When it comes to practice transformation and the patient-centered medical home, "There may not be any silver bullets that will work for all or even most clinics." That's the conclusion reached by researchers in an article published in the August issue of the Journal of the American Board of Family Medicine.(www.jabfm.org)
Christopher Hawley, M.D., ends a visit to his patient-centered family medicine practice on a light note with a patient "high-five."
The article, titled "Challenges of Medical Home Transformation Reported by 118 Patient-Centered Medical Home (PCMH) Leaders," summarized the results of two surveys completed by medical clinics that were certified as PCMH practices.
The authors noted in their introduction that primary care leaders and national policymakers think that the PCMH model of care will "rejuvenate essential primary care services while reducing health care costs and improving quality, equity and patient experience," but concluded that clinics "may need to find their own unique path to transformation," using items identified in the surveys as a guide when appropriate.
Corresponding author Leif Solberg, M.D., is the director for care improvement research at HealthPartners Institute for Education and Research in Bloomington, Minn., and the corresponding author for the study. He told AAFP News that the research comes at a pivotal moment in health care.
- New research on the patient-centered medical home (PCMH) suggests that medical practices need to forge their own unique paths to practice transformation.
- Practices that made the greatest changes in their systems were those that paid close attention to the process, especially regarding culture and patient-centeredness.
- Family physicians with successful PCMH practices in Tennessee and in California offer their perspectives on practice change.
"There is broad recognition of the importance of primary care transformation and many efforts (are underway) to facilitate it, but (there is) little specific information about the kinds of changes that matter the most," said Solberg. "Since most primary care practices have limited time and resources, they need to focus on the most important changes."
Solberg said family physicians should take to heart the finding that each clinic has different needs, saying that the change factors identified by survey participants "should be evaluated and considered by any clinic interested in transformation."
Collecting and Crunching the Numbers
Researchers surveyed 120 newly certified medical homes in Minnesota using a questionnaire that asked about the presence and function of practice systems now and three years ago. They also collected data from the practices on standardized composite clinic performance measures for diabetes and cardiovascular disease, as well as responses from a survey about PCMH transformation. In all, they received responses from 118 of the practices.
For the PCMH transformation survey, researchers conducted qualitative interviews with participants from nine diverse clinics about the barriers, facilitators and change strategies involved in PCMH transformation.
Researchers noted that their findings suggested that "clinics that made the greatest changes in their systems were those that paid a lot of attention to the change process, especially regarding their culture and patient-centeredness."
"Despite the hundreds of published articles about the medical home, there is a surprising dearth of even descriptive information about how anyone built one or recommendations about how to do so," said the authors.
"If there is no single best path forward, perhaps that dearth of process prescriptions is both understandable and desirable. But it does require individual clinics to assess carefully their own situation and identify those changes and strategies best suited to their situation and context.
"Perhaps we should all be more humble about our ability to know just what changes are needed in individual clinics and care systems and how others should go about making them," authors wrote.
One Step at a Time in Tennessee
Susan Andrews, M.D., of Murfreesboro, Tenn., started on her PCMH journey with Family Practice Partners nearly 11 years ago by working with a national research group that taught the practice how to collect and use data to improve patient care.
The practice later became part of TransforMED's three-year National Demonstration Project(www.annfammed.org) and has since achieved Level 3 PCMH recognition from the National Committee for Quality Assurance (NCQA).
Andrews' words of advice to her family physician colleagues were simply this: "When you're a small practice, you can't do it all at once."
Implementing new ideas, such as initiating patient portals or encouraging patients to complete their electronic medical histories, takes time and preparation. Andrews said the practice starts each new potential project by asking a series of questions: How will we set it up? How can we fit it into our workflow? How much will it cost? How do we get our patients excited about it and get everyone on staff involved?
"Practice transformation is a constant process of assessing what we have and adding additional aspects of the PCMH piece by piece," said Andrews. "And it takes the whole team."
Changing for the Right Reasons
Christopher Hawley, M.D., is a family physician in Turlock, Calif. The practice he joined there in 2002, Romeo Medical Clinic, was built from the ground up as a place where patients could come and feel like they were being cared for by family.
"Our whole goal was to create a really different type of practice," said Hawley, recalling for AAFP News the early days of the clinic founded by brothers Michael Romeo, M.D., and Samuel Romeo, M.D.
"When we were first putting the pieces together back then and creating some principles and our practice mission statement, what we didn't realize was that we were really creating what would later be called the patient-centered medical home," said Hawley.
Romeo Medical Clinic was also part the TransforMED project, although it was randomly assigned to the control arm of the study, in which the physicians essentially worked on practice change without expert assistance.
Even so, in 2009, the practice received a full three-year PCMH accreditation from the Accreditation Association for Ambulatory Health Care Inc. (AAAHC) and, in 2012, was reaccredited for another three years.
The AAAHC, like the NCQA, is one of a number of PCMH accrediting/certifying organizations in the United States.
According to Hawley, the most important consideration comes at the very beginning of the change process: Physicians need to ask -- and answer -- the question "Why?"
"Do it for the right reasons and understand your reasons before you ever get started," Hawley advised.
"Change is always hard, no matter what, but if the answer to your 'Why change?' question is not inspiring and compelling, it won't be enough to push you through those really difficult pieces that are necessary in any sort of transformative change.
"So, if you're just doing it for the money -- or doing it for efficiencies -- when things get hard, suddenly you just want to give up and go back to doing it the old way," said Hawley.
"Our whole motivation for becoming a PCMH was that we really thought it was the right thing to do for our physicians, our patients and our community. We felt like it was a win-win-win for everybody."
With the help of an efficient EHR system, the practice is able to deliver on cost-effective elements such as excellent preventive care. "We're able to prevent problems or at least identify them early so that they don't become big life-threatening, expensive illnesses," said Hawley.
The practice's mission statement -- "Caring for People as Family" -- sums it all up, according to Hawley. "The mindset amongst our staff members is, 'Oh. I get it; I understand. Now I will jump through hoops and walk across burnings coals to get this done, because we care about people, and we care about people like they are our family.'"
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