Patient-centered medical home implementation and sustainability in clinics serving vulnerable patients

The patient-centered medical home is an effective model for improving care and reducing costs. Yet, limited literature and evidence describes implementation and sustainability in non-private health care systems. Essential providers, those who care disproportionately for underserved, vulnerable patients, face a number of barriers to implementing this model due to resource constraints and complex patient populations. We sought to better understand the motivating factors, trends in adapting the model, and results experienced by essential providers when implementing the medical home.

We examined the experiences of four essential health systems that successfully implemented the medical home model. Individual and group interviews were conducted following a standard interview guide across four sites. From these interviews, we then identified recurring themes as well as key similarities and differences between each health system’s experiences.

We found that these providers all experienced unique motivational factors which led them to medical home implementation. Additionally, each site has tailored the model to fit their patient population, provider, and institutional needs through multidisciplinary team-based care, risk stratification, and integrating community and social services. To date, these tailored models have yielded positive outcomes for patients and staff. Overall, the patient-centered medical home is not a perfect model but, when tailored to patient and provider needs, can be an effective care delivery model for improving outcomes in underserved, complex patient populations.