142nd APHA Annual Meeting and Exposition

Annual Meeting Recordings are now available for purchase

Using quantitative data to focus medical home facilitation interventions in the Massachusetts Patient Centered Medical Home Initiative (MA PCMHI)

142nd APHA Annual Meeting and Exposition (November 15 - November 19, 2014): http://www.apha.org/events-and-meetings/annual
Wednesday, November 19, 2014 : 9:10 AM - 9:30 AM

Sai Cherala, MD MPH , Commonwealth Medicine, University of Massachusetts Medical School, Shrewsbury, MA
Joan Johnston, RN, CIH, CPE , University of Massachusetts Medical School, Shrewsbury, MA
Jaime Vallejos, MD MPH , University of Massachusetts Medical School, Shrewsbury, MA
Judith Steinberg, MD MPH , Commonwealth Medicine, University of Massachusetts Medical School, Shrewsbury, MA
Christine Johnson, PhD , Commonwealth Medicine, University of Massachusetts Medical School, Shrewsbury, MA

Enhance clinical performance in a Patient Centered Medical Home demonstration by utilizing analysis of quantitative clinical quality measures data at aggregate and practice levels to inform targeted practice facilitation. 


MA PCMHI is a statewide, three-year, multi-payer demonstration involving 45 primary care practices. This is a quality improvement study utilizing practices’ self-reported monthly clinical quality measure data to inform targeted practice facilitation. Data on 22 clinical quality measures from June 2011 through November 2013 were studied.  Measures covered domains of adult diabetes, pediatric asthma, care transitions and care management, and adult prevention.


The data was divided into 10 three-month periods.  Changes in statistical significance of clinical quality data from baseline to Time 9 and baseline to Time 10 were assessed using linear mixed model Analysis of Variance (ANOVA). On aggregate analysis, we identified five measures with a trend toward improvement from baseline to Time 9. These measures included screening for depression and tobacco cessation counseling for adults; self-management goals for adult diabetics, appropriate medications for pediatric persistent asthma and follow-up after hospital discharge. Using ANOVA, we analyzed the individual practice contribution to the aggregate for each of these measures. Practices with negative contributions were targeted for facilitation follow-up; customized interventions were developed and delivered by three medical home facilitators over a three-month period (Time 10). Facilitators used a wide array of tools including: practice-wide assessments, PCMH team based care workflows, Lean trainings and online courses. For example, facilitators encouraged practices with low rates of screening for depression to use root cause analysis to understand the problem and to ensure care team members were working at highest professional levels. Following the PDSA cycle, practices assessed impact of their QI interventions on the measure.


At Time 9, 4 of 22 clinical quality measures showed statistically significant improvement from baseline. At Time 10, 11 of 22 clinical measures showed statistically significant improvement from baseline (including the four measures from Time 9). 

Two of the five chosen measures showing improvement trends by Time 9, demonstrated statistically significant improvement by Time 10 (screening adult patients for depression and documenting self-management goals for adult diabetic patients). 


Thirty months into MA PCMHI, participating practices have shown significant improvement on clinical quality measures. Our analysis suggests that targeted practice facilitation, informed by analysis of practice level and aggregate clinical quality data, may be effective in promoting achievement of practice and initiative goals in PCMH implementation.

Learning Areas:

Conduct evaluation related to programs, research, and other areas of practice

Learning Objectives:
Explain the role of clinical quality measures in the evaluation of Patient Centered Medical Home initiative Explain how analysis of clinical quality measures data can inform medical home facilitation interventions Describe three QI methods that can be used to advance PCMH transformation

Keyword(s): Health Care Reform, Patient-Centered Care

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have been evaluting Massachusets Patient Centred Medical Home Intiative for past 2 years. I have also experience in creating clinical models for other reform intitiaves . My past experience inlcuding working on different chronic disease models.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.