Implementing Effective Care Management in the Patient-Centered Medical Home

Background: There is growing evidence that practice-based care management can improve clinical quality and reduce costly healthcare utilization.

Objectives: To explore how a disparate group of patient-centered medical homes (PCMHs) embedded care management in their team care environment to identify best practices.

Study Design: A positive deviance approach was used to contrast care management implementation in practices having the greatest and least improvement on clinical measures of diabetes, the initial target disease for a multipayer-supported statewide initiative involving 25 National Committee on Quality Assurance–recognized PCMH practices participating in a regional learning collaborative.

Methods: Practices were ranked according to their average absolute percentage point increase from baseline to 18 months on 3 diabetes quality measures. Semistructured interviews were conducted with 136 individuals in 21 of the 25 practices. Interview data were analyzed using grounded theory with NVivo 9.0 software. To develop hypotheses related to care management best practices, we compared and contrasted emerging themes across clinical performance tertiles.

Results: Practices with the greatest diabetes improvement described (1) more patient-centered care manager duties, (2) better use of the  electronic medical record (EMR) for messaging and patient tracking, and (3) stronger integration of the care manager into the care team compared with practices with the least diabetes improvement. Conclusions: PCMHs may want to ensure that care managers are available to meet with patients during visits, support patient self-management, fully leverage the EMR for team messaging and patient tracking, and ensure integration into the care team with office huddles and ongoing communication.