The empowerment paradox as a central challenge to patient centered medical home implementation in the veteran's health administration

This article is not subject to United States copyright laws.

Abstract

In this paper we present results of a mixed methods study conducted to identify barriers to team function among staff implementing patient aligned care teams – the Department of Veterans Affairs' patient centered medical home (PCMH) model. Using a convergent mixed methods design, we administered a standardized survey measure (Team and Individual Role Perception Survey) to assess work role challenge and engagement; and conducted discussion groups to gather context pertaining to role change. We found that the role of primary care providers is highly challenging and did not become less difficult over the initial year of implementation. Unexpectedly over the course of the first year nurse care managers reported a decrease in their perceptions of empowerment and clerical associates reported less skill variety. Qualitative data suggest that more skilled team members fail to delegate and share tasks within their teams. We characterize this interprofessional knowledge factor as an empowerment paradox where team members find it difficult to share tasks in ways that are counter to traditionally structured hierarchical roles. Health care systems seeking to implement PCMH should dedicate resources to facilitating within-team role knowledge and negotiation.

• Health and social care
• interprofessional collaboration
• mixed methods
• patient centered practice
• professional identity
• team-based care

Acknowledgements

The authors acknowledge the VISN 23 PACT teams and technical support from Melissa Fox and the VISN 23 Primary and Specialty Medicine Service Line.

Declaration of interest

The authors report no declarations of interest. The authors are responsible for the writing and content of this paper. This study was supported by the VISN 23 Patient Aligned Care Team Demonstration Lab, funded by the VA Office of Patient Care Services. Additional support was provided by the Center for Comprehensive Access & Delivery Research and Evaluation, funded by the VA Health Services Research and Development Service. None of these sponsors had any role in the study design, methods, analyses, or interpretation or in the preparation of the manuscript and the decision to submit it for publication. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Notes

This article is not subject to United States copyright laws.