Article Figures & Data
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PCMH Standard Content Summary 1. Enhance access/continuity Patients have access to culturally and linguistically appropriate routine/urgent care and clinical advice during and after office hours The practice provides electronic access Patients may select a physician The focus is on team-based care with trained staff 2. Identify/manage patient populations The practice collects demographic and clinical data for population management The practice assesses and documents patient risk factors The practice identifies patients for proactive reminders 3. Plan/manage care The practice identifies patients with specific conditions, including high-risk or complex care needs and conditions related to health behaviors, mental health, or substance abuse problems Care management emphasizes: Previsit planning Assessing patient progress toward treatment goals Addressing patient barriers to treatment goals The practice reconciles patient medications at visits and after hospitalization The practice uses e-prescribing 4. Provide self-care support/community resources The practice assesses patient/family self-management abilities The practice works with patient/family to develop a self-care plan and provide tools and resources, including community resources Practice clinicians counsel patients on healthy behaviors The practice assesses and provides or arranges for mental health/substance abuse treatment 5. Track/coordinate care The practice tracks, follows-up on, and coordinates tests, referrals, and care at other facilities (eg, hospitals) The practice manages care transitions 6. Measure/improve performance The practice uses performance and patient experience data to continuously improve The practice tracks utilization measures, such as rates of hospitalizations and emergency department visits The practice identifies vulnerable patient populations The practice demonstrates improved performance -
NCQA = National Committee for Quality Assurance.
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Reprinted with permission from the NCQA.6
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Practice Practice Sizea Practice Type Service Area Initial NCQA Levelb 1 Small Private Urban 2 2 Small FQHC Suburban 1 3 Small Private Urban 3 4 Medium Private Urban 3 5 Medium Private Suburban 3 6 Solo/partner Private Suburban 1 7 Medium FQHC Urban 1 8 Small FQHC Urban 1 9 Solo/partner FQHC Urban 1 10 Large Residency Urban 3 11 Medium Residency Suburban 1 12 Medium Residency Urban 1 13 Medium Private Urban 3 14 Small Private Suburban 2 15 Small FQHC Urban 1 16 Small FQHC Urban 1 17 Medium Systemc Suburban 1 18 Solo/partner Private Suburban 3 19 Medium Private Suburban 2 20 Solo/partner Private Urban 1 -
FQHC = federally qualified health center; FTE = full-time equivalent; NCQA = National Committee for Quality Assurance.
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Note: Includes the 20 practices used in this study. Five other practices were excluded because they had no data for this study.
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↵a Practice size based on the number of FTE clinicians in each practice, as follows: solo/partner = 1–2 FTE clinicians; small = 3–4 FTE clinicians; medium = 5–9 FTE clinicians; large = ≥10 FTE clinicians.
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↵b To achieve NCQA level 1 recognition, practices must comply with at least 5 of 10 must-pass elements in practice standards; achieving level 2 or 3 depends on overall scoring and compliance with all 10 elements (http://www.ncqa.org/portals/0/PCMH%20brochure-web.pdf).
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↵c Community-based practice owned by a system.
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- Table 3
Effective Communication and Internal Campaigning Strategies That Facilitate Practice Buy-in to PCMH
Strategy Exemplary Qualitative Data Ensure clear and concise communication and support from accessible practice leadership “We have monthly staff meetings…communicate with everybody when there are any changes. I send group e-mails out to update things or new ways we are going to do something. Of course, I see everybody every day, so anything that is new or different or any problems that anyone is having, we try and address them, so that people don’t get too frustrated.… As the director, I’ve always directed with consensus as much as possible. Sometimes things come from the top that can’t be flexible, ‘we just have to do it this way because of whatever reason,’ but generally, they are rational decisions that we make. I think everyone has bought into it, felt like it lets us provide better care. We want to see our numbers doing better, and everybody likes each other, and everybody has the same mission or goal.” Educate about PCMH: not just what and how, but why [In response to why there was lack of buy-in at the beginning]: “There was not much information that was given to us when it started…that’s why one of our physicians just said no…. Why would I want to do this? What’s the benefit?” Provide concrete information and guidance on known or learned techniques that achieve PCMH-like medical practice “[We] brought in a rep from [Company] who had a really…a formal…program—Motivational Interviewing, smoking cessation. So now…they start the process…query the patient on every visit about smoking.… They’re maintained those measures for the diabetics. They take it on very seriously.” Provide constant feedback on PCMH implementation “I bring the graphs in, and I’ll show them, and we try to do little celebrations. We try to give positive reinforcement. And then I think they can see the benefit of it as they see patients coming in.” Use external and internal data to benchmark, reinforce benefits, highlight success “The only thing that has changed for me is the pride that I feel in this agency, and what we have been able to accomplish because of the data. And I think that communicates out to the whole staff. I also feel that I have grown a lot in terms of skills and tools to use.” Leverage respect of PCMH champions to foster buy-in “You have to have very strong leadership that is going to pursue those things with everybody that comes into the practice…. The administrative people working with the docs to get it taken care of and convincing the staff that they have to do it and have enough time to do it and be paid enough money to do it.” Concentrate advocacy efforts on skeptical or hesitant members, dispel misconceptions [In response to how to handle skeptical clinicians]: “And trying to explain and have a more global picture of ‘yes, I understand it adds 2 steps to your process, but it cuts down on 6 other steps.’ ” -
PCMH = patient-centered medical home.
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- Table 4
Effective Resource Utilization Strategies That Increase Practice Confidence and Buy-in to PCMH
Strategy Exemplary Qualitative Data Appropriately manage and organize staff for PCMH [When asked what change had the most positive impact on the practice]: “On a more systematic level…we tried very hard to get [personnel] to identify tasks they were doing that they could unload to other team members, so that more of their time would be available for doing [new responsibilities]. That was probably the biggest thing, that kind of re-shifting of responsibilities to free up more time…. Then we hired this new medical assistant to enable this health-coaching process.” Secure sufficient funding to make PCMH changes [When asked, “Do you think any of these changes would have been possible if you didn’t have the financial support from the Initiative?”]: “Absolutely not. As it is, we are running the practice on a shoestring. The doctors’ earnings every year is at the very low end of what primary care physicians earn, and we have accepted that because we would rather spend more time with patients than see more patients, and generate more revenue that way.” Participate in PCMH learning collaborative(s) “Getting people to go to the collaborative, and getting understanding of what really the collaborative was about, and also seeing their peers there from other practices and how other practices were embracing the collaborative—that was very helpful, and it made people understand this was a bigger deal than just my ruminations.… They could see what their peers were doing, and to one degree other people were embracing the process, and so why couldn’t we do the same thing?” -
PCMH = patient-centered medical home.
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- Table 5
Strategies That Increase Practice Buy-in to PCMH by Creating Team Environment Encouraging Ownership, Accountability, Support, and Confidence
Strategy Exemplary Qualitative Data Have a work flow of defined, overlapping, and flexible roles and responsibilities within an incremental transformation plan “Everyone just falls right in the flow…if there’s something that’s on one person more, we’ll try to spread it out and say ‘maybe you can have this person do this so you’re not so overworked with doing a certain task.’ Whatever it is that we have to do for the patients. So we just spread out the work.” Create an open environment where everyone’s input is sought and respected “Staff is encouraged to share their buy-in or lack of, their ideas, so conflict to us is probably not viewed as conflict, more of a negotiation. Sometimes, I think I know everything, but I don’t. Staff will ground me and say ‘that’s not going to work,’ and I think I speak for the providers when I say they are open…to the ideas of everybody.” Foster a culture of creativity and innovation “It’s not like someone is coming in and imposing a program on us. We’re designing our own program. We’re seeing what works for us. We’re experimenting with different ways of doing things…being willing to experiment and not have anything written in stone…if it doesn’t work, onto the next one.” -
PCMH = patient-centered medical home.
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Additional Files
The Article in Brief
Strategies for Achieving Whole-Practice Engagement and Buy-in to the Patient-Centered Medical Home
William K. Bleser , and colleagues
Background The Patient-Centered Medical Home (PCMH) shows promise in strengthening quality of care, but often requires organizational change. This study aims to understand and illustrate how practices achieve staff "buy-in" to (belief in) and engagement in the PCMH transformation process.
What This Study Found This study identifies 13 distinct strategies for obtaining organizational buy-in and whole-staff engagement in PCMH transformation and practice improvement efforts. The strategies cluster into three areas that facilitate practice buy-in: effective internal communication, effective resource utilization, and creation of a team environment.
Implications
- These strategies can be particularly useful for facilitating PCMH transformation in primary care.
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