TransforMED Evaluators Detail Initial Lessons From Demo Project

Massive Practice Change Harder Than Expected

By Sheri Porter
5/13/2009

An independent evaluation team under contract with the Academy to analyze data from TransforMED's national demonstration project, or NDP, on the patient-centered medical home, or PCMH, took the unusual step of releasing a preliminary report with findings the team said were too important to keep under wraps.

"We have already learned enough from the NDP to identify some potentially dangerous red flags fluttering over the demonstrations just getting under way," wrote the authors, referring to a host of similar medical home pilots popping up all around the country.

The report, "Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home," is published in the May/June issue of Annals of Family Medicine. An in-depth analysis of TransforMED's two-year NDP is scheduled for publication in 2010.

Corresponding author Paul Nutting, M.D., M.S.P.H., director of research at the University of Colorado Health Sciences Center in Denver, told AAFP News Now that it was important to share some lessons now regarding how practices make the transformation to a medical home rather than wait for the data to go through a lengthy academic peer review process.

"One of the things we discovered -- and we think others will discover it, as well, as they struggle with the demonstration projects -- is it turns out to be more difficult and to take longer than many people imagined," said Nutting.

The evaluators issued serious caveats to others attempting to undertake massive practice changes, particularly those who are launching projects with short time frames of just six months to year. According to Nutting, the evaluators were concerned that unrealistic timelines could set practices up for failure and, subsequently, stall the medical home movement.

The authors also found that practices need substantial financial support from a combination of sources, and they need it "sooner rather than later," said Nutting. "Asking the practice to front the cost in hopes that they may see greater reimbursement later is just kind of a flawed strategy," he said.

Six Lessons Learned

Nutting and his team urged stakeholders to heed observations the evaluators made while working with the 36 TransforMED NDP practices. Here are the six lessons they learned.

Becoming a PCMH requires transformation. Transformation to a PCMH "requires epic whole-practice reimagination and redesign. It is much more than a series of incremental changes," wrote the authors.
Technology needed in a PCMH is not "plug and play." The authors said the "hodge-podge of information technology marketed to primary care practices resembles more a pile of jigsaw pieces than components of an integrated and interoperable system."
Transformation to a medical home model requires personal transformation by physicians. The move from physician-centered care to a team-based environment requires physicians to use "facilitative leadership skills instead of the more common authoritarian ones," said the authors.
Change fatigue is a serious concern even within capable and highly motivated practices. The authors warned that transformation does not occur at a steady and predictable pace "but in fits and starts." They called the work "daunting and exhausting" and said it could cause "staff burnout, turnover and financial distress."
Transformation to a medical home is a developmental process. "Such transformation takes more time than the two years allocated to the NDP," concluded the authors.
Transformation is a local process. The authors noted that each practice had unique characteristics and circumstances and the path to a PCMH was "highly dependent on initial conditions at the local practice, health care system and community level."

Long-term Outlook

The authors included recommendations for entities supporting practices undergoing change. In particular, they call for the National Committee for Quality Assurance, or NCQA, to modify its PCMH recognition process. They argued that most practices would have trouble completing the NCQA process in the required three years.

Although the authors applauded the NCQA for taking the lead in defining essential components of the medical home and for its work in creating a recognition process, they cautioned against premature closure of the process "before the rich data have emerged from the NDP and other current demonstrations."

The report hands out tips to practices in the midst of change, advising them to

establish realistic expectations for the time and effort required,
develop flexible and reflective health information technology plans,
monitor change fatigue, and
become continuous learning organizations.

Nutting said physicians must focus on the big picture. "The whole is larger than the pieces. A practice could literally check off every item in the NDP model and not actually make the transformation," he said.

Academy Welcomes Report

AAFP President Ted Epperly, M.D., of Boise, Idaho, said the report offered a candid assessment of the TransforMED project while confirming that change is hard.

"No one expected it would be easy for family physicians to change the way they practice and deliver care," said Epperly. "Change starts with a hard look at the problems at hand and progresses with bold actions like the Academy's commitment to the medical home model.

"The Academy is committed to helping family physicians overcome the barriers and challenges they face as they make this transition," he added.

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