Wednesday, January 18, 2012

Patient Centered Medical Home (PCMH) Attributes and Correlation With Staff Morale, Satisfaction and Burn Out: From Bad to Not So Bad to So What?

Nice medical home laptop, but
how do I feel about it?
Over the years, the Disease Management Care Blog has repeatedly reminded the spouse of her particularly good fortune in marriage. Her lingering skepticism, however, has prompted the DMCB to amass further evidence of her marital bliss by

a) asking other spouses in similar relationships if they feel as fortunate and, if so,

b) collecting data about the DMCB-like personality traits in their husbands.

Bonhomie? Check.

Willingness to share the TV remote? Check.

Cooking the occasional meal at great personal sacrifice? Check.

Announcing how good that meal is? Check.

Yet, when confronted with the indisputable statistical associations that correlate nuptial happiness and DMCB"ness," the spouse has remained stubbornly unmoved. At the spouse's pointed request, the DMCB is rechecking the math.

Readers will probably also remain unmoved about this publication that uses a similar approach to examining the impact of the Patient Centered Medical Home (PCMH) on clinic staff morale, satisfaction and burnout. Sara Lewis and colleagues surveyed the staff of 65 "safety net" clinics participating in a "5 Year Safety Net Medical Home Initiative" that had been co-funded by the Commonwealth Fund.

At the time of the survey, the 65 clinics were in the process of implementing becoming PCMHs but had not yet attained that status. The authors used a Likert-style survey to assess PCMH-"like" attributes among these non-PCMH clinics, such as patient access, data tracking, care management and quality improvement.  The survey also asked about staff morale, satisfaction and burnout.  The authors then correlated whether individual scores or a total roll-up score of all the PCMH-like attributes correlated with better clinic morale, higher satisfaction and less burn out.

There were 773 providers and staff members and 603 (78%) responded. 33% rated morale as good, 54% rated job satisfaction as very good and 40% had some burnout.  Based on an analysis of odds ratios, some features of a PCMH - particularly quality improvement - resulted in up to a three fold improvement in the three measures. However, while the total PCMH score was associated with better morale, it looked like there was also a greater association with worse burn-out, which had a statistically significant lower odds ratio of .48.

The DMCB finds these up and down results about the PCMH in nonPCMH clinics unconvincing.  It believes the attributes of a PCMH, if carried out as envisioned, should add up to more than the sum of its parts.  While some of the parts that are outside of a medical home seem, according to this paper, to correlate with morale, satisfaction and burnout, this gives little insight on how medical staff would really react to the transformation of a primary care clinic.  By the way, this is not the first time a PCMH-"like: methodology has been used, which makes the DMCB wonder if fully functioning PCMHs are less common than we think.

What is striking, however, are the basic measures of morale, stress and burnout. Based on these data, it would appear that these safety net clinics have some serious staff issues with 67% not having good morale, 46% not having good job satisfaction and just under half having burn out.

More evidence of primary care's travails says the DMCB.

The good news is that the DMCB remains optimistic that the math will eventually bring the DMCB spouse around.  Maybe the enthusiasm - and the math - about the PCMH will similarly prevail someday.  Until then, this paper's approach doesn't lend much insight about the real potential of the PCMH. Last but not least, if these 65 clinics are representative of primary care morale, satisfaction and burnout in general, the DMCB far less optimistic about their future with or without the PCMH.

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