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Research ArticleOriginal Research

Facilitators and Barriers to Care Coordination in Patient-centered Medical Homes (PCMHs) from Coordinators' Perspectives

Asia Friedman, Jenna Howard, Eric K. Shaw, Deborah J. Cohen, Laleh Shahidi and Jeanne M. Ferrante
The Journal of the American Board of Family Medicine January 2016, 29 (1) 90-101; DOI: https://doi.org/10.3122/jabfm.2016.01.150175
Asia Friedman
From the Department of Sociology and Criminal Justice, University of Delaware, Newark, DE (AF); the Department of Family Medicine and Community Health, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ (JH, JMF); the Department of Community Medicine, Mercer University School of Medicine, Savannah, GA (EKS); the Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC); and APS Consulting, San Ramon, CA (LS).
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Jenna Howard
From the Department of Sociology and Criminal Justice, University of Delaware, Newark, DE (AF); the Department of Family Medicine and Community Health, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ (JH, JMF); the Department of Community Medicine, Mercer University School of Medicine, Savannah, GA (EKS); the Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC); and APS Consulting, San Ramon, CA (LS).
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Eric K. Shaw
From the Department of Sociology and Criminal Justice, University of Delaware, Newark, DE (AF); the Department of Family Medicine and Community Health, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ (JH, JMF); the Department of Community Medicine, Mercer University School of Medicine, Savannah, GA (EKS); the Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC); and APS Consulting, San Ramon, CA (LS).
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Deborah J. Cohen
From the Department of Sociology and Criminal Justice, University of Delaware, Newark, DE (AF); the Department of Family Medicine and Community Health, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ (JH, JMF); the Department of Community Medicine, Mercer University School of Medicine, Savannah, GA (EKS); the Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC); and APS Consulting, San Ramon, CA (LS).
PhD
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Laleh Shahidi
From the Department of Sociology and Criminal Justice, University of Delaware, Newark, DE (AF); the Department of Family Medicine and Community Health, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ (JH, JMF); the Department of Community Medicine, Mercer University School of Medicine, Savannah, GA (EKS); the Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC); and APS Consulting, San Ramon, CA (LS).
PhD
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Jeanne M. Ferrante
From the Department of Sociology and Criminal Justice, University of Delaware, Newark, DE (AF); the Department of Family Medicine and Community Health, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ (JH, JMF); the Department of Community Medicine, Mercer University School of Medicine, Savannah, GA (EKS); the Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC); and APS Consulting, San Ramon, CA (LS).
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References

  1. 1.↵
    Patient-centered Primary Care Collaborative. Joint principles of the patient-centered medical home. 2007. Available from: http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf. Accessed March 6, 2015.
  2. 2.↵
    1. Stille CJ,
    2. Jerant A,
    3. Bell D,
    4. Meltzer D,
    5. Elmore JG
    . Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Ann Intern Med 2005;142:700–8.
    OpenUrlPubMedWeb of Science
  3. 3.↵
    1. Flocke SA,
    2. Stange KC,
    3. Zyzanski SJ
    . The association of attributes of primary care with the delivery of clinical preventive services. Med Care 1998;36(8 Suppl):AS21–30.
    OpenUrlCrossRefPubMedWeb of Science
  4. 4.↵
    1. Parkerton PH,
    2. Smith DG,
    3. Straley HL
    . Primary care practice coordination versus physician continuity. Fam Med 2004;36:15–21.
    OpenUrlPubMedWeb of Science
  5. 5.↵
    1. Palfrey JS,
    2. Sofis LA,
    3. Davidson EJ,
    4. et al
    . The Pediatric Alliance for Coordinated Care: evaluation of a medical home model. Pediatrics 2004;113(5 Suppl):1507–16.
    OpenUrlPubMedWeb of Science
  6. 6.↵
    1. Antonelli RC,
    2. Stille CJ,
    3. Antonelli DM
    . Care coordination for children and youth with special health care needs: a descriptive, multisite study of activities, personnel costs, and outcomes. Pediatrics 2008;122:e209–16.
    OpenUrlAbstract/FREE Full Text
  7. 7.↵
    1. Ewing M
    . The patient-centered medical home solution to the cost-quality conundrum. J Healthc Manag 2013;58:258–66.
    OpenUrlPubMed
  8. 8.↵
    1. Bodenheimer T
    . Coordinating care–a perilous journey through the health care system. N Engl J Med 2008;358:1064–71.
    OpenUrlCrossRefPubMedWeb of Science
  9. 9.↵
    1. White B,
    2. Carney PA,
    3. Flynn J,
    4. Marino M,
    5. Fields S
    . Reducing hospital readmissions through primary care practice transformation. J Fam Pract 2014;63:67–73.
    OpenUrlPubMed
  10. 10.↵
    1. Berry LL,
    2. Rock BL,
    3. Smith Houskamp B,
    4. Brueggeman J,
    5. Tucker L
    . Care coordination for patients with complex health profiles in inpatient and outpatient settings. Mayo Clin Proc 2013;88:184–94.
    OpenUrlCrossRefPubMedWeb of Science
  11. 11.↵
    1. Marek KD,
    2. Stetzer F,
    3. Ryan PA,
    4. et al
    . Nurse care coordination and technology effects on health status of frail older adults via enhanced self-management of medication: randomized clinical trial to test efficacy. Nurs Res 2013;62:269–78.
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. Miller K
    . Care coordination impacts on access to care for children with special health care needs enrolled in Medicaid and CHIP. Matern Child Health J 2014;18:864–72.
    OpenUrlPubMed
  13. 13.↵
    1. Boudreau AA,
    2. Perrin JM,
    3. Goodman E,
    4. Kurowski D,
    5. Cooley WC,
    6. Kuhlthau K
    . Care coordination and unmet specialty care among children with special health care needs. Pediatrics 2014;133:1046–53.
    OpenUrlAbstract/FREE Full Text
  14. 14.↵
    1. Wagner EH,
    2. Ludman EJ,
    3. Aiello Bowles EJ,
    4. et al
    . Nurse navigators in early cancer care: a randomized, controlled trial. J Clin Oncol 2014;32:12–8.
    OpenUrlAbstract/FREE Full Text
  15. 15.↵
    1. McDonald KM,
    2. Sundaram V,
    3. Bravatoa DM,
    4. et al
    . Closing the quality gap: a critical analysis of quality improvement strategies. Technical review 9. Care coordination. Vol 7. AHRQ publication no. 04(07)-0051–7. Rockville, MD: Agency for Healthcare Research and Quality; 2007.
  16. 16.↵
    1. Mattke S,
    2. Seid M,
    3. Ma S
    . Evidence for the effect of disease management: is $1 billion a year a good investment? Am J Manag Care 2007;13:670–6.
    OpenUrlPubMedWeb of Science
  17. 17.↵
    1. Peikes D,
    2. Chen A,
    3. Schore J,
    4. Brown R
    . Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA 2009;301:603–18.
    OpenUrlCrossRefPubMedWeb of Science
  18. 18.
    Patient-Centered Primary Care Collaborative. The medical home's impact on cost and quality: an annual update of the evidence, 2012–2013. Available from: https://www.pcpcc.org/resource/medical-homes-impact-cost-quality. Accessed March 6, 2015.
  19. 19.
    1. Peikes DN,
    2. Reid RJ,
    3. Day TJ,
    4. et al
    . Staffing patterns of primary care practices in the comprehensive primary care initiative. Ann Fam Med 2014;12:142–9.
    OpenUrlAbstract/FREE Full Text
  20. 20.
    1. Larkin H
    . Lessons learned on the road to population health. Hosp Health Netw 2014;88:30.
    OpenUrl
  21. 21.↵
    1. Wagner EH,
    2. Sandhu N,
    3. Coleman K,
    4. Phillips KE,
    5. Sugarman JR
    . Improving care coordination in primary care. Med Care 2014;52(11 Suppl 4):S33–8.
    OpenUrl
  22. 22.↵
    1. Taylor EF,
    2. Machta RM,
    3. Meyers DS,
    4. Genevro J,
    5. Peikes DN
    . Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers. Ann Fam Med 2013;11:80–3.
    OpenUrlAbstract/FREE Full Text
  23. 23.↵
    1. Henderson S,
    2. Princell CO,
    3. Martin SD
    . The patient-centered medical home: this primary care model offers RNs new practice-and reimbursement-opportunities. Am J Nurs 2012;112:54–9.
    OpenUrlCrossRefPubMed
  24. 24.↵
    1. Ferrante JM,
    2. Cohen DJ,
    3. Crosson JC
    . Translating the patient navigator approach to meet the needs of primary care. J Am Board Fam Med 2010;23:736–44.
    OpenUrlAbstract/FREE Full Text
  25. 25.↵
    1. Ferrante JM,
    2. Friedman A,
    3. Howard J,
    4. Shaw EK,
    5. Cohen DJ,
    6. Shahidi L
    . Lessons learned using an asynchronous online discussion forum for qualitative research. Qual Health Res 2015 Oct 18. [Epub ahead of print]
  26. 26.↵
    1. Fox FE,
    2. Morris M,
    3. Rumsey N
    . Doing synchronous online focus groups with young people: methodological reflections. Qual Health Res 2007;17:539–47.
    OpenUrlAbstract/FREE Full Text
  27. 27.↵
    1. Fielding N,
    2. Lee R,
    3. Blank G
    1. Hewson C,
    2. Laurent D
    . Research design and tools for internet research. In: Fielding N, Lee R, Blank G, eds. The Sage handbook of online research methods. London: Sage; 2008:58–79.
  28. 28.↵
    Closing the quality gap: a critical analysis of quality improvement strategies. Vol. 7: care coordination. Technical reviews, no. 9.7Available from: http://www.ncbi.nlm.nih.gov/books/NBK44015/. Accessed March 6, 2015.
  29. 29.↵
    1. Williams S,
    2. Clausen M,
    3. Robertson A,
    4. Peacock S,
    5. McPherson K
    . Methodological reflections on the use of asynchronous online focus groups in health research. Int J Qual Methods 2012;11:368.
    OpenUrl
  30. 30.↵
    1. Seale C,
    2. Charteris-Black J,
    3. MacFarlane A,
    4. McPherson A
    . Interviews and Internet forums: a comparison of two sources of qualitative data. Qual Health Res 2010;20:595–606.
    OpenUrlAbstract/FREE Full Text
  31. 31.↵
    1. Spradley J
    . The ethnographic interview. New York: Holt, Rinehart, & Winston; 1979.
  32. 32.↵
    1. Glaser B,
    2. Strauss A
    . The discovery of grounded theory: strategies for qualitative research. Chicago: Aldine; 1967.
  33. 33.↵
    1. Strauss A,
    2. Corbin J
    . Basics of qualitative research: techniques and procedures for developing grounded theory. Thousand Oaks, CA: Sage Publications; 1998.
  34. 34.↵
    1. Fielding N,
    2. Lee RM,
    3. Blank G
    1. Wakeford N,
    2. Cohen K
    . Fieldnotes in public: using blogs for research. In: Fielding N, Lee RM, Blank G, eds. The Sage handbook of online research methods. Los Angeles: Sage; 2008:307–326.
  35. 35.↵
    1. Crabtree BF,
    2. Miller WL
    1. Borkan J
    . Immersion/crystallization. In: Crabtree BF, Miller WL, eds. Doing qualitative research. 2nd ed. Newbury Park, CA: Sage Publications; 1999:179–194.
  36. 36.↵
    1. Rubak S,
    2. Sandbœk A,
    3. Lauritzen T,
    4. Christensen B
    . Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract 2004;55:305–12.
    OpenUrl
  37. 37.↵
    1. Casalino LP
    . Markets and medicine: barriers to creating a “business case for quality.” Perspect Biol Med 2003;46:38–51; discussion 52–4.
    OpenUrlPubMed
  38. 38.↵
    1. Fagnan LJ,
    2. Dorr DA,
    3. Davis M,
    4. et al
    . Turning on the care coordination switch in rural primary care: voices from the practices–clinician champions, clinician partners, administrators, and nurse care managers. J Ambul Care Manage 2011;34:304–18.
    OpenUrlPubMed
  39. 39.↵
    1. Ciccone MM,
    2. Aquilino A,
    3. Cortese F,
    4. et al
    . Feasibility and effectiveness of a disease and care management model in the primary health care system for patients with heart failure and diabetes (Project Leonardo). Vasc Health Risk Manag 2010;6:297–305.
    OpenUrlPubMed
  40. 40.↵
    1. Miller WL,
    2. Crabtree BF,
    3. Nutting PA,
    4. Stange KC,
    5. Jaen CR
    . Primary care practice development: a relationship-centered approach. Ann Fam Med 2010;8(Suppl 1):S68–79.
    OpenUrlAbstract/FREE Full Text
  41. 41.↵
    1. Zickuhr K,
    2. Smith A
    . Home broadband 2013. August 26, 2013. Washington, DC: Pew Research Center. Available from: http://www.pewinternet.org/2013/08/26/home-broadband-2013/. Accessed March 6, 2015.
  42. 42.↵
    1. Naughton D,
    2. Adelman AM,
    3. Bricker P,
    4. Miller-Day M,
    5. Gabbay R
    . Envisioning new roles for medical assistants: strategies from patient-centered medical homes. Fam Pract Manag 2013;20:7–12.
    OpenUrl
  43. 43.↵
    1. Sequist TD,
    2. Taveras EM
    . Clinic-community linkages for high-value care. N Engl J Med 2014;371:2148–50.
    OpenUrlCrossRefPubMed
  44. 44.↵
    1. Anderson DR,
    2. St Hilaire D,
    3. Flinter M
    . Primary care nursing role and care coordination: an observational study of nursing work in a community health center. Online J Issues Nurs 2012;17:3.
    OpenUrlPubMed
  45. 45.↵
    1. Ferrante JM,
    2. Wu J,
    3. Dicicco-Bloom B
    . Strategies used and challenges faced by a breast cancer patient navigator in an urban underserved community. J Natl Med Assoc 2011;103:729–34.
    OpenUrlPubMed
  46. 46.↵
    1. Berwick DM,
    2. Nolan TW,
    3. Whittington J
    . The triple aim: care, health, and cost. Health Aff (Millwood) 2008;27:759–69.
    OpenUrlAbstract/FREE Full Text
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The Journal of the American Board of Family     Medicine: 29 (1)
The Journal of the American Board of Family Medicine
Vol. 29, Issue 1
January-February 2016
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Facilitators and Barriers to Care Coordination in Patient-centered Medical Homes (PCMHs) from Coordinators' Perspectives
Asia Friedman, Jenna Howard, Eric K. Shaw, Deborah J. Cohen, Laleh Shahidi, Jeanne M. Ferrante
The Journal of the American Board of Family Medicine Jan 2016, 29 (1) 90-101; DOI: 10.3122/jabfm.2016.01.150175

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Facilitators and Barriers to Care Coordination in Patient-centered Medical Homes (PCMHs) from Coordinators' Perspectives
Asia Friedman, Jenna Howard, Eric K. Shaw, Deborah J. Cohen, Laleh Shahidi, Jeanne M. Ferrante
The Journal of the American Board of Family Medicine Jan 2016, 29 (1) 90-101; DOI: 10.3122/jabfm.2016.01.150175
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