Building on Successful Patient-Centered Medical Home Transformation

Colorado Family Physician, Practice Team Members Embrace Continuous Improvement

June 13, 2012 05:25 pm Sheri Porter Lakewood, Colo. –

Editor's Note: This is the third and final article in a three-part series detailing one family physician's commitment to building a patient-centered medical home practice in Lakewood, Colo. Parts one and two of this series appeared previously in AAFP News Now.

Visitors to Belmar Family Medicine( in Lakewood, Colo., likely sense that this medical practice is different the moment they walk through the door and enter into a warm and inviting environment.

No sterile white walls here. Warm colors mark the walls, and soothing artwork, including a water sculpture, greet visitors. Tropical plants backlit with soft lighting are tucked into corners of the outer office. Patients and their families help themselves to hot coffee or tea at a strategically placed drink station, and classical music plays in the background.

Beyond the front desk, clinic hallways sport a myriad of framed certificates and awards signifying that this practice, owned by Tracy Hofeditz, M.D., has been recognized for its performance in providing high-quality patient care, which is a result of the transformation to the patient-centered medical home (PCMH) model of care the practice began in 2007.

Since then, Belmar has received level three PCMH recognition from the National Committee for Quality Assurance (NCQA), but he is always striving to make his practice better.

Improving the Patient Experience

Although Belmar Family Medicine works hard to put the patient at the center of the practice, the only way to know for sure that patients embrace the enhanced services they began receiving since the practice embarked on its expansive change effort is to ask them.

But, as Hofeditz discovered, asking for patient feedback sometimes produces unexpected results.

story highlights

  • Although Belmar Family Medicine earned level three patient-centered medical home (PCMH) recognition from the National Committee for Quality Assurance in 2009, the practice continues to add new components to enhance patient care.
  • Most recently, the practice hired a care coordinator to work with patients diagnosed with diabetes, and it continually urges patients to take responsibility for their own care.
  • Maintaining a PCMH practice is an ongoing task, but doing the extra work means extra revenue for the practice and higher quality of care for patients.

"It's been hard for me to receive patient satisfaction survey results because I've worked so hard to be an excellent physician," says Hofeditz. Despite some stinging remarks on surveys -- produced twice yearly -- the experience gives the Belmar team an opportunity to tend to problems highlighted by patients.

Most often, it's practice processes that cause patients distress. And sometimes the fix is fairly simple. For example, in an effort to help patients access care more easily, Belmar improved its long-established same-day scheduling policy by adding more same-day "urgent care" slots and by offering extended hours two days a week. In addition, staggering lunch breaks for staff members allows the office to remain operational right through the lunch hour.

The practice has not moved to weekend hours, but that option remains on the table, as does re-establishing group visits for patients with chronic ailments, such as diabetes.

As part of its ongoing patient outreach, Belmar also began offering private patient portals via its electronic health record system in 2009. The practice upgraded the site in 2011. Still, according to Belmar's practice manager, Judy Hewitt, only about 10 percent of patients seen in the past 18 months have signed up for their personal portal through Belmar's website. "We have about 300 patients enrolled, and we'd like to increase that number," she says.

Diane Cardwell, M.P.A., A.R.N.P., vice president of health care solutions for TransforMED(, the AAFP's nonprofit health care transformation subsidiary, has guided many practices like Belmar through the maze of change that today's health care system demands, and that includes helping practices improve patient portal enrollment. She agrees with Hewitt that it can be challenging.

"I make sure everyone in the practice is using the portal, because if staff members experience it, they will promote it," says Cardwell. A patient portal system can save everyone in the office time by enhancing communication with patients; for example, the portal can be used to trigger patient appointment reminders and to send test results directly to patients.

And if staff members also are patients at the practice, remind them to set up their own patient portals, Cardwell adds. "If I use it as a patient, I'm much more likely to promote it."

Another of the new additions to Belmar's buffet of services is its "Passport 2 Health" program, which serves patients with diabetes. The health-coaching program consists of five 60-minute private sessions between the patient and Belmar's patient care coordinator, Mackenzie Bell, M.P.H.

"We're trying to empower patients to take care of themselves and take a role in their health care," says Bell. "That's the point of care coordination."

She talks to patients about living with a chronic disease, coaches them on the importance of physical activity and good nutrition, and impresses upon them that healthy living must be a lifelong habit. "It's my job to educate patients about possible outcomes if they don't control their disease," says Bell.

"I'm also the annoying person who calls them when they're overdue for labs or if we haven't seen them for a while," she adds.

Creating a 'Partners-in-Care' Mindset

Patient-centered care is so important to Hofeditz that he deleted the phrase "noncompliant patient" from the office vocabulary and replaced it with the TLC (tender loving care) list.

"To call a patient noncompliant is an easy way for physicians to give up their responsibility to provide better care," says Hofeditz. "We define our TLC list as high-risk diabetic patients who have not met goal on certain measures or who have not followed up. Those patients are called weekly by the care coordinator until they schedule their visit to come in for recommended care.

"We want to be a pain in their tails until they commit to being a better partner in their care." Hofeditz calls this method "activating patients" and says it is an important tool in the national quest to provide better health care at a lower cost.

But for this family doc, the end goal also is personal. "I want patients to engage, or I want them to leave my practice," he says.

Then, appearing surprised by his own words, Hofeditz quietly adds, "I want patients to take responsibility for their health and not leave it all on my shoulders."

Belmar Family Medicine Shares Its PCMH Blueprint

Tracy Hofeditz, M.D., is eight years into his patient-centered medical home building project. Winnowing down all the steps he's taken into one short list looks something like this:

  • Recognize and accept the need to change.
  • Look outside the practice for organizational help.
  • Enlist the help of a coach to discover practice weaknesses.
  • Build and nurture the practice team.
  • Implement a daily team huddle.
  • Join a chronic disease registry.
  • Measure quality and compare your outcomes to those of other practices.
  • Embrace electronic health records.
  • Invite patient feedback via a survey instrument.
  • Hire a care coordinator.
  • Implement a mental health outreach program.
  • Insist on continuous improvement.

Implement the above steps, and your practice is on the way to increasing practice revenues and improving the quality of patient care, says Hofeditz.

Dealing With Ongoing Medical Home Maintenance

Most recently, Belmar Family Medicine entered the maintenance phase of its PCMH building project, and practice manager Hewitt is deeply involved in the practice's renewal process.

According to her, the initial NCQA application process took 80-100 hours, and she laments that the renewal process for the more rigorous 2011 standards was equally time consuming.

Still, says Hewitt, the work was worth the effort because official recognition as a PCMH practice will continue to open new streams of revenue, such as incentive payments from insurance companies and grant funding for practice improvement projects from any number of outside organizations.

"If you think you're already doing the (PCMH) work, why not get paid for it?" asks Hewitt. "Document your efforts, prove your quality and start looking around for resources to tap into."

Hofeditz agrees. "As family physicians, we must learn new ways to increase the value of our care and demand reimbursement consistent with our value." This work of practice transformation can and must be done by small practices, he says. "I challenge physicians to embrace these changes and see for themselves. It's not easy, but neither was medical school."

Finding a PCMH Project in Your Area

Physicians interested in participating in a PCMH pilot program but who don't know what's available in their area should start by contacting their AAFP constituent chapter, says TransforMED's Cardwell.

Talk to major payers, too, because if they're not engaged in any pilots yet, repeated interest from physicians with whom insurers contract could encourage them to take action.

Cardwell also recommends checking in with TransforMED. "We have a map with all of the projects we're touching," says Cardwell. Take advantage of TransforMED's Delta-Exchange network( (it's free to AAFP members) and post a query on the network asking for suggestions from physician colleagues who practice nearby.

Lastly, says Cardwell, the Patient Centered Primary Care Collaborative( offers resources on all of the ongoing PCMH projects nationwide. And if nothing is available in your region right now, don't despair. "Learn everything you can about existing PCMH pilots, and you'll be poised to jump into the next available PCMH slot in your area," she notes.