After nearly 2 years, TransforMED, a limited liability company wholly owned by the AAFP, marked the end of its national demonstration project (NDP) at an April meeting in Kansas City, Missouri. More than 70 family physicians and other health care professionals involved in the project attended.
Edward Schwager, MD, of Tucson, Arizona, summed up what the practices involved in the NDP discovered about implementing changes in a busy family medicine practice: “It’s very difficult to work on the practice while being so busy working in the practice,” he said.
TransforMED launched the NDP in June 2006 as a way of testing how practices would have to change to achieve a new model of care that could deliver high-quality, efficient, and cost-effective health care in a patient-centered medical home. In all, 36 practices enrolled in the NDP; 32 completed the project. A final report is due in 2009.
The recent meeting was billed as a “learning collaborative” and a time to “celebrate milestones.” Participants shared the successes and challenges encountered during the course of the NDP, and heads nodded when FPs spoke about change fatigue, staff turnover, time pressures and temporary lapses in practice productivity.
But phrases such as “networking,” “teamwork,” “job satisfaction,” “integrity,” “professionalism,” and “hope for the specialty of family medicine” also peppered the discussions.
FACILITATED PRACTICE REAPS BENEFITS
From the demonstration project’s outset, practices were randomized into 2 groups: “facilitated” or “self-directed.” Trained facilitators guided the facilitated practices through the change process, offering expertise, resources and assistance every step of the way. The self-directed practices represented a control group, of sorts. They, too, were immersed in the hard work of practice change, but without any direct assistance from TransforMED.
Bruce McElroy, MD, of Redmond, Oregon, said that 2 years ago, he was burned out and contemplating a career change. “I enjoyed being a doctor, and I hated it at the same time,” said McElroy. After nearly 8 years as a partner at Central Oregon Family Medicine, he was close to quitting medicine.
McElroy said that he and the other 3 physicians in the practice “were pulled in so many different directions that we couldn’t do any one thing well.”
“I had no time for myself and very little time for my family,” he said, adding that the stress resulted in poor job performance and poor job satisfaction.
“(TransforMED) gave us a vision,” said McElroy. “The (facilitator) was essential for exposing our warts and pushing us.” He added that the facilitator’s help was crucial when it came time to implement practice changes, including changes outlined in TransforMED’s medical home model, such as increasing the functionality of the practice’s electronic health record, or EHR, system; developing the practice’s Web site; launching a patient Web portal; and refining billing processes.
But the turning point for McElroy was the implementation and success of open-access scheduling. Today, nearly 90% of his patients are able to get same-day appointments.
The NDP also created stress in the practice, and 2 FPs left early in the process. Contemplating change was “overwhelming,” said McElroy, and it was “humbling” to acknowledge that the practice was “antiquated.” He learned that some enhancements called for in the TransforMED medical home model didn’t work in his practice; for instance, his patients didn’t embrace group visits or electronic visits.
However, McElroy said that adopting efficien-cies and dropping hospital calls—a decision he made before the NDP—saved him so much time that he shaved 40 hours off of his work week. Now, McElroy spends more time with his family and looks forward to another 10 years of practicing medicine.
SELF-DIRECTED PRACTICE STEERS OWN COURSE
Representing a self-directed practice, Schwager said that although being part of the control group eliminated the “pressure to perform,” he’ll always wonder how much more the practice might have achieved with a facilitator. He pointed out that the NDP results likely would be skewed because the practices that applied were already amenable to change.
Schwager’s mantra was and continues to be “focus on the patient,” and he said all practice changes were made with that in mind. “I’m most proud of our group visits. It’s the damnedest thing I’ve ever participated in,” said Schwager. Although the concept is “foreign to the traditional training of one-on-one patient encounters behind closed doors, the patient surveys are uniformly positive,” he added.
On the other hand, open-access scheduling, which is so successful in McElroy’s practice, is an ongoing challenge for Schwager because of the advanced age and medical complexity of many of his patients. “I start each day with an hour-and-a-half of prescheduled appointments, and by 8:30 am, my entire schedule is full,” said Schwager. “Open access (only) works when the average daily demand for patients to be seen equals the time available to provide that service,” he added.
NEW PHYSICIAN LEARNED TOUGH LESSONS
James Meyer, MD, of Littleton, Colorado, closed his solo practice in March before the end of the NDP. Although his was a facilitated practice, Meyer said his facilitator “couldn’t undo the mistakes that I had already made.”
Where did he go wrong? Meyer said the lack of good business advice as he prepared to open his practice doomed him from the beginning. “Young, eager, and naive can be a bad combination,” said Meyer, who graduated from the University of Colorado Family Medicine Residency program in 2005. The residency was where Meyer learned about and embraced the patient-centered medical home concept.
“I want my story to be a cautionary tale,” said Meyer. “I made business decisions that would make anyone running a practice smile to themselves and say, ‘Good luck, kid.’”
Young physicians coming out of residency “will need something like (TransforMED) to get good advice at the time they need it,” he added.
TransforMED Offers Free Medical Home Assessment Tool
- © 2008 Annals of Family Medicine, Inc.
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