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Team functioning as a predictor of patient outcomes in early medical home implementation

Wu, Frances M.; Rubenstein, Lisa V.; Yoon, Jean

doi: 10.1097/HMR.0000000000000196

Background: New models of patient-centered primary care such as the patient-centered medical home (PCMH) depend on high levels of interdisciplinary primary care team functioning to achieve improved outcomes. A few studies have qualitatively assessed barriers and facilitators to optimal team functioning; however, we know of no prior study that assesses PCMH team functioning in relationship to patient health outcomes.

Purpose: The aim of the study was to assess the relationships between primary care team functioning, patients’ use of acute care, and mortality.

Methodology/Approach: Retrospective longitudinal cohort analysis of patient outcomes measured at two time points (2012 and 2013) after PCMH implementation began in Veterans Health Administration practices. Multilevel models examined practice-level measures of team functioning in relationship to patient outcomes (all-cause and ambulatory care-sensitive condition-related hospitalizations, emergency department visits, and mortality). We controlled for practice-level factors likely to affect team functioning, including leadership support, provider and staff burnout, and staffing sufficiency, as well as for individual patient characteristics. We also tested the model among a subgroup of vulnerable patients (homeless, mentally ill, or with dementia).

Results: In adjusted analyses, higher team functioning was associated with lower mortality (OR = 0.92, p = .04) among all patients and with fewer all-cause admissions (incidence rate ratio [IRR] = 0.90, p < 0.01), ambulatory care-sensitive condition-related admissions (IRR = 0.91, p = .04), and emergency department visits (IRR = 0.91, p = .03) in the vulnerable patient subgroup.

Conclusion: These early findings give support for the importance of team functioning within PCMH models for achieving improved patient outcomes.

Practice Implications: A focus on team functioning is important especially in the early implementation of team-based primary care models.

Frances M. Wu, PhD, is Statistical Consultant, Information Support for Care Transformation, Kaiser Permanente, Oakland, California. E-mail:

Lisa V. Rubenstein, MD, MSPH, is Professor of Medicine, VA Greater Los Angeles, and UCLA Senior Scientist, RAND, VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, North Hills, California.

Jean Yoon, PhD, MHS, is Health Economist, Health Economics Resource Center, VA Palo Alto, Menlo Park, California.

Funding for this study was provided by the Department of Veteran Affairs, Veterans Health Administration, Patient Care Services, the VA Improvement and Assessment Laboratory (Project XVA 65-018). Dr. Wu was supported by the VA Office of Academic Affairs and VA HSR&D Service in conjunction with a VA HSR&D Advanced Fellowship. This work was supported by resources at the VA Assessment and Improvement Laboratory, a part of the VA Office of Primary Care’s Demonstration Laboratory Initiative.

At the time of this study, Dr Wu was the Postdoctoral Fellow in Health Services Research, Center for Innovation to Implementation, VA Palo Alto Health Care System; Center for Primary Care and Outcomes Research, Stanford University School of Medicine, California.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

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