Factors Associated with Patient-Centered Medical Home Teams' Use of Resources for Identifying and Approaches for Managing Patients with Complex Needs

Susan E. Stockdale
Danielle E. Rose
Michael McClean
Ann-Marie Rosland
Evelyn T. Chang
Donna M. Zulman
Gregory Stewart
Karin M. Nelson
Peer-Reviewed Article
July 2022


Nurses and members of fully staffed interdisciplinary care teams are more likely to use patient identification and care management tools.


The majority of patients with complex health and psychosocial needs within the Veterans Health Administration (VHA) receive primary care in patient-centered medical homes (PCMHs), which emphasize coordinated care delivered by a multidisciplinary team. PCMHs in the VHA system have access to tools and resources within the electronic health record (EHR) for patient identification and population management. This study examines PCMH team member perspectives on the most highly-rated tools.


PCMH teams with full staffing were more likely to use care management tools. While many sophisticated prediction scores, dashboards, and care management tools are linked to the EHR, many VHA PCMH team members preferred simpler metrics related to utilization and illness. Team role significantly predicted the value placed on patient identification tools, as registered nurses (who often serve as care managers) were more likely than primary care providers to describe these tools as very important.


PCMH and other interdisciplinary teams may have access to patient identification and care management tools, but their use of these tools will be affected by whether they work within fully staffed teams. PCMH teams may need additional training and supports to use these tools.

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