Medical home interventions and quality outcomes for older adults: a systematic review.

Q Manage Health Care Vol. 23, No. 4, pp. 226–239 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Medical Home Interventions and Quality Outcomes for Older Adults: A Systematic Review Matthew J. DePuccio, MS; Timothy J. Hoff, PhD Purpose: Medical home care has been identified as a model for improving primary care delivery and population-specific quality and safety outcomes. Questions remain how this model affects older adult quality. This systematic review addresses 2 important questions: Are quality and safety outcomes associated with medical home and patient-centered interventions, and how is quality studied in older adult primary care research? Methods: The authors searched MEDLINE for articles that examined interventions that were associated with medical home principles. Each article was evaluated using a standardized data abstraction form. Studies were categorized according to how interventions influenced specific quality and safety outcomes—improved clinical and treatment measures and care delivery processes—for older adults. Results: Thirteen research studies were identified by the authors. A great deal of variety exists in both research design and how quality and safety outcomes for older adults are operationalized in primary care. In general, studies indicate potentially beneficial relationships between 3 types of medical home interventions targeting health care utilization, disease management, and patient-provider communication to improved quality outcomes. Conclusion: It would be advantageous for practices looking to align with patient-centered medical home quality and safety goals to consider the needs of older adults when redesigning care delivery.

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here has been less than optimal progress in reaching select quality goals set forth by the Institute of Medicine, especially in primary care in which there are increased administrative requirements, implementation of new delivery models, and decreased reimbursements that affect the attention and resources around improving quality.1 Some of the desired quality goals include appropriate treatment, effective disease management, and ongoing care coordination.2 Meeting these quality goals has important implications for primary care delivery systems and patient populations alike. For this reason, it is worthwhile to understand how specific types of care delivery interventions improve patient outcomes and/or improve practice capabilities to provide quality and safe care. At the patient level, those aged 65 years or older may suffer from comorbidities and chronic conditions that need constant management to maintain their quality of life and to reduce the likelihood of being admitted to the hospital.3 The combination of physical and mental disorders may hinder an older adult’s ability to control certain chronic

Author Affiliations: Department of Health Administration, Virginia Commonwealth University, Richmond, Virginia (Mr DePuccio); and Northeastern University, D’AmoreMcKim School of Business and School of Public Policy and Urban Affairs, Boston, Massachusetts (Dr Hoff). Correspondence: Matthew J. DePuccio, MS, Department of Health Administration, Virginia Commonwealth University, PO Box 980203, Richmond, VA 23298 ([email protected]). The authors thank Donna Tarman for her editorial assistance with the manuscript. Reprinted from QMHC Vol. 22, No. 4, pp. 327–340.

Key words: literature review, medical home, older adult, patient-centered care, quality

The authors declare no conflicts of interest. DOI: 10.1097/QMH.0000000000000041

226 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Medical Home Interventions and Quality Outcomes for Older Adults

diseases and may lead to greater health care utilization and mortality.4,5 Primary care plays an important role in providing necessary specialty referrals,6 managing safe medication regimens,7 assessing the risk of falling,8 and providing cancer screenings, influenza vaccinations, and counseling services for older adults.9-11 Unfortunately, the extant literature notes that medical quality and safety need to improve when it comes to managing older adult patients and providing preventive services.12,13 In reaction to unsatisfactory patient outcomes, care models such as the patient-centered medical home (PCMH) have been implemented with the intent to improve the quality and safety of primary care delivery.14 The PCMH model encourages patient and physician collaboration to enhance health practices and decision-making processes, thus improving quality and safety.15 The National Committee for Quality Assurance (NCQA), a medical home accrediting body, identifies quality and safety as important dimensions for primary care practices to improve the care they provide.16 The NCQA and the Patient-Centered Primary Care Collaborative both acknowledge that to achieve quality and safety goals, the patient must be an active participant in the care planning process.15 Patient-centered medical home care is a general umbrella term that includes a variety of different approaches, tools, and innovations within it that, when implemented in unison, are designed to improve the medical care experience for individuals in particular quality outcomes.14-16 These approaches, tools, and innovations shape different aspects of the quality and safety experience for patients. These aspects include accountability, communication, decision making, patient satisfaction, efficiency, and disease management (Table 1). They also derive from specific care interventions such as feedback, advocacy, performance improvement, engagement, and care continuity that in theory contribute to an enhanced quality and safety experience for patients, thus improving population-specific outcomes.14,17,18 It is worth noting that the concept of quality encompasses a wide array of dimensions including clinical outcomes, patient experiences with care, and

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Table 1 DEFINING PATIENT-CENTERED AND MEDICAL HOME CARE INTERVENTIONS AND SELECT QUALITY AND SAFETY GOALS17,18 Clinical and information technology is utilized to support patient care, patient education, communication, and quality improvement (eg, clinical registries). Evidence-based medicine and clinical decision-support tools guide decision making. Care is coordinated and integrated across specialties and other health care providers who care for a patient to prevent errors across sites. Patients are engaged partners in care planning and decision making, and are well-informed on treatment responsibilities. Patients’ feedback is sought to ensure that patients’ expectations are being met and collective decisions are being made. Partnerships between physician, patients, and patient’s family dictate care planning and patient-centered outcomes. Families participate in quality improvement activities at the practice level. Information is publicly available on how practices are performing on the basis of patients’ needs.

health care delivery effectiveness19,20 within the field of health services research. For the purpose of this review, we measure quality as the ability of primary care interventions in meeting the kinds of goals associated with the PCMH model of care, as described previously and in Table 1. As expressed through the PCMH framework, this model of care is designed to accommodate the particular health needs and preferences of the individual patient. It is unknown at this point how primary care interventions geared toward older adults have performed in meeting the PCMH outcome goals set forth by physician groups and accrediting agencies. In short, what progress has been made in reaching the quality outcomes as defined by the PCMH model? Two research questions guide the review: (1) “How have primary care interventions performed in reaching medical home and, in general, patient-centered quality and safety goals?” and (2) “How is medical home quality and safety studied in the research

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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examining older adult receipt of patient-centered primary care services?” In this review, older adults are defined as individuals 65 years of age or older. Given that the older adult population consumes the vast majority of primary care services, and as more primary care practices become medical homes, this review of the literature can tell us in part whether the current model is sufficient as a “one-size-fits-all” approach and can identify best practices of PCMH implementation for older adults that have implications in the development of new or revised medical home practices and processes.21-23 To our knowledge, there has not been a review of the literature that specifically examines these 2 questions. This review is relevant for both policy and practice because it can inform discussions of how to align the medical home model with the needs and preferences of older adults.

METHODS Search term criteria The comprehensive definition of PCMH demands an explicit explanation with regard to article eligibility criteria and the article selection procedure. A total of 41 search terms were identified by the first author after reviewing the Joint Principles of the PatientCentered Medical Home17 and the PPC-PCMH Standards and Guidelines from the NCQA PCMH recognition process, including the “must pass” elements.24 The first author also consulted the references in Table 1 to help generate the necessary search terms. It was appropriate to use multiple sources to identify search terms to comprehensively define quality. These terms identified different quality and safety outcomes, primarily outcomes that derived from interventions or activities meant to improve quality and safety, or components that were aligned with quality and safety outcomes. The second author reviewed these terms and any questions about the validity of the terms were resolved through discussion between the 2 authors. Medical Subject Headings term selection The next step was to select the appropriate Medical Subject Headings (MeSH) for as many of these terms

as possible to maximize the relevant studies to be identified through peer-reviewed literature. Twentytwo of the 41 terms did not yield MeSH term matches or equivalents in the National Library of Medicine Database (Table 2). Of the remaining 19 terms, a total of 28 specific MeSH terms were identified that could be mapped onto the NCQA or Joint Principles– derived terms. These 28 MeSH terms were then used to search for relevant studies. The terms “medical errors” and “mistakes” were searched using the same process as the MeSH terms mentioned in Table 2. These 2 terms were deemed necessary to ensure peerreviewed articles analyzing patient safety including medical errors and mistakes were not overlooked. Data source and MeSH searches In searching for relevant studies, 2 MeSH terms were used to help filter out only studies that had a primary or secondary emphasis on older patient populations. These terms were “health services for the elderly” and “health services for older adults.” These 2 MeSH terms were separately but concurrently linked to the MeSH term “patient-centered care” and to each of the 28 MeSH terms to search the MEDLINE database for relevant articles. Patient-centered care was included in each search because “medical home” is nested within this broader heading. For example, one library included articles that were identified using the following search protocol in MEDLINE: “health services for the elderly” + “patient-centered care” + “patient satisfaction.” Another library used the search protocol “health services for older adults” + “patient-centered care” + “patient satisfaction.” Therefore, a total of 56 MEDLINE libraries were created (28 libraries linked to “health services for the elderly” and 28 libraries linked to the “health services for older adults” protocols). Literature search process Once the articles were retrieved using the MeSH terms (stage 1 in Figure), the next step was to gather the articles that were published in English between the years 2000 and January 2012 (stage 2). The year 2000 was used as a cutoff because (a) this would



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Table 2 PATIENT-CENTERED MEDICAL HOME QUALITY AND SAFETY TERMS (LEFT COLUMN) AND MATCHING MESH TERMS (RIGHT COLUMN) AFTER SEARCHING THE MESH DATABASE OF THE NATIONAL LIBRARY OF MEDICINEa Joint Principles/PPC-PCMH Patient Quality and Safety Terms 1. Accountability 2. Advocate 3. Appointments 4. Chronic disease 5. Clinical data 6. Communication 7. Cooperation 8. Decision making 9. Efficiency 10. Engagement 11. Evidence based 12. Family education 13. Family experience 14. Family needs 15. Patient feedback 16. Health information technology 17. Medical home 18. Partnership 19. Patient education 20. Patient empowerment 21. Patient expectations 22. Patient experience 23. Patient health management 24. Patient preparation 25. Patient satisfaction 26. Performance improvement 27. Performance measurement 28. Prescribing 29. Quality

30. Quality improvement 31. Recognition process 32. Registry 33. Safety

MeSH Term Match ... ... Appointments and Schedules [N04.452.095] Chronic Disease [C23.550.291.500] ... Health Communication [L01.143.350] Patient Compliance [F01.145.488.500] ... Efficiency, Organizational [N04.452.227] ... Evidence-Based Medicine [H02.249.750], Evidence-Based Practice [H02.249] ... ... ... ... Medical Informatics [L01.313.500] Medical Home (under patient-centered care heading [N04.590.233.675]) ... Patient Education as Topic [I02.233.332.500], Medication Reconciliation [N04.590.656] ... ... ... ... Patient Care Planning [N04.590.233.624] Patient Satisfaction [N04.452.822.360.600] ... ... Electronic Prescribing [N02.421.668.778.750], Physician’s Practice Patterns [N04.590.748] Delivery of Health Care, Integrated [N05.300.262], Physician-Patient Relations [N05.300.660.625], Practice Guidelines as Topic [N05.700.350.650], Standard of Care [N04.761.789.900], Quality of Health Care [N04.761] Quality Improvement [N04.761.744] ... ... Safety [N06.850.135.060.075], Patient Safety [N06.850.135.060.075.399], Safety Management [N06.850.135.060.075.800] (continues)


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Table 2 PATIENT-CENTERED MEDICAL HOME QUALITY AND SAFETY TERMS (LEFT COLUMN) AND MATCHING MESH TERMS (RIGHT COLUMN) AFTER SEARCHING THE MESH DATABASE OF THE NATIONAL LIBRARY OF MEDICINEa (Continued) Joint Principles/PPC-PCMH Patient Quality and Safety Terms 34. Timely 35. Support tools 36. Waiting times 37. Chronic care model 38. Internal medicine 39. Geriatrics 40. Primary care 41. Continuity of care

MeSH Term Match ... ... ... ... Internal Medicine [H02.403.429] Geriatrics [H02.403.355] Primary Health Care [N04.590.233.727] Continuity of Patient Care [N04.590.233.727.210]

Abbreviation: MeSH, Medical Subject Headings; PPC-PCMH, Physician Practice Connections–Patient-Centered Medical Home. a Numbers within parentheses designate the MeSH tree number in the National Library of Medicine database. The 22 medical home-related terms that did not have MeSH term matches were linked to “health services for the elderly” + “patient-centered care” and searched in MEDLINE. This was necessary to make sure that there were no additional research articles that captured quality and safety components of PCMH care that were not obtained from the MeSH term searches. After title and abstract review of these articles from the additional search, no new articles met the inclusion criteria.

allow a sufficient time period to capture medical home–oriented research on older adults and (b) 2000 was the year in which the Institute of Medicine formally identified the need to improve the quality of health care delivery in the United States through its seminal report.2 The titles and abstracts of the articles that met stage 2 criteria were reviewed manually by the first author to determine whether the publication satisfied a specific set of inclusion criteria (stage 3). Studies passed stage 3 of the review process if they satisfied the criteria: (1) US health system only, (2) peerreviewed empirical studies that used qualitative or quantitative methodologies (or both) that had a clear methods and results section, and (3) investigated some valid dimensions of patient-centered or medical home care and acknowledged health care quality or patient safety outcomes of the population in the abstract. In addition, (4) the study population in a given study had to include patients or participants who were 65 years of age or older or had a study population mean age of 65 years or older. Each article was then reviewed in its entirety by both coauthors (stage 4) and additional articles in

the stage 3 sample were not included in the final review given that they did not satisfy all the inclusion criteria. Research articles that passed the stage 4 review represented the final sample included in the literature review and were subjected to an abstraction form (detailed later) review process. Each of the samples was subjected to separate reviews by the 2 coauthors using the data abstraction form. The abstraction form used is available from the authors upon request. Information obtained included type of research setting, research design and methods, type(s) of data collection, use of specific intervention(s) to improve quality and safety of study participants, and primary safety and quality-related findings. Any disagreements between the 2 author reviews were reconciled through meetings and discussion, with final consensus reached in all cases.

RESULTS Table 3 summarizes the research designs, methods, interventions, and findings of the 13 articles in the final review. Each article analyzed included



Stage 1 library: 1563 total articles 147 articles predating 2000 and non-English Stage 2 library: 1416 English articles published between 2000 and 2012 995 duplicate articles

345 articles that did not comply with inclusion criteria during initial title and abstract review

Stage 3 library: 76 articles passed initial title and abstract review

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while Ferrante et al25 and Lasser et al31 used a qualitative research design. Eight of the 13 articles used original survey data collected by the authors to associate quality and safety items with primary care services. Secondary data were used in almost half of all the samples in whole or in part to measure and analyze quality and safety outcomes. Some examples of surveys used include the Health Care Financing Administration’s National Claims History Database,37 patient-centered outcomes of self-care from the Diabetes Quality Improvement Project Patient-Reported Measures set,26 and the Ambulatory Care Experiences Survey.32

39 articles that did not comply with inclusion criteria during second title and abstract review Stage 4 library: 37 articles retrieved for full-article read-through

Patient-centered/medical home interventions and quality and safety outcomes Older-adult health care utilization

24 articles did not comply with all inclusion criteria

Final sample: 13 articles subjected to data abstraction form

Figure. Schematic of article selection process for the systematic literature review.

patients who were 65 years of age and older. Eight of the 13 articles studied populations that were 65 years and older exclusively. With respect to specific quality and safety outcomes, 10 of the 13 articles studied clinical processes, outcomes, and utilization, while 2 articles studied patients’ perceptions regarding patient-physician and patient-pharmacist relationships. One article did not acknowledge any patient quality or safety outcome.25 Across the 13 studies, 4 analyzed cross-sectional data that were collected as either primary data or secondary data. The second most used research design was a more stringent quasi-experimental design that included case-controls to analyze patient safety or quality outcomes. For example, Sommers et al37 used a randomized controlled design to examine the effects of a practice intervention involving an interdisciplinary health team on chronically ill older adults. Eleven of the 13 articles used quantitative methods,

Five studies measured medical care utilization as an outcome. Utilization outcomes are linked to quality because primary care plays an important role in making sure that older adults receive appropriate and timely care so to reduce unnecessary specialty or inpatient services. Chumbler et al27 examined a patient-centered care coordination program and noticed a trend of lower hospital admissions. However, the likelihood of 1 or more need-based primary care visits actually increased in those receiving the intervention, while emergency department visits decreased for both the intervention and control groups. Ferrante and colleagues28 observed that older adults participating in a guided care program were more likely than those who received usual care to have higher rates of preventive services. More interestingly, the use of electronic medical records, the use of information technology, and practice engagement in continuous quality improvement were not associated with higher rates of preventive services. In all, the authors stressed that the findings were mixed because the definitions and outcomes measured were inconsistent.28 Similarly, Sommers et al37 found no significant difference in older adult hospital utilization rates in the first year between those who received an interdisciplinary health team


Ferrante et al25

Older Adult Quality and Safety Finding

IN

Ferrante et al28

Disease management: Clinically based diabetes care (inpatient or outpatient)

Older Adult Quality and Safety Outcome Measured

Disease management, Positive associations self-care, overall care between absence of rating, and general problems with diabetes well-being (created by care and greater age, author) and between the understanding of diabetes self-care and increasing age QuasiQuantitative, Mean (64.85) Utilization: Care Service utilization (eg, Lower hospitalizations in experimental, observation coordination/home ED), hospital days and treatment and control case control telehealth program admissions groups. Likelihood of primary care visits increased in the treatment group, while the likelihood of ED visits decreased in the treatment and comparison groups Cross-sectional Quantitative, 65+ Utilization: Use of Rate at which patients Use of clinical support data analysis survey, chart guided care through were up-to-date on tools and having review, secondary a patient navigator preventative services referral systems in data analysis place were associated with higher rates of preventative services Qualitative Interviews, Range Use of guided care Work processes of N/A analysis observation, note (19-105) through a patient patient navigator; taking, logs, navigator barriers and debriefings facilitators to implementing and utilizing patient navigator in primary care (continues)

Cross-sectional Quantitative, 65+ data analysis medical charts, and DQIP; phone interviews

Methods

Age Group, y

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Chumbler et al27

Anderson et al26

Authors

Research Design

PatientCentered/Medical Home Intervention Target

RESEARCH DESIGN, METHODS, AND QUALITY OR SAFETY FINDINGS OF ARTICLES INCLUDED IN THE SYSTEMATIC REVIEW

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Age Group, y

Cross-sectional Quantitative, data analysis secondary data analysis

Liss et al32

Observation (physicianpatient encounters)

Qualitative analysis

Lasser et al31

65+

65+

65+

Cross-sectional Quantitative, 56% of data analysis survey, secondary patients data analysis 65+

Methods

Keshishian Cross-sectional Quantitative, data analysis original survey et al30 (primary data collection)

Flach et al29

Authors

Research Design

Utilization: Continuity of care

Patient-provider relationship: Patient-centered communication and other facilitation strategies

Patient-provider relationship: Perceived relationship quality between patient and pharmacist/physician


Better care coordination and communication, incorporating patient preferences were all associated with higher benchmarking scores (more prevention activity) Perceived relationship Quality of quality with physician-patient pharmacist and relationship predicted physician medication-related knowledge and outcome expectations, and self-efficacy for medication management Barriers related to Shared power/common receipt of vaccinations ground and empathy and screenings; extent are patient-centered of communication communication around prevention in strategies used to encounters overcome barriers of screening and vaccinations Care coordination Positive association between primary care continuity and patient-reported care coordination for patients with ≥3 PCP visits and low specialty care utilization (continues)


Patient-provider Benchmark score for relationship: Various delivery of 12 elements of a recommended patient-centered care preventative service approach (eg, care interventions coordination)


RESEARCH DESIGN, METHODS, AND QUALITY OR SAFETY FINDINGS OF ARTICLES INCLUDED IN THE SYSTEMATIC REVIEW (Continued)

Table 3



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QuasiQuantitative, 65+ experimental, survey, secondary case-control data analysis

Quantitative, Mean (69) survey, secondary data analysis

Quantitative, EMR and prescription claims database review

Randomized controlled trial


Pindolia et al35

Slatore et al36

Sommers et al37


Abbreviations: DQIP, Diabetes Quality Improvement Project; ED, emergency department; EHR, electronic health record; EMR, electronic medical record; EPIC, Empowering Patients in Care; HbA1c , hemoglobin A1c ; N/A, not applicable; PCP, primary care physician.

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Utilization: Series of medical home interventions (eg, dedicated PCP, disease management, care coordination) Disease management: Medication and therapy Improved medication Medication therapy adherence adherence and clinical management outcomes for program; various intervention vs control component patients interventions Patient-provider Patient-reported quality Ongoing relationship relationship: Quality of care with physician of clinician-patient positively associated communication with perceived quality of care Utilization: Service utilization and In year 2, hospital use Team-based patient health status decreased in the intervention intervention group involving different compared with the health professionals control group and prevention strategies

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65+

Longitudinal Quantitative, EHR, 65+ data analysis and billing record review

Phillips Jr et al34


Patients receiving EPIC intervention had significantly lower HbA1C levels at 3-mo and 1-y follow-up than the control patients (educational intervention) Clinical outcomes (eg, Improved primary and prevention measures secondary prevention including screenings, for colon cancer chronic disease screening control)


Quantitative, Range Disease management: Improved glycosylated survey, laboratory (50-90); Clinician-led, HbA1c and patient self-efficacy results Mean (63) diabetes self-management group (EPIC); diabetes educational sessions


Methods

Age Group, y

Naik et al33

Authors

Research Design


RESEARCH DESIGN, METHODS, AND QUALITY OR SAFETY FINDINGS OF ARTICLES INCLUDED IN THE SYSTEMATIC REVIEW (Continued)

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intervention and those who received regular care. As a result of the intervention, there were a higher number of social activities for intervention patients than for the control group. This study was not able to explore how the physician’s relationship with the patient influenced hospital utilization vis-`a-vis the interdisciplinary health care team’s intervention. Phillips Jr et al34 analyzed how older adult hospital admissions and readmissions changed over the course of medical home implementation. The specific health care system, WellMed, saw improvements in the rates of primary and secondary prevention for colon cancer screening. But there were no significant changes in emergency department visits and overall hospitalizations between 2000 and 2008. A gap remained in that there was no linkage between preventive screenings, hospitalizations, and readmissions to specific medical home principles. Liss and colleagues32 found a positive association between primary care continuity and patient-reported care coordination among older adult patients with 3 or more primary care visits and patients with low specialty care outpatient utilization. Furthermore, there was no association between primary care continuity and care coordination in patients who had high utilization of specialty care services. Chronic disease management and planning Anderson et al26 reported positive associations between absence of problems with diabetes care management and increasing age in older adults participating in the diabetes management intervention. The authors also reported a positive association between patients’ understanding of diabetes self-care and increasing age. Naik et al33 examined a diabetes mellitus management intervention in which patients went through 4 sessions of diabetes education and care planning with clinicians. Immediately after the 3-month intervention, the intervention patients had significantly lower levels of glycosylated hemoglobin A1c and higher diabetes self-efficacy scores than those receiving a traditional diabetes education program. Sharing the responsibility of devising and integrating care plans helped the patients adhere to

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medication regimes and enhance self-management skills.33 Blood glucose benchmarks were also used in a study to understand how a medication therapy management program improved medication use, thus reducing older adult adverse drug events.35 There was improvement in adherence to congestive heart failure medication regimes in the patients who accepted the medication therapy management program. But there was greater nonadherence to coronary artery disease goals in patients within the program than in those who declined the medication therapy management program. In this study, the pharmacists had to revise therapy plans and delete unnecessary medications for Medicare patients to decrease the likelihood of an adverse drug event.35 Patient-provider relationships and communication Flach et al29 used a multidimensional construct of patient-centered care as defined and measured by the Veterans Health Administration. There are 8 specific domains in the Veterans Health Administration construct including (1) access to care, (2) incorporating patient preferences, (3) patient education, (4) visit coordination, (5) overall coordination of care, (6) courtesy of care, (7) continuity of care, and (8) emotional support.29 Of the 8 domains, only continuity of care and emotional support significantly predicted improved preventive care delivery. However, the mechanisms in which better preventive care delivery was related to better performance remained unclear. Lasser and colleagues31 identified different barriers during the patient-provider interaction that inhibited older adults from getting the care they needed. Predisposing factors such as patient’s fears of the influenza vaccine and enabling factors such as when a patient is dependent on others for transportation to the provider’s office were identified barriers. The authors discovered that the clinicians were using patient-centered communication strategies to facilitate patients’ acceptance of vaccinations and preventive screenings. Shared decision making was one strategy used by the physicians to help patients


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decide whether they wanted to receive physicianrecommended vaccinations and colonoscopies. Similarly, Slatore et al36 wished to describe associations between physician communication and patient-reported outcomes. General quality of communication was computed as a mean score of 6 attributes such as caring about the patient as a person, using words the patient understands, and listening to what the patient has to say. The authors found that patients who had an ongoing relationship with the same provider for more than 5 years, compared with less than 2 years, were more likely to report having received the “best-imagined care.”36 The quality of physician-patient communication was positively associated with chronic obstructive pulmonary disorder patients’ confidence in dealing with breathing complications and reports of highquality health care. No such association, however, was seen between communication and the patient’s self-rated health. Keshishian et al30 discovered that an older adult’s relationship with his or her physician was positively associated with medication-related knowledge, outcome expectations, and medication management self-efficacy. The authors found that older adults perceived a lower-quality relationship with their pharmacist. This finding implies that there is still room for improving patient-centered safety outcomes for patients who are at higher risks of medication discrepancies.38

DISCUSSION The studies in this review suggest that medical home and patient-centered interventions geared toward care coordination, disease management, and communicative aspects of the patient-provider relationships are loosely coupled to improvements in primary care quality and safety for older adults. More specifically, enhancing continuity of care, establishing compassionate relationships, and orienting care to best manage chronic illnesses have been shown to enhance older adult quality. Table 4 summarizes the broader findings related to this review and the impli-

Table 4 OLDER ADULT MEDICAL HOME INTERVENTION FINDINGS AND IMPLICATIONS FOR IMPLEMENTATION

Medical Home Intervention Target

Strategies Benefiting Older Adults Found Quality and Safety Through the Goals of PCMH Review Interventions

Utilization

Care coordination and integration of team-based care

Disease management

Implement diabetes education and individualized medication regimes

Patientprovider relationship

Create supportive and empathetic relationships that consider older adult preferences

Reduce unnecessary hospitalizations and patient handoff errors Practice advocates for patientcentered care plans to improve outcomes and meet patient goals Patients actively participate in care-planning and ongoing relationship with physician

Abbreviation: PCMH, patient-centered medical home.

cations for attaining PCMH goals. By implementing some of the suggested strategies, a practice may enhance its ability to improve quality for older adults and reduce unnecessary utilization and spending related to mismanaging care. Other observations can be made from the review. First, quality and safety outcomes are inconsistently operationalized across empirical literature that focuses in whole or part on how patient-centered and medical home approaches impact older adults (see Table 3). In addition, there appears to be no standardized approach to studying patient quality and safety outcomes with respect to older adults receiving primary care. This makes comparison and synthesis across studies difficult. On the positive side, it may present useful variety that can meet the needs of



researchers and practitioners with diverse interests in the quality and safety area. Each data source, from self-administered surveys to secondary data analyses of medical charts and electronic health data, has its strengths and weaknesses. Secondary data are easier to obtain and analyze from a time perspective, helping to promote more timely research that can inform research and practice. Primary data collection, such as that through interviews or original surveys, allows researchers to ask more targeted questions and research particular items of interest. Thus, the variety found in this literature has value for expanding our understanding of how different aspects of quality and safety play out for older populations and lends itself to further evaluation. Second, the findings reveal opportunities to expand the research approaches now used in studies of the linkages between medical home and patientcentered care interventions and safety and quality outcomes among older adults. For example, a case can be made that longitudinal designs can aid scholars pursuing research questions on particular aspects of medical home and patient-centered care that remain largely unexplored. A number of medical home and patient-centered care interventions are ongoing and occur over months and years, such as aspects of care coordination and care management. Thus, research designs examining the effects of these interventions on quality and safety outcomes for older adults should also incorporate an ability to study systematic variation in such outcomes as a result of these interventions over time. In addition, studying populations and practices over the course of months or years, for example, we can see how an intangible and multidimensional concept such as patientcenteredness evolves over time, and how this evolution relates to improving quality and safety outcomes for the older cohort that may particularly benefit from care continuity. With regard to the types of quality and safety interventions studied for older adults, shared decision making is one type of quality outcome that could use further examination. For older adults, sharing the ability to make decisions, having a long-standing relationship with a provider, and observing the pa-

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tient’s demands and concerns during office visits are important ways patient-centered care manifests itself to either improve older adult primary care processes and clinical outcomes or enhance the value of care as judged by the patient.18,39 In a related vein, none of the studies in the review articulated study questions or findings related to an older adult family’s involvement in the care-planning process or how families participate in helping to achieve higher quality care for their loved ones. Another quality-related intervention that was not addressed in the studies comprising this review was older adult use of information technology in relation to quality and safety outcomes. Only 1 study focused on the relationship between information technology and a quality or safety outcome. Yet, information technology is a major component of medical home care. Future research will need to address how the implementation of different forms of information technology in the care of older adults (eg, telehealth, e-portals, electronic health records) impacts safety and quality outcomes for this cohort. Given the mixed reviews, thus far, of certain forms of information technology on patient care,40-42 making these types of approaches and interventions front and center is imperative. This systematic literature review has several limitations worth noting. First, only 1 searchable database, MEDLINE, was utilized in the search process. Including searches from other engines such as EBSCO, Google Scholar, or other scholarly catalogs may have identified other primary care research focusing on older adult populations. The small number of studies included in this review may indicate, however, that this is an area of research ripe for additional investigation. Second, the author used a series of search terms related to quality and safety approaches and outcomes that were derived from the Joint Principles and NCQA guidelines related to medical home care. In some instances, subjective judgments needed to be made regarding how these sources conceptualized either interventions or outcomes related to quality and safety. The search terms ultimately used potentially limit the scope of the article search process. Similarly, it is important to note


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that there is extensive literature on topics such as chronic disease management, information technology, and quality improvement in primary care. A greater number of studies were not selected for this review because the authors’ purpose was to identify studies that examined populations that had mean ages around 65 years or examined only populations aged 65 years or older. A third limitation involves the interwoven nature of outcomes such as quality and safety with other medical home outcomes. Because the adult model of PCMH care is a comprehensive approach that seeks to improve patient-centered quality and safety outcomes at the same time as other outcomes, it is difficult to actually separate quality and safety variables from variables, for example, that are specific to outcomes such as “care coordination’ or “whole-person orientation.” This fusing of different outcomes is compounded by the reality that the Joint Principles and NCQA recognition standards treat quality and safety outcomes as more intangible than other outcomes such as access. With studies in this review operationalizing quality and safety differently, it becomes more difficult to imply causality between quality and safety strategies or interventions and medical home or patient-centered quality and safety outcomes, specifically. In summary, only a few studies in the review were able to associate improved quality and safety outcomes for older adults with a “patient-centered” approach as defined by various interventions articulated by the medical home model. As medical home care continues to be implemented on a national scale, it will be necessary for future research to study carefully the linkages between quality and safety outcomes and patient-centered care interventions directed at older adults. Older adults consume the vast majority of primary care services and will comprise the nation’s largest demographic cohort in the near future. At present, the current research is limited in how it studies older adult medical home quality and in terms of what it finds. While some degree of empirical variety is preferred, because it reveals a robustness of potential findings across care settings, it is important to gain comparable evidence to sug-

gest which specific dimensions of medical home care be promoted to improve quality and safety for older adults in primary care.

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