Strategies for Achieving Whole-Practice Engagement and Buy-in to the Patient-Centered Medical Home

INTRODUCTION

Primary care in the United States, intended to address acute and episodic illness, unintentionally limits comprehensive and coordinated preventive and chronic care and is in need of repair.^1–4 The patient-centered medical home (PCMH) care model addresses these limitations through organizing patient care, emphasizing team work, and coordinating data tracking.⁵ According to the National Committee for Quality Assurance (NCQA), a US PCMH-accrediting agency, PCMH transformation requires successful redesign across 6 categories of standards (summarized in Table 1) that (1) enhance access and continuity, (2) identify and manage patient populations, (3) plan and manage care; (4) provide self-care support and community resources, (5) track and coordinate patients, and (6) measure and improve performance.⁶

In 2010 a PCMH Stakeholder Collaborative (endorsed by the NCQA⁶) reviewed prospective US studies evaluating PCMH implementation and found that PCMH transformation improved quality of care and patient experiences and reduced hospital and emergency department utilization.⁵ In 2013, Jackson et al published a systematic review of PCMH outcomes describing small, positive effects on patient experiences, small to moderate effects on preventive care service delivery and staff experiences, and reduced emergency department visits (in older adults), but results related to chronic illness care processes, clinical outcomes, hospital admissions, and costs of care were inconclusive.⁷ Although PCMH is included in the Patient Protection and Affordable Care Act (PPACA) as a successful pilot model for achieving national health care reform goals,⁸ mixed results in evaluations of PCMH interventions call for a deeper understanding of practice change efforts.^9,10

Several change models address PCMH transformation; Solberg’s conceptual framework for practice improvement¹¹ was used to guide the current study. Solberg draws on organizational development theory,¹² which argues systems change occurs as a result of planned change “dependent on agreement between individuals and organization goals.”¹¹ Within this framework, 3 elements must be substantially present to produce the desired organizational change and quality improvements: priority, change process capability, and care process content.

Our study findings illustrate and extend Solberg’s notion of priority. When articulating priority, Solberg argues that for any major change to happen, it must be tethered to both a strong desire for change and an internalized belief for the need for change; otherwise, it is unlikely to occur. Solberg posits that organizational leaders must do more than say change is a priority: implied in his argument is a need for personnel buy-in at all organizational levels to assure a shared value for making change a priority. We were guided by the model conceptually, but we also explored the implied concept of buy-in more completely, extended the model to include buy-in as a necessary condition, and illustrate lessons learned about how to foster organizational buy-in to PCMH transformation.

The relationship of buy-in to organizational change is explored in quality improvement literature and is implicit in discussions of organizational change in health care. For example, Nutting and colleagues^13,14 argue that a shared vision is an essential ingredient in managing practice change. Hroscikoski and colleagues¹⁵ suggest systemic change requires agreement between individual and organization goals. Similarly, Clarke¹⁶ argues there must be a negotiation between the understandings of the organizational members toward congruence of thought. Garside¹² argues a need for staff buy-in when making recommendations for organizational change in health systems, highlighting the need for clarity of vision and a supportive organizational culture. Unfortunately, even though shared visions and staff consensus appear to be key elements in facilitating organizational change, little information exists to guide leaders who are directing PCMH transformation in ways to obtain buy-in among personnel at all organizational levels. Buy-in is conceptualized in this study as a person’s agreement about the value and need for proposed change.¹⁷ In the case of PCMH transformation, whole-staff engagement entails practice members at all levels not only making the intellectual decision that PCMH transformation is necessary and beneficial but also agreeing that quality improvement and organizational change are priorities. It is important to know what strategies practices use to obtain buy-in as well as which are perceived as most effective. Both may assist in identifying barriers to or facilitators of successful transformation.

To investigate PCMH buy-in strategies, we focused on the transformation experiences of personnel in 20 adult medicine practices participating in the first regional rollout of a state-led, multipayer-supported, chronic care–focused PCMH initiative in Pennsylvania.

Self-appointed multidisciplinary teams from each practice participated in a regional state-funded learning collaborative supported by multipayer supplemental payments to practices, reported monthly quality measures, and utilized Improving Performance in Practice coaches funded by payers and the state of Pennsylvania.¹⁸ Specifically, we aimed to understand and illustrate how practices achieved buy-in to and whole-staff engagement in the PCMH transformation process.

METHODS

As part of a larger institutional review board–approved evaluation study, semistructured interviews with 136 individuals and 7 focus groups involving 48 individuals were conducted in 20 medical practices. Table 2 describes the practices in terms of size, type, service area, and initial NCQA recognition level. Participants were chosen by practice leaders and purposefully included learning collaborative team members and those not involved in the collaborative. Individual interviews were conducted with 59 clinicians (physicians and nurse practitioners), 28 medical assistants, 16 office administrators, 11 care managers, 6 front office staff, 5 nurses, 5 patient educators, and 6 others. Interviews and focus groups were conducted in person during researcher site visits; however, telephone interviews were used when schedules did not allow in-person meetings. Interviews were guided by a script of open-ended questions and probes designed to elicit participants’ perceptions of their PCMH transformation. Interviews were conducted at the end of the second or third year of PCMH implementation, audio-recorded with participant consent, transcribed verbatim, and corrected for accuracy. Site visit field notes and monthly practice narrative reports were also reviewed.

Efforts to enhance the trustworthiness of data collection and interpretation included a variety of recommended strategies^19–21: triangulating data and researchers, collaborating among medical and social science researchers, interpreting process memoranda documentation, attending to disconfirming evidence, peer review and debriefing, and applying a consensual team-based qualitative research approach to analysis.^22,23 This consensual approach involved 3 phases.

In phase 1 (the larger study), 2 qualitative researchers performed data reduction, creating a coded list of key concepts that emerged across the data. They conducted line-by-line analysis, using the constant comparison method to compare and contrast ideas discussed in each text.^24,25 Codes were negotiated and refined in weekly meetings through discussions and writing memos. The research team included a PCMH practice coach, 1 physician, and 2 qualitative social science researchers.

In the second phase, 2 researchers synthesized and coded on^26,27 the phase 1 coding for descriptive information pertaining specifically to personnel buy-in and strategies for achieving buy-in. Coders used 2 strategies. First, they conducted a search for the terms “buy-in,” “vision,” and “agreement” and examined transcripts to assess whether the discourse addressed the question at hand, conceptually defined as agreement about the value and need for proposed change. At this point, change could refer to personal, team, or organizational change. Only search terms yielding data relevant to our questions were retained for analysis. The second strategy identified phase 1 codes conceptually aligned with the idea of buy-in and applied a focused coding of those data for insight about member buy-in to PCMH transformation. For example, phase 1 data, coded into the category “roll out” (conceptually defined as commentary about how practices got started with PCMH implementation) would likely contain useful information about the concept of buy-in. Second-phase (focused) coding identified the specific strategies discussed in the data related to achieving buy-in. The final stage of analysis—data abstraction—linked strategies and findings to identify broad lessons learned. All data management and analyses were performed using NVivo 9.0 qualitative data management software (QSR International).²⁸

RESULTS

We identified 13 strategies across 3 overarching lessons for obtaining medical practice buy-in and whole-staff engagement to PCMH transformation. There were no discernible differences in responses when comparing categories of medical practice staff, and there was general consensus across individual participants and across practices on the usefulness of these strategies.

DISCUSSION

Our first lesson highlights the value of an intentional internal campaign characterized by effective, concise communication plans for PCMH implementation, especially in the beginning stages of transformation. Consistent with existing organizational change literature,^29–33 buy-in was enhanced through frequent meetings to discuss evolving organizational change. Novel findings of this study are that practice personnel strongly desired formalized solicitation of their input, access to leaders, and acknowledgement of how their input was or was not used. Whether through e-mails, bulletins, newsletters, or informal discussions, participants agreed on the importance of integrating the language of PCMH values into everyday communication, as other studies have found.^34–36

In addition to clear and consistent communication, participants emphasized the need for education and training of personnel on the precepts of PCMH, particularly given the lack of preparation within most teams for collaborative, evidence-based, accountable care. Generally, the literature suggests that education and training were most effective when provided early and often and when they included concrete information and guidance on what the PCMH is and how it is implemented. Most commonly cited educational and training needs revolved around health information technology systems.³⁸ One study supported our finding of using motivational interviewing as a general patient engagement method.³⁹ Another novel contribution of this study is the finding that team members strongly desired to understand why PCMH is an optimal care model, not just what it is or how to achieve it.

Our study findings also emphasized the effectiveness of positive reinforcement and participatory problem solving based on objective comparative data, such as benchmarked clinical performance. Data sharing may cause concern in some personnel, though our study suggested allowing clinicians a 1- to 2-month buffer period to improve their measures before sharing. Because these issues can be complicated, others have suggested drafting a policy statement or establishing a task force for responsible, safe, and secure collection and use of shared data.^40,41

A general point in our study findings, which is found abundantly in the literature, was the importance of champions of change in their abilities to send clear messages, encourage team mentality, and provide thought leadership by promoting PCMH values. Some researchers argued having both administrative and physician champions working in conjunction is optimal to minimize the perception of change as a managerial mandate (especially among older, more seasoned personnel, who are more likely to be skeptical and hesitant).^29,32

Our second lesson was the importance of mobilizing resources. Participants espoused the value of appropriate use of resources (especially of existing resources, when possible) during PCMH transformation, and they were adamant about the need for external resources, both financially and in terms of technical and transformation assistance. Two key human resource strategies were developing the role of the medical assistant⁴² and adding care management and coordination capabilities focused on the highest risk patients.^43–45 Practices in our study relied on the multipayer financial incentives they received as part of the statewide initiative to fuel their transformation engines. Many acknowledged they would have been unable to both start and sustain PCMH work without the added payments, supporting arguments for realigning financial incentives in the health care system.^46–48 Likewise, they credited the learning collaborative for providing essential know-how and peer support for transforming their care processes.

Finally, promoting team synergy was perceived as central to securing buy-in to transformation.⁴⁹ Participants in our study articulated the need for organizational culture that promotes an open exchange of ideas, shared creativity, overlapping but clear roles and responsibilities, and system-wide incremental change. Other researchers suggested that a culture of creativity and innovation can be accomplished through an organizational adhocracy model that maximizes decentralized structure, encourages creative problem solving, values flexible and adaptive responses, tries new ideas, and promotes development of innovative programs.^50–52 Practices in our study emphasized the importance of being clear that PCMH transformation takes years and is an evolving process.

There are 2 limitations of this study. First, it is restricted to primary care practices in a single geographic region (in which the practices differed by size, specialty, ownership type, and communities served); and second, the participating practices received additional funding and technical support to help with transformation. Both limitations could impede generalizability. Conversely, an important strength was that the research team was balanced with medical and nonmedical analysts, thus reducing positivity bias in interpretation and offering multiple opportunities for challenging, discussing, and revising data interpretations. The presented interpretations are meant to be descriptive, rather than predictive or causal; they are intended to inform future policy and practice. Future studies should formally assess the effectiveness of these strategies in a comprehensive model of PCMH implementation; such empirical evidence would provide a better understanding of the predictive or causal nature of these strategies in accomplishing successful, efficient PCMH transformation.

Given the promise of PCMH for providing a better model of primary care, it is likely that the PCMH will continue to grow nationally. To successfully achieve quality improvement and transformation, health care organizations must make improvement a priority by promoting a strong desire for transformation and a shared agreement for change among personnel at all organizational levels. Upon close examination of the lessons learned from these medical practices, we contend that organizational buy-in might usefully be added to Solberg’s conceptual framework for practice improvement as a necessary condition to embrace and prioritize change, to capably facilitate the change process, and to effectively implement concrete changes.

This study also contributes to the growing literature providing a deeper understanding of change efforts within practice systems, in general, and specifically to PCMH transformation. Practice leaders promoting transformation in their own organization might find some or all of these strategies useful in their efforts to improve and change. By creating an organizational culture that reflects teamwork and ownership of organizational ideals, bolstering confidence and efficacy of personnel, and communicating clearly and consistently about transformation, leaders may be more successful in attaining buy-in and accomplishing their change goals.

Practices seeking to become a PCMH face numerous challenges. In our study, however, participants affirmed that the benefits can be substantial and showed that given necessary internal and external supports, long-term buy-in to PCMH can be achieved.