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Essays on the Patient-Centered Medical Home in the United States Military Health System

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Essays on the Patient-Centered Medical Home in the United States Military Health System University of Nebraska Medical Center DigitalCommons@UNMC Theses & Dissertations Graduate Studies Fall 12-14-2018 Essays on the Patient-Centered Medical Home in the United States Military Health System Glen N. Gilson University of Nebraska Medical Center Follow this and additional works at: https://digitalcommons.unmc.edu/etd Part of the Health and Medical Administration Commons Recommended Citation Gilson, Glen N., "Essays on the Patient-Centered Medical Home in the United States Military Health System" (2018). Theses & Dissertations. 317. https://digitalcommons.unmc.edu/etd/317 This Dissertation is brought to you for free and open access by the Graduate Studies at DigitalCommons@UNMC. It has been accepted for inclusion in Theses & Dissertations by an authorized administrator of DigitalCommons@UNMC. For more information, please contact [email protected]. Essays on the Patient-Centered Medical Home in the United States Military Health System by Glen Gilson A DISSERTATION Presented to the Faculty of The University of Nebraska Graduate College in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Health Services Research, Administration & Policy Graduate Program Under the Supervision of Professor David W. Palm University of Nebraska Medical Center Omaha, Nebraska November, 2018 Supervisory Committee: David W. Palm, Ph.D. Fernando A. Wilson, Ph.D. Thomas G. Tape, M.D. Hyo Jung Tak, Ph.D. i ACKNOWLEDGEMENTS I would like to express my sincere gratitude to my advisor, Dr. David Palm, for his excellent mentoring, continuous support and boundless patience. I would also like to acknowledge my wife, Jamie, and thank her for her patience and encouragement. There were several people who were instrumental in helping me acquire the necessary data, specifically I’d like to thank Stephen Greentree and Jacob Dunham. I would also like to thank my Army-Baylor colleagues for their support and for being a sounding board as I struggled through the analysis. Finally, I would be remiss if I did not mention the rest of my committee, Dr. Thomas Tape, Dr. Fernando Wilson and Dr. Hyo Jung Tak for their patience and feedback during my, at times glacial, progress. DISCLAIMER While it should not create a bias, in the interests of full disclosure, it should be noted that the author of this dissertation is an officer in the United States Air Force (USAF). The views expressed in this dissertation are those of the author and do not reflect the official policy or position of the USAF, Department of Defense or the U.S. Government. Essays on the Patient-Centered Medical Home in the Military Health Service Glen Gilson, Ph.D. University of Nebraska, 2018 Supervisor: David W. Palm, Ph.D. The Patient-Centered Medical Home has been endorsed by the primary care community as the model of the future, with hopes that it will increase quality of care and the patient and provider experience while decreasing costs. Many aspects of the implementation of the Patient- Centered Medical Home model remain unexplored. This dissertation comprises three independent studies examining Patient-Centered Medical Home implementation in the Military Health System, including (1) the effects of environmental correlates on the time to implement the model, (2) the impact of differences in implementation on preventive care quality outcomes, and (3) the effect of differences in implementation on chronic care quality outcomes. Survival analysis was utilized to analyze the effect of environment, defined as resources and governance, on how long it took Military Health System clinics to adopt the Patient-Centered Medical Home model. Clinics were assumed to have adopted the model when they achieved National Committee on Quality Assurance recognition. Differences-in-differences models were created to compare both preventive and chronic care quality outcomes in Military Health System clinics by branch of service before and after Patient-Centered Medical Home implementation. Dependent variables included Chlamydia and various cancer screenings as well as heart condition and diabetes care HEDIS metrics. Measures were drawn from Military Health Mart, a patient- level utilization database, and aggregated at the clinic level. SPSS was used to analyze the data and we considered a p-value of less than .05 as statistical significance. Our research suggests that, while the environmental correlates of resources and governance did impact the time to adoption of the Patient-Centered Medical Home model, differences in how the model was implemented had mixed results on both preventive and chronic care quality outcomes. The differences in significant measures were small. More research is needed on cost, utilization and patient/provider satisfaction to assess the impact of implementation differences. ii TABLE OF CONTENTS ACKNOWLEDGEMENTS .............................................................................................................. i DISCLAIMER .................................................................................................................................. i TABLE OF CONTENTS ................................................................................................................. ii LIST OF FIGURES ........................................................................................................................ iv LIST OF TABLES ........................................................................................................................... v LIST OF ABBREVIATIONS ........................................................................................................ vii CHAPTER 1: INTRODUCTION .................................................................................................... 1 CHAPTER 2: ENVIRONMENTAL CORRELATES OF PATIENT-CENTERED MEDICAL HOME IMPLEMENTATION IN THE UNITED STATES MILITARY HEALTH SYSTEM...... 5 INTRODUCTION ....................................................................................................................... 5 THEORY ..................................................................................................................................... 5 LITERATURE REVIEW .......................................................................................................... 10 METHODS ................................................................................................................................ 11 RESULTS .................................................................................................................................. 16 DISCUSSION ............................................................................................................................ 18 CONCLUSION .......................................................................................................................... 20 CHAPTER 3: EXAMINING THE EFFECT OF PATIENT-CENTERED MEDICAL HOME ON PREVENTIVE CARE MEASURES IN THE MILITARY HEALTH SYSTEM ......................... 21 INTRODUCTION ..................................................................................................................... 21 METHODS ................................................................................................................................ 24 iii RESULTS .................................................................................................................................. 28 DISCUSSION ............................................................................................................................ 38 CONCLUSION .......................................................................................................................... 41 CHAPTER 4: EXAMINING THE EFFECT OF PATIENT-CENTERED MEDICAL HOME ON CHRONIC CARE MEASURES IN THE MILITARY HEALTH SYSTEM ............................... 42 INTRODUCTION ..................................................................................................................... 42 METHODS ................................................................................................................................ 43 RESULTS .................................................................................................................................. 48 DISCUSSION ............................................................................................................................ 60 CONCLUSION .......................................................................................................................... 62 CHAPTER 5: POLICY IMPLICATIONS ..................................................................................... 63 BIBLIOGRAPHY .......................................................................................................................... 65 iv LIST OF FIGURES Figure 1: Organizational Structure of the Health Systems of the Department of Defense................................................................................................................................9 Figure 2: Overall Conceptual Model of Organizational and Environmental Factors Affecting Performance…………………………………………………………….……..10 Figure 3: Relationship of Clinic Size to Length of Time for PCMH Certification….…..16 Figure 4: Relationship of Clinic Ownership to Length of Time to PCMH Certification……………………………………………………………………………...17 v LIST OF TABLES TABLE 1: Joint Principles of the Patient-Centered Medical Home ................................... 2 Table 2: Ownership of Facility by size ............................................................................
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