Date of Award

Spring 2022

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Public Health

First Advisor

Cleary, Paul

Abstract

In 2013, CMMI awarded Connecticut a $45 million State Innovation Model (SIM) grant to support healthcare payment and delivery model reforms aimed at improving health system performance, increasing quality of care, and decreasing costs. In the five years that followed, the Office of Healthcare Strategy led care delivery changes across the state with an emphasis on bolstering the role of primary care. In particular, many of these efforts centered on furthering team-based, patient-centered models, such as the patient-centered medical home (PCMH). In this dissertation, I use physician, patient, clinical outcome, and organizational data from the SIM project to explore the impact of team-based primary care on three areas of healthcare quality. In the first paper of this dissertation, I explore the relationship between team-based care and physician burnout using physician-reported survey data. I hypothesized that primary care physicians would exhibit greater levels of burnout compared to specialists, and that those physicians who were practicing under team-based models would be less likely to report burnout. I conducted both multivariate linear regression analyses and inverse probability weighting with regression adjustment to test this hypothesis, evaluating the impact of care teams, PCMH-designation, and ACO-designation on burnout. Primary care physicians were more burnt out than specialists. In addition, I found that while care teams did reduce physician burnout, models that encouraged the use of care teams, including PCMHs and ACOs, did not. In addition to informing the literature on team-based primary care, this paper advances the evidence base on physician burnout, an increasingly critical area to understand given the COVID-19 pandemic and its exacerbation of existing physician burnout challenges. In the second paper, I assess the relationship between four medical home organizational characteristics – organization size & affiliation, payment reform experience, team-based care, and patient tracking and reporting – and antihypertensive medication monitoring using fuzzy set Qualitative Comparative Analysis (QCA). I hypothesized that team-based care would be positively associated with antihypertensive treatment monitoring. However, I found that primary care organizations that had a commitment to IT programs, care management protocols, and policies to track their patient populations were most likely to perform antihypertensive monitoring. This chapter used data from an organizational-level practice survey and clinical outcome data, and served to assess clinical quality among organizations participating in the SIM project. In the third chapter of this dissertation, I assess the impact of team-based care on four summary measures of patient experience: timely care, communication, coordination, and courteous staff. In addition, I explore whether the relationship between care teams and patient experience differed by a patient’s health status. I hypothesized that team-based models of primary care would be positively associated with all four domains of patient care experiences, with the strongest effects observed for the domains of communication and courteous staff. I found that teams had a small, but statistically significant, impact on both the communication and courteous staff measures, with the strongest association between teams and courteous staff. In addition, I observed that teams had the largest impact on patients in poor health for the courteous staff measure, but did not have differential effects of teams among chronically ill patients for the other three outcomes. Taken together, the papers presented in this dissertation serve three purposes; they 1) evaluate key metrics for policymaking purposes in the state of Connecticut; 2) inform the evidence base around the impact of delivery reform on physicians, patients, and other key stakeholders and 3) contribute to the peer-reviewed literature on team-based care.

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