In 2005, Tracy Hofeditz, M.D., stood at a crossroads. He'd been in a large group practice in Lakewood, Colo., for several years. But he increasingly found that the way he had to practice -- cramming maximum patients into each day -- was unsustainable and even degrading for him and his patients. Finally, he couldn't hack it anymore.
He left his group practice and considered an attractive opportunity in another field. "Yet I was born and called to be a family physician," he says. "I also didn't want to abandon my patients. I was surprised at how valuable my relationship with them was to me."
So, Hofeditz established his own solo practice with a commitment to caring for patients in a different, better way. That different way was by participating in Colorado's Improving Performance in Practice, or IPIP, pilot program, and then by participating in the three-year Colorado Multi-Payer PCMH Pilot(www.healthteamworks.org), which will conclude next April.
Hofeditz is among the hundreds of family physicians in the United States working on transforming their practices with the help of a PCMH pilot program. According to Hofeditz and four other physicians AAFP News Now spoke with, the benefits they've experienced in the PCMH model have more than made up for the challenges they've encountered along the way.
Hofeditz's practice now includes another physician; a nurse practitioner, or NP; a care coordinator; and other staff. Through the pilots, they've all gained experience in quality improvement and practice transformation.
"I changed from assuming my excellence in performance to realizing that I wasn't as good as I thought," Hofeditz says, adding that he's been revitalized by the opportunity for change embedded in the transformation process. "By measuring quality, finding opportunities to change and then showing that those changes make a difference in patient care, I am pursuing my own excellence and that of my practice."
He's also had to learn to be a team player. "As a solo doc, I saw myself running the show and taking all the responsibility," he says. "Now, I've learned that I can trust my team. I can lead and help the team function better. I have pretty much the same staff that I had before, but now they're more excited about their own work."
- Recognize that becoming a patient-centered medical home, or PCMH, will require you and your practice to change, and then find ways to get help with those changes, such as a pilot program. In addition to financial help for transformation, pilots may offer practice improvement coaches to keep the transformation going.
- Talk to other physicians who have transformed their practices or are in the process of doing so. For example, the Maryland PCMH pilot program's learning collaborative serves that purpose for practices in the pilot. If you're not in a pilot, latch on to someone who's a little further along the transformation curve to serve as your mentor.
- Don't let the paperwork scare you off. The tiny practice of Ramona Seidel, M.D. -- just her and one staff member -- completed all the paperwork necessary for recognition from the National Committee for Quality Assurance and the Maryland PCMH pilot program. "If we can do it, then other practices should be able to do it," she says. "You need smart staff and someone to spearhead the effort. It can seem daunting -- but if you're already doing the work, it's just a matter of documenting it."
- Reliable technology support is a must, whether it's someone you bring on staff or an outside support group with which you contract. If your system is down for part of a day, it will snarl things up for a couple of days while people catch up. Make sure the support group has expertise with the software you have. For Maryland's Donald Richter, M.D., that meant contracting with a support group in Ohio because they knew his software and could help him generate the reports he needed.
- When you're determining which patients are at high risk and should be followed by a case manager, consider taking the time to gather data on ER and hospital admissions. Richter was surprised when this data showed that some of his patients had been in the ER every three weeks, but he hadn't been aware of it. "If we could get such patients into our office more frequently for attention by our staff and care manager, we likely could make frequent ER visits unnecessary, saving the health system money," Richter says. "Over time, we might reduce their need for frequent office visits as well."
There have been challenges, including lower-than-expected patient satisfaction scores thus far. "Patients may sense the change process and know it's stressful," Hofeditz says. "I'm confident that, over time, it will evolve into increasing patient satisfaction."
He's also been challenged by the financial cost and time required to transform, although "we've been less stressed financially than others may be, because the pilot provides a care-management fee." There also will be a bonus if the practice meets or exceeds quality targets.
"But the work we're doing is worth it no matter what we're getting paid for it," Hofeditz says. "This work is not optional to me, but necessary."
He also knows that practice transformation is a never-ending process. "My practice will never be the perfect PCMH," he says. "That shouldn't be the goal -- instead, it should be to pursue perfection and keep it up throughout your career. That was another change for me, but it's critical to understanding the new culture of the PCMH."
Like Hofeditz, when Chris Linares, M.D., started looking at her practice's quality data, it was an eye-opener. "We all think we're doing a great job until we figure out we're just average," she says. "Most family doctors think they're doing a pretty good job for diabetic patients, for example, but they may not realize that a lot of patients aren't coming in on a regular basis until they start looking at their quality data."
Linares practices in Lone Tree, Colo., with another physician; a physician assistant, or PA; an NP, who serves as a care coordinator; and several other staff. The practice participated in the IPIP pilot and now participates in the Colorado Multi-Payer PCMH Pilot.
Participating in the PCMH pilot has changed the culture of her practice, Linares says. For example, "I used to feel responsible for every task, but now many repetitive tasks have been doled out to other team members who are working at a higher level than before. I enjoy feeling that my team has my back, and my staff is happier, too."
In addition, she says, "Taking away those rote tasks means I have more time to talk with patients about important things, like getting to the root of getting them to change to improve their health. In the past, we've allowed this culture of denial with our patients about their problems. Now, we're making them look at it, and that's a little uncomfortable. Some are way on board, but some probably wish we wouldn't do it because we bug them all the time."
Her practice offers group visits for patients with diabetes and for those who wish to quit smoking.
Linares says she was surprised at how easily practice staff adjusted to the culture changes and extra work needed for a PCMH, but she worries about burnout. "People still love what they do, but we've been adding tasks for several years now, and there's probably a limit on what we can add," she says. "Thank heavens the pilot provides some financial support. We've used that money to support the care coordinator and to hire and train more staff than we had before."
A big challenge for Linares and her practice has been the difficulty of pulling data from the practice's electronic health record, or EHR. "This is our third (EHR), so we're not babies at using one," she says, "I really thought we could push some button and have a registry -- but we couldn't."
Instead, the practice maintains three separate registries for diabetes, cardiovascular disease and asthma. "I don't think we can add any more separate registries because of the workload involved," Linares says. "I suspect our (EHR) could do registries, but we'd need a lot of help to learn how. We're not big enough to have dedicated (information technology) staff, which might be part of the problem."
When they switched to their current EHR last March and had to change the way they gathered data, their numbers suddenly looked terrible. "For example, we had been at 90 percent for asking people if they smoked, and suddenly we were down to 3 percent," Linares says. "We fixed that issue, but for each data point, we have to figure out if it's accurate or inaccurate because we can't find the data in our system.
"I was shocked to learn that there are companies whose sole purpose is to find your data in your (EHR) that you pay a lot for already. There's just something wrong with that."
In addition to transforming her practice with the help of the Colorado PCMH pilot program, Helen Story, M.D., who practices in Littleton, has reached out to her medical neighborhood to make mental health care more easily accessible for her patients.
"Often, when you refer people to mental health care, they say it's too hard and come back to you again," Story says. "This was frustrating for our three PAs, who are young and haven't had training and experience in dealing with people who are overwhelmed with life, severely depressed, bipolar or struggling with substance abuse.
"So we called our county mental health center and asked if they would consider sending a clinician here a couple of days each week," Story says. After exploring the possibility, the center sent a clinician to the practice one day a week, and then bumped it to two days. The arrangement has worked well, she says.
The practice has arranged to have another company do cardiovascular risk screening in the practice. Bone density tests were offered until the company that did them went out of business.
Transforming to the PCMH model has definitely changed the way Story practices. "I've learned to delegate things better, and we have set up systems in the practice so we don't lose people in the cracks so much," she says. For example, once a month, the receptionist checks a list of people who are on warfarin and sends recall letters or calls them to set up an appointment.
A medical assistant serves as a clinical care coordinator, looking through patient charts the day before appointments to determine what each patient needs, such as a flu shot or lab work. During the appointment, the medical assistant is responsible for getting those things done before the doctor walks into the treatment room.
Story points to another financial reward of the PCMH model. "If you look at the big picture, you're generating more revenue because your diabetic patients are coming in regularly, and your patients on warfarin are coming in every month," she says. "Also, you've moved some tasks from the physician to others, and the doctor could see additional patients in the time that's been freed up."
Donald Richter, M.D., is medical director of a federally qualified health center in Oakland, a town in rural western Maryland. The center has a staff of about 20 people, including Richter, a part-time physician, three NPs and one PA. Before joining the center three years ago, Richter had a solo private practice for 24 years.
He and the center's administrative staff had already been talking about transforming the health center into a PCMH when the three-year Maryland Multi-Payer Patient Centered Medical Home Program(mhcc.maryland.gov) was announced. "We thought the pilot offered a good opportunity to take the PCMH plunge with some financial help, since the pilot would provide a fixed transformation payment and the possibility of additional money from shared cost savings," Richter says. The center applied and was accepted into the pilot, which launched this year.
The center already was conducting patient satisfaction surveys and tracking some quality measures, but the pilot layered other requirements on top of these. The biggest change for Richter was the switch to team-based care. Other changes include more quality measures, a scheduling system that is partially open access and a patient tracking system.
The center recently hired a nurse as the case manager for high-risk patients with diabetes, hypertension and depression. Information from patient registries for these conditions helped determine which patients were at highest risk. The center also considered input from other health care professionals about patients they were worried about, and then looked at data on hospital and ER use. About 35 patients were determined to be at highest risk and are now followed by the case manager.
The latest patient survey results show that patients like the changed appointment scheduling system and the written patient plans they receive during each visit. Results regarding improved outcomes are harder to measure, Richter says, but he points to an anecdotal example that illustrates the effect of case management: With the increased attention of the case manager, one patient who's frequently been in the ER has been able to stay out of the ER for the past four months.
The "micropractice" of Ramona Seidel, M.D., is almost certain to be the smallest practice in the Maryland PCMH pilot program because it consists of just Seidel and one staff person who does administrative work and everything else except see patients.
Seidel was a very early adopter of the PCMH concept. She read the Future of Family Medicine report and decided she wanted a practice that emulated what was published there. When the larger practice she was in wouldn't support her, she left and established her micropractice in 2005. Less than a year later, her practice was in TransforMED's National Demonstration Project as a facilitated practice. Now, she's participating in the Maryland PCMH pilot program.
Seidel acknowledges the challenge of implementing the PCMH team-based care concept with only two people in her practice. "We use community partners to help educate our patients," she says. "The two of us do a lot of the patient reminders, and (the staff person) checks people in, checks the chart to see if the patient is up-to-date, and so on. Between us, we do some of the team effort."
She admits that practicing her way is a great deal of work. "It's gratifying," she says, "but financially, it's not at all rewarding. Hopefully, it will be a little more rewarding with this state project than without it."
Seidel says that her practice journey has been interesting, beginning when the term PCMH hadn't really been created. Now, the PCMH has become a hot ticket item, a thing to reach for. "It's been exciting to be there from the ground up," she says.