Evidence-Based PracticeEvidence-based Practice Progra.docx

Evidence-Based
Practice
Evidence-based Practice
Program
The Agency for Healthcare Research and
Quality (AHRQ), through its Evidence-
based Practice Centers (EPCs), sponsors
the development of evidence reports and
technology assessments to assist public-
and private-sector organizations in their
efforts to improve the quality of health
care in the United States. The reports
and assessments provide organizations
with comprehensive, science-based
information on common, costly
medical conditions and new health care
technologies. The EPCs systematically
review the relevant scientific literature
on topics assigned to them by AHRQ
and conduct additional analyses when
appropriate prior to developing their
reports and assessments.
AHRQ expects that the EPC evidence
reports and technology assessments will
inform individual health plans, providers,
and purchasers as well as the health care
system as a whole by providing important
information to help improve health care
quality.
The full report and this summary are

available at www.effectivehealthcare.
ahrq.gov/reports/final.cfm.
Background
The United States spends a greater proportion
of its gross domestic product on health care
than any other country in the world (17.6
percent in 2009),1 yet often fails to provide
high-quality and efficient health care.2-6 U.S.
health care has traditionally been based on a
solid foundation of primary care to meet the
majority of preventive, acute, and chronic
health care needs of its population; however,
the recent challenges facing health care in
the United States have been particularly
magnified within the primary care setting.
Access to primary care is limited in many
areas, particularly rural communities. Fewer
U.S. physicians are choosing primary care as
a profession, and satisfaction among primary
care physicians has waned amid the growing
demands of office-based practice.7 There has
been growing concern that current models
of primary care will not be sustainable for
meeting the broad health care needs of the
American population.
The patient-centered medical home (PCMH)
is a model of primary care transformation that
seeks to meet the variety of health care needs
of patients and to improve patient and staff
experiences, outcomes, safety, and system
efficiency.8-11 The term “medical home”
was first used by the American Academy of
Pediatrics in 1967 to describe the concept of a

single centralized source of care and medical
record for children with special health care
Evidence Report/Technology Assessment
Number 208
2. The Patient-Centered Medical Home
Closing the Quality Gap: Revisiting the State of the Science
Executive Summary
2
needs.12 The current concept of PCMH has been greatly
expanded and is based on 40 years of previous efforts to
redesign primary care to provide the highest quality of care
possible.13,14 The chronic care model,15,16 a conceptual
model for organizing chronic illness care that is associated
with improved health outcomes, is the cornerstone of
PCMH.17 Interventions based on the chronic care model
(CCM) and focused on single conditions such as diabetes
mellitus, asthma, chronic obstructive pulmonary disease, or
depression have been shown to improve patient outcomes
and/or quality of care.18-21 PCMH builds on this model
and is intended to address the full range of patient-focused
health care needs.8 As defined by physician and consumer
groups, the core principles of the PCMH are wide-ranging
team-based care, patient-centered orientation toward the
whole person, care that is coordinated across all elements
of the health care system and the patient’s community,
enhanced access to care that uses alternative methods
of communication, and a systems-based approach to
quality and safety.9 While these principles are frequently

cited in relation to PCMH, it should be recognized that
specific PCMH definitions vary widely, reflecting the
rapid expansion of the use of PCMH concepts in the last
decade.22 As described below, we based the operational
definition of PCMH for this review on the definition
outlined by the Agency for Healthcare Research and
Quality (AHRQ).8
It has been hypothesized that comprehensive PCMH
interventions hold promise as a pathway to improved
primary health care quality, safety, efficiency, and
effectiveness. The PCMH has also been described as
a “lifeline for primary care” that has the potential to
transform and increase the appeal and viability of primary
care practice.23 Given the conceptual promise of PCMH,
professional societies have endorsed the model,24 and
payers (e.g., Medicare) and large health systems have
begun to implement PCMH-based programs. These include
health maintenance organizations (HMOs), networks of
Medicaid providers, community health centers, private
integrated delivery systems, private practices, the U.S.
Department of Veterans Affairs (VA) health care system,
and components of the Department of Defense military
health care system.25-28 The goal is to improve the care of
patients across the continuum of prevention and treatment
of chronic and acute illness, while potentially improving
both patient and provider experiences with the health care
system. Further, it has been hypothesized that PCMH may
introduce efficiencies in care that help contain rising health
care costs.25
Although PCMH is built on a solid foundation, the
evidence for benefit of comprehensive PCMH interventions
is uncertain. Therefore, AHRQ commissioned a systematic
review to evaluate the current state of the evidence for a
range of outcomes and to identify ongoing studies that

could address current gaps in evidence. Medical homes can
be established in specialty settings, but for the purposes of
this review we chose to focus on evaluations of the model
in the primary care–based setting, the setting of broadest
applicability and with the most extant research. Further,
we developed an operational definition of a comprehensive
PCMH intervention that is based on the AHRQ definition
of PCMH, which does not require an enhanced payment
model.8 Using the AHRQ definition made our review
more inclusive of studies that tested the critical principles
that embody the Institute of Medicine (IOM) concept of
patient-centered care.29
Objectives
As part of the Closing the Quality Gap: Revisiting the State
of the Science series of reviews by Evidence-based Practice
Centers (EPCs), this systematic review was commissioned
to identify completed and ongoing efforts to evaluate the
comprehensive PCMH model, summarize current evidence
for this model, and identify gaps in the evidence. Because
the PCMH model is being implemented widely but the
number of completed studies was expected to be small, the
identification of ongoing studies was an important goal of
this review. This “horizon scan” component of the review
helped to identify forthcoming studies that may address
gaps in the currently available evidence.
The Key Questions (KQs) for the review are listed below.
For clarification, KQs 1–3 concern published studies, while
KQ 4 is a horizon scan question that relates to unpublished
comparative studies now in progress.
KQ 1: In published, primary care–based evaluations of
comprehensive PCMH interventions, what are the
effects of the PCMH on patient and staff experiences,

process of care, clinical outcomes, and economic
outcomes?
a. Are specific PCMH components associated with
greater effects on patient and staff experiences,
process of care, clinical outcomes, and economic
outcomes?
b. Is implementation of comprehensive PCMH
associated with unintended consequences
(e.g., decrease in levels of indicated care for
nonpriority conditions) or other harms?
3
comprehensive PCMH interventions, what individual
PCMH components have been implemented?
comprehensive PCMH interventions, what financial
models and implementation strategies have been used to
support uptake?
KQ 4: What primary care–based studies evaluating the
effects of comprehensive PCMH interventions on
patient and staff experiences, process of care, clinical
outcomes, or economic outcomes are currently
underway? In these ongoing studies, what are the study
designs, PCMH components, comparators, settings,
financial models, and outcomes to be evaluated?
Analytic Framework

Figure A shows the analytic framework for the review.
Figure A. Analytic framework
KQ = Key Question; PCMH = patient-centered medical home
4
The figure illustrates how we hypothesized the potential
mechanism by which comprehensive PCMH interventions
(the combination of PCMH elements taken as a group, not
just the individual components) and their comparators may
impact outcomes of interest (KQ 1), including patient and
staff experiences, process of care, clinical outcomes, and
economic outcomes. This hypothesis motivated the search
for potentially relevant published literature. In addition, we
searched the literature to determine if there have been any
reports of an association between PCMH and unintended
consequences or other harms. The individual components
of PCMH and their incorporation and/or implementation
in PCMH evaluations were examined (KQ 2), as well as
the financial models and strategies for system change or
organizational learning used to support uptake
(KQ 3). Finally, the figure illustrates the way in which
these outcomes and moderators were identified in ongoing
studies (KQ 4).
Methods
1. Input From Stakeholders. Topics for the Closing the
Quality Gap: Revisiting the State of the Science series
were solicited from the leads of AHRQ portfolios (areas
of research). Nominations included a brief background
and context, the importance of and/or rationale for

the topic, the focus or population of interest, relevant
outcomes, and references to recent or ongoing work.
The EPC performing the review refined the KQs via
discussions with the EPC coordinating the Closing
the Quality Gap: Revisiting the State of the Science
series and with AHRQ. A Technical Expert Panel with
experts knowledgeable in PCMH as a primary care
model provided input during the protocol development
process.
2. Data Sources and Selection. For KQs 1–3, we searched
PubMed®, the Cumulative Index to Nursing & Allied
Health Literature (CINAHL®), and the Cochrane
Database of Systematic Reviews (CDSR). Our search
strategy used the National Library of Medicine’s
medical subject heading (MeSH) keyword nomenclature
and text words for the medical home and related
concepts, and for eligible study designs. We included
studies published in English and indexed from database
inception through December 6, 2011 (PubMed), or
March 30, 2011 (CINAHL and CDSR). All searches
were designed and conducted in collaboration with an
experienced search librarian. We supplemented these
electronic searches with a manual search of citations
from a set of key primary and review articles.30,31
For KQ 4, we used the term “medical home” to search for
ongoing or recently completed studies in the following
databases: ClinicalTrials.gov, Commonwealth Fund, Robert
Wood Johnson Foundation, and databases of federally
funded studies—AHRQ, Centers for Disease Control
and Prevention, Health Services Research Projects in
Progress, National Institutes of Health (NIH) Reporter
(NIH Research Portfolio Online), Health Resources
and Services Administration, VA, and Department

of Defense. All databases were searched using the
enGrant Scientific interface. In addition, we conducted
manual searches of Web-based resources that did not
have searchable databases, exploring all Web links that
showed promise for relevant information, including the
Patient-Centered Primary Care Collaborative, American
College of Physicians, National Academy for State
Health Policy, and Centers for Medicare & Medicaid
Services (CMS). To supplement electronic sources, we
sent letters to 10 contacts involved in State-level projects
funded by CMS and a letter to the VA Director of PCMH
(designated Patient Aligned Care Teams within the VA
environment) demonstration labs, requesting information
about any ongoing or recently completed studies. Finally,
we identified a published horizon scan that included
interviews with key informants designed to collect
detailed information about the participants, design, and
implementation of ongoing PCMH programs.31 We used
information from this horizon scan to verify and augment
data obtained from the above-mentioned databases/study
registries.
Using the criteria described in Table A, two investigators
independently reviewed each title and abstract for
potential relevance to the KQs; articles included by either
investigator underwent full-text screening. At the full-text
screening stage, two investigators independently reviewed
the full text of each article and indicated a decision to
include or exclude the article for data abstraction. When
the paired reviewers arrived at different decisions about
whether to include or exclude an article, or about the reason
for exclusion, we reached a final agreement through review
and discussion among investigators. Articles meeting
eligibility criteria were included for data abstraction. For
KQ 4, these procedures were modified such that a single
screener initially reviewed all citations; final eligibility for

data abstraction was determined by duplicate review.
5
Table A. Inclusion/exclusion criteria
Study Characteristic Inclusion Criteria Exclusion Criteria
Population • Adult primary care patients, selected to
represent the practice rather than on the basis of a
particular chronic illness.
• Children with special health care needs according to the
HRSA definition.
Studies where PCMH transformation
was focused on a small proportion of
patients being cared for in the practice;
for example, studies restricted to
patients with diabetes or asthma.
Interventions KQs 1–3: A comprehensive PCMH intervention
that
includes items 1, 3, and 4, below, along with at least two
components of item 2:
1. Team-based care (team may be virtual).
2. At least 2 of the following 4 components:
a. Enhanced access to care
b. Coordinated care across settings
c. Comprehensiveness
d. A systems-based approach to improving quality
and safety

3. A sustained partnership and personal relationship
over time oriented toward the whole person.
4. Structural changes to the traditional practice,
reorganizing care delivery.
KQ 4: PCMH intervention should meet the above
definition; however, because descriptions of ongoing
studies were often sparse, we accepted the designation
of “medical home” as meeting our intervention criteria
without explicit documentation that the study truly met
our functional definition.
KQs 1–3: Studies that were self-
identified as pertaining to “medical
home” but did not describe the
intervention sufficiently to meet the
AHRQ definition.
Comparators KQs 1–4:
• Usual care.
• Programs aimed at improving the quality of care,
process outcomes, or clinical outcomes that do not meet
the operational definition of a comprehensive PCMH
intervention (above).
KQ 4: For this question, we also accepted comparisons
across different levels of PCMH implementation (high vs.
low adopters).
KQs 1 and 4: No comparator. Analyses
for KQs 2–3 include studies without
comparators, while KQ 1 and KQ 4

analyses include only studies with
comparison groups).
6
Table A. Inclusion/exclusion criteria (continued)
Outcomes KQ 1: PCMH interventions may lead to a variety of
effects on the health care system and patient health status.
We prioritized and abstracted a specific subset of these
outcomes that had face validity and were reported across
studies, and/or were collected using validated instruments
or methods. These included:
1. Patient experiences:
a. Global/overall patient experiences
b. Coordination of care (as perceived by patients)
c. Patient-provider interaction
2. Staff experiences:
a. Global/overall staff experiences
b. Staff retention rates
c. Staff burnout
3. Process of care:
a. Preventive services
b. Chronic illness care services
4. Clinical outcomes:
a. Health status
b. Laboratory tests
c. Mortality
5. Economic outcomes:
a. Inpatient use
b. Emergency department use

c. Overall costs
6. Unintended consequences or other harms
KQ 2: PCMH components as listed in the Interventions
section.
KQ 3:
1. Financial models.
2. System change, along with any theoretical basis
provided.
3. Organizational learning strategies and any
theoretical basis provided for these strategies.
KQ 4 (horizon scan of ongoing studies):
1. Study design
2. PCMH components
3. Settings (e.g., practice size, geographic location)
4. Financial models
5. Outcomes assessed (if reported):
a. Patient experiences
b. Staff experiences
c. Process of care
d. Clinical outcomes
e. Economic outcomes
No outcomes of interest reported.
7
Table A. Inclusion/exclusion criteria (continued)

Timing Studies had to have at least 6 months longitudinal
followup.
Less than 6 months longitudinal
followup.
Setting Primary care settings, for example family medicine,
general internal medicine, primary care pediatrics,
general medical clinics such as Federally Qualified
Health Centers, general medical clinics primarily staffed
by midlevel providers, general practices/practitioners,
geriatric practices providing longitudinal care rather than
consultative services.
KQ 1–3: Studies conducted in a high-income economya as
defined by the World Bank.
KQ 4: Studies underway in the United States.b
• Geriatric practices providing
consultative services.
• Medical subspecialties.
Study design KQ 1, KQ 4: Patient or cluster RCT,
nonrandomized
clustered controlled trial, controlled before-and-after
study.
KQ 2, KQ 3: Patient or cluster RCT, nonrandomized
clustered controlled trial, controlled before-and-after
study, uncontrolled pre- and postintervention study.
Not a clinical study (e.g., editorial,
nonsystematic review, letter to the

editor, case series).
Publications KQs 1–4: English-language only.c
KQs 1–3:
Publication date from database inception to present.
Peer-reviewed article.
KQ 4: Studies had to be ongoing or scheduled to be
completed on or after April 2010.d
• Non-English-language publication.c
• Not peer reviewed (e.g., letter to
editor).
aWe restricted studies for KQs 1–3 to high-income economies—
i.e., to countries that have greater cultural and health care
system
similarities to the United States—to improve applicability of the
study results to the United States.
bKQ 4 studies were restricted to those conducted in the United
States to maximize applicability to our target audience and
because our
knowledge of gray literature sources is good within the United
States but poor outside it.
cWe excluded non-English-language publications for two
reasons: (a) we are most interested in health care systems that
are similar
to U.S. health care, and reports from these countries are likely
to be published in English; and (b) it is the opinion of the
investigators
that the resources required for translation of non-English
articles would not be justified by the low potential likelihood of

identifying
relevant data unavailable from English-language sources.
dOur rationale was that studies completed prior to April 2010
should already have been published.
AHRQ = Agency for Healthcare Research and Quality; HRSA =
Health Resources and Services Administration;
KQ = Key Question; PCMH = patient-centered medical home;
RCT = randomized controlled trial
8
3. Data Extraction and Quality Assessment. The
investigative team created forms for abstracting the
data elements for the KQs. Based on clinical and
methodological expertise, a pair of researchers was
assigned to abstract data from the eligible articles.
One researcher abstracted the data, and the second
reviewed the completed abstraction form alongside the
original article to check for accuracy and completeness.
Disagreements were resolved by consensus or by
obtaining a third reviewer’s opinion if the first two
investigators could not reach consensus.
To aid in both reproducibility and standardization of
data collection, researchers received data abstraction
instructions directly on each form. Forms were created
specifically for this project using the DistillerSR data
synthesis software program (Evidence Partners Inc.,
Manotick, ON, Canada). The abstraction form templates
were pilot tested with a sample of included articles to
ensure that all relevant data elements were captured and
that there were consistency and reproducibility across

abstractors. Data abstraction forms for KQs 1–3 included
descriptions of the study design, study population,
interventions and comparators, financial models,
implementation methods, study outcomes, and study
quality. Outcomes of interest included patient experiences,
staff experiences, process of care, clinical outcomes,
and economic outcomes. For KQ 4, we developed a less
detailed data abstraction form that included basic study
design; geographic location; study setting, including
health care system; number of practices/physicians;
payment reform/financial model; major components of the
intervention/PCMH model; comparator; types of outcomes
being assessed; study dates; and source of funding.
We assessed the quality/risk of bias of studies included
for KQ 1 based on their reporting of relevant data. We
evaluated the quality of individual studies using the
approach described in AHRQ’s Methods Guide for
Effectiveness and Comparative Effectiveness Reviews.32
To assess quality, we (1) classified the study design,
(2) applied predefined criteria for quality and critical
appraisal, and (3) arrived at a summary judgment of the
study’s quality. To evaluate methodological quality, we
applied criteria for each study type derived from core
elements described in the Methods Guide. To indicate the
summary judgment of the quality of the individual studies,
we used the summary ratings of good, fair, and poor,
based on the studies’ adherence to well-accepted standard
methodologies and the adequacy of the reporting. For
each study, one investigator assigned a summary quality
rating, which was then reviewed by a second investigator;
disagreements were resolved by consensus or by a third
investigator if agreement could not be reached.
The strength of evidence for the highest priority outcomes
in KQ 1 was assessed using the approach described in

AHRQ’s Methods Guide.32,33 In brief, the Methods
Guide recommends assessment of four domains: risk of
bias, consistency, directness, and precision. Additional
domains, to be used when appropriate, are coherence,
dose-response association, impact of plausible residual
confounders, strength of association (magnitude of effect),
and publication bias. These domains were considered
qualitatively, and a summary rating was assigned, after
discussion by two reviewers, as “high,” “moderate,” or
“low” strength of evidence. In some cases, high, moderate,
or low ratings were impossible or imprudent to make—for
example, when no evidence was available or when evidence
on the outcome was too weak, sparse, or inconsistent to
permit any conclusion to be drawn. In these situations, a
grade of “insufficient” was assigned. This four-level rating
scale consists of the following definitions:
• High: High confidence that the evidence reflects the true
effect. Further research is very unlikely to change our
confidence in the estimate of effect.
• Moderate: Moderate confidence that the evidence
reflects the true effect. Further research may change our
confidence in the estimate of effect and may change the
estimate.
• Low: Low confidence that the evidence reflects the
true effect. Further research is likely to change the
confidence in the estimate of effect and is likely to
change the estimate.
• Insufficient: Evidence either is unavailable or does not
permit estimation of an effect.
We did not rate the strength of evidence for KQs 2–4
because these questions were purely descriptive.

4. Data Synthesis and Analysis. We summarized key
features of the included studies by KQ. For published
studies, we created an overview table of basic study
characteristics, an intervention table giving details of the
intervention, and a summary table of implementation
strategies. Studies were categorized into those that
explicitly tested the PCMH model and those that met
our functional definition for PCMH but did not use
the terms “PCMH” or “medical home.” (The latter are
referred to as “functional PCMH” studies in the report.)
Studies were evaluated initially in aggregate, and then
by PCMH versus functional PCMH studies and adult
versus pediatric studies. For KQ 1, we used a random-
effects model to compute summary estimates of effect
for hospitalizations and emergency department visits
for the subset of studies using randomized controlled
trial (RCT) designs. Summary estimates were calculated
9
using Comprehensive Meta-Analysis software and are
reported as summary risk ratios.34 For other outcomes,
the study populations, designs, and outcomes were
too variable for quantitative analysis, and results were
accordingly synthesized qualitatively. Because the
continuous measures used for most outcomes reported
varied greatly across studies, we computed effect
sizes, represented as the standardized mean difference
(SMD), to aid interpretation. The SMD is useful
when studies assess the same outcome with different
measures or scales. In this circumstance, it is necessary
to standardize the results for the studies to a uniform
scale to facilitate comparisons. We calculated the SMD

for each study, using Hedges’ g, by subtracting (at post-
test) the average score of the control group from the
average score of the experimental group and dividing
the result by the pooled standard deviations (SDs) of the
experimental and control groups. To aid interpretation,
we standardized presentation such that beneficial
effects for the medical home are presented as positive
effect sizes. We planned to use cross-case analyses to
evaluate the association between independent variables
(e.g., specific components of comprehensive PCMH)
and study effect, using methods based on Miles and
Huberman.35 However, there were too few studies
and too little variability to complete this exploratory
analysis.
Results
Results of Literature Searches
Figure B depicts the flow of articles through the literature
search and screening process.
We identified 5,086 citations. After inclusion/exclusion
criteria were applied at the title and abstract level, 695
full-text articles were retrieved and screened. Of these,
610 were excluded at the full-text screening stage, leaving
85 articles (representing 58 unique studies) for data
abstraction. We included 27 studies from the published
peer-reviewed literature (17 were comparative and 10
descriptive) and 31 ongoing studies identified from the
horizon scan.
10

Figure B. Literature flow diagram
aAll studies/articles included for KQ 1 were also included for
KQs 2 and 3.
KQ = Key Question; PCMH = patient-centered medical home
11
KQ 1. Effects of PCMH Interventions
Only 6 studies explicitly evaluated PCMH; an additional 11
studies evaluated functional PCMH interventions. Studies
included both observational designs (n = 9) and RCTs (n =
8). Older adults in the United States with multiple chronic
conditions were the most commonly studied population
(8 of the 17 studies). Most studies were conducted in
integrated health care systems (10 of 17 studies). Studies
varied widely in the range of outcomes reported and the
specific measures used. With the exception of one study,
which examined facilitated versus nonfacilitated PCMH
implementation, all studies compared interventions
meeting the definition of PCMH to usual care.
Table B summarizes the findings and strength of evidence
(SOE) for each major outcome. The SOE is a summary
rating of the confidence in the estimate of effect for each
outcome that incorporates evidence across all relevant
studies. Rating the SOE for this body of evidence
was challenging because the range of study designs,
populations, and outcomes precluded quantitative
summaries for most outcomes. We thus did not have the

usual quantitative tools that are part of meta-analyses for
assessing consistency and precision. In brief, there was
moderately strong evidence that the medical home has a
small positive impact on patient experiences and small to
moderate positive effects on preventive care services. Staff
experiences were also improved by a small to moderate
degree (low SOE), but no study reported effects on staff
retention. Current evidence is insufficient to determine
effects on clinical and most economic outcomes. Given the
relatively small number of studies directly evaluating the
medical home and the evolving approaches to designing
and implementing the medical home model, these findings
should be considered preliminary.
Table B. Summary of the strength of evidence for KQ 1
Outcome [SOE
& Magnitude of
Effecta,b,c]
Number
of Studies
(Subjects)
SOE Domain–
Risk of Bias:
Study Design/
Quality
SOE
Domain–
Consistency

SOE
Domain–
Directness
SOE
Domain–
Precision
Effect Estimate
(Range or
95% CI)
Patient Experiences
[Moderate SOE: small
positive effects]
5 (6,884) RCT/Fair Consistent Direct Precise ES median
(range):
0.27 (-0.36 to 0.42)
2 (3,513) Observational/
Fair
Inconsistent Direct Precise ES:d +0.13
Staff Experiences
[Low SOE: small to
moderate positive
effects]
2 (NR) RCT/Fair Inconsistent Some
indirectness

Imprecise ES median (range):
0.18 (0.14 to 0.87)
1 (82) Observational/
Fair
Unknown Direct Imprecise ES median (range):
0.49 (0.32 to 0.61)
Process of Care for
Preventive Services
[Moderate SOE: small
to moderate positive
effects]
3 (8,377) RCT/Fair Consistent Direct Precise RD median
(range):
1.3% (-0.4% to
+7.7%)
Fair
Consistent Direct Precise RD median (range):
14.2% (5.6% to
20.6%)
Process of Care for
Chronic Illness Care
Services
[Insufficient]
2 (4,640) RCT/Fair Inconsistent Some

indirectness
Precise RD median (range):
6.6% (0.2% to
20.8%)
Fair
Seriously
inconsistent
Some
indirectness
Precise RD median (range):
7.1% (7.1% to
21.4%)
Clinical Outcomes:
Biophysical Markers,
Health Status, Mortality
[Insufficient]
3 (2,586) RCT/Good Consistent Some
indirectness
Imprecise Not reliably
estimated
Poor
Consistent Some
indirectness

Imprecise Not reliably
estimated
12
Table B. Summary of the strength of evidence for KQ 1
(continued)
Outcome [SOE
& Magnitude of
Effecta,b,c]
Number
of Studies
(Subjects)
SOE Domain–
Risk of Bias:
Study Design/
Quality
SOE
Domain–
Consistency
SOE
Domain–
Directness

SOE
Domain–
Precision
Effect Estimate
(Range or
95% CI)
Economic Outcomes:
Hospital Inpatient
Admissions, ED Visits,
Total Costse
[Low SOE for lower
ED visits in older adults
and no reduction in
admissions; insufficient
for total costs in adults;
insufficient for all
economic outcomes in
children]
5 (8,001) RCT/Fair Consistent Some
indirectness
Imprecision Admissions: RR 0.96
(95% CI, 0.84 to
1.10) in adults;
ED visits: RR 0.81
(95% CI, 0.67 to
0.98) in adults;
total costs: no
summary estimate

Fair
Consistent Direct Precise Admissions: RD
median (range):
-0.2% (1.4% to
-8.9%);
ED visits: RD
median (range):
-1.2% (3.1% to
-8.3%);
total costs: no
summary estimate
Unintended
Consequences or Other
Harms
[Insufficient]
0 NA NA NA NA No estimate
aSOE ratings are provided for outcomes overall (incorporating
evidence from all studies), while magnitude-of-effect estimates
are
provided for RCTs vs. observational studies. The effect size for
economic outcomes represents a summary estimate of effect
from
meta-analysis. Other effect sizes are presented as the range
across individual studies.
bIn one study, a program of facilitated PCMH (intervention)
was compared with providing practices with information on
PCMH but
not facilitating the implementation (control). This study

generally showed no differences on the key outcomes addressed.
Both arms
implemented components of the PCMH model, and this may be
why there were no significant differences between them.
cThe small number of studies conducted among children
precluded formal comparison with studies conducted in adults.
However,
results in these two populations were generally congruent.
dThe effect size for one of the two available observational
studies could not be calculated with available information. As a
result, an
effect size median and range could not be calculated.
eTwo of the 13 studies that reported economic outcomes—1
RCT and 1 observational study—reported only total costs and so
did not
inform the summary effect estimates reported in this table.
CI = confidence interval; ED = emergency department; ES =
effect size; KQ = Key Question; NA = not applicable; NR = not
reported;
RCT = randomized controlled trial; RD = risk difference; RR =
risk ratio; SMD = standardized mean difference; SOE = strength
of
evidence
For KQ 1a, there were too few studies in each outcome domain
that also had appropriate variation in PCMH elements to
conduct a planned qualitative analysis. As a result, we
concluded that there is insufficient evidence to evaluate whether
specific PCMH components are associated with greater effects
on patient and staff experiences, process of care, clinical
outcomes, and economic outcomes. For KQ 1b, no study
reported unintended consequences; therefore, we concluded that
the effects of PCMH on unintended consequences or other
harms are uncertain.

KQs 2–4
13
We included 27 studies of PCMH or functional PCMH
that described the intervention components and the
financial models and implementation strategies used
to support uptake. These studies included comparative
and descriptive designs. Most studies were conducted in
older adults or children with special health care needs.
In addition, we identified 31 ongoing studies that are
evaluating the medical home. These studies are being
carried out in all major regions of the United States,
and the majority are being fielded with participation
by a commercial insurer. Only two of these studies are
RCTs. Compared with the published literature, more of
these studies plan comparisons across different levels of
PCMH implementation. Because we limited inclusion to
comparative studies and study descriptions were often
incomplete, we believe the number of studies reporting the
impact of PCMH in the next few years will exceed the list
cataloged in this horizon scan. Table C summarizes these
findings.
Table C. Summary of findings for KQs 2–4
KQ 2—PCMH Components Implemented
Variability in components: Although most studies reported
implementing most of the 7 major medical home domains,
studies
varied considerably in their approach to implementing major
components (e.g., variable approaches to enhancing access to

care).
Evaluation of specialty care: Few medical home studies directly
address medical specialty care (n = 6) or mental health specialty
care (n = 3).
KQ 3—Financial Models and Implementation Strategies
Financial models: Few medical home studies (n = 11) provided
detailed information about the financial models used to support
the
medical home. Financial models described included enhanced
fee-for-service, additional per-member per-month payments,
stipends
to support aspects of the intervention, and payments linked to
quality and efficiency targets.
Organizational implementation strategies: Audit and feedback
were the most commonly used specific strategies to implement
the
medical home, described in 13 studies.
Organizational learning strategies: Learning collaboratives and
collaborative program planning were the most commonly used
organizational learning strategies, described in 19 studies.
KQ 4—Horizon Scan of Ongoing PCMH Studies
Ongoing studies: A relatively large number of studies
evaluating the medical home are scheduled to conclude within
the next 2
years. However, only 2 of the 31 studies are RCTs. Most studies
report planned outcomes of patient or staff experiences,
process-of-
care outcomes, and economic outcomes. These studies appear to
have the potential for improving our understanding and the

strength
of evidence for a range of important outcomes.
KQ = Key Question; PCMH = patient-centered medical home;
RCT = randomized controlled trial
14
Discussion
Summary of Findings
In summary, our review found moderately strong evidence
that PCMH improves patient experiences and preventive
care services. For staff experience, the evidence was less
robust but suggests benefit. We judged the SOE as low
for an association between PCMH and lower health care
use (combination of inpatient and primarily emergency
department use), but estimated effects were imprecise.
Further, we did not find evidence of an effect of PCMH
on total costs. These findings do not exclude an economic
benefit of PCMH, and in fact, current studies are likely
underpowered for this outcome.36 Overall, these findings
are encouraging and build on prior reviews showing that
CCM-based interventions that focus on single conditions
have improved health outcomes across a range of chronic
conditions, including congestive heart failure, diabetes
mellitus, asthma, and major depression.17,37,38
Our review identified important gaps in currently available
evidence on the effects of PCMH. Most studies evaluated
effects in older adults with multiple chronic illnesses;
few studies were conducted in pediatric or general adult
primary care populations. Effects on quality indicators for

chronic illness care and on clinical outcomes are uncertain.
These are among the most important outcomes to patients,
clinicians, and policymakers. Individuals with chronic
medical illness consume the most health care resources,
and this is a particularly important set of outcomes for
this group. Other gaps in evidence include the absence of
data on staff retention and unintended consequences. If the
improvements in staff experiences translate into improved
staff retention and greater attractiveness of primary care
practice, then PCMH will have met one of its goals. The
potential for unanticipated consequences has not received
much attention in the literature and was not evaluated
in any of our included studies. Because PCMH requires
substantial change for primary care practices, unanticipated
consequences, such as increased provider burden (e.g.,
enhanced access through 24/7 coverage and email) and
potential patient safety risks (e.g., patients using email
for emergent medical issues), are possible and should be
examined.
Given inclusion criteria that allowed for a relatively broad
set of interventions, it is not surprising that there was wide
variability in the approaches to implementing the various
components of PCMH. Interventions explicitly developed
from the PCMH model used more approaches than those
simply meeting our operational definition of “functional
PCMH.” More robust implementation of the model
and/or specific strategies to address a particular model
component may be associated with greater benefit, but
there were too few studies to conduct even an exploratory
analysis to test this hypothesis. As the evidence base
expands, these analyses will be important to clarify the
key approaches and could provide information for efficient
implementation and certifying agencies’ criteria for
medical home practices. In addition to the need to identify

the key approaches, practices and policymakers need better
information on the financial context and implementation
strategies needed for successful spread and sustainability of
the PCMH model. Fewer than half of the studies included
in this report described any new payment model, such as
enhanced fee-for-service or additional per-member per-
month payments to PCMH practices. Further, there was
an absence of data on direct financial consequences to
the practice of implementing PCMH. This information,
possibly gained through the mechanism of detailed case
studies, could inform implementation efforts and the
design of enhanced payment mechanisms for medical home
practices.
Finally, our horizon scan identified ongoing studies with
specified comparator groups that, when published, should
more than double the size of the published literature. In
contrast to the majority of studies included in our review,
all of these studies describe explicit plans to test the
medical home, and most are being conducted with the
participation of a commercial insurer. These studies have
the potential to add substantially to our knowledge about
the medical home, particularly if some of the evaluations
can be tailored to address the gaps in evidence identified by
our report.
Limitations of the Review Process
The PCMH is a model of care with considerable flexibility,
not a narrowly defined intervention or manualized
protocol. Further, multiple definitions of the PCMH model
have been proposed by various professional and patient
organizations.22 We developed an operational definition—
derived from the AHRQ definition of the medical home,8
which does not require an enhanced payment model—to
identify eligible interventions. Because we used the AHRQ

definition, our review was more inclusive of studies that
tested the critical principles that embody the IOM concept
of patient-centered care.29 However, greater inclusivity
came with the trade-off of greater variability in study
interventions. Heterogeneity in study designs, populations,
and outcomes meant that standard quantitative summary
methods were generally not possible. The general nature
of the intervention also complicated our literature search,
given the potential for relevant studies that did not use the
term “medical home” and the lack of MeSH terms for this
topic. Finally, no standard nomenclature or measures exist
15
for many of the concepts that form part of the definition.
The lack of a standard nomenclature and the often sparse
reporting of interventions made uniform data abstraction
and classification of intervention components particularly
challenging.
Implications for Future Research
The horizon scan conducted for this review identified 31
ongoing PCMH studies that are broadly representative
of the U.S. health care system, both in geography and in
the complexity of private and public health care payers
and delivery networks. Many of these studies are being
done in cooperation with payer organizations, and most
are expected to be completed in the next 2 years. As a
result, the evidence base related to PCMH will soon be
greatly expanded. We encourage investigators to report
the interventions in detail, adjust for clustering when
appropriate, report meaningful quality indicators for
chronic illness (both processes and clinical outcomes),

and provide data related to the impact of PCMH on staff.
If researchers clearly link intervention components to the
core components of PCMH, this could greatly improve our
understanding of the conceptual basis for interventions
tested and, ultimately, the key features of successful
models. Finally, we encourage long-term followup of
results. Outcomes examined in this report rarely had
followup periods longer than 2 years. In addition to
addressing the impact of PCMH on specific outcomes,
we encourage the expanded use of both quantitative and
qualitative methods to address the processes used to
implement the PCMH model.
Although ongoing studies have the potential to fill
important gaps, the lack of detail contained in published
research plans generates uncertainty about how well these
studies will address these gaps. We therefore describe a
series of research priorities in this report.
Missing Outcomes
The strength of evidence was judged to be low or
insufficient for most outcomes. Studies that address
quality indicators for chronic illness care and clinical
outcomes (e.g., symptom status or functional status)
are urgently needed. Because PCMH is oriented toward
broad populations of patients and not focused on specific
illnesses, the impact on chronic illness could be attenuated.
Studies assessing staff retention and the impact of PCMH
on practice costs or patient out-of-pocket costs would
provide an important new perspective on economic
outcomes. Evaluators should also carefully consider
the outcomes most relevant to the population studied,
particularly considering differences in the emphasis of the
medical home and relevant outcomes for pediatric versus

adult populations.39
Most Important PCMH Components
We were unable to determine the PCMH components
most associated with benefit. Understanding the “active
ingredients” of PCMH is important to help practices with
limited resources realize the greatest return on investment
and to assist organizations developing certifying standards
for medical home practices. Observational studies from
natural experiments comparing differing levels of PCMH
and different approaches to PCMH could address this
gap. In addition, as the evidence base grows, an updated
systematic review could be valuable. For this latter
approach to succeed, studies will need to report the
details of the PCMH intervention and, ideally, use a more
consistent set of outcome measures and nomenclature for
PCMH components and measures of PCMH components.
Most Effective Implementation Approaches
PCMH is a complex intervention that requires substantial
changes to most practices. Understanding the level of
support needed to implement and sustain the model,
including the necessary financial context, is critical to
any long-term success. Our horizon scan identified a
number of studies that planned formative evaluations to
identify factors associated with successful implementation.
Additional studies that examine long-term sustainability
are needed.
Effects of PCMH in More Representative Populations
Most PCMH studies were conducted in older adults with
multiple chronic health conditions or in children with
special health care needs. Studies that examine the effects

in more broadly representative primary care samples
are needed to fully understand the impact of this care
model. Because PCMH has the potential to reduce heath
disparities, evaluating effects in important subgroups (e.g.,
the socioeconomically disadvantaged) is important.
Conclusions
The PCMH model is a conceptually sound approach to
organizing patient care and appears to hold promise,
especially for improving the experiences of patients and
staff involved in the health care system. Evidence points to
the possibility of improved care processes. If ongoing and
future studies indicate that these improvements translate
into improved clinical outcomes or economic benefit, the
health care value would be increased.
16
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Full Report
This executive summary is part of the following document:
Williams JW, Jackson GL, Powers BJ, Chatterjee R, Prvu
Bettger J, Kemper AR, Hasselblad V, Dolor RJ, Irvine
RJ, Heidenfelder BL, Kendrick AS, Gray R. The Patient-
Centered Medical Home. Closing the Quality Gap:
Revisiting the State of the Science. Evidence Report/
Technology Assessment No. 208. (Prepared by the Duke
Evidence-based Practice Center under Contract No.
290-2007-10066-I.) AHRQ Publication No. 12-E008-
EF. Rockville, MD. Agency for Healthcare Research and
Quality. July 2012. www.effectivehealthcare.ahrq.gov/
reports/final.cfm.
For More Copies
For more copies of The Patient-Centered Medical
Home. Closing the Quality Gap: Revisiting the State of
the Science: Evidence Report/Technology Assessment
Executive Summary No. 208 (AHRQ Publication No. 12-
E008-1), please call the AHRQ Publications Clearinghouse
at 800–358–9295 or email [email protected]

AHRQ Pub. No. 12-E008-1
July 2012
Running Head: INTERNAL AND EXTERNAL STAKEHOLDER
1
INTERNAL AND EXTERNAL STAKEHOLDERS
5
Internal and External Stakeholders
Student’s Name
University Affiliation
Internal and External Stakeholders
1. Identify the Internal and External Stakeholders.
Internal stakeholders in this issue are individuals within the
criminal justice system who directly contribute to this issue
(Baugh, 2015). They include police officers, correctional
officers, probation officers, parole officer, judges as well as
inmates. The external stakeholders include the government and
society in general. They are the individuals who do not make up
the criminal justice system but in one way or another affect it
(Baugh, 2015).
2. Discuss how internal or external stakeholders have
influenced the situation in a positive or negative way?

The influence of the external stakeholders on this issue is
mostly negative. The government, on one hand, has negatively
influenced this issue by allowing it to go on for so long and
even to grow in two main ways. The first way is through lack of
proper policy formulation and implementation. The government
is in charge of running the prisons and the overall criminal
justice system. They have failed in terms of not having good
enough policies in place that can first and foremost reduce the
level of delinquency in our society and consequently the number
of offenders and also policies to help solve the issue of
overcrowding given the fact that this is an issue that has
persisted on for such a long time. Government efforts have
obviously not been successful in bringing the number of
offenders down and also reducing the level of overcrowding and
this is a major reason why this problem has really persisted on
(Dandurand & Griffiths, 2006). The government has also failed
in terms of funding since they have not been able to adequately
fund the prisons to meet the needs of the big population of
inmates or build more prison facilities to accommodate the
growing numbers.
The society, on the other hand, has influenced this issue
negatively in the simple sense that offenders come from the
society. The level of moral degradation in the society is the
source of this negative influence alongside the lack of proper
values, systems and role models among other social issues. This
has seen more and more individuals get into crime and as a
result, there are large numbers of offenders being arrested who
end up overcrowding the prisons.
The influence of the internal stakeholders is both negative and
positive. Some internal stakeholders such as parole officers and
probation officers have contributed positively. This is because
there are a lot of efforts from the parole and probation
department to give alternative sentences for prisoners who have
shown positive changes by allowing them to serve in parole in
probation and consequently easing the population in the prisons
(Dandurand & Griffiths, 2006). Courts, however, have had a

negative influence because they sometimes give unreasonably
long sentences. Correction officers in the prisons have further
had a negative influence in the sense that they have failed to
effectively impart positive behaviour change among inmates
whether it’s their fault or the fault of the system and therefore
individuals persist being prisons for long. Most inmates in the
same sense go to prison and start engaging in bad activities
which keep them in prison longer by denying them a chance to
parole or probation. Police officers finally influence this
problem negatively by engaging in unfair arrest acts for
example against the minority and hence filling up prisons with
individuals who should not be there in the first place. 3. How
will you consider stakeholders in your solution to the problem?
From the above discussion, this problem is obviously not the
doing of only one party. Each of the stakeholders mentioned
above influences this issue in one way or another. In making
consideration of the stakeholders in the solution to the problem,
it is important to first be aware of the role that each of these
stakeholders plays in bringing forth this problem. This is
important to help understand how each of these parties will
contribute to the solution. This is because the solution cannot
be holistic unless there is buy-in from each of these
stakeholders. The solution to this problem requires a collective
effort. Beyond even considering the role that each of these
stakeholders, I will also consider their input. To be able to
develop a comprehensive solution, it is important to listen to
the different perspectives around the issue for one to fully
understand the different factors that come to play in regards to
this issue. It is therefore important to consider the input of the
stakeholders in the solution to avoid bias in the solution that
one develops.
4. How will you motivate individuals to buy into your
solution?
The first way to motivate individuals to buy into the solution is
finding a way to engage them in coming up with the solution.
Engaging individuals even in the smallest of ways in developing

the solution will help them develop a sense of ownership of the
solution and therefore making it a lot easier for them to buy into
it (Baugh, 2015). When they feel like they were part of
developing it, they will most likely also want to be part of
implementing it. The second way to motivate individuals to buy
into the solution is by showing them the value in the solution
(Freeman, 2014). The value in the solution, in this case, would
mean demonstrating to them how effective the solution will be
in solving the problem. Prison overcrowding is a problem whose
impact people already know and one which they already know
they need a solution to. Bringing to the table a solution that
gives them hope that the problem can be resolved will lead them
to easily buying into the solution.
References
Baugh, A. (2015). Stakeholder engagement: the game changer
for program management. Boca Raton, FL: CRC Press.
Dandurand, Y. & Griffiths, C. (2006). Handbook on restorative
justice programmes. New York Vienna: United Nations United
Nations Office on Drugs and Crime.
Freeman, R. (2014). Strategic management: a stakeholder
approach. Boston: Pitman.
Running head: ASSIGNMENT 3: TECHNOLOGY
INFLUENCES
1
ASSIGNMENT 3: TECHNOLOGY INFLUENCES

4
Assignment 3: Technology Influences
Student’s name
University affiliation
Assignment 3: Technology Influences
1. Discuss how technologies or information systems have
contributed to the problem.
The advancement and increased use of technology and
information systems have contributed to the problem of
overcrowding of prisons and correction centers in different
ways. First, technologies have improved the security
surveillance systems which are used to gather evidence related
to crime in most urban centers. For example, the use of
surveillance systems and detectors has made it easier for
investigators to identify pieces of evidence which have been
used to pass judgment on offenders (Carlen, & Morgan, 2016).
Besides this, technology has also made it efficient for the police
to capture prisoners. It is now easier for someone to be
imprisoned since the investigation and arrest time is reduced
and evidence can easily be retrieved.
Second, technology has contributed to an increase in the rate of
crime in different walks of life i.e. technology-based crime. The
introduction of technology has brought new avenues which are
used by criminals to commit criminal acts. For example, a
platform such as social media has led to crimes such as cyber-
terrorism and fraud which are serious offenses (Bagaric, Hunter,
& Wolf, 2018). As such, the criminal justice system has been
forced to include laws and statutes which ensure that there is a
fair and just procedure to pass judgment on technology-based
criminals. Due to the seriousness of some of these crimes, the
criminal justice system is forced to sentence serious offenders
to imprisonment. The increase of technology-based criminals
has therefore contributed to the overcrowding of prisons and

correctional centers.
Third, some of the technology and information systems are very
new to the United States population and the United States laws.
Without enough guidance, people have committed crimes
related to technology unconsciously. Besides this, people may
use technology without understanding the full impact of their
actions which may be linked with certain prohibited actions.
Due to this many people end up in correctional centers where
they will be rehabilitated before they can be allowed to join the
civil public.
2. Discuss how you will propose technology be implemented
into the solution.
Even though technology has contributed to the challenge of
overcrowding in prisons and correctional centers, it can be
utilized to be part of the solution. One way technology can be
implemented to reducing overcrowding in prisons and
correctional centers are by using it to improve the quality of
information about criminal behavior. Technology can make it
easier for police officers to study crime in order to formulate
better strategies to reduce it, thereby reducing the rate of
imprisonment. For example, studying the behaviors of offenders
such as the rate of re-offenders can help in devising better
rehabilitation programs for first-time offenders. Besides this,
technology can be used to improve the utilization of data and
information in reducing crime rates.
Another solution is that technology has improved the
rehabilitation of offenders by improving how options such as
probation and parole can be utilized to replace incarceration.
Through technology, officers and probation officials have found
a better method to monitor the behaviors of offenders in order
to ensure that they are on the right (Raphael, & Stoll, 2009).
For example, the probation can use global positioning system

(GPS) and radio frequency (RF) to ensure that convicts are
where they claim to be.
References
Bagaric, M., Hunter, D., & Wolf, G. (2018). Technological
incarceration and the end of the prison crisis. J. Crim. L. &
Criminology, 108, 73.
Carlen, P., & Morgan, R. (Eds.). (2016). Crime Unlimited?
Questions for the Twenty-First Century. Springer.
Raphael, S., & Stoll, M. (2009). Why Are So Many Americans
in Prison? In S. Raphael and M. Stoll (Eds.), Do Prisons Make
Us Safer? The Benefits and Costs of the Prison Boom (pp. 27-
72). New York: Russell Sage Foundation.
Running Head: IDENTIFYING THE CHALLENGE
1
IDENTIFYING THE CHALLENGE
2
Identifying the Challenge
Student’s Name
University Affiliation
Identifying the ChallengeIntroduction
The area chosen for this final project is prisons/corrections.
Inmates in prisons are in the receiving end of a lot of problems

and challenges. This paper, however, will focus on one of the
most common and popular problems in prisons and that is the
overcrowding of prisons and correction centres.
Outline the context of the problem or challenge, including the
history and any policy decisions that have contributed to the
situation.
The prison system in the country is the most overpopulated in
the globe. According to the Bureau of Justice Statistics, there
are about 2.2 million individuals behind bars in the United
States (Enns, 2018). To put this in a more understandable
context it means that 655 individuals out of a group of every
100000 individuals are behind bars (Enns, 2018). The problem,
however, has not been the fact that too many people are
incarcerated but it is the fact that too many people are
incarcerated without enough resources and capacity to handle
the numbers. Most prisons in the country are forced to operate
way above 100% capacity.
This is a problem that arose in the 19th century. This is because
in the 18th-century jails only served the purpose of holding
individuals temporarily before they were taken to trial. During
this period, punishment was in the form of corporal as well as
capital punishment (Morris & Rothman, 2008). However, people
started becoming uncomfortable with this form of punishment
and hence started seeking alternatives. This led to the
introduction of the prison system first in West Jersey and
Quakers. This problem did not arise as a result of policy but
rather as a result of the population boom that took place in the
19th century as the mortality rate of individuals lowered and
immigration became high (Morris & Rothman, 2008). With 4
decades the population of the country had doubled and this
resulted in more strain on the resources, decency as well as
infrastructure in the prison system. This led to overcrowding
and ineffectiveness of the system ever since.
Why is it important that the problem be addressed?
The one main reason why this problem needs to be solved is to
help ease the financial strain that it is causing to our

government at to the taxpayers. Maintaining so many people in
the prisons is costing our government so much money and the
problem is passed down to the taxpayers (Travis, Western &
Redburn, 2014). Easing this tension would be important as it
would also ensure that the money is put to more productive
uses. It is also important to address this problem because it
makes the correction system ineffective as it becomes hard for
it to serve its purpose and denies inmates of basic rights while
in prison.
Who is impacted internally and externally?
From the description above, it is easy to see the parties that are
impacted by this problem. Internally, this problem affects the
inmates in they lack the resources and infrastructure they need
and the result of this is high gang activities, violence, disease
spread rates, mental health problems and violence (Enns, 2018).
The problem also affects the prison staff by causing work stress
since they are understaffed. Externally this affects the society in
general since more burden is imposed on them as taxpayers and
the fact that the ineffective system does very little to enhance
safety and security. The government is also impacted since more
resources are demanded from it.
Why do you feel the problem hasn’t already been solved?
Over time a lot of effort has been to try and resolve this
problem, especially in the recent past. However, the reason why
the problem has not been solved yet is because this is a problem
that has built up over time and therefore it will also take a long
time to completely solve it. This is a problem that has persisted
over decades and centuries and therefore one would not expect
efforts put over a few years to correct the whole issue.
References
Enns, P. (2016). Incarceration nation: how the United States
became the most punitive democracy in the world. New York
NY: Cambridge University Press.
Morris, N. & Rothman, D. (2008). The Oxford history of the

prison: the practice of punishment in western society. New
York: Oxford University Press.
Travis, J., Western, B. & Redburn, S. (2014). The growth of
incarceration in the United States: exploring causes and
consequences. Washington, District of Columbia: National
Academies Press.

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