Understanding adaptations to patient-centered medical home activities: The PCMH adaptations model

Primary care practices have increasingly adopted the patient-centered medical home (PCMH) model and often adapted quality improvement efforts to fit local context. This paper implemented a modified framework for understanding adaptations in the context of primary care PCMH transformation efforts. We combined an adaptations model by Stirman et al. that categorized adaptations to evidence-based interventions in research studies with dimensions from the RE-AIM framework, as well as items specific to PCMH. The resulting constructs were translated into a "plain English" adaptations interview. We conducted interviews with 27 practices and used resulting descriptive categories to inform exploratory analyses of the relationships between adaptation characteristics and improvement outcomes in PCMH domains of team-based care and data capacity. Practices most commonly focused on development and use of disease registries and enhancements to team-based care (not disease-specific outcomes). Adaptations were common, with practices most frequently making changes to format or personnel. Adaptations were most often intended to increase effectiveness and based on pragmatic considerations. Generally similar adaptation themes emerged across different content topics (registry and quality improvement team). Adaptations initiated or carried out by the entire team or made in early to middle stages of the project were most related to outcome measures of team-based care and data capacity. This paper extends adaptation models from specific interventions in research studies to PCMH quality improvement efforts. Despite limitations, the PCMH Adaptations Model provided a useful framework to understand adaptations in this context.