Editor's Note: This is the second article in a three-part series about how a small traditional family medicine practice just west of Denver realigned itself to become a high-functioning patient-centered medical home (PCMH) practice. Part one of this series appeared in AAFP News Now last week.
In 2005, Tracy Hofeditz, M.D., of Lakewood, Colo., left a large group of primary care practices to move his small, independent family medicine practice to a new location. But Hofeditz knew there would be no point in moving Belmar Family Medicine to a different site unless he also took a hard look at the way patients were cared for behind his practice's doors.
Family physicians are working very hard to provide the best care for their patients, says Hofeditz. "As family physicians, that's the basis of our training and our ideals." However, "patients are not getting about 50 percent of recommended preventive services, and we have to understand why that is," Hofeditz adds. "We need to provide more care for more patients without having to work harder …and we also need to demand payment reform that will support us in all these efforts, especially those that are costly.
"I wanted to find out how I could get help in changing my practice in a way that would make a real difference, but I didn't know where to begin."
- Tracy Hofeditz, M.D., of Belmar Family Medicine, reached out to a Colorado-based Improving Performance in Practice (IPIP) group for help in realigning his practice to become more patient-centered.
- The IPIP provided a coach to assess Belmar's strengths and weaknesses.
- Building and nurturing the practice team, participating in a disease registry and implementing an electronic health record system helped Belmar achieve patient-centered medical home level three status from the National Committee on Quality Assurance.
Shortly after he moved his practice, Hofeditz reached out to a local evidence-based practice transformation program -- an Improving Performance in Practice (IPIP) group. The relationship that ensued provided exactly the jump start and ongoing encouragement that Hofeditz so desperately needed.
This particular IPIP -- organized by the Colorado Clinical Guidelines Collaborative, which was renamed HealthTeamWorks(www.healthteamworks.org) in 2010 -- gave Belmar Family Medicine its first opportunity to work with a coach. The coach, whose salary was paid for by a grant, went straight to work. He observed the practice and conducted a work-flow analysis, gathered information about practice functions, and compared practice statistics to state benchmark numbers.
And just as coaches are expected to do, Belmar's coach spotted weaknesses that needed correcting.
Hofeditz admits that inviting outside scrutiny of his practice was difficult because it meant accepting that he was not perfect. It also implied an openness to change that he wasn't entirely comfortable with -- yet. "Physicians want to feel like the king (or queen) of their own castle, and that unbalanced power is not consistent with the culture of the patient-centered medical home (PCMH) movement," he says.
As it turned out, the problem-solving process initiated by the coach changed Hofeditz's mindset about seeking outside help. He now considers reporting to an outside entity an opportunity for improvement. Without a coach's constant nudging, "my practice could lose some of its high-functioning edge," says Hofeditz, adding that paying out-of-pocket for those services would be money well spent.
A critical teambuilding function at Belmar Family Medicine in Lakewood, Colo., is the morning huddle, a concept Tracy Hofeditz, M.D., embraced in 2007 after reading an article titled "Improve Office Efficiency in Mere Minutes" in Family Practice Management. "The huddle has become for us an everyday event where the entire team meets to talk about tools to manage care transitions, highlight scheduling changes, discuss staffing problems, clarify function problems, and go over any other planning issues," says Hofeditz. View a short video of the Belmar team huddle in action at left.
Judy Hewitt was hired as Belmar's practice manager in 2006, just as the practice was on the precipice of major change. She says that although it's tempting to skim over the team aspect of the change process, doing so could doom the effort.
"If a practice doesn't recognize the importance of teamwork, transformation won't happen," says Hewitt. "Those team members who haven't bought into the concept will only see the hard work, and they will constantly undermine what you're trying to do."
Diane Cardwell, M.P.A., A.R.N.P., vice president of health care solutions for TransforMED, a nonprofit subsidiary of the Academy, has spent a good deal of time working with practices like Belmar. She says that practice leaders must create the "why" for every team member; in other words, success must matter and must have personal significance to everyone involved.
Once a practice begins to inch its way forward in the change process, it's critical that the team celebrate its successes, no matter how small, says Cardwell. Recognizing good work "can exponentially increase the productivity of the team."
Belmar made yet another change in 2007 when a local independent practice association (IPA) made its disease registry available to Belmar without charge. Use of the registry marked another turning point in patient care for the practice.
A good deal of time went into "care and feeding" of the registry when the process was new and the learning curve steep, says Hofeditz. "We had to learn to manage the registry, and that included running reports and then responding to those outcomes with a quality improvement process."
He recalls some disheartening moments early on in the registry process. "Looking at our population management registries for diabetes, heart disease and stroke and then measuring my own performance according to quality measures -- and finding myself come up seriously short -- was a painful experience," says Hofeditz.
"I had to shift from an attitude of assuming excellence to an attitude of pursuing excellence," he notes. Today, "we know how to put data in and are excited to see the results that come out."
"The way to measure your success as a PCMH is by looking at patient outcomes every month to see if you really are accomplishing your goals," Hewitt says. "If you don't look at these reports monthly, it's easy to convince yourself that you are doing better than you really are."
Belmar Family Medicine implemented its electronic health record (EHR) system in August 2008 with financial support from a local hospital; total conversion time was three years. Although the first six months were tough, according to Hofeditz, revenues didn't decline and patient needs were met.
"I worked as hard as I did in internship," says Hofeditz, admitting that he spent many late-night hours working on the EHR project at home.
Hofeditz prepared for his EHR conversion by creating -- several years out -- a face sheet for each patient chart that listed essentials such as chronic problems, medications and vaccinations. Patients' electronic charts began to take shape when that basic information was outsourced for preloading into the system. More detailed medical information was added as patients scheduled appointments.
In addition, the EHR opened up other tools, such as electronic prescribing and electronic tracking of lab reports, that save time and improve quality and safety, according to Hofeditz. "Having an EHR is a clear expectation for high-functioning practices in the 21st century," he notes.
In 2009, after an arduous documentation process to show that it was providing quality care in a patient-centered environment, Belmar Family Medicine received level three PCMH recognition status from the National Committee for Quality Assurance and earned significant financial rewards from its participation in the three-year Colorado Multi-Payer PCMH Pilot.
Although that pilot ended in April, it's not the end of the story for Belmar Family Medicine. Hofeditz says the practice is a work in progress. In the final installment of this series, read about how Hofeditz continues to add new components to his patient-care package, including a care coordinator and on-site mental health services.