Physicians involved in the TransforMED national demonstration project share what they've learned about practice transformation.
Fam Pract Manag. 2009 Jul-Aug;16(4):15-18.
The patient-centered medical home (PCMH) has been in the spotlight recently because of its potential for improving health care quality while reducing costs. The heart of the PCMH is a continuous relationship between a patient and his or her physician who coordinates care for both wellness and illness. (Read about all nine components of the PCMH model at http://www.transformed.com/transformed.cfm.)
Initial data from TransforMED's National Demonstration Project (NDP) show that becoming a PCMH isn't easy, and it doesn't happen overnight.1 “In transforming one's practice, there is no moment when the work is completely done,” says NDP participant Bob Eidus, MD. “The goal is continuous transformation.”
This article presents some ideas gleaned from TransforMED's practice facilitators and the physicians actively involved in the change process. These are not intended to be the 12 ideas that will make your practice a PCMH. However, the beginning of any journey starts with a single step, and that's what we're providing here: 12 “steps” to get your journey started.
1. Check your attitude
It's easy to feel frustrated, even angry, when thinking about the U.S. health care system, particularly the way primary care doctors are reimbursed. It's important to acknowledge these issues, but there comes a time when physicians have to move beyond complaining and begin to prepare their practices for the future. “The current method of caring for patients is no longer acceptable, so either get on the train of change or wait at the station for the next one to come along,” says NDP participant Joseph Mambu, MD. If you grapple with frustration and anger toward the system, your first (and probably most important) step must be to let go and take on a new attitude.
2. Don't try to do it all yourself
Getting through residency may have required a “do-it-yourself” attitude, but that's not healthy or effective in a medical practice. Schedule a time for the physicians in your practice to meet and create a list of all the tasks they currently do. How many of these tasks require an MD? It's important to make this list together so you can all agree on which tasks should be delegated, and then hold each other accountable. This list will be different for every practice. “Figure out what you need your doctor brain to do and what other team members can do. Examples include ordering mammograms and preventive health screenings, administering vaccines and reviewing what medications need refills,” says NDP participant Susan Nelson, MD. After you've come to some conclusions about how to do things differently, meet with your staff to collaborate about the changes in procedures.
3. Learn to lead
Make a commitment to improve your leadership skills to become a visionary, facilitative leader. Physicians are notoriously autocratic in their leadership style. There are times when this style is important for a physician, but there are also times when it can be a hindrance. It's important for leaders to understand their tendencies, seek feedback and continuously look for ways to improve.
4. Engage your staff
Without the full engagement of the practice team – either through regular communication and updates or through their direct participation on implementation teams – any changes will appear to be imposed on them. By engaging all staff in the process, the practice benefits. With team input, the practice is better equipped to meet the needs of patients. Research in change management shows that success and sustainability are closely coupled with how much everyone feels involved in the change process. The more engaged they are, the more likely they are to become models for others and increase the healthy behaviors needed. Even those who are resistant to change can become valued members of the team if you help them feel involved in the process and let them know that their opinions count.
One way to begin engaging your staff on the PCMH concepts is simply to find a time when all the staff can watch the “Introduction to Patient-Centered Medical Home” video developed by Emmi Solutions, the Patient-Centered Primary Care Collaborative and TransforMED. Discuss what you think of the video and what this would mean for your practice and your patients.
5. Invest in a registry
Patient registries are electronic databases that allow a practice to track key measures for patients with chronic conditions and identify patients who are overdue for their check-ups or other services. We learned in the NDP that improvements were needed in these systems in order for them to perform as efficiently as practices need; however, these care management tools are improving. In fact, you can now find systems that interface with your practice management, EHR, e-prescribing and lab systems, and thus eliminate the need for duplicate data entry.
6. Know your customer
In a patient-centered medical home, you cannot make changes to your practice that are in the best interest of your patients without knowing what they want. Find ways to incorporate patients into the decisions made by your practice. Physicians at Olio Road Family Care have begun to ask themselves this question in every physician meeting: “How does this decision affect the patient?”
Patient satisfaction surveys are another way to accomplish this goal. NDP participant Marta Kroo, MD, MPH, said, “Because our patients told us that they found our office cold and unwelcoming, I began to look at the office more from their perspective. I realized that we had many signs saying ‘Don't do this, and don't do that,’ but none that said ‘You are welcome here.’ So I put up a sign in the window that simply said ‘Welcome!’ Many patients have commented on that sign and the way it makes them feel.”
There are many ways to understand your patients' needs – from surveys to simply walking around the practice and seeing things from their perspective.
7. Make information more accessible
It's a fact of the times: Patients want greater access not only to their doctors but also to their health care information. This progression toward the consumer as expert has happened in many businesses throughout the years. Think about banking. It wasn't that long ago when consumers only had access to their money when banks decided they could, which was typically between 9 a.m. and 4 p.m., Monday through Friday. Now people have complete access to their money and their account history 24/7. Kevin Grumbach, MD, says it this way: “Most of us would agree that the ATM better met the banking needs of the public than the traditional bank-teller delivery system and created tremendous efficiencies in banking.” He continues, “There are some patients who don't find a three-hour expedition – consisting of traveling to their beloved family physician's office, waiting in the office to be seen, being seen, waiting for their result, and traveling back home or to work – to be an approach that optimizes their experience of the medical home. Many patients in this situation would gladly trade a personal encounter with their physician for a more convenient method for addressing their care need.”
One benefit of technology, such as a patient portal, is that it can connect patients with the information they need outside of a traditional face-to-face visit during regular business hours. This will become increasingly important in the future.
WANT TO GO DEEPER?
For more information on the individual medical home components – from advanced access to patient registries – visit these online resources:
8. Take a vacation
Believe it or not, it may be important to plan a vacation in the middle of your change efforts to avoid change fatigue. Plan a month where everyone takes a break from any new or change-oriented projects. It is also important to regularly discuss with staff how change projects are progressing and whether any parts of a project are not going well and need to be revisited. This could be done as part of a retreat; even a half-day away from the office can be beneficial for the staff. These staff retreats can be facilitated or you can pick a team-building activity. Either can help bring the team together in a meaningful way and revive them.
9. Know your numbers
How often do you urge your patients to know their numbers related to certain health conditions, such as high blood pressure or cholesterol? How many times are you discouraged by their lack of response – or pleasantly surprised when they take assertive action? Businesses also need to know their numbers to run effectively. Do you know your practice's PCMH numbers? One tool to help your practice assess itself as a medical home is the Medical Home Implementation Quotient (MHIQ). This free tool can help practices learn more about the nine components of the PCMH. You can even use it as a guide to making changes in your practice because each section includes how-to resources. Very few tools work perfectly for everyone, and this one is no exception, but it can be a great starting point for your practice. Go online to http://www.transformed.com and click on the MHIQ banner at the top of the page.
10. Let your patients help
Look at the skill sets of the patients in your practice. They are most likely a diverse group of people with valuable skills that could benefit your practice. Maybe you have a patient who is a web site developer, or someone who is an electrician. NDP participant Theresa Shupe, MD, discovered that patients in her practice were willing to paint the office. Another patient, a plumber, noticed a leak and offered to fix it. “I also bought inexpensive fabric on sale and asked one of my patients who sews to make the practice some nice, soft gowns. They're not appropriate for every type of visit, but they're great for physicals,” she said.
Patients want to feel like they're contributing, and including them in the business of the practice creates a more proactive role for them, that of engaged participant in their medical home. This furthers the collaborative feel that patients have for the practice and helps you see your patients in a new light.
11. Provide guidance
How can your patients know what to expect from your practice (e.g., what hours you are open, and what services you provide)? They need a guidebook. The Center for Advancing Health has developed a document called “Creating a Patient Guide for a ‘Medical Home’ Physician Practice,” which offers a template for developing your own guide (see http://www.cfah.org/pdfs/PACT_Guide_0109.pdf). “A patient guide lets patients know that you want them to make the best possible use of your practice's services,” says co-author Jessie Gruman, PhD. A guide also communicates that belonging to a PCMH is different than belonging to a traditional practice.
12. Be willing to experiment
It's important to remember that you don't have to make leaps in order to see changes in your practice. Although taking a leap here and there can be important, it can be equally important to take single steps. You should even be prepared for a few missteps along the way and use those experiences to refine your approach.
Dr. Grumbach said it best: “This is a very exciting time of experimentation in primary care. No one has figured out the perfect blueprint for the thorough remodeling of the primary care home to achieve the sustainable, high-performance system that is needed at an affordable cost. We are all learning together.”
About the Authors
Marly McMillen is chief operating officer for TransforMED in Leawood, Kan. She was executive director of TransforMED's national demonstration project (NDP). Elizabeth Stewart is qualitative data analyst for TransforMED's NDP. Author disclosure: nothing to disclose. The authors would like to acknowledge Diane Cardwell, MPA, ARNP, PA-C, Ana Elena Jensen, PhD, Jim Arend, MBA, and Sheila Richmeier, MS, RN, BC, CMPE, for their contributions to this article.
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1. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7:254–260.
Copyright 2009 TransforMED. Published with permission.
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