Abstract Session F4: Organization of Care and Chronic Disease Management Moderator: Karin M. Nelson, MD, MSHS PATIENT-CENTERED MEDICAL HOME IMPLEMENTATION AND PROVIDER JOB TURNOVER Philip W. Sylling 1 ; Edwin Wong 1,4 ; Chuan-Fen Liu 1,4 ; Susan Hernandez 1,4 ; Adam Batten 1 ; Christian Helfrich 1,4 ; Karin M. Nelson 1,2 ; Stephan D. Fihn 3,5 ; Paul Hebert 1,4 . 1 VA Puget Sound Healthcare System, Seattle, WA; 2 VA Puget Sound Healthcare System, Seattle, WA; 3 University of Washington, Seattle, WA; 4 University of Washington, Seattle, WA; 5 Veterans Health Administration, Seattle, WA. (Tracking ID #1938371) BACKGROUND: The aim of this study was to examine the relationship between the implementation of a patient-centered medical home (PCMH) model and primary care provider (PCP) job turnover. The Veterans Health Administration (VHA) began implementing a PCMH through its Patient Aligned Care Team (PACT) initiative in April 2010. Although elements of PACT have been individually associated with greater PCP job satisfaction, the magnitude of organizational change required by PACT's restructuring of primary care may result in higher provider turnover, at least in the short-term. Existing literature has not specifically examined the effect of PCMH on PCP turnover. METHODS: We applied an interrupted time series model using VHA administrative data. PCP turnover was defined by providers' dropping out of the primary care workforce for two or more consecutive quarters. We constructed discrete-time longitudinal data from PCPs employed by the VHA anytime from 2003 to 2012 with the unit of analysis at the PCP-quarter level. PCPs included physicians, nurse practitioners, and physician assistants. We estimated the association between PACT and provider turnover using logistic regression and adjusted for seasonality and secular trend, provider and job characteristics, and the local area unemployment rate. For adjusted analysis, we calculated average marginal effects (AMEs), which reflected the change in PCP turnover probability associated with unit increases in the explanatory variables. To examine differential effects of PACT across providers, we interacted a PACT indicator variable with PCP demographics. RESULTS: The unadjusted quarterly rate of PCP turnover was 3.06% prior to PACT and 3.38% after PACT. In adjusted analysis, PACT was associated with higher provider turnover (AME=0.004, p=0.004). The association between PACT and PCP turnover was significantly different across age groups and experience levels. PACT was associated with a -0.0008 (p=0.711), 0.0046 (p=0.011), and 0.0069 (p=0.002) percentage point increase in turnover probability for providers under age 45, age 45 to 55, and over age 55, respectively. Compared to PCPs with 5 years of experience (AME=0.0019, p=0.239), the estimated effect of PACT on turnover was higher for PCPs with 20 years of experience (AME=0.0106, p<0.001). Provider type was also associated with baseline provider turnover. Nurse practitioners (AME=0.0055, p<0.001) and physician assistants (AME=0.0084, p<0.001) had higher baseline turnover than physicians. CONCLUSIONS: PCMH implementation in VHA primary care required providers to adopt a team-based model of care as well as utilize new patient-centered forms of care delivery. This transition represented substantial organizational change which may have increased job stress among some providers. Our results suggest that PCMH implementation was associated with higher initial provider job turnover, particularly among older and more experienced providers. From a policy perspective, health system decision makers should consider the potential short-term impact of increased PCP turnover when implementing PCMH models, which could adversely impact quality of patient care delivery. Also, health systems implementing PCMH may maximize resources by focusing retention efforts on older and more experienced providers.
IMPACT OF LOSS OF INTERPERSONAL CONTINUITY ON PATIENT EXPERIENCE OF CARE AND AMBULATORY QUALITY OF CARE Ashok Reddy 1,4 ; David A. Asch 2,3 ; Anne Canamucio 2 ; Rachel M. Werner 2,3 . 1 University of Pennsylvania, Philadelphia, PA; 2 VISN 4 Center for Evaluation of PACT, Philadelphia, PA; 3 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; 4 Robert Wood Johnson Clinical Scholar Program, University of Pennsylvania, Philadelphia, PA. (Tracking ID #1938406) BACKGROUND: Continuity remains a core tenet of primary care. Several studies link a more continuous PCP-patient relationship with higher patient satisfaction, higher preventive service use, and lower hospitalizations rates. Continuity is often defined as having three components: interpersonal (having a continuous personal physician-patient relationship), longitudinal (having a medical home in which patients receive the majority of their care), and informational (having a patient's medical records available at the time a doctor sees the patient). While prior work demonstrates the importance of continuity on patient care outcomes, it is uncertain which component of continuity matters most. Our study focuses on isolating the impact of interpersonal continuity in the setting of stable informational and longitudinal continuity. In the setting of the Veterans Health Administration (VHA), we conduct an analysis of patients who experienced a loss of the interpersonal relationship (primary care provider turnover) but continue to receive care at the VHA (stable longitudinal and informational continuity). We then measure the impact of turnover on patient care experience and ambulatory quality of care. METHODS: We included all patients enrolled in primary care at the Veterans Health Administration (VHA) between 2010 and 2012 who were also included in one of two national datasets used to measure our outcome variables: the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) and the External Peer Review Program (EPRP; used to measure ambulatory quality of care). Both datasets include a random sample of veterans receiving outpatient care in the VHA. We measured primary care provider (PCP) turnover in the two years prior to measuring patient experience and quality of care using VHA primary care encounter data. A linear probability model was used to test whether PCP turnover was associated with changes in patient experience of care and ambulatory quality of care, adjusting for patient-level covariates (age, gender, race, income and DCG risk score) and clinic-level fixed effects, and clustering standard errors at clinic level. RESULTS: Our analyses include SHEP responses from 639,011 patients (9% of who experience PCP turnover) and EPRP data from 361,627 patients (10% experiencing PCP turnover). A majority of respondents reported positive experiences of care in 3 out of 5 domains: How well doctor/nurse communicate (53%), rating of personal doctor/nurse (71%), and overall rating of VHA healthcare (59%). In addition, patients had high rates of completion of testing for retinal preventive care (90%), control of hypertension (79%) and colon cancer screening (82%). In our primary analysis, PCP turnover was associated with a decrease in all 5 domains of patient care experience. For example, PCP turnover was associated with a 3.7 percentage point (p<0.05) lower response in how well a patient communicates with his or her provider. However, we found no association between PCP turnover and ambulatory quality of care measures. CONCLUSIONS: With increasing primary care turnover, interpersonal continuity in medical care continues to diminish. Our study shows that loss of interpersonal continuity is a common experience and is associated with a small but significantly worse patient experience of care. However, this loss of interpersonal continuity does not impact the quality of preventive services for common ambulatory conditions. These findings demonstrate that health care systems with robust informational and longitudinal continuity could mitigate the impact of a loss of any one provider on a person's healthcare.
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