Evaluation of an Advanced Patient-Centered Medical Home Model at Kaiser Permanente Los Angeles Medical Center

Background/Aims: Organizing cost-effective patient-centered care for individuals with complex medical and social needs continues to be challenging for many health care systems. The patient-centered medical home (PCMH) is a popular model that emphasizes enhanced access to team-based comprehensive and coordinated care that actively engages patients and their families in self-care and that which is supported by appropriate tools and technologies to facilitate proactive population-based management. Operationalizing these core principles into sustainable practice beyond mere attainment of national recognition is still the subject of intensive experimentation across many health systems, including Kaiser Permanente Southern California (KPSC). The aim of this study is to evaluate the effects of an enhanced PCMH care model at one medical center in KPSC. Methods: We will use a retrospective propensity-score matched control design to compare changes in the primary composite outcome of hospitalizations and emergency department visits in the 12 months before and after Advanced-PCMH implementation. The care transformation included changes to the structures, functions, roles/responsibilities of the care team, workflows and processes of care; chief among these changes was formalizing the role of a care navigator and embedding social medicine resources and behavioral health within primary care. Advanced-PCMH was implemented in two primary care modules with 14 providers. A total of 300 patients who were high utilizers of hospital-based services in the previous six months or at increased risk for use of hospital-based services due to their utilization patterns in the previous six months and patients who were 90 years of age or older were enrolled. Approximately 600 patients will be selected from five comparable primary care modules to serve as controls. We also will measure level of exposure to Advanced-PCMH care elements, standard quality-of-care processes, behavioral and clinical outcomes, patient satisfaction, quality of end-of-life care, and perceptions of team functioning, satisfaction and level of burnout by providers. Results: We are in the process of extracting the data and will have results available at the meeting in March 2015. Discussion: Findings from this evaluation will inform future efforts in our system to achieve the triple aim of better care and outcomes at potentially lower cost