Comparing Patient-Centered Medical Home Implementation in Urban and Rural VHA Clinics: Results from the Patient Aligned Care Team (PACT) Initiative

Abstract

BACKGROUND: Rural primary care clinics in the Veterans Health Administration (VHA) are smaller, have fewer staff and serve more rural patients compared to urban VHA primary care clinics. This may lead to different challenges to implementation of the Patient Aligned Care Team (PACT) model, VHA’s Patient-Centered Medical Home (PCMH) model. OBJECTIVE: To determine whether PACT implementation at VHA primary care clinics varied by rural or urban clinic classification. DESIGN: Cross-sectional, observational study of data from fiscal year 2012. SAMPLE: 905 VHA primary clinics in the United States and Puerto Rico. MAIN MEASURES: The primary outcome measure was the PACT Implementation Progress Index (PI2), a composite score measuring the extent to which clinics have integrated components in 8 core PCMH domains. The PI2 score (range from -8 to 8, categorized from greatest to least implementation as 5 to 8, 2 to 4, -1 to 1, -4 to -2 and -8 to -5) summarizes the relative performance of clinics across all domains. We classified clinics as rural or urban using 2 definitions: 1) by clinic Rural-Urban Commuting Area codes based on clinic address 2) by the proportion of each clinic’s assigned patients residing in rural areas. KEY RESULTS: Rural clinics had significantly greater overall PACT implementation, as measured by mean PI2 score, compared to urban clinics (0.39 vs. -0.24, p<0.005). Clinics with ≥50% rural patients assigned to primary care also had significantly higher mean overall PI2 score compared to clinics with <50% rural patients assigned (0.34 vs. -0.37, p<0.002). Trends across PI2 implementation categories were significantly different for both rural measures (location-based measure: p<0.003; patient-based measure: p<0.002), with higher proportions of rural clinics in the highest implementation categories compared to urban clinics. Adjustment for clinic organizational factors using linear regression attenuated the association between clinic rurality and PI2 score. CONCLUSIONS: Overall, PCMH implementation in a large, integrated health care system was more effective in rural compared to urban primary care clinics. Urban-rural differences in PCMH implementation may largely be related to clinic organizational factors.