Description of Conceptual Framework

The study applied a modified theory of determinants of diffusion of innovations in the organization and delivery of health services described by Greenhalgh et al(59). The focus of the study was on innovation implementation – in this case the implementation of Patient-Centered Medical Home in the State of Maryland investigating the role of the change agency and the internal and external environment within which the innovation is implemented. The change agency in the study was the Maryland Learning Collaborative (MLC) that was set up to facilitate the implementation of PCMH among 52 primary care practices.

Figure 1: Theoretical Conceptual Model: Diffusion of Innovations in Healthcare (Extracted from Greenhalgh et al, 1st _{Edition 2005: Page 6)}

The study’s underpinning hypothesis was that implementation of PCMH innovation was enhanced by the MLC as a change agent and the effectiveness of the process is explained by external and internal factors. The learning collaborative approach was a goal-directed process and mobilized external and internal actors to learn together through a common vision as a catalyst for change(70).

Research on PCMH implementation identified internal factors, namely leadership support, adaptive reserve or innovation capability and change champions as factors that enhanced implementation of PCMH. In addition, this study also examined staff

commitment/support/resistance to the change. Financial incentives and technical support received towards quality improvement for desired outcomes were key external influences. This study examined how these factors affected the process. In addition, the study looked at the learning collaborative process itself and how that might have affected the implementation of PCMH. Specifically, the study looked at: 2) learning agenda/goal for the collaborative, 2)

organization of the collaborative, and 3) group processes. The study did not address all aspects of the internal and external context for innovation implementation but rather was more nuanced, and focused on the interface between the internal and external context in far as they enhanced or constrained the role of the change agent. To this end, the study did not seek to assess whether the practices were ready for the innovation – i.e. did not assess structural and cultural determinants of innovativeness since a decision was already made to implement the innovation. At the same time, the focus of the external context was limited to how the innovating

organizations brought together into the learning collaborative and by the State policy push implemented the innovation and formed beneficial networks with each other.

Conceptually, the study was based on the premise that the change agency’s

involvement in the dissemination of the innovation influenced the success of implementation and whether the beneficiary organizations in this case the practices agreed with that

interaction between the change agent and the affected organizations, namely 1) human relations, 2) sharing of common language, 3) sharing of resources in both directions, 4) facilitation of networking and collaboration between participating organizations, and 5) joint evaluation of the innovation consequences. Was this true for the MLC? In addition the change agency should possess the capacity, commitment, technical capability, communication and project management skills to assist participating organizations with operational issues.

For purposes of this study I adopted the Learning Collaborative definition advanced by Greenhalgh et al(59): “an initiative that brings together groups of practitioners from different healthcare organizations to work in a structured way to improve one aspect of quality of their service”. In this case the MLC, aimed to enhance the capacity of participating practices to improve quality through: 1) chronic disease management improvement with care management and coordination plus preventive metrics and outreach, and, 2) reduced utilization of services through care transitions that streamline with local hospital discharges and encounter notification for emergency department and hospital visits. The theory of diffusion of innovation through learning collaboratives describes the process as that of mutual learning by multiple organizations for purposes of bringing about change. The process requires organizations to share experiences, techniques, ideas and knowledge and set common goals for change while focusing on their internal organizational priorities for change. Study findings shed light on the process and how it might have influenced final desired outcomes as stated in the Maryland Multi-Payer Program for Patient-Centered Medical Home.

PCMH implementation process in the State of Maryland started with the desire of

practices to transform into “ideal” practices on one hand, and health care financing stakeholders seeking to reduce costs of care. These two goals could be met through adoption of an

advanced primary care model also known as patient-centered care. However, this did not happen in a vacuum. In addition, the State Government policy objectives and ongoing national healthcare reforms provided the optimal condition for the PCMH model implementation.

Receiving NCQA recognition as a PCMH was an important and necessarily step in the process. The learning collaborative in this case the MLC became the strategy employed to support the PCMH implementation process.

Implementation of PCMH model within a practice is confirmed through the NCQA recognition process. However, the goal for PCMH implementation goes beyond recognition and so are the goals of the MLC. The goal is for practices to adopt a patient-centered care model considered an advanced form of primary care and achievement of the three main outcomes for PCMH implementation namely: 1) quality and patient outcome improvement, 2) enhancement of provider and patient experiences, and 3) efficiency improvement and health care cost reduction. The learning collaborative created the mechanism and environment that brought the practices together to implement a needed change – the PCMH model. In addition the learning

collaborative provided tools and introduced structural changes within the practices that arguably enhanced the implementation process. Study results will further elaborate on what these

changes were.