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Care Management and Care Coordination Within a Patient-Centered Medical Home
Bonnie J Wakefield1, Michelle A Lampman, Monica B Paez
1Author Affiliations: Investigator (Dr Wakefield), Veterans Integrated Service Network 23, Primary Care Analytic Team (PCAT), VA Office of Patient Care Services, Iowa City VA Healthcare System, Iowa; Associate Professor (Dr Wakefield), Sinclair School of Nursing, University of Missouri, Columbia; Investigator (Dr Lampman), Veterans Integrated Service Network 23, PCAT, VA Office of Patient Care Services, Iowa City VA Healthcare System, Iowa; Assistant Professor (Dr Lampman), Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Ethnographic Methods and Implementation Core (EMIC) Program Manager (Ms Paez), Veterans Integrated Service Network 23, PCAT, VA Office of Patient Care Services, and The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City VA Healthcare System, Iowa; Director (Dr Stewart), Veterans Integrated Service Network 23, PCAT, VA Office of Patient Care Services, Iowa City VA Healthcare System, Iowa; and Professor (Dr Stewart), Tippie College of Business, University of Iowa, Iowa City.
Objective:
The aim of this study was to analyze perceptions and experiences of clinicians implementing the patient-centered medical home (PCMH).
Background:
The PCMH model focuses on several important concepts, including team-based care management as well as care coordination and continuity among providers and across settings of care.
Methods:
A qualitative analysis of data collected in 2016 from primary care personnel through a national survey was conducted.
Results:
Four themes were found consistent with care management and care coordination: the importance of teamwork and optimized team member roles, need for adequate prioritization of care management and care coordination, need to refine tools and resources supporting care management and care coordination, and challenges with managing and coordinating care with and across complex systems.
Conclusions:
Successful implementation requires adequate support for teamwork and ensuring team members can work according to their clinical competency. Nurses practicing in expanded roles need clear role guidelines and adequate time to function in these roles.
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