Change Is Hard: What Really Happens When You Try to Implement a New Care Model


Even with a laudable goal, such as reducing physicians' administrative burdens, it can be difficult to implement change. These real-world lessons can help.

Fam Pract Manag. 2017 Nov-Dec;24(6):10-15.

Author disclosures: This study was funded by AHRQ, contract #HHSA290201000034I. The views expressed are those of the authors and are not endorsed by AHRQ. No other relevant financial affiliations disclosed.

It's hard to change. Practice settings, workflows, individual characteristics, and time constraints all affect our will and capacity to try something new even when the status quo is not working for us.

Penobscot Community Health Care (PCHC) is a federally qualified health center located in rural Maine. It serves more than 60,000 patients across 15 practice sites, including nine primary care practices, and it employs 700 people, including 200 providers. In January 2014, we attempted a major change across our primary care sites – implementing a “delegate model,” a team-based approach to care featuring an enhanced medical assistant (MA) role.1

Under this model, MAs are trained to take on additional administrative tasks thereby reducing the burden on primary care providers. The model combines two primary care providers and their MAs to form a team with a shared panel of patients and adds a full-time “care team MA” (CTMA) as a fifth team member. The CTMA, after approximately 30 hours of training, can then take on a range of responsibilities. These include previsit planning, standardized prescription renewals, schedule management, provider in-box management, and identification of patients for routine auxiliary testing and referrals (e.g., mammograms, behavioral health, and care management) using an expanded set of standing orders.

Three goals drove our interest in the delegate model:

  1. Reduced provider burnout,

  2. Improved access to care,

  3. Improved quality of care.

Our change team's initial strategy was to identify teams in five of our larger primary care practices that would champion the new model and share their experience with their peers. As others observed and heard about the success of the model, they too would want to participate. After two or three years, the new model would become the new norm – or so we thought.

In this article, we will share what really happened, as well as the lessons we learned at the three critical stages of change – adoption, implementation, and sustaining change.

Adoption: getting people on board

To encourage adoption of the new practice model, we needed to “sell” it to everyone. Staff and leaders at every level had different expectations for the model and prioritized our three goals differently. Organizational leadership thought all three goals – reduced provider burnout, improved access, and improved quality – were important, but they stressed that the model also had to pay for itself through increased visits to be sustainable. Practice leadership also agreed with all three goals but thought there might be ways to achieve them instead of using the delegate model (they wanted to retain their autonomy and not be pressured into adopting a standard model). Providers

About the Authors

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Susan Grantham, PhD, served as principal investigator for this project and is the director of research and evaluation for the Health Services Division at John Snow Inc., in Boston....

Theresa Knowles is vice president of quality improvement at Penobscot Community Health Care in Bangor, Maine.

Dr. Nesin, a family physician, is vice president of medical affairs at Penobscot Community Health Care.

Natalie Truesdell was project manager and conducts program evaluation of health services innovations in federally qualified health centers at John Snow Inc.

Eugenie Coakley served as statistician and provides research design and statistical expertise to health services research projects at John Snow Inc.

The authors thank Michael Harrison, senior social scientist for the Organizations & Systems Center for Delivery, Organization, and Markets at the Agency for Healthcare Research and Quality (AHRQ) for his guidance and input. Additionally, the authors thank Janet Van Ness and Frances Marshman from John Snow Inc., who contributed to the article's editing.

Author disclosures: This study was funded by AHRQ, contract #HHSA290201000034I. The views expressed are those of the authors and are not endorsed by AHRQ. No other relevant financial affiliations disclosed.



1. Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21(6):23–29.

2. Sinsky CA, Sinsky TA, Rajcevich E. Putting pre-visit planning into practice. Fam Pract Manag. 2015;22(6):34–38.


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