Patient-centered medical home implementation in rural Veterans Affairs clinics: Facilitators and barriers

Objectives: The “Veteran-Centered Medical Home” pilot project sought to implement a patient-centered medical home (PCMH) at rural Veterans Affairs (VA) Community-Based Outpatient Clinics (CBOCs) in Vermont, Maine, and Northern New Hampshire. Goals of the project included increasing veteran access to comprehensive healthcare, improving care coordination, and improving care continuity through office system improvements. We conducted a process evaluation of PCMH implementation to better understand the complexities of practice transformation, including identification of implementation facilitators and barriers.

Methods: We conducted in-depth staff and provider interviews at nine CBOCs, using a semi-structured interview guide to explore PCMH conceptual dimensions (e.g., treatment team structure and functioning, care coordination, access to care), perceived facilitators/barriers to implementation, and perceived changes following implementation. Sampling was purposive to ensure the richest possible data pool. Interviews were audio-taped and transcribed verbatim. Data analysis was conducted with Atlas.ti v6.0 and employed an iterative, constant comparison process of textual review, code development and refinement based on Grounded Theory.

Results: A total of 46 staff completed interviews (mean interview time = 22 minutes, range 10-41). Themes related to facilitators and barriers aligned into 5 categorical areas: personal attributes, interpersonal dynamics, clinic functioning/processes, organizational characteristics, and case manager impact. Facilitating factors were grounded in personal attributes (e.g., personal commitment to the VA mission; work ethic), interpersonal dynamics (e.g., years of staff shared experiences; feeling anchored within small rural communities; feeling supported by clinic leadership), and the perceived value of adding a case manager to the team (e.g., ability of the case manager to commit needed time and focus to complex patient cases).

Implementation barriers often focused on clinic functioning/processes (e.g., availability of adequate staffing numbers/patterns; expressed sense of disconnection from the main VA Medical Center and the resulting barriers related to distal clinic location) and organizational characteristics (e.g., perception of fluctuating leadership commitment to past initiatives; perceived lack of organizational preparation and clarity of vision prior to implementation).

Implications: Interpersonal dynamics in VA clinics seem to have both positive and negative impacts on model implementation. Personal characteristics of the workforce (e.g., commitment to the organizational mission) can be harnessed to facilitate changes, even when faced with limited resources. Leadership, at the local clinic and higher organizational level, must communicate a clear vision of goals prior to implementation. On-going leadership support must be made evident to staff engaged in implementation in order to sustain staff efforts and cultivate locally occurring innovations.