Strong Foundation Key to Expansion of Medical Home Teams

TOPLINE:

Veterans Affairs (VA) piloted three new patient-centered medical home (PCMH) models adding new team roles and increasing panel sizes. Implementation revealed that basic structure and processes must be in place first, while physical therapist and high-risk care manager roles were valuable additions for improving care delivery and team efficiency.

METHODOLOGY:

• Researchers conducted a qualitative study to describe the experiences of frontline staff in integrating new team members into established PCMH teams and to identify challenges during the implementation of the expanded models.
• The selected pilot sites received funding for hiring new roles and implementation support, including coaching, written guidance on implementation best practices, and feedback through regular calls and site visits.
• Semi-structured interviews were conducted with 25 frontline staff across six VA sites in 2022, approximately 1 year after the implementation of the modernization pilot.
• The interviews covered topics such as barriers and facilitators to implementation and sustainability, perception of patient experiences, integration of new team roles, and team functioning.
• Participants included physicians, nurses, physical therapists, high-risk care managers, and other staff members, yielding a participation response rate was 74%.

TAKEAWAY:

• Prior to the implementation of new models, participants at all sites described a lack of adherence to foundational PCMH principles, such as full teamlet staffing, huddling, and pre-visit planning. Staffing shortages before the pilot coupled with difficulties in filling the new roles outlined in the pilot model further complicated implementation efforts.
• Lack of role clarity emerged as a barrier to team functioning and implementation of the modernization pilot across all sites, particularly affecting nursing roles where task overlaps created coordination challenges among registered nurses, licensed practical nurses, and high-risk care managers.
• The roles of physical therapists and high-risk care managers were recognized as valuable additions.
• Matching the panel size expansion with adequate staffing support was considered essential for optimizing team efficiency while increasing healthcare access.

IN PRACTICE:

“Existing issues with adherence to the foundational PCMH model and role clarity will need to be resolved for team members to operate efficiently and at the top of their license,” the authors wrote. “High-risk care managers embedded in PCMH teams could play a vital role in addressing complex patient care needs,” they added.

SOURCE:

This study was led by Neetu Chawla, PhD, MPH, of the HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy at VA Greater Los Angeles Healthcare System, Los Angeles. It was published online on March 17, 2025, in the Journal of General Internal Medicine.

LIMITATIONS:

The availability of frontline staff and their responses to invitations to participate in the study affected the ability to achieve even sampling. The generalizability of the findings across the VA healthcare system was limited due to the lack of randomization of the pilot model sites. 

DISCLOSURES:

This study was funded by the VA Office of Primary Care and was undertaken as part of the US Department of Veterans Affairs. The authors declared having no conflicts of interest. 

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.