Lessons Learned From the Study of Primary Care Transformation

Our practice, the Casey Health Institute (CHI), is different from practices described in the journal in four essential ways:

1. We're not transforming; we're building. We opened our doors in March 2013, structured as a PCMH from the get-go.

2. We're integrative and team-based. Many Americans use complimentary and alternative medicine, so their care team should reflect that. This kind of "integrative primary care" works exceedingly well in a team environment, where all members of our team are engaged, involved and actively focused on implementing a true patient centered experience. Our staff and clinicians aren't "told" what to do - they are building what needs to be done together.

3. We invested in having a patient and family advisor on the team as we designed and are now implementing our integrative PCMH. A patient herself, with a professional background working for consumer organizations, our advisor is a core part of our operations. We are also collecting patient experience data from the start, and are using it to inform our implementation. It's striking that very few PCMH evaluations involved patients (McNellis et al)

4. We offer PCMH services to all patients, not just the chronically ill or patients with a certain health plan. We believe all patients can benefit from a care plan, wellness coaching and pro-active care coordination inside and outside of our walls. And yes, we take all major insurance.

We hope future research will study the experiences and outcomes of practices that built for PCMH from the day they opened their doors.

David Fogel, MD; Co-Founder
Ilana Bar-Levav MD; Co-Founder
Kisha Davis, MD MPH; Director of Community Health
Christine Bechtel; Patient & Family Advisor
Nancy Starbuck, MS; Practice Administrator
www.caseyhealth.org

Competing interests:   None declared

Much like the blind man trying to describe an elephant, attempts to make concise comments on the large creature which is PCMH transformation risks leaving a reader with a sense of the matter which is incomplete. I believe careful reading of this supplement gives you a good idea of this animal, as remarks echo what I have sensed as I have experienced and am experiencing this process.

In retrospect our practice has been in transformation since 2000, though we did not know that was what we were doing. A partners strong leadership took us on a path motivated by principles existing outside any particular stated theory of practice. We began by sensing good care and moving toward it as we were able. We were blessed to be in the NDP and have the vision toward which we ought to further move consolidated. Having that vision allowed/accelerated further growth. Yet we did this without compensation for our efforts other than our own satisfaction. This extended to NCQA recognition in 2011.

Now I reflect on our path as I look to guide area PCP practices within our IPA to adapt the model. (The realities of the "elephant" become more clear as one wonders about leading others in that direction.) It is so true that qualities of PCMH exist in non-recognized practices. It is so true that recognition does not certify "PCMH behavior" will shine strongly in every corner. It is so true that leadership, team, and communication are the keys to the function and also the recognition.

What we are venturing to learn is how leveraging recognition as a surrogate for desirable behavior through higher payment for recognition in our marketplace can facilitate the function necessary for best care. In process now are negotiations to pay FFS at a 30% premium for recognition while also bonusing for quality performance. One would expect adapting the PCMH vision will allow those practices to "score again" in that sphere. Early results indicate that adding a clear financial incentive accelerates acceptance of the vision and helps develop available leaders for the change. Changes in function are occurring well before recognition. What will analysis of this effort reveal after the payment system has appropriately followed the initial push of change?

We are still early in this experiment. The elephant lumbers forward as we attempt to describe it. I am guessing that the weight of the elephant will shape the space within which it lives and its momentum will bring those who "believe" and those who do not "believe" to a new and better place for primary care when a new stable healthcare system gels.

Competing interests:   None declared

The Annals of Family Medicine issue, "Transforming Primary Care Practice," and the AHRQ-funded supplement provide important insight into several areas that the Jewish Healthcare Foundation (JHF) and the Pittsburgh Regional Health Initiative (PRHI) have been reflecting upon, including the role of the practice facilitator, why some practices fully engage or transform while others deviate from the intended model or do not participate, how to build leadership skills for PCMH transformation, how small practices can creatively implement the "spirit" of the resource- intensive PCMH model, and the evidence for the PCMH.

As Shaw et al. describe, the role of the facilitator is to enhance the practice's capacity to learn and change by helping the team identify and implement their own solutions. The approach of eliciting solutions instead of imposing solutions is a core principle of effective behavior change strategies. However, despite the use of on-site facilitation and learning collaboratives, Shaw et al. did not find statistically significant improvements in colorectal cancer screening rates and observed that some practices fully participated while others did not. Their qualitative analyses suggest that facilitators to transformation include strong communication between leaders and other team members, cohesive teams, leadership, and psychological safety for the QI intervention. Similarly, Donahue et al. observed that the transformed practices were characterized by highly engaged organizational leadership and the use of data to drive decisions, while the other practices experienced staff turnover, competing priorities, fiscal stress, and a lack of trust in the concept of a team. Gill and Begley, in their editorial, summarize that practice facilitation without leadership, teamwork, communication, and metrics is not likely to succeed.

The AHRQ-funded supplement adds further insight into what it takes to transform practice. Gabbay et al., for example, found that the highest- performing medical home practices tended to have existing structural elements such as EHRs, facilitative leadership, plans for testing change such as PDSA cycles, more expanded roles among non-physician staff such as new tasks for medical assistants, and monitoring and feedback systems, among other factors. After reviewing the outcomes of the AHRQ grantees, McNeillis notes the importance of having a "strong foundation for redesign," including existing EHRs, operations management, resources, broad organizational support, experience with teams, financial stability, and focus, among other factors.

Many of the qualitative findings from these articles reflect PRHI's experience with providing coaching to small primary care offices with the goal of implementing the PCMH or collaborative care management models. As we recently described in "Putting the PRIME in Primary Care," a common lesson learned has been that leadership, clear communication, staff engagement, and a culture of data-driven quality improvement need to be in place for successful transformation; in addition to effective payment systems and investments in health information technology.

These findings raise an important question: How can communities help small primary care offices, including community health centers, develop the necessary infrastructure to pursue enhanced primary care models and community-based interventions such as the models described in "Putting the PRIME in Primary Care"?

This issue of the Annals of Family Medicine and our practice coaching experience - and our CMMI-funded primary care resource center project (PCRC) in which we are creating hospital-based PCRCs which serve as extensions of primary care practices, improving the transition of complex patients from the hospital to outpatient care and ensuring they continue to get the medical and other services they need - suggest that developing shared resources among small primary care centers to develop a strong foundation for redesign and helping the organizations build their teamwork, internal communication, facilitative leadership skills, and health information technology systems prior to implementing transformative models of care appear to be warranted.

Competing interests:   None declared

Facing a collective crisis in primary care driven by AMA-inspired disparities in specialty income, the AAFP, AAP, and ACP went in search of the Patient Centered Medical Home. It wasn't a bad idea, and it looked like good politics, especially since specialists were solidly in control of the RUC. Who could disagree with Marcus Welby, MD and the medical home he provided for his patients? And maybe if the AAFP had started out by carefully examining Welby-esque practices, and drawing evidence-based conclusions, we wouldn't be in the mess which the Annals has so dispiritedly documented over the past few years. Hand it to the AAFP: they went "all in," betting that the evidence, when it arrived, would be more congenial than it is. You gotta admire their stones. Still, I'm a hard-headed, evidence-based FP, and I ain't going to be transformed based on what I've seen so far. There was a better way, all along. Here are some facts and assertions, based on 27 years of solo practice in Topeka, USA. I've said all this before in detail; search my last name in Family Practice Management. I'm tired of this foolishness. 1. I earn over twice the specialty average in 32.5 scheduled office hours per week, plus about 15 OBs a year. I don't have any gimmicks-- no cosmetic procedures or colonoscopies. 2. I described "open access" appointments in FPM long before the term was invented. A new patient can see me in a week, an old one in a day. 3. My "team" consists of 3 RNs, and no MAs. Where I stand filling my electronic prescriptions, I can hear everything they say, as well as the voices of my receptionist, and patients checking in and out. We don't need huddle groups or team meetings. CQI is continuous and almost effortless. 4. Laughter fills the office. We're always joking around with each other and our patients. We've vacationed together, weddinged together, and funeraled together. Although I'm 63 years old, I'll never retire. Where else could I have so much fun? 5. An "early adopter" of almost every other technical advance, I use paper charts. The electronic medical record in Topeka (which I use in the hospitals, but not my office) has been a huge step backwards in every respect. A cold in the ED now earns me 18 faxed pages; and a cogent, dictated discharge summary has now become an indecipherable mess, making it almost impossible to reconstruct the hospital course. I have found errors in the record which must have plaintiffs' attorneys conducting seminars. 6. Obtaining a diabetes certification from NCQA was a breeze. Most of my adult onset diabetics are found and treated at the pre-diabetic stage. Maybe I'll never get recognized by an ACA. Who cares? 7. When I go to a conference, or learn of a practice advance, change is almost instantaneous. No committee meetings for me. We Just Do It. 8. I don't survey my patients' satisfaction. Our town is filthy with good physicians, and if my patients weren't happy, I'd be out of business in a year. The two hospitals, and their primary care groups, are always advertising for patients. My advertisement is happy customers. I could go on, but enough is enough. The whole TransforMed experience has been a faith-based initiative which has failed, and should be junked by pragmatic physicians. The EMR, which may still hold promise if they ever figure out a way to communicate across platforms and focus on the important stuff, has so far been an expensive disaster. But it's great for huge practices which use to deliver paper charts to their widespread offices by truck. I know that Marcus Welby has lost, because newly-minted FPs just want to collect a salary and complain about their work conditions. It's all such a tragedy, but that's life.

Competing interests:   None declared