The Impact Of Implementing A Patient-Centered Medical Home Model In The Primary Care Setting

Submitted by Kristie Johnson, DNP, RN, NP-C

Tags: care health patient Primary Care

The Impact Of Implementing A Patient-Centered Medical Home Model In The Primary Care Setting

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Objective                                                                                                                                Literature demonstrates a trend of shared decision-making models that are centered around the patient. By implementing the Patient Centered Medical Home (PCMH) model, patient encounters will encompass a patient-centered decision-making approach regardless of the reason for the visit. This model incorporates ongoing preventative screenings into routine visits to create a continuum of meeting wellness initiatives without relying on a routine wellness visit yearly.


To implement this model, the clinician will thoroughly review the patient’s chart prior to the office visit. If any preventive screening is identified, then the primary care provider addresses the initiatives during the encounter.         

Results                                                                                                                                                    Post-implementation data showed a marked increase in ordered preventive screenings, wellness exams, and revenue to the clinic. There was also an increase in patient satisfaction perception among participating providers.                                                        Conclusion                                                                                                                                   The PCMH model allows the clinician avenues to address, create dialogue, and implement shared decision-making to incorporate preventative screenings and keep preventive care moving forward.


Keywords: medical home model, patient centered care, wellness screenings, preventive screenings

Table of Contents

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   4

Chapter One:  Introduction and Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

Chapter Two:  Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 30

Chapter Three:  Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 40

Chapter Four:  Results and Discussion of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .   47

Chapter Five:  Discussions and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  59

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  64

Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 74















The Impact of Implementing A Patient-Centered Medical Home Model in the Primary Care Setting

Chapter One: Introduction and Overview

             Traditional wellness exams currently exist as a scheduled and separate patient encounter to identify chronic disease processes. According to Lee et al., (2004) many of these routine preventive screenings identify diseases that may be asymptomatic or without signs or symptoms of pending illness. Diseases that are detected early can impact cure and may lead to longer survival rates. The current recommendations call for periodic screening examinations to detect specific chronic diseases such as cancer, diabetes, and cardiovascular disease (Lee et al., 2004). While some disease processes are fatal, others can be treated or even cured if diagnosed in the early stages of illness (Karunathilake & Ganegoda, 2018).

 Although maintaining good health and well-being is a goal of healthcare providers and poses significant challenges for humankind as illness often challenges them. There is a growing concern whether the United States healthcare delivery system is prepared to supply an adequate workforce, control rising costs, and meet the needs for the current aging population (Carver & Jessie, 2011b). Researchers have also highlighted data regarding the United States healthcare system, noting that it is the world’s most expensive, with some of the poorest outcomes compared to other developed countries (Bates, 2009). The disparity between the fees for healthcare services and quality of healthcare is quite alarming. Teisberg et al., (2019) stated that “Value in healthcare is the measured improvement in a person’s health outcomes for the cost of achieving that improvement”. Others will describe value-based healthcare as cost reduction, quality improvement, or patient satisfaction. However, those efforts while important are not the same as value. Healthcare value should primarily focus on improving patient health outcomes” (Teisberg et al., 2019).

According to the American Medical Association (AMA), data reveals that preventative healthcare visits and screenings have declined significantly during the COVID-19 pandemic (AMA, 2020). This is understandable due to patients trying to avoid potential exposure to this illness. The AMA also noted that childhood vaccinations decreased by 60% in the spring of 2020 compared to 2019 data. In addition, both mammograms and Pap smears decreased nearly 80% while colonoscopies for routine colon cancer screening declined by 90% (AMA, 2020). The delay of these screenings as a result of the pandemic may negatively impact the future of patients’ health outcomes.

Defining the Medical Home (2017) describes a Patient-Centered Medical Home (PCMH) model to address the rapid changes in healthcare. Within this model are ways to address wellness exams and preventative screenings to keep our goal of quality of care moving forward. The vision for this project is as follows: ensuring each patient within the practice is offered an opportunity to participate in a conversation regarding preventive screenings. Applying the PCMH concept in the primary care setting will promote coordinated and comprehensive care utilizing ongoing collaboration among all stakeholders. Implementing the PCMH model could positively impact patients by identifying an early disease process and allowing the patient to access treatment earlier versus making a diagnosis later. While our healthcare system calls for improved patient outcomes, the PCMH model can be used globally because it promotes collaboration among the patient and provider. Therefore, ongoing and open dialogue promotes and creates positive patient experiences that will impact outcomes in the United States.  Implementing the PCMH model in a primary care setting with an emphasis on preventive screenings will positively impact patient outcomes that will address historical events like the pandemic. This chapter will focus on the background, purpose, significance, and theoretical framework for this project.

Background of the Project

The headlines of higher admission rates, increased length of stays, cost of healthcare, patient satisfaction scores, and poor outcomes in healthcare never seem to improve (Bates, 2009). These represent many of the ongoing arguments regarding the American healthcare system. The data is overwhelming when articles continue to be published, speaking to the United States spending triple dollars per person on healthcare compared to other countries our size and with comparable incomes (Bates, 2009). The Centers for Medicare and Medicaid Services (2009) reported that national health expenditures were 17.6% of the U.S. gross domestic product. Newer data shows that health expenditures in 2020 will be more significant than 19% (Projected CMS, n.d.). Reports demonstrate that nearly 30% or approximately $700 billion of annual United States healthcare spending is unnecessary (Nielsen et al., 2012). Our healthcare outcomes are relatively poor when looking at infant mortality, rates of chronic disease processes, and preventable disease management (Bates, 2009). Sherman et al., (2016) noted that newer healthcare policies and payment systems have driven reimbursement to medical providers based on quality measures in efforts to improve overall outcomes. However, there are still astounding reports of healthcare coverage lapse in over 47,000,000 Americans (Sherman et al., 2016).                                  

According to Healthiest Countries 2022 (2022), the U.S. is ranked 35th in the world for healthcare. Countries such as Spain, Italy, Japan, Switzerland, and Iceland have better outcomes. These scores or rankings are determined by factors such as obesity, life expectancy, clean water, and tobacco use. Health problems such as suicide and drug overdoses contribute to America’s ranking as they are considered higher than others worldwide.

            Additional research shows a gap between the quality of care delivered in the United States. Some have blamed this inadequacy on the individual providers' shortfalls of providing quality healthcare services (Bates, 2009). The United States has the means to prevent and treat disease; however, it appears our population does not have the willingness to apply our interventions or have the drive to seek opportunities to have medical health insurance. These actions lead to the importance of healthcare reform and change. Change is warranted, and the incorporation of practice models is a change that positively impacts healthcare. Nurses encompass the largest percentage of healthcare providers and are confident to meet this challenge (Bryman, 2007) with their clinical skills and training. Furthermore, the role of the advanced practice registered nurses is ideal for educating and promoting health and this can prove to impact population health on a large scale.

Movement for Change

            The 2001 Institute of Medicine (IOM) report Crossing the Quality Chasm: A New Health System for the 21st Century blames healthcare safety issues and quality problems due to the limited infrastructure and encouragement of evidence-based practice. Crossing the Quality Chasm also challenged healthcare systems to show performance improvement and include all stakeholders (Bryman, 2007):

        Safety: Do not allow injuries to patients.

        Timeliness: Be mindful of wait times and avoid harmful delays for both patients and caregivers.

        Effectiveness: Focus on services utilizing evidence-based practice and avoid providing services with no benefit.

        Efficiency: Do not be wasteful with equipment, supplies, and energy.

        Equity: Show all patients the same level of care despite personal characteristics.

        Patient-centeredness: Understand an individual patient’s need for their situation and help guide them with clinical decision-making.

The focus of this project will emphasize patient-centered care. Significant changes are achievable, and quality healthcare improvement is attainable when incorporating all six dimensions. These dimensions also ensure quality standards of care for all. Healthcare services are based on individual needs. The services should not change based on race, ethnicity, or other individual characteristics unrelated to the patient's condition or reason for seeking care.                                                                                                                      “Value and patient satisfaction are also commonly confused” (Teisberg et al., 2019). The importance of the patient satisfaction movement, especially in large healthcare organizations, has placed an emphasis on treating people with dignity and respect. These qualities are fundamental teaching for nurses. However, value is about helping individuals without asking. For example, satisfaction surveys often ask questions such as, “How were we doing?” Value-based care providers ask, “How are you?”                                              


                                    Patient-Centered Care                                                                                                                   Patient-centered care is a holistic approach that identifies the need for physical comfort while addressing the emotional health of the patient. Each patient and their circumstances are unique based on their social, cultural, and spiritual perspectives (Defining the Medical Home, 2017). This concept encourages patients to participate in all decision-making regarding care. Patient's may also involve their families in the decision-making process which creates a dynamic collaboration between the patient and healthcare provider.

Figure 1:

Note: Patient-Centered Care: Patient at heart of care continuum. Patient goals & values top priority. Family involved in every stage. (What is patient-centered care?, 2017)


In the primary care setting physicians, nurse practitioners, physician assistants, and other staff often cultivate personal relationships with their patients over time. This setting also allows healthcare providers to meet family members and hear their concerns during office visits making primary care the opportune place to encourage a patient-centered medical home model.                                                                                                   Patient- Centered Medical Home Model                                                                                        A structured healthcare delivery system is crucial. This delivery system must consistently show high-quality clinical outcomes while proving the added value it delivers. This delivery system must consistently show high-quality and value-added clinical outcomes. It is a complex model that addresses the patient's acute, chronic, and preventive care needs. Additionally, this structured system must be reproducible in all healthcare settings, especially primary care. The PCMH concept is a model of care that strengthens the healthcare provider and patient relationship by replacing episodic care with coordinated care. Each patient has a relationship with a primary care provider responsible for leading the patient to their anticipated health care needs. These responsibilities also include arranging appropriate referrals for services with other qualified clinicians. The medical home model intends to result in more personalized, coordinated, effective, and efficient care (NCQA, 2011c, p. 2.).                                       In 2001, the Institute for Healthcare Improvement (IHI) developed an initiative to improve outcomes and reliability utilizing the concept of teamwork and communication among multi-disciplinary teams. Primary care or family practice is an essential part of the patient-centered care models. State, federal, and many commercial healthcare insurance companies have begun encouraging this model and offering incentives to support its efforts. Nielsen (2012) noted that PCMH models used in the primary care setting had demonstrated a decrease in their overall healthcare spending by up to 20% in the first year. The PCMH is not limited to a single discipline and should be utilized across the healthcare continuum. This model allows a comprehensive team approach that is coordinated and focused on quality of care. Another benefit of this model is its ability to be integrated into health information technology systems to assist in identifying medical concerns.                                                                                   Wellness Exams                                                                        A recent article by Ettinger (2020) stated that preventative screenings or wellness exams are not standard in the United States. The author adds that over 80% of Americans have some form of healthcare coverage, but roughly only 25% of those patients will schedule a routine office visit focused on preventative health. Both primary care providers and patients agree that routine wellness exams are needed. However, wellness exams are scheduled appointments annually versus episodic office visit(s) due to illness or medication refills that are needed throughout the year. More than ever, we need to manage our health and utilize the services available for routine screenings for early detection and prevention of disease. Dr. Niket Sonpal was recently quoted as saying "If you are healthy and have no chronic conditions then once a year for an annual physical to the internist and once a year for your flu shot is at least the minimum" (Ettinger, 2020). Even though this is the status quo it is not enough to meet the current demands of quality healthcare in America.

What does the annual wellness exam include? Medicare has specific measures to address during the wellness exam, including depression, risk for suicide, and physical function screening. However, most insurance companies will use the following guidelines as a minimum:

·         Children ages 0-5 years – Height, weight, immunizations, and a developmental screening.

       Children ages 6-12 years – Height, weight, immunizations, and developmental assessment.

       Women – Yearly breast exams and a Pap test

       Adults – Lipid panel, diabetes screening, and colon cancer screening

            Preventative screenings will be different based on each patient's age and health history. For example, recent guidelines indicated changes for adults between 50 and 80 years old who have a "20 pack a year smoking history or have quit within the last 15 years should have a lung cancer screening with a low-dose CT" (Jonas et al., 2021).

Noncommunicable Disease

            Noncommunicable disease (NCD) are “non-infectious and non-transmissible diseases that may be caused by genetic or behavioral factors” (The U.S. Government and Global Non-Communicable Disease Efforts, 2019). NCDs generally have a slow progression and long duration of illness. Examples of NCDs are cardiovascular disease, cancer, chronic respiratory disease, and Type 2 Diabetes. According to Non-Communicable Diseases (2022), NCDs disproportionately affect people in lower socioeconomic incomes. The article also shows that NCDs are the leading cause of death and disability worldwide to date; however, NCDs are preventable. NCDs kill 41 million people each year which is over 73% of all deaths globally. Cardiovascular disease accounts for the highest death rate affecting over 17 million people annually (Non-Communicable Diseases, 2022). Risk factors for NCDs include tobacco use, pollution, poor diet, obesity, and excessive amounts of alcohol use. These risk factors can vary by age, sex, genetics, and socioeconomic status.

Healthcare providers can implement strategies that are specific to a patient. These strategies should aim to prevent or intervene in potential illness through risk reduction. These interventions can combine primary, secondary, and tertiary prevention techniques (Karunathilake & Ganegoda, 2018). Primary prevention refers to the patient preventing the onset of the disease by maintaining a healthy lifestyle. Secondary prevention reduces the impact of the disease through early detection, such as preventive screenings. Tertiary prevention assists patients with pain management, interventions to increase life expectancy, and support quality of life. By implementing any of the above interventions, healthcare providers can reduce the risk of diseases, disabilities, and death.

Statement of the Problem

            A healthcare system is an organization of people and resources with the intended objective of delivering healthcare services to a target population. There are usually two main goals of every healthcare delivery system. First, patients must be able to access the offered healthcare services. Second, services must be cost-effective and meet standards of quality care. Improving primary care for all individuals is an essential task for healthcare delivery in the United States. Our current healthcare system provides incentives to provide quality healthcare services but can result in a highly fragmented system that may emphasize specialty care versus the patient-centered approach (Bodenheimer and Pham, 2010). The PCMH model focuses on improving primary care efficiency to create "accessible, continuous, comprehensive, and coordinated and delivered in the context of family and community" (Peikes et al., 2012, p. 1).

           The IOM has been at the forefront of healthcare reform and released a policy statement regarding the nurse's role. This statement has led to change in nursing in areas such as the scope of practice, education, and leadership. The IOM's policy statement recognized the increasing demand for healthcare services and the imminent primary care physician shortage. Harcus (2011) noted that medical school graduates are choosing specialty areas over primary care medicine. This creates a mismatch of primary care providers to patients creating expanded reliance of primary care services, delivery of more services in less time and leading to burn out among providers (Wise et al., 2011). The recognition of this shortage has increased the demand for nurse practitioners in all areas working at the full scope of their education and training (Bodenheimer and Pham, 2010). This movement is essential to meet the population's healthcare needs while emphasizing preventive medication.

           Healthcare reform has opened the door to advanced practice registered nurses (APRN) such as family nurse practitioners. APRNs can impact our current healthcare system and drive quality care by utilizing evidence-based practices as exhibited by this model (Berryman et al., 2012). The APRN’s role focuses on patient-centered strategies. In primary care, family nurse practitioners serve an essential role as they can meet patients' needs with evaluation, diagnosis, and the ability to implement a treatment plan utilizing a patient-centered approach. The American Nurses Association of Nurse Practitioners released a report, Quality of Nurse Practitioner Practice, finding that nurse practitioners had fewer hospital readmissions, fewer preventable hospitalizations, higher patient satisfaction, and fewer unnecessary emergency room visits compared to physicians (2020). Additional data in the article showed that nurse practitioners were more likely to address social risk factors such as smoking cessation and focused on health education more than their physician colleagues. These findings reveal the core fundamentals of nursing to provide a holistic or patient-centered approach and the basis for this Doctor of Nursing (DNP) scholarly project.

            With the growing concerns of the U.S. healthcare system, changes must be implemented. The problems associated with healthcare delivery have clearly been identified and the PCMH model will address issues in the primary care setting. This fundamental movement has the support from policymakers, healthcare organizations, and healthcare providers with a common goal to impact healthcare delivery (Berryman et al., 2012). By utilizing the available resources, patient outcomes will improve and serve as a catalyst for further advancements.

Purpose of the Project

The PCMH model positively changes healthcare delivery to those who embrace their individual needs. This model provides resources for decision-making for treatments and provides accountability to all stakeholders, especially the most critical member of the team- the patient. Only when medical providers, healthcare staff, and patients work together to achieve common goals will we achieve the clinical and financial outcomes that healthcare providers want to accomplish (Schlesinger & Fox, 2017). By implementing this model or even portions of its design into the primary care setting, patients can discuss preventive screenings at each office visit as an ongoing line of communication to minimize missed opportunities such as mammograms, immunizations, colorectal cancer, and cardiovascular screenings. Each office encounter shifts from a focused to a holistic visit. The holistic approach aims to identify potential disease processes early on and impact patient outcomes.

Research Question

In the primary care setting, what is the overall effect of implementing the PCMH model on patient outcomes regarding health maintenance?

PICO Question

            Using the PCMH model, what is the impact of incorporating preventative screenings into routine adult primary care office encounters on the number of ordered preventive screening tests made compared to the previous eight weeks?

P - Adult primary care

I - Implementing the PCMH model

C - Not implementing the PCMH model

O - Increased orders for preventive screenings

T- Previous eight weeks

Theoretical Framework

            John Kotter’s 8-Step Change Model is a proven theory that provides a stepwise approach that is proven to secure long-lasting change. He describes in his work that we must create a sense of urgency, form powerful coalitions, develop vision and strategies, communicate our vision, remove obstacles and empower those that are called for action, followed by consolidating gains and strengthening change (Kotter & Rathgerber, 2006). The advantage of using this model is that it has a step-by-step approach.


Establish a Sense of Urgency                                                                                              

With the alarming statistics mentioned above and the heavy volumes within the primary care setting the DNP student practices, there is a legitimate concern that patients may not receive the preventative services needed to identify specific disease processes. It is important to note that most of these services are covered by their insurance companies. In regard to uninsured or underinsured patients, they may be missing preventative services due to cost. As a country, our healthcare outcomes are somewhat poor when looking at infant mortality, rates of chronic disease processes, and preventable diseases (Carver & Jessie, 2011b). Preventing diseases is the purpose of a wellness exam.  

Creating the Guiding Coalition     

            The second step is to engage primary care practices to meet quality improvement initiatives such as scheduling wellness exams. This is essential to the population's health, patient care outcomes, and reducing healthcare costs. Pay for Performance in healthcare is also known as a value-based payment system. This system is how healthcare providers, including hospitals, are compensated for the patient's outcomes (Sherman et al., 2016). This payment model attaches financial incentives and disincentives to the provider's performance. Pay for Performance is a national strategy to help contain costs with healthcare and move to value-based medicine. Reimbursement to medical providers (physician, nurse practitioner, and physician assistants) are metric-driven based on evidence-based practice and patient satisfaction with the goal of value and quality healthcare. Another example is participation in the Federal Quality Improvement programs such as Merit Based Incentive Payment System (MIPS). MIPS adjusts Medicare Part B payments based on performance of the primary care provider or the office as an entity. The four performance categories are quality, cost, promoting interoperability, and improvement activities. (Merit-Based Incentive Payment System, n.d.) By engaging the DNP student's colleagues in this new focus, the model ensures improvement in preventative services and the benefits of having screenings completed to identify potential disease processes.                                                       

Change Vision and Strategies                                                                    

            The third stage is building a vision and creating a strategy to implement the intended plan. By implementing the PCMH model, addressing preventive medicine becomes part of the routine office visit. The change vision and strategy will provide a mental picture of what the change will look like after implementation. This method will provide the DNP student's leadership and staff with a strategy to meet the intended goals. If done correctly, a change vision and strategy should create a sensible and appealing goal for the future. Not only is the vision easily seen, but it will provide guidance for organizational decision-making (Kotter & Rathgerber, 2006).

  Communicate the Vision                                                                                                                            The fourth stage focuses on communication. This stage needs to be consistent and easy to understand. Often employees and leadership are concerned with new change and will need convincing that this new goal will bring about positive changes (Kotter & Rathgerber, 2006). Communication needs to be two-way. It does not always start with the top and trickle down; however, it can ascend from the bottom upwards. Effective communication utilizes an open pathway and welcomes feedback. This form of communication is critical to the success of any change vision.

Empowering Others to Act on the Vision                                                                           

            The fifth stage of Kotter's model is to create a strong, motivating, and inspiring vision without barriers for those involved. This vision should allow the team to see what is needed to achieve the idea leading to change (Kotter & Rathgerber 2006). Often people will only move in the direction of comfort and clear direction. By providing the vision, a leader can motivate those involved to move outside their comfort zone and remove barriers to the team's success. Implementing a process where preventative screenings are addressed and updated during a sick or routine visit will differ based on each patient's health history and age. Therefore, removing barriers is imperative. 

           According to Kotter and Rathgerber, (2006), there are four barriers leadership should be mindful of: structural, skills, systems, and leadership barriers. A structural barrier is ensuring that the organization's existing structure can support the vision. A skills barrier means one has the right skill sets, and team members have positive attitudes and behaviors necessary for this vision. System barriers ensure that the team is empowered to act on the change (Kotter & Rathgerber, 2006). Finally, leadership can block changes and tend to be a product of their environment. Therefore, avoid those with habits that may not benefit the healthcare organization's vision for change.   

            According to Lv and Zhang (2017), using a collective leadership style will encourage staff engagement, establish an organizational culture of learning, and allow continuous improvements within the organization. We can easily meet this need by changing our practice process in primary care using Defining the Medical Home (2017) as a guide. Kotter and Rathgerber (2006) are quoted “With empowered individuals ready to act and who understand the change vision for the organization, it is time to plan for and create short-term wins” (p.124).

Create Quick Wins                                                                                                                                                                             

            Identifying short-term wins, also known as quick wins, is the sixth step of John Carter's 8-step change model. This step addresses the importance of leading change throughout the organization. This step also focuses on keeping the momentum going (Kotter & Rathgerber 2006). Short-term or quick wins should not be a gimmick but an opportunity to show that improvement is already happening. The goals for this step should meet one of the following criteria below:

       Its success must be unmistakable.

       It must be evident throughout the organization.

       It must demonstrate clarity associated with the intended change.

       With each step, everyone must remain engaged.  

Consolidating Gains and Anchoring Change                                           

            The seventh stage of Kotter's model is to sustain acceleration on one's vision. During this step of Kotter's 8-step model, organizations will often make two common mistakes. First is allowing the team to become overwhelmed with quick wins. Second is looking for immediate progress when the goals are long-term. Avoiding these two common mistakes will keep the team and leadership moving forward on the project. Therefore, avoiding common mistakes in this step will be imperative. Kotter and Rathgerber (2006) note that change is often slow and ongoing. During this step, leadership should review the organization's values, objectives, and vision for the proposed project. Kotter's eighth and final step addresses the importance of integrating the project organizationally and guarantees that the incorporated changes in behaviors and work ethics will be sustained and enriched in the organization's culture.

Significance of the Project  

The main goal of patient-centered care is to improve an individual's health outcomes. When patients are engaged in their decision-making, they often recover quicker and are more satisfied with their care. This design empowers patients to become more active participants in their healthcare. Studies have also found that patient and medical provider collaboration is an important motivator for preventive care. (Nielson et al., (2012). When patients feel respect and empathy, they are more likely to return for wellness examinations, immunizations, and other preventive healthcare services (Tislam, 2020). For example, this model identifies patients with a lower socioeconomic status who are often more vulnerable to engaging in unhealthy behaviors, developing medical problems, and struggling to access healthcare despite abundant resources. Patients who fall in the lower socioeconomic group are more likely to face overcrowding, lack of transportation, lack of basic amenities, and may have low health literacy. The PCMH model is focused on an individual’s specific healthcare needs incorporating the patient-centered care approach.

 Additionally, the Journal of Family Practice found that patient-centered practices not only showed improved patient satisfaction, they ordered fewer diagnostic tests and referrals during acute care patient encounters (Tislam, 2020). The benefits of this model also encourage better staff morale, productivity, improved resource allocation, and reduced healthcare expenses. These key points outline the significance of implementing the PCMH model in the primary care setting. 



Definition of Terms

            Non-communicable disease: Defines a group of medical conditions that are often preventable and can have a long-term impact on the patient. These conditions include cancers, cardiovascular disease, diabetes, and chronic lung illnesses (Lee et al., 2004).

           Patient-centered care: Provides care that is respectful to the individual patient’s needs, wishes, and values towards their clinical care (O’Neil, 2022).

Patient-Centered Medical Home: The patient-centered medical home (PCMH) model is a systematic approach to delivering high-quality, cost-effective primary care. Using a patient-centered, culturally appropriate, and team-based approach, the PCMH model coordinates patient care across the health system (O’Neil, 2022).   

              Preventive screenings: Screenings encompass a health examination, patient interviews, and/or testing to identify and avoid the development of future health problems (Lee et al., 2004). 

            Primary care provider: A physician, nurse practitioner, or physician assistant who provides coordinated healthcare services (Primary Care Provider - Glossary, n.d.).

Nature, Scope, and Limitations of the Project

            The project was implemented at a primary care office in east Alabama. Several steps were changed from their current process. First, the patient’s chart was reviewed before the appointment. The primary care office utilized an electronic medical record (EMR) called Cerner. Having access to an EMR offers an efficient way to identify patients due for certain health maintenance items quickly.

            The primary care provider noted previous labs, diagnostics, and health maintenance items due during the office visit. This process was performed at routine appointments to discuss preventive initiatives. A thorough review of the patient’s social and family history also helped to identify risk factors for their health. The primary care provider then discussed with the patient the importance of any identified screenings due. For example, certain medications will require routine laboratory monitoring or even eye exams for continued prescribing.

           Lastly, the primary care provider will monitor quality metrics and set benchmarks for the future. Currently, billing and reimbursement are based on quality measures. Improving patient outcomes and patient satisfaction will open the door for a potential decrease in healthcare expenditures and increased revenue for the healthcare organization allowing for more resources.                                                     


            During the eight weeks allotted for this DNP project, each routine office visit for patients greater than 18 years of age were screened for preventative measures that have not been addressed in the last calendar year. All races, gender, and ethnicities were included regardless of insurance coverage. If the screening identified any missing preventative initiatives that need to be addressed, this opened dialogue between the primary care provider and the patient. The patient elected to participate in the screenings or decline once the education has been provided. If the patient agreed, the appropriate screenings were ordered. The data collected was then documented on a spreadsheet provided from HIT via a secured server. Data was compared to the previous eight weeks assessing for an increase in preventive screenings being ordered. This allowed the primary care providers an opportunity to review the impact on their early identification of needs and utilize the information found specific to the primary care clinic.     


            There were several limitations to this project. First, there was a limited time frame to implement the PCMH model and collect meaningful data. The data was collected over an eight-week time frame for pre-implementation and post-implementation of this project. This limited time frame may also have affected the patient volumes in the clinic. Volumes are affected by the presence of providers, holidays, office hours, and scheduled patient encounters. The second limitation will be the additional time each primary care provider will need to dedicate to address preventative screenings. It is important to create processes that do not hinder workflow. Lastly, there may be a delay in receiving the total number of preventive screenings on the identified patient population due to the short implementation timeline.                                                                                                                    Delimitations

            The delimitations for this DNP scholarly project included data review and data collection on patients greater than 18 years of age. The focus of this study is not only to look for healthcare disparities but identify the impact of implementing the PCMH model on the total of ordered screenings. The goal is to show the quality of care provided using this model and the impact on patients receiving annual preventative screenings.

Proposed DNP Essentials

This project compassed several DNP essentials. These essentials detailed the appropriate curriculum and competencies required by all DNP programs to push nursing forward by utilizing the use of evidence-based practice concepts to enhance healthcare delivery. Most importantly, these essentials promote positive patient outcomes (DNP Essentials, n.d.-b).

Essential II: Organizational and Systems Leadership for Quality Improvement

            Scientific underpinning is the ability to examine and evaluate knowledge. The knowledge is gathered through multiple sources (The Essentials of Doctoral Education for Advanced Nursing Practice, 2006), and the DNP student utilizes series and evidence-based practice in their approach to the primary care setting. Literature reviews were obtained from scholarly sources such as PubMed.

Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice

            Clinical scholarship, research, and analytical methods are emphasized as research becomes practice (The Essentials of Doctoral Education for Advanced Nursing Practice, 2006). The DNP student will exhibit this essential via research and development of processes to implement the project appropriately. This translation of research in practice helps create positive patient outcomes.

Essential V: Health Care Policy for Advocacy in Health Care

            The process of health policy development is essential to creating a robust healthcare system that meets the needs of its population. Political activism is imperative to the profession of nursing practice. Healthcare policy influences the profession of Nursing.

Essential VI: Inter-Professional Collaboration for Improving Patient and Population Health Outcomes

            Communication skills are essential to building relationships, sharing experiences, and addressing the needs of others. The DNP student should employ effective communication with all disciplines on the healthcare team. Leadership skills are needed to implement practice models, lead peer reviews, and promote standards of care.

Essential VII: Clinical Prevention and Population Health for Improving the Nation’s Health

            Health promotion and risk reduction are defined as clinical prevention. The DNP student should feel confident in analyzing epidemiological and environmental data. This information should be used to develop population health planning, disease prevention, and addressing healthcare disparities.

Essential VIII: Advanced Nursing Practice

            A DNP graduate is expected to validate their advanced assessment skills based on the foundation of practice utilizing science in their specialty area (The Essentials of Doctoral Education for Advanced Nursing Practice, 2006). The DNP graduate should feel confident in their skill set by demonstrating advanced levels of clinical judgment, systems thinking, and adaptability.                                 

                                                Conclusion                                                                             In summary, the United States healthcare system has a national vision for quality-improvement indicators that are essentially aligned with a patient-centered model. Healthcare delivery is being challenged to be more collaborative, coordinated, and an accessible system. This ensures quality care is provided in every setting. The need for increased patient satisfaction begins with focusing on physical comfort as well as emotional well-being. By engaging families, the model shows collaboration leading to more informed decision-making. According to Defining the Medical Home (2017), PCMH models are driving some of the most significant reforms in healthcare delivery today. This model is focused on a patient centered approach and when implemented, will quickly address the challenges in healthcare. Within this model are ways to address wellness exams and preventative screenings specific to this scholarly project. Numerous studies have been published demonstrating that PCMH models reduce healthcare expenditures by reducing hospital and emergency department visits, addressing health disparities, and improving patient outcomes. The literature supports this model and will detail the benefits of implementing in the primary care setting.

The next chapter will present research on the impact of the medical home concept on quality care outcomes, creating engagement surrounding patient relationships, capturing savings through expanded access to healthcare, and focusing on non-communicable diseases. This model aligns patient preferences with payer and provider capabilities (O’Neill, 2022) and, when implemented, quickly addresses the challenges in healthcare.

Chapter 2:  Literature Review

The PCMH is a comprehensive model that treats the patient by providing a collaboration of care for the healthcare providers, family members, and the patient. This model helps the healthcare team treat the patient individually and considers culture, values, and preferences for their healthcare needs (Berryman et al., 2012). In contrast, previous medical models focused on specific diseases and treatments. Several articles have supported healthcare systems that utilize a healthcare delivery model, such as the PCMH. These healthcare systems have been shown to deliver more “efficient, effective, and equitable care” (Grumbach & Grundy, 2010) than organizations that do not use such models. It is well known that the U.S. healthcare system has shown escalating costs, fragmented services, and poor outcomes (Bates, 2009). These issues have created a movement to push for innovative healthcare delivery models focusing on patient outcomes, efficiency, and satisfaction. Patient-centered care models are not new but have increased momentum over the last decade. An analysis of patient-centered models has shed light on three key areas to impact patient outcomes: improved patient satisfaction with shared decision-making, a greater use of healthcare resources, and early identification and treatment of disease processes. Evidence-based practice recommendations support the implementation of the PCMH model in the primary care setting as demonstrated in the literature review and through application of a theoretical and methodological framework. This chapter will utilize published literature to demonstrate the impact of the PCMH model in the primary care setting.

Literature Review

            Literature searches were completed utilizing various health websites such as the Centers for Disease Control and Prevention, CINAHL, and PubMed databases. The review of supporting literature is divided into five sections: 1.) Development of Evidence-Based Screenings 2.) The Patient-Centered Medical Home Model 3.) Special Populations 4.) Communication, and 5). Information Technology.

Development of Evidence-Based Screenings

The United States Preventive Services Task Force (USPSTF) was created in 1984 and serves as a volunteer panel of national experts in disease prevention who promote evidence-based medicine through prevention. They have published evidence-based recommendations in conjunction with Agency for Healthcare Research and Quality (AHRQ) regarding preventive services such as screening, counseling, and medications. This panel has created screening recommendations for over 84 topics on healthcare (Kurth et al., 2018). Each recommendation statement is followed by a letter grade and summary. The letter grades are A-I. The letter A indicates there is enough evidence to provide this service. The letter I indicates that clinical considerations should be made due to the uncertainty of benefit versus harm. The USPSTF has also termed levels of certainty or safety from high to low according to the available evidence.

        High: Reliable results from well-designed studies to assess the effect of the medical service on healthcare outcomes.

        Moderate: Evidence is satisfactory to determine the effects of the service. However, the assumption may change as more information becomes available.

        Low: The evidence is unsatisfactory to measure effects on health outcomes.

The recommendations apply when there are no signs or symptoms of disease in the primary care setting (Kurth et al., 2018).  For this project we will utilize the USPSTF for most of our screening guidelines.

            The Health Resources and Services Administration (HRSA) was created in 1982 and has focused on providing equitable healthcare to all Americans. HRSA is well known for its guidance on vulnerable patients such as infants, children, and adolescents. These recommendations are often age-specific and are created using the latest scientific evidence (Evidence-Based Practices & Programs, n.d.).

           The Center for Disease Control (CDC) publishes evidence-based findings and recommendations routinely. The CDC is a community resource for preventive programs. The CDC also releases healthcare policies for health promotion and disease prevention to be utilized in any forum (Evidence-Based Practices & Programs, n.d.).  

           Each agency provides a wealth of information constructed on evidence-based information and offers its area of expertise. Although the guidelines reflect the most recent recommendations, they are not a substitute for the clinical judgment of a primary care provider. The clinician should not only stay up to date on the latest information but on advising and caring for individual patients.

The Patient Centered Medical Home Model

           The PCMH is a transformational model applicable in any primary care setting. This model seeks to meet the healthcare needs of patients in real time and improve patient satisfaction and outcomes. The American Academy of Pediatrics first defined the medical home model in 1967 to create a concept of a centralized way to address needs (Jackson et al., 2013). There are many definitions of the PCMH model depending on the specialty area or size of the practice in the primary care setting. The National Committee for Quality Assurance has created a design for the structure of this model in primary care. This design also assigns goals to achieve a PCMH and impact patient care outcomes (Patient-Centered Primary Care Collaborative, n.d.). The PCMH will redesign the current approach for primary care providers by delivering comprehensive healthcare for patients of all ages. 

           In 2010 MassHealth and Medicare formed a partnership in Boston. This program implemented a patient-centered care model that included a multidisciplinary approach. They included physicians, nurse practitioners, geriatric social workers, and community-based staff with various backgrounds. They compared the number of preventative screenings from 2005 until 2011 after the program began and found alarming results. Nielsen et al (2012) reported that their data showed that influenza vaccination rates increased from 65% to 77%, colorectal screening rates increased from 30% to 51%, and routine eye exams increased from 69% to 73%. The hospital readmission rates had an overall decrease, with a reduction from 20% to 18% (Nielsen et al., 2012). Additional research from Nielsen et al. (2012) found that 45% of patients had a 50% or more significant reduction in depression when patient-centered care was provided.           


A scoping review was published by Constand et al. (2014) that focused on communication, partnership, and health promotion for patient-centered care models using literature. The authors found over 101 articles on the topic. Nineteen articles met their inclusion criteria, and 12 were review articles. Five documents reviewed were qualitative research papers and one randomized trial. They found that patient-centered care often included strategies to achieve effective communication, strengthen partnerships, and focus on health promotion (Constand et al., 2014). However, Constand et al. (2014) concluded that there was significant evidence to show that communication defined a major component of patient-centered care. The PCMH model promotes conversation between the healthcare provider, patient, and family surrounding decisions in direct care, care planning, and future decision-making. Communication within this model also impacts the community by bringing community resources and healthcare organizations together. Communication is vital when creating healthcare policies that impact direct patient care.

Special Populations

            Simpson & Kovich (2019) conducted a review of 11 studies focused on the aging population. The authors felt the growing number of Medicare participants creates challenges in preventing frailty and functional decline. Patient-centered care maximizes the well-being and quality of all patients involved. Literature reiterates that the aging population must participate in preventative screenings and risk reduction. They concluded that preventative screenings and health promotion significantly strengthened the need for patient-centered care models.

            The American Academy of Pediatrics has long advocated for family-centered care models. Many of the first published papers on the topic are from pediatric settings. These studies focused on increased patient satisfaction when children with special needs received care under the model ("Patient- and Family-Centered Care and the Pediatrician's Role," 2012). This data was collected via telephone survey. They also found that, in comparison, children not in a medical home model were four times as likely to have unmet healthcare needs and three times more likely to have dental issues (Strickland et al., 2011). 

            Literature reviews also showed a need to use a universal family-centered care model, especially when patients have chronic illnesses or disabilities. Researchers continue highlighting the need for this model in a primary care setting. In research performed by Kokorelias et al. (2019), they explored existing family-centered care models, seeking the essential components and identifying gaps in healthcare within the literature. In this paper, the researchers examined multiple models. They researched over 14,000 papers and utilized 55 that met the criteria. They found that the critical components of a patient center model included 1.) collaboration between medical care providers and the family members, 2.) consideration of family dynamics, 3.) policy and procedures, 4.) ongoing education for family and healthcare members. These key concepts can be universal or specific to certain types of illnesses. The authors did find a specific concern regarding the patient's confidentiality and healthcare decision-making privacy.

Information Technology                                                                                                                                          Berry et al. (2013) stated that a key component of the PCMH model is the use of the electric medical record (EMR) and communication between data exchanges that facilitate coordination, efficiency, and improved health outcomes. This makes integration of health information imperative. In an 18-month qualitative study medical assistants were added to offices that were implementing the PCMH model. They were used to help streamline information such as problem lists, medications, and obtaining vital signs. They found that use of the EMR did improve efficiency and decreased the time spent by the medical provider documenting (Berry et al., 2013).

            Medical errors can occur as patients transition to and from outpatient and inpatient settings. EMRs have helped coordinate care regarding medication lists and discharge summaries and allow access to labs and diagnostics. Over the last several decades, improvements in the EMR have allowed healthcare organizations to move beyond physical, monotonous, and often inefficient practices (Romero et al., 2020). Technology has allowed healthcare staff to access new forms of computerized data analysis. This paradigm shift allows technology, organizations, and healthcare providers to move forward in this ever-changing healthcare system. The goal in any healthcare setting is to improve profitability while positively impacting clinical flow and patient outcomes (Bates, 2009).

            Researchers have also linked outcomes between preventive screening tools and electronic medical records leading to increased preventive care for females. Romero et al. (2020) published information using EMRs and incorporating a provider tool to prompt health screening questions. This research was a quantitative study with a cross-sectional retrospective design. The primary intervention of the study was to implement health maintenance tools initiated by the EMR versus the provider. Ultimately, they concluded that clinical decision-making was more accurate when the provider was involved versus utilizing the EMR alone. This conclusion reiterates the model’s push for provider and patient communication.

            The Renaissance Medical Management Company has published data on their innovative EMR tools that have shown significant outcomes regarding patient engagement. By using nurses to follow patients with diabetes, the EMR allows for the tracking of patterns in glucose readings and hemoglobin A1Cs. They have also demonstrated that tools such as e-prescribing and telehealth services for high-risk patient populations positively impacted their pay for performance reimbursement (Nielsen et al., 2012). 

Summary of Literature Review

By using current evidence-based practice recommendations and the abundance of literature provided, healthcare providers can work together and treat the patients with an individualized care plan. This literature review shows how both mental health and social needs can be met. The overview from the NEJM Catalyst states, patient-centered care plans promote healthcare organizations to redesign their approach to healthcare delivery enhancing patient outcomes. This allows “active collaboration and shared decision-making with patients'' (What is patient-centered care? 2017).

Related Studies

            In 2005, the World Health Organization launched an initiative to reduce the rates of non-communicable diseases. The goal was to increase this percentage by 2% per year. The researchers examined how many deaths could potentially be prevented over a 10-year period and included 23 countries (Asaria et al., 2007). Within this time frame, the investigators chose a population-based intervention and calculated the financial costs of their implementation. The researchers implemented interventions to educate on sodium intake and smoking cessation. The data at the end of the project revealed that over ten years, an estimated 13 million deaths could have been avoided (Asaria et al., 2007). Asaria et al (2007) also concluded that the implementation cost of these interventions was less than U.S. $0.40- $1.00 per person annually based on location.

            Truglio-Londrigan et al. (2012) performed a review to identify and report the best available evidence related to the influences on shared-decision-making. They included both adult patients and healthcare providers in all settings for this study. The researchers found that evidence suggests shared decision-making does positively impact health outcomes. However, there is a greater emphasis on patient-centered care models. The patient-centered care model showed significantly more “patient engagement, participation, partnership, and shared decision-making” (Truglio-Londrigan et al., 2012).  

                                                Conceptual Framework

This project will discuss two conceptual frameworks that offer similar approaches and are applicable at different times during the implementation process. From a nursing standpoint, Jean Orlando's Deliberative Nursing Process Therapy incorporates the core fundamentals of a patient-centered approach. The Deliberative Nursing Process Theory focuses on the collaboration between the nurse and patient. This theory also promotes the concept of perception validation which is being open to others' feelings, thoughts, and behaviors (Faust, 2002). This nursing theory utilizes the nursing process to produce positive patient outcomes. Gonzalo (2021) states that this is one of the most important steps because it opens communication. Orlando's theory emphasizes the function of nursing and distinguishes the nurse-patient relationship (Faust, 2002). The Deliberative Nursing Process has five stages. The first stage is the assessment which identifies patient issues objectively and subjectively. Planning allows the nurse to create a plan using a nursing diagnosis to address the issues identified. Implementation is putting the plan into action, followed by an evaluation of the process. Ida Jean Orlando's goal according to Faust (2002) was for nurses to find out and meet the anticipated patient needs, which is modern-day patient-centered care. This theory differs from traditional nursing theories because it is not task oriented. Orlando sought to introduce a patient-centered, clear-cut approach (Faust, 2002). 

 Santana et al. (2017) published a conceptual framework with a step-by-step approach to guide healthcare practitioners and organizations to create a patient-centered care model. The Donabedian model for healthcare improvement was named after the physician and researcher who formulated it (Types of Health Care Quality Measures, 2018). This model utilizes three domains: structure, process, and outcome. This framework begins with creating a culture of patient-centered care within the patient setting. Next, healthcare providers should implement educational opportunities such as handouts, videos, or one-on-one teaching. Referrals to diabetes educators are another example linked to positive outcomes in this patient population. Finally, integrating health information technology is crucial to measuring outcomes.  

Both the Deliberative Nursing Process and Donabedian’s model offer frameworks for molding a patient-centered approach. These can be utilized in various healthcare settings and in all patient demographics. By using either approach a partnership between patients and their healthcare providers are formed. The patient drives their healthcare decisions and outcomes.     

Methodological Framework

For this project, a non-experimental design was used to assess the impact of the PCMH model when successfully implemented in the primary care setting. In non-experimental designs, the researcher does not manipulate the independent variable (Van Breukelen, 2010). This design will assist in the data the project hopes to capture.

Data was collected over eight weeks. All patients over the age of 18 years were included in the data regardless of the reason for the visit. All genders, ethnicities, races, insured, and uninsured were included. The primary care provider assessed each patient's EMR looking for specific preventive health screenings during the appointment and engage the patient on the decision to order the screenings. The preventive screenings that were included in the project are below:

       Mammogram completed annually at the age of 40 in females.

       Pap Smear based on age and previous results.

       Colorectal screening at the age of 50.

       Pneumococcal vaccine series at the age of 65.

       Bone Density screening at the age of 65. 

       Lung cancer screening based on history and age.

Once the preventive screenings have been addressed, the ordered screenings tests provided the information needed begin data collection. This data was used to compare the primary care providers ordered screenings from the previous eight-weeks. This captured the providers number of ordered screenings thus showing an impact to identifying patient needs. If a screening results in a positive finding, such as identifying cancer, this will also show the overall effect of engaging patients outside of a scheduled wellness exam and the benefit of identifying the outcomes of diseases prior to symptomatology.     


            Literature shows that primary care providers have a wealth of guidelines that offer evidence-based practice recommendations to guide their conversations with patients on preventive screenings. Agencies such as the USPSTF, AHRQ, and CDC have outlined the evidence for preventive screenings by providing sound recommendations for the primary care provider to follow. The NCQA has created a patient-centered design for the structure of this model in the primary care setting. This design also aligns goals to achieve a PCMH model and impact patient care outcomes in the primary care setting (Patient-Centered Primary Care Collaborative, n.d.). The PCMH model is increasingly promoted as the standard for the delivery of high-quality, comprehensive healthcare. It reinforces the need to increase federal, state, and community efforts to ensure that all patients have access to this model of care (Strickland et al., 2011). The PCMH model has been found in the literature review to improve health outcomes, enhance satisfaction, and reduce healthcare costs by promoting preventive screenings.

Constand et al., (2014) found that patient-centered care often included strategies such as effective communication, strengthened partnerships, and focus on health promotion. Romero et al. (2020) published information using EMRs and incorporating a provider tool to prompt health screening questions. Integration of the PCMH model pushes for healthcare information technology. This technology enhances communication, collaboration, and use among special populations.

This literature review shows that primary care providers have the opportunity to introduce and support the PCMH model within their practices. By utilizing this model, the opportunity to change disease prevention and health promotion by moving into the active care planning process will undoubtedly impact healthcare within the community they serve. In the next chapter, the methodology and design for the project will be discussed.

Chapter 3: Methodology

            The United States healthcare system has discovered the benefits of turning patients into partners and embracing patient-centered care models. This approach is supported by literature and moves the patient's role to more of a decision-maker in their treatment (What is patient-centered care?, 2017). When patients are active participants in their healthcare, they become empowered, and outcomes improve. Historically nurses are known to treat holistically, focusing on physical and mental health, thus building trust, which is crucial in a patient-centered care model. Nurses counsel patients on unhealthy behaviors and help them develop lifestyle modifications that will impact their health. Advanced practice nurses are valuable team members who move toward a patient-centered care model in the primary care setting (Bodenheimer and Pham, 2010). In this project, three family nurse practitioners will participate. The impact of implementing the PCMH model could help identify an early diagnosis of diseases such as cancer and allow a patient to access treatment quicker than a diagnosis made later. In this chapter the project will utilize literature and evidence-based recommendations on patient-centered care to capture data supporting improved patient outcomes in the primary care setting. 



Project Design

            This project used a nonexperimental design. The nonexperimental design ensures that relationships are not randomly assigned and that the independent variable is not manipulated. This allows the researcher to simply answer questions. The outcome measures will identify the impact on the patient and demonstrates the project's end result (Van Breukelen, 2010). Example outcomes of this project are an increase in overall referrals for identifying an illness through obtaining a preventative screening and the provider's perception of changing current practice. The outcome measures will validate the effectiveness of implementing the medical home model in primary care. The process measure will reflect how well the processes in this study work when implemented in the clinical setting. Next is the structure measure, which refers to how and what data was collected over the course of eight weeks. Finely balancing measures recognize the project's impact and are addressed in the publication of the findings.                                                                          Sample and Setting

            Utilizing a nonexperimental design in addition to Orlando’s theory for this DNP project assisted in identifying key measures. The site is a rural primary care clinic with each provider seeing an average 102 patients per week. All genders, ethnicities, races, insured, and uninsured were included. The participating primary care providers assessed each patient's EMR looking for specific preventive health screenings that are due or past due and engaged the patient on the decision to order the screenings. For this project, not all preventative screenings were included in data collection due to limitations. The preventive screenings that were included in the project are listed below:

       Breast cancer screening: Mammogram completed annually at the age of 40 in females (ACS Breast Cancer Screening Guidelines, n.d.)

       Cervical Cancer screening: Starting at age 21, get a Pap smear every three years until the patient is 30 years old. Women 30 years of age or older can choose to switch to a combination Pap smear and/or human papillomavirus (HPV) test every five years until the age of 65 (Cervical Cancer: Screening, 2018).

       Colorectal cancer screening: A colonoscopy is recommended starting at the age of 50 and every ten years if negative until 75 years old. A repeat colonoscopy is recommended in 3-5 years if polyps were found on the initial screening (Colorectal Cancer: Screening, 2021).

       Lung cancer screening: Between the ages of 50 and 80, have a 20-pack-year smoking history, and smoke now or have quit within the past 15 years (Lung Cancer: Screening, 2021).

       Pneumococcal vaccine (PCV15 or PCV20): At the age of 65 (Pneumococcal Vaccination CDC, 2022).

       Osteoporosis screening: Dexa Scan at age 65 (Osteoporosis to Prevent Fractures: Screening, 2018).

            For this project, the focus is on the impact of implementing the PCMH model regarding the number of ordered preventive screenings compared to the previous eight weeks prior to project implementation. For future projects, data may include positive findings such as identifying cancer. Both positive screenings and an overall increase in ordered preventive screenings will demonstrate the impact of engaging patients outside of a scheduled wellness exam and the benefit of identifying the outcomes of diseases prior to symptomatology.


            Data collection is a systematic process of gathering and analyzing specific information and is an important step. This data was used to answer pertinent questions of the research and evaluate the results. It focuses on finding out all there is to a particular subject matter. Data is collected to be further subjected to hypothesis testing, which seeks to explain a phenomenon. For this project, the data instrumentation used consisted of library resources, computer software such as Excel, and observations. Data was gathered utilizing the EMR.

            With the assistance of the medical director for the primary care clinic an educational handout with routine preventative screenings was created to share and help guide patients on preventive screening encounters. This form is labeled Appendix B. The educational handout was disseminated to all providers during the monthly provider meeting allowing each provider the opportunity to review and make any changes. Copies of the form were placed in each patient room. Using the existing EMR, Cerner, a review of the location for health promotion items was discussed with all staff. Updates were completed by the medical assistant at triage or by the primary care provider during the office visit. The data collected was entered into a spreadsheet and updated accordingly with the assistance of the healthcare organization's Health Information Technology (HIT) staff who manage this data.                                                                                                                                                           


Data Collection

            The clinic has eight medical providers (three family nurse practitioners and five physicians). The medical director, staff physician, and two nurse practitioners agreed to participate in the PCMH model for the specified time frame. Data was collected for eight weeks on the number of ordered wellness initiatives for the specified screenings, total volume, and total billed wellness exams. All patients over the age of 18 years were included in the data regardless of the reason for the encounter. However, this fell under the discretion of the primary care provider to ensure appropriateness based on the office visit reason. Data was collected from the EMR via reports from HIT without patient identifiers. This data included the number of ordered preventive screenings per provider for the identified time frame. Discrete and continuous variable data was collected.

Data Analysis Methods

             For this project, the data analysis will be descriptive as we seek to answer how the PCMH model implementation will impact patient outcomes. This data analysis will show the impact of how implementing the PCMH model will affect the number of preventive screening referrals in comparison to eight weeks prior to implementation while summarizing data using indexes. A nonexperimental design was applied to analyze the data collected over the designated eight weeks. The independent variables were the preventive screenings chosen in this quality improvement project and included the following:

       Breast cancer screening

       Cervical Cancer screening

       Colorectal cancer screening

       Lung cancer screening

       Pneumococcal vaccine

       Osteoporosis screening

 The dependent variable was the patient. The HIT staff created reports to expedite data analysis and assisted with the creation of graphs of the information gathered.  

Data Management Methods

            The primary care providers did not collect patient identifiers during the office encounter. All data was collected by the HIT department and reported via a spreadsheet of the total number of ordered screenings made during the identified timeframes. This data will be kept on a secured server of the healthcare organization for two years, as indicated on the research contract. This ensures all data is protected and secured by the organization’s policy and procedures that are in place.

Ethical Considerations

            For this project, ethical considerations were in place regarding the planning, conducting, and evaluating of the research data. Special regard to the three principles of all human subjects were followed. These are respect for persons, beneficence, and justice. Participants will verbally agree to the screenings and may decline for any reason. Expedited IRB review was approved by the university and research site.

            This scholarly project adheres to the following: “Minimal risk means that the probability and magnitude of harm or discomfort anticipated in the research are not greater than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests (45.CFR.46.102(j) (Common Rule)” (Center for Drug Evaluation and Research, 2019).

Internal and External Validity

            Validity is reviewing the cause-and-effect relationships of a design. Validity has two forms; internal and external. According to Streefkerk (2022), internal validity refers to the degree of confidence in the relationship being tested. This should be reliable and not influenced by other factors or variables. External validity defines the extent to which results from a study can be applied to the topic.

The identified threats to internal validity are testing and history. Threats to external validity are multiple treatment interference and reactive effects of the experimental arrangement. Using criterion-related validity will assist in verifying the outcomes predicted within the PCMH model. Data will be correlated with the screenings. If a correlation of data exists, then criterion- related validity exists (Lani, 2021).


            The United States healthcare system is undergoing scrutiny and a call for rapid changes. The benefits of patient-centered care are well documented in the literature. While the primary goal of any patient-centered model is to improve patient healthcare outcomes, healthcare providers will benefit from improved patient satisfaction scores. This makes the PCMH approach worth exploring in almost any healthcare delivery setting. Primary care physicians and APRNs can implement the PCMH and address disease prevention and create health promotion opportunities.

By utilizing the frameworks and experimental design discussed, the data collected should show an increase in ordered screenings in the primary care setting. The project’s design also ensures validity with the assistance of outside resources such as HIT. While the PCMH model is well supported it is expected in this project that patients will become more engaged and satisfied with the delivery of their individualized care. By following the outlined design, it is anticipated the evidence of its clinical efficacy should be apparent.

Adopting the PCMH model and measuring the outcomes of missed preventive screenings will offer a new method for ensuring that patients are not lost in the system and are offered screenings that may identify disease processes that may be life-threatening. This project aimed to show positive outcomes by interpreting and presenting the data regarding higher patient engagement rates in a primary care setting using a team approach with nurse practitioners and physicians. This also shows the model’s design allowing both the caregiver and the patient’s healthcare goals to be met and leads to the results of the project.                                             

Chapter 4: Results and Discussion of Findings


The application of the PCMH model in any healthcare setting will promote coordinated and comprehensive care by emphasizing ongoing collaboration among all stakeholders as evident in the literature reviews and project results. Implementation of the PCMH model in the primary care setting specifically targets disease processes for patients before symptoms present. The goal is to allow the patient to access treatment earlier versus making a diagnosis later. Thus, improving patient outcomes, satisfaction scores, and decreasing healthcare costs long term. This chapter will discuss the implementation process and data analysis post-implementation.

Preparation for Implementation

            Using Kotter’s stepwise approach as a guide this model was implemented at a rural primary care clinic in Alabama with eight medical providers (three family nurse practitioners and five physicians). Two physicians and two nurse practitioners agreed to participate by implementing the PCMH model for the specified time frame within their own practice. The goal was not only to implement the PCMH model but review the overall the impact on the number of ordered tests made for identified screenings compared to the previous eight weeks before project implementation.

            To prepare the providers for this project, meetings were conducted to review the project goals, clinical evidence, workflow, and potential patient care impact to the practice. The group also collaborated and agreed on a wellness handout that includes all recommendations by age for all patients to utilize during the decision-making process. This is listed as Appendix A. This process shows the flow from Kotter’s “creating a sense of urgency to enabling by removing barriers” which are the first five steps. The medical providers also requested a form to be created to serve as a reminder of the screenings for the project. The five screenings and the correlating CPT or ICD-10 code were placed on a Word document, printed in color, and laminated. This is labeled as Appendix B. This form was then placed in the patient exam rooms to help prompt the conversation regarding preventive screenings. 

Summary of Methods and Procedures


            The “go live” date for the project’s implementation began on March 20, 2023. Data was collected for the previous eight weeks using the ICD-10 or CPT code associated with the screening. This data was provided via an excel spreadsheet from the HIT department. No patient identifiers were collected. The data was provided per each participating provider of the total number of ordered screenings pre and post-implementation. All patients over the age of 18 years were included in the data regardless of the reason for the encounter. However, this fell under the discretion of the participating primary care provider to ensure appropriateness based on the office visit reason. The data was then added to a graph for visualization purposes in addition to the numerical data on the excel spreadsheet. This allowed the providers to see the overall data of the pre and post-implementation data.

            Jean Orlando’s nursing process focuses on the patient’s needs and was used throughout this project. This integrates the PCMH model directly with nursing. The observations found in this project identify patients' needs being met. By reviewing these observations and sharing data, this research can be used to impact patient outcomes in all areas. This model provides a framework not only for nursing but all healthcare providers and has guided this project to success. Nursing leaders should embrace this theory and build frameworks within their healthcare organizations to address areas of need or special populations where patient-centered care models will impact patient care

DNP Essentials

            The outcomes of this project show significant impact on patient outcomes and outline strategy is for other healthcare providers to implement in their specific settings.  Successful implementation of any portion of a PCMH will meet the goals establish by leadership. The DNP essentials listed upon implementation of this project were successfully met and articulates the DNP essentials outlined below:

Essential I: Scientific Underpinning for Practice

Essential II: Organizational and System Leadership for Quality Improvement and System Thinking.

Essential III. Clinical Scholarship and Analytical Methods for Evidence-based Practice

Essential IV: Information System/Technology and Patient Care Technology for the Improvement and Transformation of Healthcare

Essential V: Healthcare Policy for Advocacy in Healthcare

Essential VI: Interprofessional Collaboration for Improving Patient and Population Health


Essential VII: Clinical Prevention and Population Health for Improving the Nation’s Health (AACN, 2006).



            The total volume of patient encounters for the four participating providers during the pre-implementation phase was 2503 and 2237 post-implementation which was an overall volume decrease of 11% for the time frame allotted for this project.


            The total number of administered Pneumococcal vaccines prior to implementation was 52 and 79 post-implementation. This is an overall increase of 52% of the total number of ordered screenings. Provider three and four had a 100% increase in ordered pneumococcal vaccines.








            The total number of colon cancer screenings pre-implementation was 135 and post-implementation 120. This is a decrease of 11% the total number of ordered screenings during pre-implementation. However, provider one had a significant individual increase of the ordered screening. Provider four showed an increase in their total as well. Combined these two providers had an overall 42% increase in ordered screenings together.






            Only two providers at the primary care clinic provide well-woman services. Cervical cancer screening totals for pre-implementation were 13 and post-implementation 15. This is an overall 15% increase in the ordered screening. However, provider four had a 100% increase during the project time frame. Well-woman services are dependent upon the number of males to female patients included in the total number of patient encounters.






            The number of breast cancer screenings with mammography pre-implementation was a total of 75 and post-implementation increased to 107. This is a 43% increase overall. Provider one had the highest individual growth.








            The total number of lung cancer screenings with CT pre-implementation was 11 and post-implementation was a total of 9. However, provider three and provider four together had over 100% overall increase in screening for lung cancer. Of note, this screening is dependent on patient age and risk factors.








            Osteoporosis screening by DEXA scan had a total of 19 pre- implementation and increased to 39 post-implementation. This is over a 100% increase in ordered screenings. This shows a significant increase of ordered screenings for all participating providers.








            Despite the volume decrease in patient encounters during the project implementation the office had an overall 41% increase in billed wellness screenings. Each provider showed a significant increase in their individual practice. Regardless of the individual provider results this data shows the project’s success with implementing a patient centered model in the primary care center.







            Of the four participating primary care providers two were family nurse practitioners and two medical doctors. By implementing this patient centered approach, the medical doctors showed the greatest overall increase of ordered screenings. They also had the greatest increase to billed wellness exams.


            The overall project was considered a success. The project goals were met showing an overall increase in several ordered screenings. Although not every area saw an increase in ordered screenings every provider increased their total of wellness exams performed. The project data showed that primary care providers were able to change their individual practices to implement a patient centered approach. Also, there were no reported patient issues such as patients declining the identified preventive screenings. There was also an increase in patient satisfaction perception among participating providers. This is evidence of the PCMH model’s impact on patient care and leads to the project’s final conclusion.

Chapter Five: Discussions and Conclusion

            The primary care clinic was highly motivated in maintaining success of this project. Each provider that participated understood the importance of their role in patient-centered care. The project was well supported by the primary care clinic manager and medical director. The major change from this project from implementation to end was a holistic approach to each patient encounter showing that the culture embraced the patient centered care model. Not only did data show an overall increase in ordered screenings, there was also an increase in revenue which aligns with pay for performance. In this chapter the final analysis of the findings, dissemination, and goals will be discussed.

Discussion of Findings and Best Practices


            The literature supports the use of a PCMH model that primary care providers can support within their own practices to impact disease prevention and optimize health promotion by moving into an active care planning model. Chapter 2 of this manuscript details a literature review that shows the impact of utilizing evidence-based practice recommendations to guide conversations with patients on preventive screenings. With a wealth of resources such as the USPSTF, AHRQ, and CDC the evidence for preventive screenings has created sound recommendations for the primary care provider to follow. The NCQA has created a patient-centered design for the primary care setting which guides the provider to achieve a PCMH model in their practice (Patient-Centered Primary Care Collaborative, n.d.). The PCMH model has been found in literature reviews to improve health outcomes, enhance satisfaction, and reduce healthcare costs by promoting preventive screenings. In addition, researchers such as Constand et al., (2014) found that patient-centered care models created strategies such as effective communication, strengthened partnerships, and focused on health promotion. This was evident in the overall clinic response to the implementation of this project. Information published by Romero et al. (2020) helped guide the use of EMRs effectively during this project as well. The literature reviews discussed in this manuscript were utilized during the implementation phase and found to be a valuable resource.

Analysis of the Results

            The total volume for each 8-week period was greater than 2200 patient encounters divided among four primary care providers. Pneumococcal vaccine administration increased 52% during the post-implementation phase. Colon cancer screenings declined in the post-implementation phase but provider one and provider four showed an overall increase of 42% as an individual. Cervical cancer screenings are performed only by two providers. However, there was a 15% increase in cervical cancer screenings performed with Pap smear. This screening is dependent on the patient's gender and may fluctuate based on patient encounters. Breast cancer screenings using mammography had a 43% increase overall post-implementation. Lung cancer screenings via CT showed a slight decline in post-implementation. However, this screening is based on patient's history and current smoking status. Therefore, fluctuations will be seen based on patient population. Osteoporosis screening by DEXA scan had over a 100% increase post-implementation. Of note, by implementing this patient centered approach, the medical doctors showed the greatest overall increase of ordered screenings. They increased their preventative screening orders by 26%.

            Despite the volume decrease in patient encounters during the project implementation the office had an overall 41% increase in billed wellness screenings. The participating providers reported no issues with implementing the patient-centered model into their daily routine

Plan for Dissemination

            Upon the completion of this project the data obtained from pre and post-implementation were shared throughout the clinic showing the potential outcomes on patient care and the organization’s revenue by ordering preventive screenings. This quality improvement project will be submitted for publication in a peer review journal. This project can be used at any healthcare organization presentation or conference seeking a patient-centered approach and its impact.  

Personal and Professional Goals

            During this quality improvement project, I have gained new knowledge and the experience of implementing a quality improvement project within a healthcare organization. I have gained a deep understanding of the importance of effective communication and organizational leadership. By working through this process, I have developed a level of confidence and skill set that will be beneficial in my future career as a DNP. The understanding and acknowledgement of evidence-based practice as a clinical guide and the potential outcomes learned during this project will certainly impact patient care.                                                                                                                                                                                Recommendations for Future Studies

            This project could easily be expanded to identify if ordering a preventive screening results in a positive finding, such as identifying cancer, and the impact of early identification. This would also show the overall effect of engaging patients outside of a scheduled wellness exam. Also, patients who decline any screenings could offer additional data on reasoning, such as concerns with co-pays, time, transportation issues, and feelings regarding the screening. Additional research is needed to study the benefit of identifying the outcomes of diseases prior to symptomatology using the PCMH model in the primary care setting as well. Sampling a large population in a different healthcare organization will validate the results obtained in this quality improvement project. However, this project is of great importance to the nursing field because it has identified strategies that can be used across all disciplines to improve patient outcomes. This makes it ideal for publication in various nursing journals.


            The clinic made significant progress in developing and testing the PCMH model into their standard of care. By utilizing the PCMH model it was evident that patient outcomes were being impacted positively, potential revenue increases with ordered screenings, and patient encounters were holistically approached routinely. The PCMH model utilizes evidence-based practice and will help meet quality measures as evident in this quality improvement project. The patient-centered care model has been successful in various clinical settings as seen in the literature reviews. Nursing as a profession is interested in providing safe and quality patient care to a diverse patient population. Advanced practice registered nurses that are serving in the role such as nurse practitioner, have the opportunity to work along physician colleagues utilizing evidence- based projects to implement within their settings. 













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Appendix A

Preventive Screening Recommendations

Breast Cancer- Women over the age of 40 need a mammogram every year. All women should perform a breast exam each month after their menstrual cycles.

___ Schedule Mammogram


Cervical Cancer- Starting at age 21, get a Pap smear every 3 years until you are 30 years old. Women 30 years of age or older can choose to switch to a combination Pap smear and/or human papillomavirus (HPV) test every 5 years until the age of 65. If you are older than 65 or have had a hysterectomy, talk with your medical provider or nurse about whether you still need to be screened.

___ Schedule visit for Pap Smear/HPV testing


Colon Cancer- Between the ages of 50 and 75, get a screening test for colorectal cancer. A Cologuard test or a colonoscopy can be used for colon cancer patients. Your health care team can help you decide which is best for you. If you are between the ages of 76 and 85, talk with your medical provider or nurse about whether you should continue to be screened.

___ Schedule Colonoscopy    ___ Schedule Cologuard


Prostate Cancer Screening: Men age 50 to 70 should discuss with their doctor about prostate cancer screening with a PSA (prostate specific antigen) blood test.

___ Schedule PSA blood test


Lung Cancer- Talk to your medical provider or nurse about getting screened for lung cancer if you are between the ages of 55 and 80, have a 30 pack-year smoking history, and smoke now or have quit within the past 15 years. (Your pack-year history is the number of packs of cigarettes smoked per day times the number of years you have smoked.) Know that quitting smoking is the best thing you can do for your health.

___ Schedule Low-dose CT Chest for Lung Cancer screening


Osteoporosis (Bone Thinning)- Women should have a screening test at age 65 to make sure your bones are strong. The most common test is a DEXA scan—a low-dose x-ray of the spine and hip. If you are younger than 65 and at high risk for bone fractures, you should also be screened.

___ Schedule DEXA scan


Diabetes- Get screened for diabetes (high blood sugar) if you have high blood pressure or if you take medication for high blood pressure, if you are overweight or have a family history of diabetes.

___ Schedule blood test for fasting glucose or Hgb A1C

High Blood Cholesterol- Have your blood cholesterol checked regularly with a blood test if:

       You use tobacco.

       You are overweight or obese.

       You have a personal history of heart disease, blocked arteries or diabetes.

       A male relative in your family had a heart attack before age 50 or a female relative, before age 60.

___ Schedule blood test for Lipid Panel


High Blood Pressure- Have your blood pressure checked at least every 2 years. High blood pressure can cause strokes, heart attacks, kidney and eye problems, and heart failure. ___ B/P


Abdominal Aortic Aneurysm (AAA): Medicare will cover an ultrasound to screen for AAA (an enlargement of the aorta) in males 65 and over who smoke.

___ Schedule an abdominal aorta ultrasound


Depression- Your emotional health is as important as your physical health. Talk to your health care team about being screened for depression, especially if during the last 2 weeks:

       You have felt down, sad, or hopeless.

       You have felt little interest or pleasure in doing things.

Hepatitis C Virus (HCV)- Get screened one time for HCV infection if:

       You were born between 1945 and 1965.

       You have ever injected drugs.

       You received a blood transfusion before 1992.                                                    

____ Schedule Blood test for HCV antibody titer

HIV- If you are 65 or younger, get screened for HIV. If you are older than 65, talk to your medical provider or nurse about whether you should be screened.

___ Schedule Blood test for HIV screening


Sexually Transmitted Infection- Sexually transmitted infections can make it hard to get pregnant, may affect your baby, and can cause other health problems.

       Get screened for chlamydia and gonorrhea infections if you are 24 years or younger and sexually active. If you are older than 24 years, talk to your medical provider or nurse about whether you should be screened.

       Ask your medical provider or nurse whether you should be screened for other sexually transmitted infection.

Overweight and Obesity- The best way to learn if you are overweight or obese is to find your body mass index (BMI). You can find your BMI by entering your height and weight into a BMI calculator, such as the one available at: A BMI between 18.5 and 25 indicates a normal weight. Persons with a BMI of 30 or higher may be obese. Obesity can lead to diabetes and cardiovascular disease: Your BMI is: ____



    Get an Influenza (flu) vaccine every fall. ___ Schedule/administer Influenza

    The vaccine for tetanus, diphtheria, and whooping cough should be given as an                 adult. A booster for tetanus is due every 10 years. ___    Schedule/administer/prescribe TDaP

    If you are 55 or older, get a vaccine to prevent shingles.       ___Schedule/administer/prescribe Shringrix

    If you are 65 or older, get a pneumonia vaccine.___ Schedule/administer Prevnar












Appendix B

Patient Room Reminder

       Breast cancer screening: Mammogram completed annually at the age of 40 in females.      

       Cervical Cancer screening: Starting at age 21, get a Pap smear every three years until the patient is 30 years old. Women 30 years of age or older can choose to switch to a combination Pap smear and/or human papillomavirus (HPV) test every five years until the age of 65.

       Colon cancer screening: A colonoscopy is recommended starting at the age of 50 and every ten years if negative orc until 75 years old. A repeat colonoscopy is recommended in 3-5 years if polyps were found on the initial screening.

       Lung cancer screening: Between the ages of 50 and 80, have a 20-pack-year smoking history, and smoke now or have quit within the past 15 years.

       Pneumococcal vaccine: At the age of 65.

       Osteoporosis screening: Dexa Scan at age 65.