Publications

BACKGROUND

New models of patient-centered primary care such as the patient-centered medical home (PCMH) depend on high levels of interdisciplinary primary care team functioning to achieve improved outcomes. A few studies have qualitatively assessed barriers and facilitators to optimal team functioning; however, we know of no prior study that assesses PCMH team functioning in relationship to patient health outcomes.

PURPOSE

The aim of the study was to assess the relationships between primary care team functioning, patients' use of acute care, and mortality.

METHODOLOGY/APPROACH

Retrospective longitudinal cohort analysis of patient outcomes measured at two time points (2012 and 2013) after PCMH implementation began in Veterans Health Administration practices. Multilevel models examined practice-level measures of team functioning in relationship to patient outcomes (all-cause and ambulatory care-sensitive condition-related hospitalizations, emergency department visits, and mortality). We controlled for practice-level factors likely to affect team functioning, including leadership support, provider and staff burnout, and staffing sufficiency, as well as for individual patient characteristics. We also tested the model among a subgroup of vulnerable patients (homeless, mentally ill, or with dementia).

RESULTS

In adjusted analyses, higher team functioning was associated with lower mortality (OR = 0.92, p = .04) among all patients and with fewer all-cause admissions (incidence rate ratio [IRR] = 0.90, p < 0.01), ambulatory care-sensitive condition-related admissions (IRR = 0.91, p = .04), and emergency department visits (IRR = 0.91, p = .03) in the vulnerable patient subgroup.

CONCLUSION

These early findings give support for the importance of team functioning within PCMH models for achieving improved patient outcomes.

PRACTICE IMPLICATIONS

A focus on team functioning is important especially in the early implementation of team-based primary care models.

BACKGROUND

The Montreal Cognitive Assessment (MoCA) has not been administered to a representative national sample, precluding comparison of patient scores to the general population and for risk factor identification.

METHODS

A validated survey-based adaptation of the MoCA (MoCA-SA) was administered to a probability sample of home-dwelling US adults aged 62 to 90, using the National Social Life, Health, and Aging Project (n=3129), yielding estimates of prevalence in the United States. The association between MoCA-SA scores and sociodemographic and health-related risk factors were determined.

RESULTS

MoCA-SA scores decreased with age, and there were substantial differences among sex, education, and race/ethnicity groups. Poor physical health, functional status, and depression were also associated with lower cognitive performance; current health behaviors were not. Using the recommended MoCA cut-point score for Mild Cognitive Impairment (MoCA score <26; MoCA-SA score <17), 72% (95% confidence interval, 69% to 74%) of older US adults would be classified as having some degree of cognitive impairment.

CONCLUSIONS

Our results provide an important national estimate for interpreting MoCA scores from individual patients, and establish wide variability in cognition among older home-dwelling US adults. Care should be taken in applying previously-established MoCA cut-points to the general population, especially when evaluating individuals from educationally and ethnically diverse groups.