A lean approach to advancing the patient-centered medical home model at a community health center

The patient-centered medical home (PCMH) has emerged as an innovative primary care model that promotes the financing and delivery of comprehensive, patient-focused, coordinated care across the lifespan. As primary care practices face increasing demands for services and resource shortages, many are adopting the PCMH model in an effort to control costs, improve quality, and provide more efficient and effective care for patients. Transformation to a PCMH represents the implementation of multiple, interconnected elements related to patient services and practice organization. Each element requires significant changes to work processes and staff roles, such as developing multidisciplinary care teams, offering alternative scheduling arrangements, using patient registries, and tracking clinical outcomes. Research studies have evaluated the effectiveness of the PCMH model and the prevalence of PCMH elements in medical practices. However, few have assessed how these practices have incorporated features of the PCMH model into the delivery of health care. This study assessed the process and short-term outcomes associated with the use of lean continuous process improvement strategies to advance the PCMH model at a large, multi-site community health center. Specifically, we examined how lean training and value stream mapping, a tool used to analyze process flow and increase value-added work, were used to institute changes needed to meet the following PCMH requirements: team-based approach to care, population risk stratification and management, and practice-integrated care management. Over an 18-month period, mixed quantitative and qualitative data collection methods were used. Semi-structured interviews were conducted with a purposive sample of 50 organizational leaders, physicians, and frontline staff. On a monthly basis, secondary data were gathered on primary care supply and demand, “third next” available appointment, office visit cycle time, and the patient no show rate. Together, the findings suggest that lean was useful in advancing the PCMH model at this health center by: (1) providing structure, focus, and a shared vision; (2) increasing awareness of staff roles and responsibilities; (3) identifying and removing barriers necessary to implement changes; (4) establishing accountability; and (5) maintaining momentum among the staff making changes. In addition, the use of lean to advance the PCMH model may be associated with positive changes in indicators of operational processes, such as access to care and cycle time. The implications of these findings for primary care practices, particularly community health centers, will be discussed as the PCMH model continues to evolve in the health care system.