The Journey toward the Patient-Centered Medical Home: A Grounded, Dynamic Theory of Primary Care Transformation

Introduction: This dissertation develops a grounded and dynamic theory of primary care transformation (PCT) in a health service delivery organization (HSDO) implementing the Patient-Centered Medical Home model, in the United States of America. The focus of this theory is on the structural facilitators and challenges to achieving and sustaining high quality primary care. Methodology: Fieldwork performed included semi-structured interviews conducted across the HSDO (n=82), direct observations (n=10 clinics) and archival review. This dissertation utilizes newly-developed methods for theory development and validation, in concert with existing system dynamics methods; with an improved potential to integrate findings across quantitative and qualitative research directions. Results: My theory illuminates how the actions of various stakeholders (medical assistants, managers, clinicians and patients) interact with each other and with the fundamental characteristics of primary care service delivery to create diverse transformation trajectories. Two types of leverage points are identified: policies and preferences. The latter are more difficult to modify as they require changing stakeholders’ mental models. It is the combination of policies and preferences interacting within the system structure that produces hoped-for and feared transformation trajectories. There is no policy that induces success regardless of stakeholder preferences. There are some preferences that induce success or failure regardless of the policies being implemented. Conclusion: Sustaining success requires understanding the system structure within which policies and preferences operate – how decisions are made, their consequences, and the delays involved. Otherwise, transformation risks being overwhelmed by unintended consequences, misunderstood system behavior or impatience. This work presents an improved understanding of what PCT involves, and of how operational and cognitive aspects intersect. Overall, this work is more than a study of transformation. It presents theory, methods and a case for the development of an integrative methodology and paradigm.