Care Delivery Model Change: Patient-Centered Medical Home Care Access


BTC is a primary care physicians’ office

BTC has a team of four physicians and two nurse practitioners

BTC provides care to individuals of all ages

Primary care practices incur considerable costs when adopting and implementing comprehensive primary care abilities

BTC is not an exception

A care delivery model change can help BTC mitigate this challenging issue

Background of issue

The cost of operating a primary care office can run primary care physicians out of business

Research reveals that by 2032, the USA would face a shortage of up to 55,200 primary care doctors, compared to about 480,000 primary care physicians in the USA in 2019 (The Lancet, 2019)

Physicians are needed in a health care sector where their skills and expertise are mostly needed to enhance effectiveness of care and promote quality care across the continuum

The main goals for a department that aligns costs, quality are cost containment and sustainability promoting efficiency of care care coordination with other specialties for best patient outcomes

High health care cost necessitates finding strategies to manage healthcare resources appropriately and effectively for the patient, providers, the health care system, and the population

SWOT Analysis of the issue


  • Accessibility due to office location, the ability of patients to visit, and prominent health promotion for proactive health care methods
  • A strong and trusted image as a result of customer satisfaction, supplier reliability, and positive performance in new markets
  • Highly skilled workforce with specialized and general capabilities to address patient needs (Stanborough, 2020).
  • Cohesive referral system in relation to secondary or tertiary care in the case of more specialized intervention


  • The limited profitability of the office, which can inhibit growth or cause a decline in the business
  • Inability to be successful outside the central offered service of primary care
  • Often lacking the necessary technology, equipment, or resources to provide complete care and intervention for patients
  • Possibility to be too reliant on the sale of products for financial success and expansion of care procedures and models
  • Inability to service large populations and a higher quantity of patients (Blumenthal, 2022).


  • Primary health care providers are less affected by inflation variations and can begin or continue business in a more stable manner
  • Advancements in technology provide better opportunities as they become more available and more accessible to patients
  • Consumer trends are also more positive toward primary care physician and provider models
  • Changes in government policies also benefit primary care physicians through agreements that target technology, free trade, and taxation


  • Due to the size of a primary care physician’s office, changes in consumer preference or the economy can cause detriment that is severe
  • Competition is diverse, stemming from other primary care providers, secondary and tertiary care firms, and from hospitals, clinics, and other healthcare facilities
  • The external impact such as price changes or the inability to purchase certain equipment can cause inadequate care for patients
  • Due to the heavy reliance on suppliers, changes in the supply chain may cause harm

Proposed Solution

Adopting a comprehensive primary care model can potentially improve:

  • Quality of care
  • Effectiveness of care
  • Improved care coordination (Martsolf et al., 2019)
  • A care model that can assist in mitigating challenges faced in primary care practices such as BTC is
  • The primary care medical home (PCMH) care model
  • PCMH provides coordinated care for patients based on their personal preferences and needs
  • Attributes PMCH includes
  • Comprehensive care
  • Patient-centered care
  • Lowers costs
  • Coordinated care

Accessible services Image retrieved from Web.

Commitment to quality and safety (National Committee for Quality Assurance, [NCQA], 2020)

Benefits to physicians

According to the National Committee for Quality Assurance ([NCQA], 2020)

Many payers acknowledge PCMH recognition as a hallmark of high-quality care

Many payers offer benefits ranging from enhanced reimbursement, to preferred provider status, to complimentary coaching/practice support

Many payers provide incentives to NCQA-recognized practices

A study found PCMH practices rapidly increase office visits relative to non-patient-centered clinics, with 163 more office visits per 1,000 members per year (Chu, Tu, Lee, Sayles, & Sood, 2016)

To be credentialed as a PCHM provider, the provider must meet some criteria

Team-based care and practice organization

Knowing and managing your patients

Patient-centered access and continuity

Care management and support

Care coordination and care transitions

Performance measurement and quality improvement

These criteria are evidence-based guidelines and best practices categorized as competencies (NCQA, 2020)

Ways Proposed Solution Meets Needs of the Population

To the patient and the health care system

The PCMH model is coordinated through the primary care physician

It ensures that the patient’s care is at the forefront

It serves as a means to enhance several chronic disease outcomes and reduce healthcare costs (American College of Physicians [ACP, 2019]; NCQA, 2020; Almalki, et al., 2018)

It promotes better-coordinated care among the different healthcare disciplines

Promotes interprofessional collaboration

Saves cost

Ways Proposed Solution Meets Needs of the Population

Ensures that care is specific to each individual patient

Improves patient experience

Improve patient-centered access

Improve staff satisfaction

Reduce fragmentation and improve quality

Proposal for a Change Process

Kurt Lewin’s change theory is the prosed implementation strategy for the proposed care delivery model

It has three stages of change (Unfreezing, Changing, and Refreezing)

In this change management process

Change initiatives need to weaken the status quo, implement the alternative, and improve the improve (Batras, Duff & Smith, 2016)

This change management model is acknowledged throughout the nursing literature as a framework to transform care

Experts affirm that Lewin’s theory offers the vital principles for change (Wojciechowski, Murphy, Pearsall, & French, 2016)

Freezing stage

Creates problem awareness

Demonstrate issues or problems

Increase the group behaviors for change

Challenge status quo

Leadership intensifies pressure for change to a higher level

Changing stage

Involves a shift from the old method of doing things to the new method that is introduced

Key stage of implementation which requires support from all levels of leadership

Leadership is expected to help in providing structure and encouragement

Team members are expected to actively participate

Refreezing stage

Involves instituting stability and permanence once change has occurred

The change initiative is acknowledged as the new norm, and part of the organization’s culture

Every staff member works in collaboration to

Continue to implement, continue to evaluate, make necessary adjustments, and create permanence for the new process to thrive

Reasons for using this change model for implementation

Can be used to effectively implement a change vison with minimal complexity

It is used by clinicians in different specialty areas for diverse quality improvement strategies to transform care

It can be used in health care organizations with different degrees of difficulty such as the high cost of running a primary care provider setting

Adopting this change management model can increase productivity, effectiveness, and sustainability can be expanded by integrating organizational change as a key element of health promotion practice and research

Expected Outcomes

Improved value for all stakeholders

The PCMH model provides value to patients, payers and practice to physicians

Improved quality of care, and reduced costs of care

Enhanced physician experience

Provide primary care physicians with delight in their practices by placing them in a better financial position than most other practices (O’Dell, 2016)

Patient-centered care

Patient-centered care has an excellent connection to increased patient satisfaction and improved patient outcomes

Since it is patient-centered, it empowers patients

Patients who are treated as a unique entity feel that they are truly cared for

Enhanced population health

The PCMH is a robust primary care model believed to be vital to transforming and enhancing population health

Enhanced patient-provider relationship

Focuses on the patient-provider relationship, enabling providers to partner with patients to better meet patient goals

Patients’ needs and preferences are fore-front

Helps providers integrate patient preferences, needs, desires, and experiences into every phase of medical treatment, and care

The PCMH model typically integrates increased virtual visits, patient education, and links to social determinants of health (Bokhour et al., 2018)

Improves patient experience

It is recognized as a critical aspect of quality that leads to improved patient experience, trust, and care quality (Bokhour et al., 2018)

Implications that aligns with current and future health care financing

The PCMH model saves costs ….. by reducing hospital and emergency department visits mitigating health disparities improving patient outcomes

Inspires quality in care

Cultivates more engaging patient relationships

Encourages effective care coordination

Captures savings through expanded access and delivery options that align patient preferences with payer and provider capabilities (NCQA, 2020)

As evidence reveals….. the PCMH model has been demonstrated to improve outcomes in terms of quality, cost and utilization

A major implication is the model’s potential to enhance practice and proven best outcomes that is a win-win for all stakeholders


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