can increase the complexity in PCMH implementation and evaluation.  For instance, participants expressed that some of the conventional methods and metrics of evaluating PCMH may not capture the full extent of a provider’s effort and impact. To address these concerns, participants highlighted a need for evaluation approaches that consider the local context in which PCMH care is delivered and is responsive to; increases key stakeholder engagement (e.g., patients, community members, staff, partners) throughout the PCMH process continuum (e.g., planning, reporting); and that gives providers the flexibility to capture key outcomes of high need patients with co-occurring health conditions.

Conclusion and Implications: Results from the study identified challenges that emerge with PCMH implementation and evaluation, and indirectly highlighted culturally responsive evaluation approaches as the missing link in improving PCMH implementation and evaluation. This knowledge supports future PCMH implementation efforts by confirming the literature that local context matters and that developing evaluation approaches that are responsive to the needs of the provider, patients, and local communities may increase the success of PCMH implementation as well as in capturing a broader picture of the successes on the ground.