Patient-Centered Care Improves Satisfaction at Teaching Clinics

The results of a recent, cross-sectional study demonstrated improved patient and resident satisfaction at a safety-net teaching clinic during the first year after implementing Galaxy Health Care, a program developed using principles from the patient-centered medical home (PCMH) model of primary care.

Researchers noted that the program did not, however, reduce emergency department utilization or hospitalizations during the study period.

The PCMH model, an approach to providing comprehensive, patient-centered primary care, has previously demonstrated improvements in the primary care setting but has not been adequately tested in a teaching setting.

“As best we can tell, this has been the first attempt at creating patient-centric home within a resident teaching clinic at a public hospital setting,” said senior author David A. Goldstein, MD, chief, division of geriatric, hospital, palliative and general internal medicine, Keck School of Medicine, University of Southern California, Los Angeles.

Galaxy Health, a joint University of California, Los Angeles, and University of Southern California program, was implemented in 2012 at a primary care internal medicine teaching clinic with resident physician healthcare providers at the Los Angeles County + USC Medical Center (LAC+USC). The model provided round-the-clock, seven-day-a-week access to physicians; urgent clinic appointments within hours; and coordinated care in an ambulatory setting.

“We were hopeful that the Galaxy model would demonstrate that with little or no increase in funding, dramatic improvements in patient access, patient, nursing, and physician satisfaction might be achieved,” said Goldstein.

Researchers measured the effect of the PCMH-guided intervention on patient and resident satisfaction by use of the Consumer Assessment of Healthcare Providers and Systems survey and a validated teaching clinic survey, both of which were conducted at baseline and at 1 year after the intervention. The effect on emergency department and hospital utilization were also examined in the study. Researchers used two clinics as controls.

Despite the fact that the intervention clinic did not achieve all of the elements to qualify as a PCMH, its score on the National Committee for Quality Assurance’s PCMH certification tool improved from 35 to 53 of 100 possible points after implementation.

The composite patient satisfaction rating increased from 48% to 65% in the intervention clinic and only from 50% to 59% in the control clinics. “The improvements were particularly notable for questions relating to access,” the authors write. They found, for instance, that patient satisfaction with urgent appointment scheduling increased from 12% to 53% in the intervention clinic and only from 14% to 18% in the control clinics.

Further, the composite resident satisfaction score increased from 39% to 51% in the intervention clinic and decreased from 46% to 42% in the control clinics.

There were no significant differences found in emergency room utilization between the intervention and control clinics. In addition, hospitalizations increased from 26 to 27 visits per 1000 patients per month in the intervention group compared with a decrease from 28 to 25 visits in the control groups.

“I am not surprised that there was no reduction in emergency room or hospital utilization after only one year,” said Goldstein. “Indeed, seeing the utilization be flat is rewarding since it has been well documented that providing enhanced access leads to increases in utilization, at least for the first year or two.”

While addressing the significance of these results, Dr. Goldstein stated, “Already, the other resident adult medicine continuity clinics at our institution are being modified to adapt the Galaxy model. Perhaps other public hospitals in which resident training occurs might see how a reoriented emphasis on patients and their access to care need not be an expensive proposition, and one that is easy to emulate.”

The results may also have an effect on the number of primary care physicians in the future. “If young physicians see that such modifications make their experience in primary care more rewarding for patients as well as themselves, more will choose primary care as their career choice,” said Goldstein.

“At a national level, we are trying to reinvigorate primary care,” added lead study author Michael E. Hochman, MD, MPH, a Robert Wood Johnson Clinical Scholar at UCLA at the VA at the time of this project and currently Medical Director for Innovation, AltaMed Health Services. “We know that health systems with robust primary care infrastructures are more efficient and provide more value to patients. We hope that some of the lessons from this project will help with this.”

“I think we have made some important initial steps in developing primary care at LAC+USC,” said Hochman. “But we can’t stop there. We not only need to keep the momentum going to sustain the Galaxy program, but we need to build on the model to improve all aspects of our primary care delivery system.”

For additional information on the Galaxy Health program and the study, see JAMA Internal Medicine online.

-Meredith Edwards White

Reference

Hochman ME, Asch S, Jibilian A, et al. Patient-centered medical home intervention at an internal medicine resident safety-net clinic. JAMA Intern Med. 2013 Sep 4. doi: 10.1001/jamainternmed.2013