Beyond PCMH: Case Studies of Emergence, Self-Organization, & Co-Evolution in Primary Care Innovation.

Context: The Patient-Centered Medical Home (PCMH), the dominant innovation seeking to rebuild primary care, is 10 years old. Reviews of its performance raise many concerns. Are some variations of the PCMH more effective than others? Are there other emerging organizational innovations that may be better? Objective: To compare PCMH models and other innovative configurations of primary care that have emerged and co-evolved in the United States over the past decade to identify features for future transformation efforts. Design: An exploratory comparative case study of advanced primary care practices recruited from March 2015 to March 2017. Researchers conducted 10-12 days of ethnographic data collection in each practice, including interviews with practice personnel and observations of practice operations and patient visits. Fieldnotes, transcripts, and practice documents were analyzed across cases to identify salient themes. Setting: Nationally recognized advanced PCMHs and other emerging innovative non-PCMH models from across the continental U.S. Patients or Other Participants: Fourteen practices purposively selected from a national registry of 151 workforce innovators compiled for Robert Wood Johnson Foundation. Practices recruited to maximize diversity in policy context and organizational structure. Intervention/Instrument: NA. Main and Secondary Outcome Measures: Features that appear to optimize quadruple aim of better health, better care, lower cost, and more joy. Results: 10 practices self-described as PCMHs; whereas, the others included a nurse-led FQHC, two direct care models and a Medicare Advantage contract model self-organized around health coaches. All practices accentuated relationships and had high levels of internal motivation; however, practices that chose not to self-organize around the principles of the PCMH also emphasized smaller scale and different attractors. Conclusions: It may be time to learn from emerging new practice innovations and move beyond the PCMH. More systematic mixed-method evaluation of emerging models is needed