JGIM
PERSPECTIVE
The Patient-Centered Medical Home: Preparation of the Workforce,
More Questions than Answers
P. Preston Reynolds, MD, PhD1,11, Kathleen Klink, MD2, Stuart Gilman, MD, MPH3,4,
Larry A. Green, MD5, Russell S. Phillips, MD6, Scott Shipman, MD, MPH7,8, David Keahey, MSPH, PA-C9,
Kathryn Rugen, PhD, FNP-BC4,10, and Molly Davis, BA1
1
University of Virginia, Charlottesville, VA, USA; 2Robert Graham Center, Washington, DC, USA; 3University of California at Irvine, Long Beach, CA,
USA; 4Veterans Health Administration, Washington, DC, USA; 5University of Colorado, Boulder, CO, USA; 6Harvard University, Cambridge, MA, USA;
7
Dartmouth College, Hanover, NH, USA; 8Association of American Medical Colleges, Washington, DC, USA; 9University of Utah, Salt Lake City, UT,
USA; 10University of Illinois at Chicago, Chicago, IL, USA; 11Center for Biomedical Ethics and Humanities, University of Virginia, Charlottesville, VA, USA.
As American medicine continues to undergo significant decrease in racial and ethnic disparities with implementation
transformation, the patient-centered medical home of the PCMH.5
(PCMH) is emerging as an interprofessional primary care With the passage of the Affordable Care Act that in-
model designed to deliver the right care for patients, by the
cludes provisions to stimulate the development of new
right professional, at the right time, in the right setting, for
the right cost. A review of local, state, regional and nation- delivery models to promote access to primary care ser-
al initiatives to train professionals in delivering care with- vices and achieve the Triple Aim1, it is imperative to
in the PCMH model reveals some successes, but substan- review factors that may enhance or impede wider adoption
tial challenges. Workforce policy recommendations de- of the PCMH. Building on a successful conference in
signed to improve PCMH effectiveness and efficiency in- 20096, the Society of General Internal Medicine, in col-
clude 1) adoption of an expanded definition of primary laboration with the Society of Teachers of Family Medi-
care, 2) fundamental redesign of health professions edu- cine and the Academic Pediatric Association, hosted a
cation, 3) payment reform, 4) responsiveness to local
needs assessments, and 5) systems improvement to em-
second conference in 2013 to identify relevant research
phasize quality, population health, and health disparities. and policy agendas as well as to assess what, if any,
significant impact the PCMH transformation may have
KEY WORDS: Health policy; Workforce; Patient-centered care; Medical from both a clinical and economic perspective.7
education—financing and administration; Medical education—interprofessional
training, faculty development, undergraduate and graduate training.
One of six groups, the PCMH Workforce Workgroup, was
J Gen Intern Med 30(7):1013–7 charged with identifying workforce-related research areas that
DOI: 10.1007/s11606-015-3229-2 could either facilitate or prevent wider PCMH adoption. These
© Society of General Internal Medicine 2015
areas include the number and appropriate ratio of professionals
required to maximize team effectiveness in delivering high-
value care, required individual and collaborative training, and
an evaluative schema for both practitioners and trainees. Re-
INTRODUCTION search outcomes should inform policies and program initia-
American medicine is undergoing a transformation driven by tives at federal, state, and local levels, and address priorities
the need to improve population health outcomes, enhance the relevant to academic institutions and accrediting, licensing,
patient care experience, and manage the cost of care, referred and funding bodies. This manuscript emerged from the delib-
to as the "Triple Aim.1 Evidence continues to accumulate on erations of the Workforce Workgroup, with input from partic-
the benefits of primary care, including a reduction in avoidable ipants at the national conference. Professional groups repre-
hospitalizations.2,3 Ideally, patients who are engaged in the sented included physicians, physician assistants, and nurses,
patient-centered medical home (PCMH), especially those all of whom endorse the principles of the PCMH and inter-
most vulnerable, will experience reduced health risks and professional education.8–12
improved outcomes. About half of the states in the U.S. are Discussions revealed unanimous agreement that, beyond
implementing the PCMH for their Medicaid populations in an mastering the skills relevant to interprofessional practice, cli-
effort to improve outcomes while controlling health care costs, nicians practicing in PCMHs must effectively engage patients,
as these populations are often at highest risk for poor health families, and communities, incorporate strategies that reduce
status,4 particularly in light of evidence that demonstrates a health disparities, and integrate behavioral health team mem-
bers. Health information technology must be employed both
Received March 25, 2014
Revised October 8, 2014
as a vehicle for communication among care team members
Accepted January 26, 2015 and patients, and as a means to enhance quality assessment
Published online February 24, 2015 and improvement.
1013
, 1014 Reynolds et al.: The Patient-Centered Medical Home: Preparation of the Workforce JGIM
FACILITATORS AND EARLY ADOPTERS physician assistant, dentist, and dental hygienist training in
medical home models. The THCGME is based on evidence
The Preparing the Personal Physician for Practice (P4) initia-
tive (2007–2012), sponsored by the American Board of Fam- that residency training influences physician practice choices,
ily Medicine, the Association of Family Medicine Residency with greater retention of physicians in primary care following
Directors, and TransforMED, was designed to drive graduate completion of training in these settings.20 THCGME funds
medical education reform among 14 residency programs in flow directly to the residency program, which is generally
order to prepare family physicians for PCMH practice.13–15 located in community health centers and rural health clinics
The National Demonstration Project, launched by the Ameri- that have traditionally delivered care with PCMH features.21
can Academy of Family Physicians in 2006 in an effort to As of 2014, 60 THCGME residencies supporting more than
assess the comprehensive PCMH model and findings related 550 resident full-time equivalent positions in 24 states have
to transformation process requirements, reported in 2010 that been funded,22 an investment that will be sacrificed if Con-
this evolution was a complex process requiring motivated and gress does not re-authorize funding beyond 2015.
engaged practice members. Over time, this process should In response to recommendations of the Advisory Commit-
continue to emphasize core attributes of collaborative care tee for Training in Primary Care Medicine and Dentistry, re-
within primary care and attention to mental and public authorization of the Title VII grant program under the Afford-
health.16 able Care Act created new funding priorities to encourage
The Veterans Health Administration (VA) is the largest applicants to propose educational innovations that equip stu-
organization to have engaged in training clinicians in a PCMH dents, residents, and faculty with the knowledge and skills
model that includes undergraduate, graduate, and post- necessary for interprofessional practice in a PCMH.23 These
graduate levels of an array of health professionals.17,18 grants have helped to drive educational transformation and
Through the PCMH-like model known as the Patient Aligned implementation of the PCMH in academic health centers
Care Team (PACT), the VA has hired and trained clinicians in (AHCs).24 The Interprofessional Education Collaborative has
the skills needed to deliver health care in more than 900 published competencies for team-based care,11 and the
ambulatory practices through interprofessional teams as part Patient-Centered Primary Care Collaborative (PCPCC, www.
of its New Models of Care transformation initiative introduced pcpcc.org)Education and Training Task Force has endorsed
in 2011. The VA’s five Centers of Excellence in Primary Care specific PCMH competencies.25
Education develop and test innovative approaches to educat- In addition to the THCGME and Title VII Primary Care
ing health professionals, including medical students, resident Training and Enhancement grant programs, in 2012 the Health
physicians, nurse practitioners, pharmacists, behavioral health Resources and Services Administration (HRSA) funded a
clinicians, and physician assistants, to provide care through contract to provide faculty development focused on the pro-
implementation of the PCMH model. motion of PCMH curricular advancement and to support
VA-based trainees of all involved professions have reported collaboration among the three primary care certification
deriving value from learning about professional development boards (internal medicine, family medicine, and pediatrics)
and roles of other primary care professions; they have also in creating a pilot interdisciplinary faculty development pro-
noted greater satisfaction with the increased patient continuity gram. The program focused on teamwork, change manage-
provided by these programs as well as with the curriculum ment, leadership, population management, clinical
incorporating performance improvement.19 The five Centers microsystems, and competency assessment skills.
of Excellence in Primary Care Education may offer important Some have observed that there is a “perfect storm” brewing
insights into system-level and local issues through expansion on the horizon in health care, as reform is implemented on
of interprofessional primary care education. Given the scale of multiple levels, highlighted by the Triple Aim. Increasingly,
the VA facilities serving as training locations, particularly in the PCPCC, with membership comprising payers, profession-
internal medicine, the impacts on trainees and faculty involved al organizations, and health care systems, is demanding a
in the PACT educational intervention process are likely to delivery system—and by extension, an educational
increase as the VA expands the use of improved academic system—to support the PCMH model. The Center for Medi-
models across the system. care & Medicaid Innovation (CMMI) is encouraging innova-
tion in primary care and accelerated development and testing
of new payment and service delivery models. Many CMMI
efforts are focused on primary care, including the Comprehen-
DRIVERS OF EDUCATIONAL CHANGE sive Primary Care Initiative, the Federally Qualified Health
Other national initiatives designed to train health care profes- Center Advanced Primary Care Practice Demonstration
sionals in the PCMH include the Teaching Health Center (FQHC APCP), the Independence at Home Demonstration
Graduate Medical Education (THCGME) and the Title VII project, and the Multi-payer Advanced Primary Care Initia-
Primary Care Training and Enhancement (PCTE) and Train- tive. Other initiatives relevant to primary care include pro-
ing in General Dentistry, Pediatric Dentistry, and Public grams targeting low-income adult and child (Medicaid and
Health Dentistry grant programs that support physician, Children's Health Insurance Program [CHIP]) populations for
