The Millbank Quarterly – Medical Home Implementation: A Sensemaking Taxonomy of Hard and Soft Best Practices

December 11, 2013


Tim Hoff, Associate Professor of Management, Healthcare Systems, and Health Policy, just published his work on patient-centered medical home care models in the #1 ranked health policy and health services research journal, The Millbank Quarterly. The article is based on a study funded by the Agency for Healthcare Research and Quality and is one of first studies nationally looking at medical home implementation for older adult patients.

Continue reading for details on his article. 

Volume 91 | Issue 4, 2013

Context: The patient-centered medical home (PCMH) model of care is currently a central focus of U.S. health system reform, but less is known about the model’s implementation in the practice of everyday primary care. Understanding its implementation is key to ensuring the approach’s continued support and success nationally. This article addresses this gap through a qualitative examination of the best practices associated with PCMH implementation for older adult patients in primary care.

Methods: I used a multicase, comparative study design that relied on a sensemaking approach and fifty-one in-depth interviews with physicians, nurses, and clinic support staff working in six accredited medical homes located in various geographic areas. My emphasis was on gaining descriptive insights into the staff’s experiences delivering medical home care to older adult patients in particular and then analyzing how these experiences shaped the staff’s thinking, learning, and future actions in implementing medical home care.

Findings: I found two distinct taxonomies of implementation best practices, which I labeled “hard” and “soft” because of their differing emphasis and content. Hard implementation practices are normative activities and structural interventions that align well with existing national standards for medical home care. Soft best practices are more relational in nature and derive from the existing practice social structure and everyday interactions between staff and patients. Currently, external stakeholders are less apt to recognize, encourage, or incentivize soft best practices.

Conclusions: The results suggest that there may be no standardized, one-size-fits-all approach to making medical home implementation work, particularly for special patient populations such as the elderly. My study also raises the issue of broadening current PCMH assessments and reward systems to include implementation practices that contain heavy social and relational components of care, in addition to the emphasis now placed on building structural supports for medical home work. Further study of these softer implementation practices and a continued call for qualitative methodological approaches that gain insight into everyday practice behavior are warranted.


Author(s): Timothy Hoff

Keywords: primary care, medical home, implementation, elderly

Read on Wiley

Volume 91, Issue 4 (pages 771–810)
DOI: 10.1111/1468-0009.12033
Published in 2013

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