08:11am Saturday 06 June 2020

Unprecedented Experiment on Aligning Primary Care Practices with Health Reform Concludes

After working for two years with 36 practices nationwide, a team of researchers whose leaders included Benjamin F. Crabtree, PhD, professor and chief of the division of research in the department of family medicine and community health at UMDNJ-Robert Wood Johnson Medical School, issued their findings and recommendations on the National Demonstration Project (NDP), which looked at ways to test how practices would have to change to achieve a new model of care. The new care model focuses on integrating technological and team-based care advances into the patients’ ongoing relationship with their personal physician while employing efficient and cost-effective processes.

The NDP sought to transform primary care and family medicine practices into patient-centered medical homes, a popular model of care touted for its fit into the current overhaul and redesign of the United States health care system.  Patient-centered medical homes emphasize patients as partners in managing their health, while clinicians utilize a team-based approach that takes advantage of the larger medical neighborhood to ensure comprehensive delivery of care.

In the two-year study, the evaluation team sought to answer four specific questions:

  • Can the NDP model be built so that primary care practices become patient-centered medical homes;
  • What does it take to build it;
  • Does the NDP model make a difference; and
  • Can the NDP model be widely disseminated to meet the needs of diverse practices, in size, geography and demographics of patients?

“The NDP patient-centered medical home model is largely attainable and can improve the delivery of care to benefit patients while addressing practice management concerns of the physicians,” said Dr. Crabtree, who was the lead author on the summary manuscript and a co-author on the other manuscripts and a member of the evaluation team. “However, after working with more than 70 family physicians nationwide, the evaluation team has determined that transforming the traditional primary care practice is a difficult and time-consuming process.  It is an evolving process that requires effort and self-motivation on behalf of practitioners.”

Transforming a practice requires physicians and their staff to focus on the needs of the practice itself, to continually learn, to regularly communicate and to adapt to improve healthcare delivery. According to the summary, providers must be willing to forgo traditional delivery systems and adapt team approaches to care, within the practice and within a medical neighborhood, in which different types of healthcare professionals work together as a team to improve patients’ health.  This requires major shifts in how practice members see their roles and work together.

“In addition to a personal relationship with a primary care physician, the health of a patient improves when other providers are easily accessible, such as a mental health practitioner or a nutritionist,” added Dr. Crabtree.  

The evaluation team also reports in its findings that delivery system reform incurs a substantial cost that requires funding for infrastructure support in order to successfully redesign a practice. Achieving a patient-centered medical home requires utilization of modern technology and technical components, which many smaller practices are unable to afford, to manage disease knowledge, patient records and financial controls. The study found that too often the new technology is not well implemented because components are unable to work together and practice members do not adjust their roles to take advantage of new features. In addition, according to the findings, the current formula for compensation is a key obstacle to primary care practice development, as it supports the existing model in which finances often take precedence over clinical process.

Moving forward, the evaluation team recommends the patient-centered medical home as a preliminary model for future primary care practices, but cautions that practitioners must be prepared to break with tradition in their approach to healthcare delivery. To that end, professional organizations, policy makers and medical educators must take lead roles in facilitating change system-wide to ensure improved healthcare delivery and practice management. 

Carlos R. Jaén, MD, PhD, the Dr. John M. Smith, Jr. Professor and chair of family and community medicine, professor of epidemiology and biostatistics at University of Texas Health Science Center at San Antonio, TX, served as the senior investigator of the evaluation team along with Dr. Crabtree. The evaluation team also included William L. Miller, MD, MA, Leonard Parker Pool Chair of Family Medicine at Lehigh Valley Health Network, Allentown, PA, and Penn State College of Medicine; Kurt C. Stange, MD, PhD, American Cancer Society Clinical Research Professor, professor of family medicine, epidemiology & biostatistics, sociology and oncology, Case Western Reserve University, Cleveland, OH; Gertrude Donnelly Hess, MD, professor of oncology research, Case Western Reserve University; Elizabeth E. Stewart, PhD, assistant professor, department of family and community medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX; and Paul A. Nutting, MD, MSPH, professor of family medicine, University of Colorado Health Sciences Center, Denver.

The authors comprise an independent evaluation team under contract with the American Academy of Family Physicians.  The terms of the contract give the authors complete discretion for evaluating and disseminating findings of the NDP without review or permission by the AAFP.

The American Academy of Family Physicians supported the two-year NDP, which worked with 36 practices across the country. Half received intensive assistance from change facilitators and half were given access to tools, but were asked to make changes largely on their own.  The eight-paper supplement is the result of extensive qualitative and quantitative data gathered from all 36 practices.  Additional support was provided through a Research Center grant from the American Academy of Family Physicians and The Commonwealth Fund, a national, private foundation that supports independent research on health care issues.



As one of the nation’s leading comprehensive medical schools, UMDNJ-Robert Wood Johnson Medical School is dedicated to the pursuit of excellence in education, research, health care delivery, and the promotion of community health. In cooperation with Robert Wood Johnson University Hospital, the medical school’s principal affiliate, they comprise New Jersey’s premier academic medical center. In addition, Robert Wood Johnson Medical School has 34 other hospital affiliates and ambulatory care sites throughout the region.

As one of the eight schools of the University of Medicine and Dentistry of New Jerseywith2,800 full-time and volunteer faculty, Robert Wood Johnson Medical School encompasses 22 basic science and clinical departments, hosts centers and institutes including The Cancer Institute of New Jersey, the Child Health Institute of New Jersey, the Center for Advanced Biotechnology and Medicine, the Environmental andOccupational Health Sciences Institute, and the Stem Cell Institute of NewJersey. The medical school maintains educational programs at the undergraduate, graduate and postgraduate levels for more than 1,500 students on its campuses in New Brunswick, Piscataway, and Camden, and provides continuing education courses for health care professionalsand community education programs.  To learn more about UMDNJ-Robert Wood Johnson Medical School, log on to rwjms.umdnj.edu. Find our fan page at http://www.Facebook.com/RWJMS and follow us on Twitter www.twitter.com/UMDNJ_RWJMS.


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