Original Research

Supporting Primary Care Patient-Centered Medical Homes with Community Care Teams: Findings from a Pilot Study

Journal of Clinical Outcomes Management. 2014 August;21(8)

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_CCT-MNGT= 16.93, P < 0.001, OR = 0.26, SE = 0.08; χ ²_CCT-DCREC= 10.43, P = 0.001, OR = 0.41, SE = 0.11; admission: χ ²_CCT-MNGT = 15.99, P < 0.001, OR = 0.32, SE = 0.09; χ ²_CCT-DCREC= 137.53, P < 0.001, OR = 0.05, SE = 0.01). Moreover, there were no 30-day readmissions for the non-engaged CCT patients during the post period and so the 2 groups could not be compared. Consequently, each group was analyzed separately with pre-post comparisons ( Table 5 ). There was no significant change in the probability of an ED visit for any group. For all groups, the odds of an unplanned admission was significantly reduced in the post versus the pre period for both non-engaged CCT patients (OR _CCT-MNGT = 0.28, SE = 0.11; OR _CCT-DCREC= 0.19, SE = 0.06) and CCT-engaged patients (OR _CCT-MNGT= 0.55, SE = 0.13; OR _CCT-DCREC= 0.08, SE = 0.02), although this effect was notably large for the CCT-DCREC group. There was also a significant reduction in the probability of a readmission over time for CCT-DCREC group only, OR = 0.65, SE = 0.13.

Discussion

The empirical literature indicates that PCMH practice transformation is a long, effortful process, the effects of which are not quick to manifest [20–22]. In this context, the results of the preliminary evaluation of the CCT pilot were encouraging: team-based care in the form of CCTs can be effectively used to support population health management. Overall, the results at the practice level suggest that PCMH transformation alone may be effective in creating improvements in patient care and cardiac disease (there were improvements in 3 out of 4 care gap measures and 1 disease measure for both CCT and non-CCT practices), but the presence of CCT appears necessary to reduce unplanned admissions and readmissions, at least among high-risk patients. Of course, this reduced utilization at the practice level could also be due to selection bias (practices with the longest PCMH involvement were selected for the CCT pilot) and it awaits to be seen if this finding holds as CCTs are deployed to more practices. Still, similar evidence for the CCT was found at the patient level. The probability of an unplanned admission was reduced for all groups of patients from CCT practices; however, this effect was notably large only for patients who received hospital discharge reconciliation calls from the CCT. Moreover, the only group that had a significant reduction in the probability of a 30-day readmission was also patients who received hospital discharge reconciliation calls from the CCT. Both results suggest an added benefit of CCT engagement. Although there was no change in the probability of an ED visit for any group, the CCT staff indicated that there was a substantial minority of CCT-engaged patients who were not accessing the ED when they should have been and it might be that increased appropriate use by this minority due to CCT coaching therefore cancelled out expected reductions in ED use among other CCT patients.