The use of evidence-based care management processes (CMPs) in physician practice is an important component of delivery-system reform. The authors used data from a 2006-2007 national study of large physician organizations—medical groups and independent practice associations (IPAs) to determine the extent to which organizations use CMPs, and to identify external (market) influences and organizational capabilities associated with CMP use. The study found that physician organizations use about half of recommended CMPs, most commonly disease registries, specially trained patient educators, and performance feedback to physicians. Physician organizations that reported participating in quality improvement programs, having a patient-centered focus, and being owned by a hospital or health maintenance organization used more CMPs. IPAs and very large medical groups used more CMPs than smaller groups. Organizations externally evaluated on quality measures used more CMPs than other organizations. These findings can inform efforts to stimulate the adoption of best practices for chronic illness care. This article, submitted to Medical Care Research and Review on February 10, 2009, was revised and accepted for publication on October 1, 2009.

This study sought to identify factors that increase or decrease patient time with a physician, determine which combinations of factors are associated with the shortest and longest visits to physicians, quantify how much phy-sicians contribute to variation in the time they spend with patients, and assess how well patient time with a physician can be predicted. Data were acquired from a modified replication of the 1997–1998 National Ambulatory Medical Care Survey, administered by the Kentucky Ambulatory Network to 56 primary care clini-cians at 24 practice sites in 2001 and 2002. A regression tree and a linear mixed model (LMM) were used to dis-cover multivariate associations between patient time with a physician and 22 potentially predictive factors. Patient time with a physician was related to the number of diagnoses, whether non-illness care was received, and whether the patient had been seen before by the physi-cian or someone at the practice. Approximately 38 % of the variation in patient time with a physician was accounted for by predictive factors in the tree; roughly 33 % was explained by predictive factors in the LMM, with another 12 % linked to physicians. Knowledge of patient characteristics and needs could be used to sched-ule office visits, potentially improving patient flow through a clinic and reducing waiting times. Key words: visit length, time with a physician, primary care, National

Patient-centered medical homes (PCMHs) have been endorsed by primary and specialty care medical associations, payers, and patient groups as an innovative structure for transforming health care de-livery. The cornerstone principle of the PCMH is the primary care physician’s coordination of a patient’s use of health care services, including visits to specialists, to improve effectiveness and effi-ciency. This principle aligns with the vision behind the creation of HMOs, managed care organizations that were once embraced by physicians, patients, and policy analysts but have since lost much of their luster. Many patients and physicians rejected HMOs as too restrictive, objecting particularly to the concept of gatekeeping. This article reviews the HMO experience and identifies lessons applicable to PCMHs that build on the strengths of HMOs while avoiding their mistakes. Ann Intern Med. 2010;152:182-185. www.annals.org

(PCMH) is a widely endorsed model of delivery system reform that emphasizes primary care. Pilot demonstration projects are underway in many states, sponsored by Medicare, Medicaid, major health plans and multi-payer coalitions. METHODS: In this paper we consider the development of a long-term policy-relevant research agenda on outcomes of the PCMH. We provide an overview of potential measures of PCMH impact, identify measurement challenges and recommend areas for further study. Although the PCMH should not be expected to solve every problem in the health care system, developing a research agenda for measuring outcomes of delivery system innovations such as the PCMH should be considered in the context of the larger effort to improve the US health care system, with the ultimate goal to improve population health. RESULTS: As a framework for our discussion, we have chosen the Institute of Medicine’s six specific aims for 21st century health care: (1) safe, (2) effective, (3) patientcentered, (4) timely, (5) efficient and (6) equitable. In addition, we include potential areas of PCMH outcomes that do not easily fall under this framework and consider unintended consequences. CONCLUSION: Multi-stakeholder involvement will be essential in developing a long-term policy-relevant research agenda for outcomes of the PCMH. KEY WORDS: patient-centered medical home; outcomes; primary care; physician practice; health reform (or payment reform).

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© Cameron G. Shultz 2012 ii To my parents, wife, and children: Thank you, and I love you

Purpose: Transforming a primary care practice into a patient-centered medical home (PCMH) is a re-source-dependent endeavor. The objective of our study was to evaluate a facilitation model used to sup-port rural primary care practices during a redesign of their processes to achieve recognition as National Center for Quality Assurance PCMHs. Methods: The model was a collaboration between Community Care of North Carolina and a local uni-versity where undergraduate students worked directly with practices under the guidance of a Commu-nity Care of North Carolina PCMH Team. Results: The facilitation model resulted in positive outcomes for both primary care practices and students. Conclusions: Partnerships between care networks, agencies, payers, or practices and universities or colleges can yield mutual benefits and should be explored. (J Am Board Fam Med 2013;26:784–786.)

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PURPOSE Numerous primary care practice development efforts, many related to the patient-centered medical home (PCMH), are emerging across the United States with few guides available to inform them. This article presents a relation-ship-centered practice development approach to understand practice and to aid in fostering practice development to advance key attributes of primary care that include access to fi rst-contact care, comprehensive care, coordination of care, and a personal relationship over time. METHODS Informed by complexity theory and relational theories of organiza-tional learning, we built on discoveries from the American Academy of Family Physicians ’ National Demonstration Project (NDP) and 15 years of research to understand and improve primary care practice. RESULTS Primary care practices can fruitfully be understood as complex adaptive systems consisting of a core (a practice’s key resources, organizational structure, and functional processes), adaptive reserve (practice features that enhance resil-ience, such as relationships), and attentiveness to the local environment. The effectiveness of these attributes represents the practice’s internal capability. With adequate motivation, healthy, thriving practices advance along a pathway of slow, continuous developmental change with occasional rapid periods of trans-formation as they evolve better fi ts with their environment. Practice development is enhanced through systematically using strategies that involve setting direction and boundaries, implementing sensing systems, focusing on creative tensions, and fostering learning conversations. CONCLUSIONS Successful practice development begins with changes that strengthen practices ’ core, build adaptive reserve, and expand attentiveness to the local environment. Development progresses toward transformation through enhancing primary care attributes. Ann Fam Med 2010;8(Suppl 1):s68-s79. doi:10.1370/afm.1089.

As the US health care delivery system undergoes rapid transformation, there is an urgent need to define a comprehensive, evidence-based role for the family physician. A Role Definition Group made up of members of seven family medi-cine organizations developed a statement defining the family physician’s role in meeting the needs of individuals, the health care system, and the country. The Role Definition Group surveyed more than 50 years of foundational manuscripts including published works from the Future of Family Medicine project and Key-stone III conference, external reviews, and a recent Accreditation Council on Graduate Medical Education Family Medicine Milestones definition. They devel-oped candidate definitions and a “foil ” definition of what family medicine could become without change. The following definition was selected: “Family physi-cians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health. ” This definition will guide the second Future of Family Medicine project and provide direction as family physicians, academicians, clinical networks, and policy-makers negotiate roles in the evolving health system.