May 2005 Table of Contents

The New Model of Family Medicine: What's In It for You



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Team-based, proactive care supported by effective office systems, technology and a culture of improvement will help your patients and your bottom line.

Fam Pract Manag. 2005 May;12(5):59-63.

After nearly two years and a lot of research, the Future of Family Medicine project undertaken by the AAFP and other family medicine organizations is complete. One of its primary objectives was “to recommend changes to the discipline so that family medicine can better meet the health care needs of patients in a changing environment.” In March 2004, the project leadership team reported the need for sweeping change in medical education, residency training and practice organization.1 It also proposed a “New Model” of practice for family medicine, which includes the following characteristics:

  • A personal medical home for each patient,

  • Patient-centered care,

  • A team approach to care,

  • Elimination of barriers to care,

  • Advanced information systems, including integrated electronic health records (EHRs),

  • Redesigned, functional offices,

  • Whole-person orientation,

  • Care provided within a community context,

  • Emphasis on quality and safety,

  • Enhanced practice finances (through operating efficiencies and new revenue streams),

  • A commitment to provide family medicine's “basket of services.”

If you are like many family physicians, you may be asking yourself, “What does all this mean for me and my practice?” or “Why should I make changes now, when I can wait and see how things shake out?” If you are struggling with long days, overbooked appointment schedules, difficulty returning phone calls, poor staff morale, or stagnant or shrinking personal income, there may be something in this “new model” for you.

The recent report from Task Force Six of the Future of Family Medicine project shows that family physicians who implement the New Model should be able to increase their income by 26 percent or reduce their work hours by 12 percent and maintain the same salary.2 (See the related article on page 68.) Here's a look at some of the ways you can begin implementing the New Model and help not only your patients but also your bottom line.

KEY POINTS

  • There are now clear patient care and financial incentives associated with implementing the New Model of family medicine outlined in the Future of Family Medicine report.

  • To provide team-based care, practices will need to define individual roles and responsibilities and physicians will need to delegate certain tasks.

  • To maintain a focus on quality, practices will need to develop a “measure-improve-measure” mind-set.

Team care

It is becoming clear that a multidisciplinary, coordinated approach to patient care achieves better results, especially with complex patients. Appropriate distribution and delegation of tasks to trained individuals working together in a coordinated way allows the physician to spend more time on complex decision making. Repetitive or time-consuming tasks, such as diabetes education, care coordination or regulation of routine medications (e.g., warfarin or insulin), need not be done solely by a physician. A team approach requires that you define individual roles and responsibilities and that you follow clear and consistent processes with every patient. Good teamwork reduces many of the workflow delays and bottlenecks that are so common in practice today.

Barriers and solutions. Many offices appear to work as a team, but on closer inspection, there is little attention to the interaction of team members. Brief regular meetings are required to discuss individual roles, responsibilities and hand-offs. All must agree on the transfer of responsibilities and how the team will react in unusual situations or when a team member is out.

Team-based care also requires delegation, which many physicians are reluctant to do. There are many reasons for this, but good training, clear lines of responsibility and accountability are all necessary for the physician to feel comfortable in delegating important tasks.

Developing a reliable clinical team takes time and effort, but the resulting improvements in efficiency and staff morale will be well worth the effort. (For further reading on this subject, see the list.)

FPM READING LIST

The following articles from the FPM archives can be accessed free online.

Team care

Ideas for Optimizing Your Nursing Staff. Weymier RE February 2003:51–52.

A Team Approach to Quality Improvement. Schwarz M Landis SE Rowe J April 1999:25–30.

Planned care

Asthma Days: An Approach to Planned Asthma Care. Elward KS October 2004:43–48.

Making Diabetes Checkups More Fruitful. White B. September 2000:51–52.

Using Flow Sheets to Improve Diabetes Care. White B. June 2000:60–62.

Helping Patients Take Charge of Their Chronic Illnesses. Funnell M. March 2000:47–51.

Building a Patient Registry From the Ground Up. White B. Nov/Dec 1999:43–44.

Information technology

How to Select an Electronic Health Record System Adler KG. February 2005:55–62.

Why It's Time to Purchase an Electronic Health Record System. Adler KG. November/December 2004:43–46.

Office systems

Making Every Minute Count: Tools to Improve Office Efficiency. Willis DR. April 2005:61–66.

Answers to Your Questions About Same-Day Scheduling. Murray M. March 2005:59–64.

Strategies for Better Patient Flow and Cycle Time. Backer LA. June 2002:45–50.

Same-Day Appointments: Exploding the Access Paradigm. Murray M, Tantau C. September 2000:45–50.

Quality improvement

The KISS Principle in Family Practice: Keep It Simple and Systematic. Solberg LI. July/August 2003:63–66.

Putting Measurement Into Practice With a Clinical Instrument Panel. Endsley S. February 2003:43–48.

Starting a Revolution in Office-Based Care. White B. October 2001:29–35.

Improving Chronic Disease Care in the Real World: A Step-by-Step Approach. White B. October 1999:38–43.

Holding the Gains in Quality Improvement. Giovino JM. May 1999:29–32.

Quality Improvement: First Steps. Coleman MT, Endsley S. March 1999:23–26.

Planned care

Much work has gone into developing the planned care model, a set of systems that can help care teams provide consistent, evidence-based care to patients with chronic illnesses or who need preventive care. The planned care model relies on registry systems, which keep track of patients in the practice with a particular disease and allow the care coordinator to make sure necessary lab monitoring, office visits and consultations are completed. It also uses flow sheets and checklists to help team members do and document the care recommended by national guidelines.

Another important feature of the planned care model is creating and maintaining empowered, engaged patients. There are many things the care team can do to get patients to take responsibility for their own care. These include teaching patients about their disease, showing them how to perform self-care and helping them set goals for their health. (To learn more about elements of the planned care model, visit the Improving Chronic Illness Care Web site at http://www.improvingchroniccare.org.)

Most physicians believe they are practicing good medicine and following evidence-based guidelines; however, a national study has suggested that patients receive the recommended care only about 56 percent of the time.3 Using registries, recall systems and care coordination in your office will not only improve the care your patients receive but also improve your revenue in the future. One of the new trends in physician reimbursement is “pay for performance.” The name implies that physicians will be paid more if they get better results. However, the key to achieving better results is not “just trying harder.” Instead, it involves implementing systems and processes within your practice that yield better results. The planned care model will help organize your team's approach to patients with chronic illness and put you in position to take advantage of pay-for-performance bonuses.

Barriers and solutions. There are a number of barriers to effective planned care. First, while paper-based registries can be useful, they are time-consuming to set up, use and maintain. The use of computer-based registries, especially those embedded in a fully integrated EHR, will allow this work to be done much more efficiently in the future. Second, most physician offices do not plan care very well. Practices should assign a portion of one team member's time to care coordination. Third, physicians are often reluctant to embrace planned care because they fear it will take a lot of time, effort and money. In truth, most family physicians have relatively few chronically ill or complex patients within the entire patient panel. Developing an organized approach to the care of these patients will make your practice more efficient and save you time in the long run.

Information technology

Electronic health records will be part of the future practice. The fully integrated EHR will provide support for office workflows, prescription writing, lab ordering and review, visit documentation, and billing and coding. In addition, built-in decision-support and knowledge-management functions will help you access the latest evidence-based clinical guidelines and provide the best care for every patient. You will also be able to enhance communication with patients, colleagues and pharmacies, thereby reducing errors and misunderstanding.

The everyday practice of medicine has increased in complexity to the point that it is difficult to do a good job without the aid of computers. Just remembering potential drug interactions is difficult, especially when multiple medications are involved. Paper-based records are costly to manage, move and store. Legibility is a major patient safety concern with prescriptions and physician orders. Physicians and staff now spend an inordinate amount of time searching for misplaced or missing clinical information. Tests are often repeated because of the frustration of not finding or knowing about the desired results. Finally, as the need for documentation of quality of care indicators becomes important for maximum reimbursement, EHRs can help produce these numbers as a by-product of the care.

Barriers and solutions. While many physicians cite the cost of EHR systems as a major barrier to their implementation, it is these very systems that provide the platform for improved office efficiency, better service and safer care for patients, which lead to stronger practice finances in the long run. In addition, many family physicians fear that they will choose the wrong EHR system or that the implementation plan will fail. They worry that the company may go out of business and they will have no way to retrieve stored information. To deal with these concerns, the AAFP established the Center for Health Information Technology (CHIT); http://www.centerforhit.org. This Web site offers help in evaluating your office's EHR needs and readiness. You can read comments and evaluations about software products from family physicians who currently use them. You will also find strategies that will keep your office going, with high productivity, during EHR implementation.

RESOURCES

AAFP quality Web site

http://www.aafp.org/online/en/home/practicemgt/quality.html

Center for Health Information Technology

http://www.centerforhit.org

Improving Chronic Illness Care

http://www.improvingchroniccare.org

Improve Your Medical Care

http://www.improveyourmedicalcare.org/pages/slide1.html

Institute for Healthcare Improvement

http://www.ihi.org

METRIC program

(Measuring, Evaluating and Translating Research Into Care) http://www.aafp.org/cme/cme-topic/performance-improvement/step-by-step.html

Practice Enhancement Program

http://www.aafp.org/x31033.xml

Redesigned office systems

Office functions and workflow, such as scheduling appointments, managing appointment demand, handling messages, refilling prescriptions, triaging patients and managing referrals, are key areas where office redesign can reduce costs and improve service and satisfaction.

The cumulative inefficiency from poorly designed systems of care contributes to high overhead and, therefore, lower physician income. Conversely, the efficiency of well-designed systems contributes to improved finances. For example, advanced-access (or same-day) scheduling is a system in which practices see patients on the day they call with a problem, rather than scheduling them for a future date. This reduces the amount of work required every day to maintain a large inventory of appointments and cuts down on cancellations, rescheduling, physician “book-outs” and no-show appointments, which all cost money and staff time. Patient satisfaction is also enhanced with advanced-access scheduling and may contribute to positive word-of-mouth marketing or even bonus payments if your health plans have these incentives in place.

Well-designed office systems should follow the principle of continuous flow (that is, moving through a process without stopping until it is complete), which has proven to be more efficient than batch-and-queue processing. Messages, prescription refills or billing slips that stack up on desks throughout the office contribute to delays in service, increase the accounts receivable and likely will increase the need for overtime pay.

Barriers and solutions. Physician training is generally focused on diagnosis and treatment of disease. Unless we have had some training or have a natural gift for understanding systems and process management, we may not realize why things are not working well. There is a natural tendency to blame people, when the root problem is the system in which they work.

To overcome these barriers, learn about process management and effective office systems (see http://www.ihi.org) and implement ideas that make sense to you. In addition, designate someone in your office to take responsibility for each system and to promote change.

Quality improvement

Your practice can improve patient outcomes, staff satisfaction and the bottom line by developing an improvement culture. Everyone in your office needs to have a “measure-improve-measure” mind-set. The office culture must promote responsibility and innovation. Careful analysis of process and task execution leads to ideas about how to do better. As you try new ideas, measurement helps you know whether the change actually led to improvement.

There is increasing pressure from health plans, the Centers for Medicare & Medicaid Services and the public to document the quality of our work. Applying nationally accepted performance measures to your practice will not only help your improvement effort but also position your practice to take advantage of pay-for-performance bonuses in the future. (You can download sample measurement sets for several clinical conditions at http://www.ama-assn.org/ama/pub/category/4837.html.)

Barriers and solutions. Physicians know that clinical “quality” is very hard to measure. We place high value on the interaction with the patient, which is difficult to measure objectively, and we often perceive that good training, good intention and hard work are the only necessary ingredients for quality care. However, while not perfect, practice-assessment tools and performance measures can give you a realistic picture of the care you provide. Only then can you begin to identify and remedy any problems. Quality outcomes are the consequence of a consistent, reliable care strategy.

Many physicians worry that quality improvement will take too much time and add too much complexity to their already complex practices. In reality, the most effective quality improvement efforts are the result of installing simple systems such as flow sheets, checklists or condition-specific protocols. These efforts result in more standardized, organized care.

The AAFP METRIC program (http://www.aafp.org/metric.xml) teaches the basics of quality improvement.

What are you waiting for?

There are now clear patient care and financial incentives associated with implementing the New Model of family medicine outlined in the Future of Family Medicine report. Together with your staff, you can begin to move into the future with renewed enthusiasm and expect the personal, professional and financial rewards that will result.

Dr. Bagley is the AAFP's medical director of quality improvement. He was formerly in private practice for more than 25 years in Latham, N.Y., where he led his practice's participation in the Institute for Healthcare Improvement's Idealized Design of Clinical Office Practice initiative.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

1. Future of Family Medicine Project Leadership Committee. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2:S3–S32. Available online at: http://www.annfammed.org.

2. Spann SJ for the members of Task Force Six and the Executive Editorial Team. Report on financing the new model of family medicine. Ann Fam Med. 2004;2:S1–S21. Available online at: http://www.annfammed.org.

3. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635–2645.

 

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