BACKGROUND: Healthcare purchasers have created financial incentives for primary care practices to achieve medical home recognition. Little is known about how changes in practice structure vary across practices or relate to medical home recognition. OBJECTIVE: We aimed to characterize patterns of structural change among primary care practices participating in a statewide medical home pilot. DESIGN: We surveyed practices at baseline and year 3 of the pilot, measured associations between changes in structural capabilities and National Committee for Quality Assurance (NCQA) medical home recognition levels, and used latent class analysis to identify distinct classes of structural transformation. PARTICIPANTS: Eighty-one practices that completed surveys at baseline and year 3 participated in the study. MAIN MEASURES: Study measures included overall structural capability score (mean of 69 capabilities); eight structural subscale scores; and NCQA recognition levels. RESULTS: Practices achieving higher year-3 NCQA recognition levels had higher overall structural capability scores at baseline (Level 1: 28.4 % of surveyed capabilities, Level 2: 40.9 %, Level 3: 48.7 %; p value = 0.001). We found no association between NCQA recognition level and change in structural capability scores (Level 1: 33.2 % increase, Level 2: 30.8 %, Level 3: 33.7 %; p value = 0.88). There were four classes of practice transformation: 27 % of practices underwent "minimal" transformation (changing little on any scale); 20 % underwent "provider-facing" transformation (adopting electronic health records, patient registries, and care reminders); 26 % underwent "patient-facing" transformation (adopting shared systems for communicating with patients, care managers, referral to community resources, and after-hours care); and 26 % underwent "broad" transformation (highest or second-highest levels of transformation on each subscale). CONCLUSIONS AND RELEVANCE: In a large, state-based medical home pilot, multiple types of practice transformation could be distinguished, and higher levels of medical home recognition were associated with practices' capabilities at baseline, rather than transformation over time. By identifying and explicitly incentivizing the most effective types of transformation, program designers may improve the effectiveness of medical home interventions.
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