Family physicians interested in elevating their practices to new heights when it comes to patient care will be interested in reviewing a new conceptual model for getting there put together by researchers from the University of California, San Francisco, Center for Excellence in Primary Care, Department of Family and Community Medicine.
The model, which is featured in the article "The 10 Building Blocks of High-Performing Primary Care"(annfammed.org) in the March/April Annals of Family Medicine, is based on 10 basic building blocks that, as the research authors pointed out, could help physicians looking for a "roadmap to help navigate the journey from old to new." One of the four researchers, Kevin Grumbach, M.D., is a family physician, although corresponding author and general internist Thomas Bodenheimer, M.D., is a professor of family and community medicine at the University of California, San Francisco.
The building blocks are "both a description of existing high-performing practices and a model for improvement," said the authors.
They noted that although practices may vary the implementation order, "first-tier blocks often support achievement" of other functions near the top of the building blocks hierarchy.
Defining the Building Blocks
Researchers relied on their personal experience as practice facilitators, along with site visits and a review of existing research, to build their model. In total, authors and their colleagues visited 23 practices; of those, eight were hospital-based clinics, seven integrated delivery system sites, six federally qualified health centers and two independent private practices. Seven of the 23 had five or fewer physicians.
- Researchers from the University of California, San Francisco, created a conceptual model consisting of 10 building blocks to help primary care practices transform their practices for better patient care.
- Study authors note that first-tier blocks often support achievement of other practice functions in the hierarchy.
- Full implementation of the ten-block model requires payment reform that would, among other things, replace the current payment system that primarily pays primary care physicians for in-person clinical visits.
"By comparing and discussing field notes, we discerned a set of elements -- building blocks -- that occurred with regularity among well-functioning practices," wrote the authors.
Here, then, are the 10 building blocks of high-performing primary care suggested by the researchers and listed in order from one to ten.
- Engaged leadership focuses on practice leaders who have a "practice-wide vision" that enables them to create goals and objectives that are measureable.
- Data-driven improvement relies on health information technology to track the clinical, operational and patient-experience metrics that serve to monitor progress toward those objectives.
- Empanelment suggests that every patient is connected to a primary care clinician as well as a care team. Incorporating this function allows practices to improve continuity of care and adjust the workload among clinicians and teams.
- Team-based care includes various components, such as well-trained nonclinicians to add capacity; large teams organized around the pairing of a clinician and clinical assistant, dubbed a "teamlet"; and common work areas, called pods, where clinicians and nonclinical staff work side by side.
- A strong patient-team partnership recognizes the value every participant, including the patient, brings to the medical encounter. The authors noted, "Patients are not told what to do but are engaged in shared decision-making that respects their personal goals."
- Population management entails stratification of the needs of patient panels and then creation of team roles to match those needs. In particular, panel management, health coaching and chronic care management are tools used by high-performing practices.
- Continuity of care involves linking each patient to a clinician and a team and then relies on practice schedulers to encourage each patient to see the clinician to whom he or she is empaneled. Achieving continuity improves preventive and chronic care, improves patient and clinician experience, and lowers health care costs.
- Prompt access to care relies, in many cases, on practices measuring and controlling panel size and then building capacity-handling teams. Access is a prime determinant of patient satisfaction.
- Comprehensiveness and care coordination provide a one-two punch as far as a practice's ability to provide what patients need; therefore, the authors note, "When a patient's needs go beyond (a) primary care practice's level of comprehensiveness, care coordination is required with other members of the medical neighborhood."
- The template of the future reflects the ultimate goal that high-performing practices strive to achieve, namely, "a daily schedule that does not rely on the 15-minute, in-person clinician visit but offers patients a variety of e-visits, telephone encounters, group appointments and visits with other team members," said the researchers.
AAFP PCMH Resources
The AAFP has a number of resources on practice transformation and the patient-centered medical home (PCMH), including
"Full implementation of this future template requires payment reform that does not reward primary care simply for in-person clinical visits," noted the authors. They suggested that fee-for-service payments for primary care be eliminated entirely and be replaced with a risk-adjusted comprehensive fee-per-patient payment model with adjustments for quality and patient experience.
Digging Into Discussion Points
Authors called the 10 building blocks "a practical conceptual model that can help practices in the journey toward becoming high-performing, patient-centered medical homes."
The model relies heavily on design elements controlled by the practice; however, as noted previously, implementation of payment reforms would greatly support the building blocks.
Small independent practices with five or fewer physicians were underrepresented in the study and in the practice coaching portfolios of the researchers. The authors pointed out that the 10-block-model likely would need refinement to be useful to small private practices.
Finally, regarding the ordering of the blocks, researchers acknowledged that although their shared observations and experience suggested "a degree of hierarchy in the building blocks, with some blocks being enablers of others … there is no single right way of moving forward on practice improvement."
They concluded that although the model should not be construed as a "universal road map," the 10 building blocks could provide an "overview" to assist practices eager to move forward with transformation efforts.
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