Understanding and investigating challenges and opportunities within patient-centered medical home transformation: A multi-level, multi-perspective systems framework

Numerous Community Health Centers (CHCs) are now working to formally transform their centers into Patient Centered Medical Homes (PCMH). Although the PCMH model shows promise for improving health outcomes and reducing costs, noteworthy challenges face CHCs implementing the PCMH model. To better understand PCMH transformation challenges and opportunities, this study employed qualitative data analysis (QDA), utilizing a grounded theory coding scheme, to analyze semi-structured interviews with Medical Directors of CHCs in Florida. The interviewees discussed their experiences of PCMH transformations. Afterward, typed notes were sent to each interviewee for review. The QDA involved analyzing the typed notes of the interviews. Analysis began with line-by-line analyses resulting in descriptive open codes identifying small segments of text. Then, conceptually related open codes where synthesized and raised to higher conceptual levels wherein focused codes began to explain larger sections of text within and across the interviews. By analyzing the similarities and differences amongst focused codes, themes emerged that could explain larger and larger conceptual territories within and across the focused codes and interviews. Eventually, through continued analysis and memo writing, a unifying core theme emerged that articulated the relationships between the themes within and across the interviews. This QDA resulted in a multi-level, multi-perspectival theoretical framework for understanding PCMH transformation challenges and opportunities based on six emergent themes, listed below, and the resultant unifying core theme, “Open Systems Thinking, Design, and Management.” Systems theory suggests organizations seek homeostasis between their internal and external environments. The emergent themes “Patient Engagement,” “Technology Engagement,” and “Team-Based Care” (internal environment); “Patient Contexts” and “External Environment” (external environment); and “Quality and Quantity of Care” (degree of homeostasis) illustrate avenues for centers to adapt their internal systems in response to the macro-systems in which they operate to best serve their patients. This emergent framework can help practitioners/ scholars design future interventions/studies. Themes in which centers have autonomy to change (internal environment themes) could act as independent variables; themes to which health centers must respond (external environment themes) could be intervening variables; and the theme containing centers' desired outcomes (“Quality and Quantity of Care”) could be the dependent variable. The unifying core theme would provide the interventions' and studies' theoretical construct. Alternatively, a project resulting from this study seeks to address “Patient Engagement,” “External Environment,” “Patient Context,” and “Team-Based Care” to explore factors contributing to the patient experience. Applications of this systems framework for understanding PCMH transformation are numerous.