TransforMED Patient-Centered Medical Home Model Continues to Evolve in Part Based on Findings from National Demonstration Project

AAFP driving force in practice improvement and larger health system reform

Monday, June 07, 2010

Janelle Davis
Public Relations Strategist
American Academy of Family Physicians
(800) 274-2237 Ext. 6253

LEAWOOD, Kan. — Today, the American Academy of Family Physicians and its subsidiary, TransforMED, announced the release of a report by the independent evaluation team of TransforMED’s two-year, physician practice redesign initiative titled the National Demonstration Project. The report is published as a series of manuscripts in a special supplement to the May/June 2010 Annals of Family Medicine. The title of the report is "Evaluation of the American Academy of Family Physicians’ Patient-Centered Medical Home National Demonstration Project.”

The practice redesign initiative, undertaken by TransforMED and funded by the AAFP, ran from June 2006 to May 2008. It was the first and largest “proof-of-concept” project to determine empirically whether the TransforMED Patient-Centered Medical Home model of care could be implemented successfully and sustained in today’s health care environment. More specifically, the project served as a learning lab to gain better insight into the kinds of hands-on technical support family physicians want and need to implement the PCMH model of care.

“From the beginning, the national demonstration project was viewed as more of a learning lab than a research or demonstration project,” said Terry McGeeney, M.D., MBA, president and CEO of TransforMED. “The model was changed seven times during the project,” he explained. “When something wasn’t working, we changed it, with the end goal of developing a viable model of care with the tools and resources to support it.”

“Recommendations for the patient-centered medical home model will continue to come forth, but the TransforMED NDP achieved what it set out to do,” said AAFP President, Lori Heim, M.D. “The pioneers at TransforMED, as well as the family medicine practices who gave their time and effort to this project, have laid the groundwork for what has become a driving force in practice improvement, as well as in larger health system reform.”

The initial findings are what the AAFP and TransforMED expected from the two-year-old study, and are in agreement with what family medicine leaders had predicted — that moving to a patient-centered medical home model of care can be challenging, but given the necessary resources and guidance, it is certainly possible. Both the AAFP and TransforMED received quarterly status updates throughout the project. TransforMED made informed changes to practice interventions and innovations throughout the project based on accumulated learnings. Key learnings, recommendations and ongoing modifications to the TransforMED PCMH model are as follows.

  •  The NDP evaluation team reports that transformation to a patient-centered medical home requires a great deal of effort, motivation and support. Transforming from a physician-centric practice to a team-based, patient-centered model is challenging for physicians who are accustomed to being responsible for the entire patient encounter. Developing care teams requires substantial cross-training efforts, as well as developing a shared vision among front- and back-office staff of how care teams affect the patient experience. Most practices will need additional financial and human resources to achieve full medical home transformation. Intense facilitation can enhance a practice’s ability to manage and sustain change. It also can increase its success rate of implementing PCMH model components. However, in most cases, it will take longer than two years to implement and assess the sustained and evolving effects of PCMH transformation.

    As mentioned, during the two-year NDP, TransforMED made ongoing and significant changes to the practice redesign initiative. During the course of the NDP, TransforMED added a practice management component to the model to address the issues of financial and human resources. The facilitators quickly identified that change management, leadership and communication were critical success factors that enabled practices to implement model components more quickly and with less disruption.

    TransforMED has since developed new resources to support practice management as well as other PCMH components. The Medical Home Implementation Quotient is a free, online self-assessment that allows practices to find out where they stand on the journey to becoming a medical home. It is designed to provide practices with meaningful feedback on the valuable key features of the PCMH and primary care. This tool was not in existence when the NDP began, but now serves as the starting point for all TransforMED practice re-design projects.

TransforMED also created Delta-Exchange, an online social networking site to address the proven need for additional support through peer-to-peer learning. For a small monthly fee, primary care physicians and their staff can receive targeted support from TransforMED’s expert facilitators and connect with their peers via discussion zones. Members also gain access to a robust repository of tools, resources, case studies and practical how-to articles on practice transformation topics such as implementing team-based care, reducing patient cycle times, change management and maximizing office space. The site also hosts regularly scheduled, live webinars on a variety of PCMH and practice improvement topics ranging from optimized billing and collection to implementing open-access scheduling. Members also can download workflow and procedure forms that can be customized to individual practices.

Additionally, four workbooks on practice transformation are currently available. Topics are: a medical home overview, practice leadership, care management and open access scheduling. Several more workbooks, all authored by TransforMED practice enhancement facilitators, are in development.

  •  According to the NDP evaluation team, adoption of PCMH components is associated with small improvements in condition-specific quality of care. This was observed in both facilitated and non-facilitated practices. Practices that adopted more PCMH components achieved better scores for quality-of-care, chronic disease care, prevention and condition-specific outcomes included in the Ambulatory Care Quality Alliance Starter Set. There were trends for very small decreases in coordination of care in both groups. Until primary care becomes more integrated in the larger delivery system, PCMH implementation is not likely to result in statistically significant improvements to most patient quality-of-care outcomes.

    TransforMED realized early in the NDP that all PCMH components are interdependent and that quality improvement requires ongoing management. As a result, the model was adapted to view the PCMH as a system improvement rather than as an approach to address individual quality initiatives. Care coordination was an issue that needed specific focus. A care coordination component was added to the model in an effort to distinguish it from care management, which typically involves activities external to the practice.

    Additionally, TransforMED discovered that many small practices did not have a substantial number of patients with any specific disease for NDP findings related to clinical outcomes to be considered statistically significant. In the two years since the project concluded, TransforMED has become involved in numerous pilot projects under single payers that allow patient outcomes data to be collected, consolidated and analyzed in a more meaningful manner. TransforMED also has instituted a disease registry capability among its pilot practices that serves as a consolidated data repository that allows for patient outcomes analysis on a broader scale.

  • The NDP evaluation team reports it is possible to implement the NDP model in highly motivated practices, but in most, doing so seems to worsen patients’ perception of care, at least in the short term. The PCMH model must continue to evolve in a way that practices can make changes that are desirable in the long-term, but not at the expense of personal relationships with patients and other functions that are already providing good value. PCMH recognition and certification processes also should focus more on patient-centered attributes and the proven, valuable key features of primary care than on the features of disease management and technology.

    TransforMED acknowledges that, early during the NDP, too much emphasis was placed on the practice and not enough on the patient. The model further evolved to ensure the patient was maintained as the central focus. As a result, TransforMED developed the Patient Experience Assessment Tool to assess which practice attributes are most important in the eyes of the patient and not what the practice considered important to the patient. PEAT now enables practices to receive real time feedback from patients, prompting them to pay thoughtful attention to the patient experience throughout the PCMH transformation process.

  •  NDP findings suggest that practices are unlikely to front the cost of transformation themselves. For the PCMH model to become widely adopted, the delivery system must be reformed to support this approach to care. This will require adequate funding from a combination of federal, state, local, insurance industry and health system sources.
    Many family medicine leaders argue that, in the two years since the NDP ended, many primary care practices have taken steps to adopt the PCMH model. More recent data from TransforMED suggest that the upfront costs to practices are not a significant barrier when financial and operational efficiencies are addressed early in the transformation process. This was not measured as part of the NDP, but among the participating practices, TransforMED has observed directly that the change in economic and operational efficiencies have resulted in improved practice revenue and additional time for members of the practice to meet and plan.

“Current health care reform legislation clearly demonstrates that the system is willing to support the PCMH,” McGeeney said. “This is evidenced by the multiple payer pilots being conducted with large medical and hospital systems, state and federal government agencies and employers nationwide — all to address the large-scale delivery system.”

“So, while the NDP has concluded, TransforMED will continue to draw upon knowledge acquired during the project to offer support and consultation to primary care practices as they face the challenges of becoming patient-centered medical homes,” McGeeney said. “And, perhaps most importantly, the incremental learnings from this landmark project continue to inform current health care reform efforts nationwide.”

To date, TransforMED has seen evidence that implementing PCMH components is well worth the time and effort required. At the conclusion of the project, NDP participants from each practice formed a group to enable them to stay in touch and continue learning from one another. The group’s members — who call themselves the Touchstone Group — acknowledge transformation is not easy, but still advocate for the new model and would not be willing to return to pre-NDP ways of practicing medicine.

The TransforMED NDP initiative was an outcome of the 2004 Future of Family Medicine report, and was only one of several steps taken by the AAFP and other family medicine organizations to address the three key focuses of the FFM report: clinical practice, medical education and U.S. health system reform.

The FFM report confirmed what many leaders in family medicine already knew — that patients and physicians were becoming increasingly frustrated with the fragmented and complex health care system, and that family physicians needed to change the way they conduct their practices to continue to provide their patients and their communities with the best possible health care. The report called for a dramatic paradigm shift in the way family physicians practice medicine. It called for a model in which patients, not doctors, are center stage. Family medicine leaders predicted that transformation to this new model would be a long and challenging process and that family medicine could not fully succeed without fundamental changes to the larger health care system.

The TransforMED NDP selected 36 geographically diverse practices from an applicant field of more than 300, ranging in size from practices with seven or more physicians to solo practices. Eighteen of the practices received facilitation services from TransforMED; the other 18 practices received only limited access to TransforMED resources to assist in their efforts to implement the eight key elements of what is now known as the TransforMED Patient-Centered Medical Home model. Key components are:

  • Access to care and information
  • Whole-person orientation
  • Team approach to care
  • Elimination of barriers to access; open access by patients
  • Advanced information systems, including electronic health records
  • Redesigned, more functional offices
  • Focus on quality and safety
  • Sustainable reimbursement

The NDP evaluation was funded by the AAFP and the Commonwealth Fund.

About the AAFP
Founded in 1947, the AAFP represents 100,300 physicians and medical students nationwide. It is the only medical society devoted solely to primary care.

Approximately one in four of all office visits are made to family physicians. That is 228 million office visits each year — nearly 84 million more than the next largest medical specialty. Today, family physicians provide more care for America’s underserved and rural populations than any other medical specialty. Family medicine’s cornerstone is an ongoing, personal patient-physician relationship focused on integrated care.

To learn more about the specialty of family medicine, the AAFP's positions on issues and clinical care, and for downloadable multi-media highlighting family medicine, visit For information about health care, health conditions and wellness, please visit the AAFP’s award-winning consumer Web site,

About TransforMED
The Leawood, Kan.-based TransforMED LLC is a wholly-owned subsidiary of the American Academy of Family Physicians. Established in 2005, TransforMED provides ongoing consultation and support to physicians looking to transform their practices to a new model of care that is based on the concept of a patient-centered medical home. TransforMED is an active member of primary care communities and recognizes and supports the unique value that primary care offers to patients and the health care system. TransforMED shares and supports the idealism and altruism of primary care physicians and the strong commitment to their communities and patients through continuing patient relationships and independent decision making. TransforMED offers practices both products and services, including consultation and advice on implementing the new model. To learn more about TransforMED, visit