***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective To assess whether a model of care with augmented services within an existing medical home could improve immunization rates for Children with Special Health Care Needs ( CSHCN ) and to evaluate the influence of family and practice characteristics on these children ’s immunization rates . Method Participants were six general pediatric practice s , CSHCN , and their families . Enhancements were added to the medical home for CSHCN , including additional nurse practitioner time . A prospect i ve survey and chart review of volunteer families was made in 1998 repeating the chart review in 2000 . Results The immunization rates of CSHCN in the practice s before the intervention was 83.4 % for DTaP , polio and MMR and 80 % if HIB and HepB were added . The intervention did not improve these already high rates . In regression models , children with late onset disorders were more likely NOT to be up-to- date ( UTD ) by 2 years of age ( OR 3.29 ) . CSHCN cared for by non-birth parents and CSHCN whose family incomes were greater than $ 40,000 per year were also more likely NOT to be UTD ( OR 3.81 , 2.75 respectively ) as were patients of providers not satisfied with any aspect of serving patients ( OR 3.29 ) . Conclusions In these practice s already committed to a medical home model of care for CSHCN , immunization rates were at or above state and national averages before any intervention took place . Some groups of patients among these CSHCN were more likely to be delayed with immunizations , including those with late onset disorders and those with high family incomes BACKGROUND A  patient-centered medical home ( PCMH ) demonstration was undertaken at 1 healthcare system , with the goals of improving patient experience , lessening staff burnout , improving quality , and reducing downstream costs . Five design principles guided development of the PCMH changes to staffing , scheduling , point-of-care , outreach , and management . OBJECTIVE To report differences in patient experience , staff burnout , quality , utilization , and costs in the first year of the PCMH demonstration . STUDY DESIGN Prospect i ve before and after evaluation . METHODS Baseline ( 2006 ) and 12-month ( 2007 ) measures were compared .  Patient and staff experiences were measured using surveys from a r and om sample of patients and all staff at the PCMH and 2 control clinics . Automated data were used to measure and compare change components , quality , utilization , and costs for PCMH enrollees versus enrollees at 19 other clinics . Analyses included multivariate regressions for the different outcomes to account for baseline case mix . RESULTS After adjusting for baseline ,  PCMH patients reported higher ratings than controls on 6 of 7 patient experience scales . For staff burnout , 10 % of PCMH staff reported high emotional exhaustion at 12 months compared with 30 % of controls , despite similar rates at baseline .  PCMH patients also had gains in composite quality between 1.2 % and 1.6 % greater than those of other patients .  PCMH patients used more e-mail , phone , and specialist visits , but fewer emergency services . At 12 months , there were no significant differences in overall costs . CONCLUSIONS A PCMH re design can be associated with improvements in patient experience , clinician burnout , and quality without increasing overall cost This article summarizes findings from the National Demonstration Project ( NDP ) and makes recommendations for policy makers and those implementing patient-centered medical homes ( PCMHs ) based on these findings and an underst and ing of diverse efforts to transform primary care . The NDP was launched in June 2006 as the first national test of a particular PCMH model in a diverse sample of 36 family practice s , r and omized to facilitated or self-directed groups . An independent evaluation team used a multi method evaluation strategy , analyzing data from direct observation , depth interviews , e-mail streams , medical record audits , and patient and clinical staff surveys . Peer- review ed manuscripts from the NDP provide answers to 4 key questions : ( 1 ) Can the NDP model be built ? ( 2 ) What does it take to build the NDP model ? ( 3 ) Does the NDP model make a difference in quality of care ? and ( 4 ) Can the NDP model be widely disseminated ? We find that although it is feasible to transform independent practice s into the NDP conceptualization of a PCMH , this transformation requires tremendous effort and motivation , and benefits from external support . Most practice s will need additional re sources for this magnitude of transformation . Recommendations focus on the need for the PCMH model to continue to evolve , for delivery system reform , and for sufficient re sources for implementing personal and practice development plans . In the meantime , we find that much can be done before larger health system reform Guided Care ( GC ) is an enhancement to primary care that incorporates the operative principles of disease management and chronic care innovations . In a 6-month quasi-experimental study , we compared the cost and utilization patterns of patients assigned to GC and Usual Care ( UC ) .  The setting was a community-based general internal medicine practice . The participants were patients of 4 general internists . They were older , chronically ill , community-dwelling patients , members of a capitated health plan , and identified as high risk . Using the Adjusted Clinical Groups Predictive Model ( ACG-PM ) , we identified those at highest risk of future health care utilization . We selected the 75 highest-risk older patients of 2 internists at a primary care practice to receive GC and the 75 highest-risk older patients of 2 other internists in the same practice to receive UC .  Insurance data were used to describe the groups ' demographics , chronic conditions , insurance expenditures , and utilization . Among our results , at baseline , the GC ( all targeted patients ) and UC groups were similar in demographics and prevalence of chronic conditions , but the GC group had a higher mean ACG-PM risk score ( 0.34 vs. 0.20 , p < 0.0001 ) . During the following 6 months , the GC group had lower unadjusted mean insurance expenditures , hospital admissions , hospital days , and emergency department visits ( p > 0.05 ) . There were larger differences in insurance expenditures between the GC and UC groups at lower risk levels ( at ACG-PM = 0.10 , mean difference = $ 4340 ; at ACG-PM = 0.6 , mean difference = $ 1304 ) . Thirty-one of the 75 patients assigned to receive GC actually enrolled in the intervention . These results suggest that GC may reduce insurance expenditures for high-risk older adults . If these results are confirmed in larger , r and omized studies , GC may help to increase the efficiency of health care for the aging American population The purpose of this study was to examine the impact of a care coordination intervention aim ed at improving the medical home for children with special health care needs ( CSHCN ) . 100 CSHCN referred by a Medicaid managed care plan were r and omly assigned to a care coordination intervention or to a wait list comparison group that received st and ard care . For the intervention group , a care coordinator supported the medical home by consulting with primary care providers at multiple practice s to develop an integrated , individualized plan to meet child and family needs . During the second phase of the study , the wait list comparison group received the 6-month intervention . At the end of 12 months , the two groups were combined to examine within subject differences ( n = 61 ) . Compared to the control group , participants in the initial intervention group reported a decreased need for information and improved satisfaction with mental health services and specialized therapies . This effect was replicated when the wait list control group received the intervention . Additional benefits were observed in the within subject analysis , including a decline in unmet needs , improved satisfaction with specialty care and care coordination , and improved ratings of child health and family functioning . This intervention improved outcomes for CSHCN and their families by supporting the efforts of primary care physicians to provide comprehensive and coordinated care through the medical home . The consulting care coordinator may provide an efficient and cost effective approach to enhancing the quality of care for CSHCN BACKGROUND We have little systematic information about the extent to which st and ard processes involved in health care -- a key element of quality --are delivered in the United States . METHODS We telephoned a r and om sample of adults living in 12 metropolitan areas in the United States and asked them about selected health care experiences . We also received written consent to copy their  medical records  for the most recent two-year period and used this information to evaluate performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care . We then constructed aggregate scores . RESULTS Participants received 54.9 percent ( 95 percent confidence interval , 54.3 to 55.5 ) of recommended care . We found little difference among the proportion of recommended preventive care provided ( 54.9 percent ) , the proportion of recommended acute care provided ( 53.5 percent ) , and the proportion of recommended care provided for chronic conditions ( 56.1 percent ) . Among different medical functions , adherence to the processes involved in care ranged from 52.2 percent for screening to 58.5 percent for follow-up care . Quality varied substantially according to the particular medical condition , ranging from 78.7 percent of recommended care ( 95 percent confidence interval , 73.3 to 84.2 ) for senile cataract to 10.5 percent of recommended care ( 95 percent confidence interval , 6.8 to 14.6 ) for alcohol dependence . CONCLUSIONS The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public . Strategies to reduce these deficits in care are warranted PURPOSE To assess the impact on health care cost and quality among seniors of a patient-centered medical home ( PCMH ) pilot at Group Health Cooperative , an integrated health care system in Washington State . DESIGN AND METHODS A prospect i ve before- and -after evaluation of the experience of seniors receiving primary care services at 1 pilot clinic compared with seniors enrolled at the remaining 19 primary care clinics owned and operated by Group Health . Analyses of secondary data on quality and cost were conducted for 1,947 seniors in the PCMH clinic and 39,396 seniors in the 19 control clinics .  Patient experience with care was based on survey data collected from 487 seniors in the PCMH clinic and of 668 in 2 specific control clinics  that were selected for their similarities in organization and patient composition to the pilot clinic . RESULTS After adjusting for baseline , seniors in the PCMH clinic reported higher ratings than controls on 3 of 7 patient experience scales . Seniors in the PCMH clinic had significantly greater quality outcomes over time , but this difference was not significant relative to control .  PCMH patients used more e-mail , phone , and specialist visits but fewer emergency services and inpatient admissions for ambulatory care sensitive conditions . At 1 and 2 years , the PCMH and control clinics did not differ significantly in overall costs . IMPLICATION S A PCMH re design can be associated with improvements in patient experience and quality without increasing overall cost PURPOSE Underst and ing the transformation of primary care practice s to patient-centered medical homes ( PCMHs ) requires making sense of the change process , multilevel outcomes , and context . We describe the methods used to evaluate the country ’s first national demonstration project of the PCMH concept , with an emphasis on the quantitative measures and lessons for multi method evaluation approaches . METHODS The National Demonstration Project ( NDP ) was a group-r and omized clinical trial of facilitated and self-directed implementation strategies for the PCMH . An independent evaluation team developed an integrated package of quantitative and qualitative methods to evaluate the process and outcomes of the NDP for practice s and patients . Data were collected by an ethnographic analyst and a research nurse who visited each practice , and from multiple data sources including a medical record audit , patient and staff surveys , direct observation , interviews , and text review . Analyses aim ed to provide real-time feedback to the NDP implementation team and lessons that would be transferable to the larger practice , policy , education , and research communities . RESULTS Real-time analyses and feedback appeared to be helpful to the facilitators . Medical record audits provided data on process-of-care outcomes . Patient surveys contributed important information about patient-rated primary care attributes and patient-centered outcomes . Clinician and staff surveys provided important practice experience and organizational data . Ethnographic observations supplied insights about the process of practice development . Most practice s were not able to provide detailed financial information . CONCLUSIONS A multi method approach is challenging , but feasible and vital to underst and ing the process and outcome of a practice development process . Additional longitudinal follow-up of NDP practice s and their patients is needed PURPOSE The objective of this study was to eluci date the effect of facilitation on practice outcomes in the 2-year patient-centered medical home ( PCMH ) National Demonstration Project ( NDP ) intervention , and to describe practice s ’ experience in implementing different components of the NDP model of the PCMH . METHODS Thirty-six family practice s were r and omized to a  facilitated intervention group or a self-directed intervention group . We measured 3 practice -level outcomes : ( 1 ) the proportion of 39 components of the NDP model that practice s implemented , ( 2 ) the aggregate patient rating of the practice s ’ PCMH attributes , and ( 3 ) the practice s ’ ability to make and sustain change , which we term adaptive reserve . We used a repeated- measures analysis of variance to test the intervention effects . RESULTS By the end of the 2 years of the NDP , practice s in both facilitated and self-directed groups had at least 70 % of the NDP model components in place . Implementation was relatively harder if the model component affected multiple roles and processes , required coordination across work units , necessitated additional re sources and expertise , or challenged the traditional model of primary care . Electronic visits , group visits , team-based care , wellness promotion , and proactive population management presented the greatest challenges . Controlling for baseline differences and practice size , facilitated practice s had greater increases in adaptive reserve ( group difference by time , P = .005 ) and the proportion 
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There was no evidence for overall cost savings .
The PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes , but current evidence is insufficient to determine effects on clinical and most economic