All good things come to an end
This will be my final post. I want to thank all of my followers. I sincerely hope you have learned from our experience as part of the National Demonstration Project. It is hard to believe that the study has been finished for nearly three years! It was one of the first patient-centered medical home (PCMH) pilots in the country. We learned from this process that transformation is difficult. Change management is a skill that can be learned, but requires personal transformation on the part of the manager and the physician. We learned that transformation is an ongoing process that never truly reaches a finishing point. We learned that initial transformation into a PCMH takes much longer than two years.
Today, there are more than 100 PCMH pilots in the country; some complete, some ongoing. Results confirm the notion that the PCMH-way of providing medical care delivers. Patients and providers love it. Quality numbers are better. Outcomes are better. Practice and patient finances are better. Perhaps the most exciting pilots are those in the residency programs. It will be exciting to see results of those studies. See TransforMed's P4P for such a program.
I encourage all readers to continue on their journey toward building a PCMH. If you are interested enough to seek out information, you are likely very deep in creating your own PCMH. I hope you all keep in contact with wonderful resources like Family Practice Management, AAFP, Patient-Centered Primary Care Collaborative (PCPCC) and Delta Exchange. I hope to meet many of you as I continue my journey into the future of family medicine.
–Melissa Gerdes, MD
What value does the patient-centered medical home bring to physicians?
This entry is a natural corollary to my last post. The medical home is supposed to be patient-centered, so naturally we would consider the value to patients first. However, we found there to be tremendous benefits to us as physicians as well. Our practice is composed of female physicians who are all part-time and have young families. Completing our patient care duties on time and going home at 5 p.m. are unspoken values we protect. Our staff is right in line with protecting these values as well.
Organizing the practice service model around the components of the medical home (i.e., team-based care, attention to preventive care and chronic disease management, empowering clinical staff to carry out protocol driven services, open access, etc.) really helps the efficiency of the practice. All providers in our practice found it easier to begin on time, stay on time, complete all requested and necessary services during (and around) a visit time, and finish on time. Sure, we still have chaotic days when we cannot be quite as efficient. What primary care practice doesn’t? However, chaos is not the rule in a well-functioning medical home.
We might make more money. At least we make the same for less time spent working. In our setup it is difficult to tell because we're on a modified salary/RVU productivity/quality incentive compensation model. However, we are all very pleased with our part-time salaries and benefits and compare very favorably with national benchmarks.
We have made time to take care of patients between visits. We have time to research patient conditions. We have time to “consult” with consultants, asking questions and learning new things. We have time to read and do CME at the office. In fact, time may be a more important commodity to us than money and we are thrilled to have found a way to create more of it.
There is something positive and hopeful about practicing medicine on the crest of this wave. My partners and I have tremendously enjoyed networking with other like-minded physicians around the country as we have struggled and succeeded in implementing a medical home practice. Now we teach others ways to improve their practice experience, which is something we love doing.
–Melissa Gerdes, MD
What value does the patient-centered medical home bring to patients?
A prospective medical home adopter recently asked me: “What do your patients think about being part of a medical home?” I immediately responded: “They love it!” However, after thinking about this question further, my honest answer is that most of my patients do not realize what a patient-centered medical home (PCMH) is or that when they come to our office they are in one. I decided to informally survey a few patients to confirm my suspicion. The results? Only one even knew that we “were involved in some study thing ... involving the medical home.” And even this patient may only have known because we have fliers and newspaper clippings around the office about the PCMH. This got me thinking, what do patients gain by belonging to a PCMH? I came up with the following:
- One-stop shopping for medical needs. People lead very busy lives these days and any model that helps them package things they need in one place is valuable (look at Wal-Mart, for example).
- Continuous care with a personal physician who knows them well. According to several studies, Americans value having a personal physician. The benefits are real but are difficult to quantify.
- Easy access to your family physician and his or her team of caregivers. Technology and improved efficiency in office processes brought about by the PCMH allow more appointments. Medical home offices ensure patients have access to these appointments in innovative ways.
- Continuity of care between office visits and across dimensions of health care. A sense of security develops when patients know there is a stable team behind them planning for care even when that care occurs outside of the physical team environment.
- Behind-the-scenes care. Preventive reminders and adherence to evidence-based guidelines happens seamlessly. This is why patients often don't realize they are part of a PCMH.
- Access to improved technological management of care. Americans love technology. Medical homes use this technology to proactively organize and take more complete and scientifically founded care of patients.
We can also learn from pilots going on around the country. Group Health in Washington found that patients involved in a medical home were significantly happier with their experience. In many pilots, assessments of patient experience and opinions are lacking or ongoing. In future years, we look forward to hearing more from the center of the medical home: the patient.
–Melissa Gerdes, MD
E-mail communication with patients
We have been communicating with patients via e-mail for about a year. Since we use GE Centricity's electronic health record system our health system chose to use their platform to offer e-mail, refill requests and online appointment scheduling for patients as well. Our regional clinic piloted the software and found it easy to use. We set up clinical and clerical e-mailboxes within the clinic's system so clinical questions go to a nurse or physician and appointment requests go to clerical. Through the system, patients may e-mail a particular physician if they wish.
Surprisingly, e-mailing with patients is not commonly used, which is similar to our experience with virtual office visits. I think this correlates with phone access. If access is good, then patients are simply not incentivized to change to a new mode of communication. Patient users have a learning curve – albeit not steep – to set up a secure account and learn the software. Patients also seem to have some mistrust at first as to where their message goes. And if we do not respond quickly, there is more mistrust.
E-mail capability does offer convenience and another mode of communication for certain patients. For us, certain groups of patients are our biggest users. Those are patients who are shift-workers or are frequently out of town for work or for education. Other than these groups, we have a hard time getting patients to sign up for usage. When we query patients why they do not subscribe, the most common response is a concern about security. We explain that they must set up a password protected account; however, this seems to make the software seem more complicated than it is.
For those patients who do use e-mail, they generally ask simple questions like if they can increase a medication. They also ask if they need to come in for an appointment or exam, which helps streamline triage. The e-mail communication becomes a permanent part of the patient’s chart, which our attorneys tell us lessens our risk of claims regarding these non-face-to-face interactions. With e-mail communication, only the printed communication happened. Nothing less and nothing more was said or heard.
Everyone worries about the potential for patients who “overuse” e-mail by writing pages and pages of information for the clinician to sift through. We have found this really does not happen very often. Usually, patients' e-mails are very simple and to the point (as I find with most e-mail). For the few patients who have been very verbose and tangential, I have found that it is best to address this right away. I will either e-mail them my specific preferences for how they should communicate via e-mail or address it during their next office visit.
Our physicians have incorporated into the work flow printing an “invitation” and instructions about e-mail to nearly every patient we see as they leave the office. Even with this commitment, less than 20 percent of our patients utilize this service.
–Melissa Gerdes, MD
Ms. Jones is 72 years old. She was admitted for new onset atrial fibrillation. When her rhythm and rate were controlled, workup for underlying causes revealed critical coronary artery disease, which was successfully stented. Per discharge protocol, she was sent home on ramipril, an ace inhibitor, among other medications. Two days later, Ms. Jones was readmitted for syncope. Her blood pressure on admission was 70/40 and she was again in atrial fibrillation. Her second admitting physician team performed medication reconciliation and discovered that she had been taking both the ramipril prescribed at the first discharge and enalapril prescribed by her primary care physician, resulting in the hypotension and syncope. This simple double medication administration cost several thousand dollars. It also threatened Ms. Jones’ life and safety. Had medication reconciliation been done at her first admission, her second admission could have been prevented.
What is medication reconciliation? Physicians practicing in a hospital setting may already be familiar with the term, but basically it is the review and comparison of patient medication lists to ensure that the lists are complete, up-to-date and accurate. This becomes especially important when patients are moving from one location of care to another, such as from a hospital admission or discharge to the outpatient setting. Thousands of medication errors occur every year because the patient changes care venues. Having a sound process in place to avoid such errors is an important patient safety measure. The Institute for Healthcare Improvement offers a Medicare-sponsored medication reconciliation online tool, and the American Medical Association offers a monograph on the topic.
While TransforMED's National Demonstration Project (NDP) did not deal with patient safety per se, the concept was embedded in every aspect of the study. Our practice found that it is just as important to have a medication reconciliation process in place in the outpatient setting as the inpatient. Our electronic health record (EHR) has an embedded medication list where all physicians enter medication changes, which helps keep us on the same page. When patients are cared for by physicians who do not use our EHR, staff members update the patient's medication list in our EHR according to those physicians’ paper records. We catch duplicate and/or obsolete medications very often. The reconciliation process also gives providers an opportunity to teach patients about their medications and what they do for them.
Medication reconciliation takes time. However, as any safety officer (and lawyer) knows, time spent preventing mistakes is better than time spent correcting mistakes. The team concept utilized in the TransforMed study can help you put a process in place in your practice:
- The front office prints the patient’s last medication list when the patient checks in.
- The patient (who is asked to bring a current medication list to the appointment during the pre-visit reminder call) then reconciles both lists.
- The nurse reviews, updates and educates the patient from the reconciled list.
- The physician makes final adjustments and leaves time for patient education and questions.
A process like the above ensures safety, involves all members of the office and allows the patient and physician to spend time on other issues during the visit.
–Melissa Gerdes, MD
Medical home pilots: To do or not to do
When TransforMed began in 2006, the NDP was one of the first pilots to test the medical home. Today, more than 100 pilots have been completed or are underway. Many physicians are cautious and confused as to whether they should participate in a pilot. What will the practice gain by participating? Will it require too much work? Will there be any financial gain for the practice?
These are important questions in evaluating potential participation in a pilot. A pressure seems to be building to learn how to practice the “medical home way,” and many practices may be pushed into these pilots simply in an effort to learn, but practices should be very careful before they jump in.
First, make sure you clarify what the pilot will be studying. The NDP studied the “process” of change only with soft endpoints to clarify how the process affected the practices and their patients. Many pilots now are evaluating much more specific endpoints, such as cost savings. Before you join one of these pilots, clarify where the cost savings will come from -- e.g., are the savings out of your practice only, or are the savings out of the total episode of care (involving the hospital and other care facilities)?
Second, make sure you understand what the practice’s responsibilities will be. Some pilots provide consultants or facilitators to help guide the practice in the changes required. Other pilots will expect the practice to use existing staff or hire consultants to make the change. Will there be any financial support from the pilot sponsors for the consulting or for electronic implementation? The NDP either fully paid for or obtained sizable discounts from technology vendors for the products used.
Third, help set and understand a reasonable timeline. As mentioned before in this series, the change process is time and labor consuming. Each change produces a ripple effect in the practice and patients. The usual pace is design, implement, evaluate effects and correct over a three- to six-month time span per item implemented. (Stretch this to years for something BIG like EHR implementation.) As the NDP found, two years was probably just long enough to leave the practices in the middle of the transformation, but not long enough to truly measure the outcomes associated with transforming into medical homes.
Fourth, clearly understand the financial ramifications of participating. Will your practice be paid any money to do the pilot? When will your practice receive the money? Are there any contingencies on your practice receiving the money (e.g., meeting quality benchmarks or receiving only a percentage of savings)? Make sure all details of the financial arrangement are fully defined both to the practice's and the pilot sponsor's satisfaction. Clarifying these financial details can be difficult because of anti-trust laws and a lack of previous pilot examples in which the financing worked well or was beneficial to the participating practices.
Finally, realize you are entering uncharted waters. If there is a pioneer somewhere within you, you will love this aspect of participating in a medical home pilot. If not, you may honestly want to wait and see how more pilots play out for a few years prior to joining in.
–Melissa Gerdes, MD
Do you have a good understanding of practice finances?
One of the most startling findings to me in the National Demonstration Project (NDP) was that many of the practices did not have a good understanding of their own practice finances. In fact, at one point in the study, investigators gave up asking for balance sheets or income and expense statements as no coherent information could be assembled from the information. The information was available, just not in an easily understood form.
I have long argued that physicians (we’ll focus on family physicians here) really need business and management training. Many physicians realize this and go on to get a Master of Medical Management or Master of Business Administration, but it really doesn’t take a whole other degree to gain sound business basics in a practice. Physicians can certainly hire a manager or accountant to put a plan together and monitor that plan. However, it behooves the physician to understand and watch the plan as well.
I am lucky on this point. I work for a multi-specialty group essentially as an employed physician, and the company forms, accounts and adjusts my business plan. I've always felt a responsibility to learn about it, however, because working for a larger company can put you in a vulnerable position if you do not understand practice finances.
If you are not sure whether you have a handle on your practice finances, ask yourself the following questions: Do you have a plan? And can you produce an income and expense sheet monthly?
A simple plan starts with: What do you hope to accomplish financially in your practice? Is there a certain amount of money you expect to make each month? How much of his money is for your salary? How much is for your staff? Are there capital expenses you need to fund? Asking these starter questions can help you identify how much help you will need and from whom.
Here are some further tips to get you started in understanding your practices finances:
1. Start collecting copies of bills your office is paying.
2. Hire an office manager with some business experience.
3. Review the business aspects of the office on a regular basis, at least quarterly.
4. Methodically review collection rates from payers (monthly collections divided by charges).
5. Evaluate vendor costs for supplies on a regular basis.
6. Stock medical supplies on a par schedule (i.e., a standard monthly amount).
7. Re-evaluate duties, consolidate and promote staff.
A simple monthly income and expense statement looks as follows:
| Gross Revenues||$36,000||$40,000||($4,000)|
| Revenue and Deductions|
| Bad Debt||$1,000||$1,000||0|
| Net Operating Revenue||$34,000||$38,000||($4,000) |
| Overhead Expenses|
| Salaries - Staff||$2,000||$2,200||($200)|
| Benefits - Staff||$800||$800||0|
| Med/Surg Supplies||$3,000||$2,500||$500|
| Other Supplies||$2,500||$3,000||($500)|
| Purchased Services||$1,000||$1,500||($500)|
| Total Operating Expenses||$15,000||$18,000||($3,000)|
| Available for Compensation||$19,000||$20,000||($1,000)|
The simplest expense sheet takes the revenue coming in and subtracts expenses, with the difference remaining as physician compensation. Obviously, compensation models are often much more complex than this. However, having an understanding of practice finances on this basic level is crucial. Practices should compare year-to-year costs, the percentage of total expenses for each overhead category, and actual costs versus budgeted costs to stay on track. Having an expense sheet also helps you identify the largest portion of your cost structure. You can also calculate your average income per visit (revenue divided by visits) and then use that figure to analyze your collections and the rates stated in your contracts. Knowing these types of numbers will become more and more important in our near future when negotiating for positions and with payers.
Here are some additional resources:
Running a Practice (AAFP resources)
Financial Management Tools (from the FPM Toolbox)
“Vital Signs” for Assessing Your Practice's Financial Health (FPM, Nov/Dec 2009)
Peer-to-peer learning was a major benefit of participating in the National Demonstration
Project (NDP). On the facilitated side, the study was set up with three groups of six practices. Each group had a facilitator who conducted monthly conference calls, with topics ranging from a review of technology vendors to emotional support in going through changes. A Balint/book review group was spun off from our group, where we reviewed and discussed books like Better by Atul Gawande and How Doctors Think by Jerome Groopman. This format allowed members from each of the six practices to have tight personal relationships with others who were going through the same transformative processes.
We also attended several learning collaboratives, where we heard from national experts on topics such as open access, implementing an EHR system and group visits. Hearing from the experts was valuable, but so was hearing from one other. At one collaborative, for example, we heard an impromptu presentation by one practice that had achieved the best cycle times (i.e., the time it takes a patient to complete his or her visit at the office), and we naturally wanted to hear details on how they did it. Flexibility in the schedule allowed for this extremely helpful learning to occur.
Peer-to-peer learning continued after the NDP closed, with the Touchstone group continuing monthly calls for about one year and having two annual “reunion” collaboratives thus far. These continue to be wonderful opportunities for networking and ongoing assistance in navigating the medical home. Many of the practices are now embarking on NCQA recognition and learning from NDP peers on how to most efficiently do this.
One of the best peer learning tools is Delta Exchange. This networking web site launched by TransforMed now has hundreds of members, from physicians to nurses, consultants and practice managers. Members can share documents, read blogs and articles, and post questions to the group. Just last week, in going through the NCQA application process, our practice needed a one-page handout to inform patients about the medical home. Instead of reinventing the wheel, I went to Delta Exchange and “asked” the group if anyone already had such a document. That same day, I had three examples. This type of sharing is invaluable. It helps the spread of ideas and saves time in busy offices.
Clearly new pilots and experiments in the medical home arena must have peer-to-peer learning as a component of the project. Unfortunately, many states prohibit this type of shared learning due to legislative prohibition of collective bargaining. Family physicians need to be aware of these restrictions especially when discussing financial arrangements to fund medical home initiatives. Several pilots have been successful in getting legislative “safe harbors” to allow such exchange of information. (See http://www.coloradoguidelines.org/pcmh/conveningorg.asp.)
Think back to medical school where a peer group was so helpful to maintaining your sanity. Study groups, late night “talks” and social events kept us going through those four years. Hopefully most of our lives have settled down now. However, the type of change required to transform the typical family medicine practice into a medical home reminds me of those fours years. It was invaluable to have my “buddies” in the form of other practice members helping me through the process.
Improving the physical layout of your practice
One of the benefits of peer learning in the National Demonstration Project (NDP) was seeing how each practice’s physical setup could either benefit or hinder their delivery of care. In most practices, the front office was literally "up front" -- the first area that patients see. Everything else, from the physical size of the office to the layout, varied based on the services offered at each practice. Some practices provided a full complement of ambulatory ancillary services on site. Others outsourced nearly all ancillaries. Most practices admitted they were not happy with their physical layouts. Hardly any of the layouts supported medical home activities.
In changing a medical practice into a medical home, physical layout is important and can dramatically affect communication among team members. Many of the successful practices ensured that team members worked in close proximity to one other. Their offices were arranged in "pods" so that all members of a team -- e.g., receptionist, nurse and physician -- could easily talk with one other during the work day. Hospitals have long done this with the nurses' station, which is the hub from which all patient care flows. This physical proximity of team members helps with the informal communication that is necessary throughout the day to keep care moving forward. The advantage of such a layout argues against grouping "front office" and "back office" in physically separate locations, centralizing off-site appointment scheduling or sequestering physicians in their offices. The medical home is a concept that manages the controlled chaos of a family medicine practice. Physically supporting communication as the chaos unfolds during the day is critical to maintaining a patient-centered focus.
Direct patient care areas require some degree of privacy but are best positioned right off the central "communication hub." Some offices have a wheel-and-spoke model with the communication station at the center and three to five exam rooms surrounding them. Ancillary departments, such as lab and radiology, are best placed centrally so each pod can get to them easily. The fewer steps required for staff (and ill patients), the more efficient the practice will be. (You can read more about design efficiency in TransforMed practices here.)
The penultimate example of physical layout supporting the patient-centered medical home is the "medical neighborhood." Fellow family physician Christopher Crow, MD, in Plano, Texas, has assembled such a layout. He calls it a “medical village.” He has assembled common medical service providers, like mammography and orthopedics, around his clinic. By bringing services conveniently and directly to his patients, he has achieved some of the best quality results in the country.
Changing your office design does not necessarily have to cost a lot of money. Simple steps such as moving scales and desks to a more central location can make a huge difference. However, services that touch patients, such as scheduling and nursing inquiries, should be decentralized and personal. The value of family medicine is the personal touch. If we lose sense of that, we have lost the whole idea of the medical home.
Medical home ideas with low fiscal notes
Financial barriers to the medical home transformation process can be great. Why not select strategies that require no financial investment? The next great barrier is time. Why not select strategies that require very little money or time? They do exist.
The TransforMed national demonstration project was clear: The practice team needs to be solid prior to embarking on any other changes. So, why not start with the team? Ask yourself the following questions:
- Is every person on the team working to the limits of their degree?
- Is there more that a particular team member wants to do or could do?
- Is our communication as effective as it could be?
- Do we have protected time to work on our practice and communicate about it?
- Are negative, undermining or passive-aggressive behaviors present in the practice?
If you answered yes to any of these questions, you can likely do some work on team building.
Team building can be as simple as looking at the weekly schedule and carving out (not necessarily adding) one hour for a weekly team meeting. Treat the staff to lunch or just a snack and make an agenda about things in the practice that don’t work quite right. Ask staff to help form the agenda. Then sit down and discuss these items. Allow staff to participate in coming up with solutions. Make a time-line for implementation of the solutions. The next week, return to the agenda, following up on last week’s items and adding new ones. The items you tackle need not be large. They can be small, such as changing the way information/paperwork flows from the front office to the back to speed up patient through-put.
Another item that you may want to start with is researching software and electronic health records (EHRs). Commit to spending 30 minutes per week, or to reading one article per week, for the next two months. If you have been planning to implement new software or an EHR, this short time commitment can get you started on the right road. Use networking tools such as AAFP e-mail discussion lists, Center for Health IT peer reviews or TransforMed's Delta Exchange to get questions answered and real-life references on software.
You could also take an assessment to understand your practice's readiness for change and medical home implementation. Check out the AAFP’s Patient Centered Medical Home checklist or TransforMed’s MHIQ. These tools will help identify the areas in which you are most ready for and most need change. They are free and take only a few minutes to complete.
Some practice members can also educate themselves about the components of the medical home and how to best implement them. There are many free resources to help, including TransforMed, MGMA the Institute for Healthcare Improvement and the AAFP. Even pharmaceutical companies are forming free medical home implementation tools. Team members can then educate the rest of the practice members.
Whatever you choose, realize that anything worth doing (I happen to think the medical home is definitely worth doing) requires some personal investment. But it does not necessarily have to be money.
How to improve wait times
Wait times at doctors' offices are an often complained about phenomenon. We on the provider side have many reasons for our long wait times, but patients don’t often care about or accept these reasons. One component of the TransforMed national demonstration project (NDP) involved measuring cycle time (the total time a patient spends at the doctor’s office) and then working on shortening it. At the time of the NDP, there were not any “industry standards” on what a good cycle time should be, but two to three hours at the doctor's office is clearly not acceptable. What can be done to reduce wait times?
As usual, we started with a survey. Each patient was given a clipboard and a pen when entering the office and was asked to record the time at each point in their visit. Patients are quite honest about their time. Having our patients complete the survey communicated that being on time is actually important to the practice and that we value their help in making wait times better. This alone can help patients' perception of wait times.
Our survey looked like this:
Time you arrive at office: ___
Time nurse brings you to exam room: ___
Time doctor enters the room: ___
Time doctor leaves the room: ___
Time you leave the office: ___
The practice can then tabulate the total time the patient spends in the office. It will be longer, of course, if the patient is having ancillary testing such as labs or x-rays done on site. The quick survey will also help to identify bottlenecks in patient flow. It is a good idea to do the surveys on a few different days or even weeks. Patient flow patterns can markedly change from day to day for a variety of reasons such as physician absence, community illness prevalence, equipment malfunction or just one particular patient.
The next step is acting upon the survey results. Use team meetings to brainstorm reasons why the bottlenecks may occur, or have staff trail a few patients through their visit. Better yet, consider asking patients directly. Once the reasons for delays are discovered, have staff members involved in that portion of the visit come up with solutions to fix the problem. Set deadlines for implementation of changes to fix the flow issues. Then, repeat the survey to make sure the cycle time has improved.
The best practice in the NDP was able to achieve 30-minute cycle times. That practice did not perform any ancillary services on site. They were able to achieve a 30-minute cycle time by working closely in teams. They even designed their office space to put all team members, from front-office staff to physicians, in close proximity, which encouraged ongoing communication throughout the day. They started on time. They staffed appropriately and scheduled realistically for the work capacity of the day. And they made being on time a priority.
Medical home implementation: "How do we get started?"
Transitioning to the medical home can be a daunting process. What should a practice do first? How do we get started? To answer these questions, practice leaders will need to take a good hard look at the current state of the practice. One practice may discover that wait times are the bane of the practice.
It would then make sense to begin with open-access scheduling. Another
practice may wonder why its rate of payment on claims is so low. It may
want to start with an investigation into billing and coding.
Surveying staff or, better yet, surveying patients are excellent ways to help shape an agenda. There may be aspects of the practice that have not worked well for a long time and just need some time and attention to fix. Asking your customers can help you prioritize what to do first. For example, one practice developed a survey to assess patients’ readiness for online services.
During our experience in the TransforMed national demonstration project (NDP), we held staff project meetings and discussed at length where we should begin. We did not make any decisions until we had learned what it would mean to implement each component of the medical home. We ultimately decided to create a web site and start virtual office visits. We already had an electronic medical record, which we were very comfortable with, so implementing another IT project was not hard. See “Our implementation of virtual office visits” in this series to see exactly how we did this. We used a patient survey to pick topics and set prices for the virtual office visits.
For any project you are considering taking on, be sure to develop time and cost estimates up front. It is also important to take breaks between big implementation projects. TransforMed facilitators like to describe the transformation process as progressing in “fits and starts.” Breaks are needed to recover, regroup and recharge after a lot of practice time and energy have been put into making innovative changes.
Spreading ownership of change is also a good strategy to help in prioritization. If a staff member is particularly passionate about an element of the medical home, let that person take charge. You may even want to survey staff about their interests and time availability to help with the change process. Understanding and communicating the true amount of resources necessary for a particular project is critical. The AAFP has recently posted an excellent step-by-tiny-step guide to implementing medical home components.
In the end, the decision about which components of the medical home model to implement first, second, third, etc. is very individualized. No two practices in the NDP followed the same path. This is one of the important lessons learned from the NDP.
Do you need a facilitator or consultant?
The TransforMed medical home National Demonstration Project (NDP) compared 18 practices that had "facilitators" to 18 practices that did not. Facilitators were individuals with varying degrees of training who assisted study practices in transforming into medical homes. The facilitators served as guides and connectors for practices, but they did not dictate what practices must do or provide simple answers. NDP practices utilized facilitators in many different ways, including making software vendor connections, prioritizing to-do lists and structuring communicative care teams.
The "control" practices were self-directed and were expected to go through many of the same processes that the facilitated practices went through. The control practices had ready access to information about change and medical home components, but they needed to recognize their weak areas, find solutions and prioritize projects on their own.
Facilitated practices also benefited from learning collaboratives where industry experts were invited to teach on such topics as open access, group visits and team-building. Ironically, the self-directed group organized their own collaborative and taught each other on these topics from lessons learned in the first half of the study.
So, if your practice decides that it wants to take on this medical home business, do you need a facilitator or not? This is a good question without any easy answer. As the self-directed practices demonstrated, it is possible to transform without a facilitator. (See "Effect of Facilitation on Practice Outcomes in the National Demonstration Project Model of the Patient-Centered Medical Home" from the Annals of Family Medicine.) However, facilitators keep the momentum going. Practices transform in "fits and starts." Without a facilitator nudging the process along, practices can stall. The facilitator does not have to come from a firm outside the practice. He or she can certainly be a practice employee, but that employee must have the time, financial support and authority to be the facilitator. Practices will likely transform best if they have a dedicated concept pusher.
Practices may also want to strongly consider a facilitator if they do not have a strong team structure with good communication in place. A practice lacking this fundamental infrastructure will perform poorly in the face of disruptive change (the only type of change in this endeavor). If practice employees tend to be passive-aggressive and negative and work in silos ("that's not MY job"), these are signs that outside help may be needed to build healthy relationship scaffolding before taking on medical home initiatives.
Cost is another factor. If a practice is not a part of a demonstration pilot or does not have extra money lying around, it may want to consider "free changes" first (see the upcoming post "What you can do with no money" in this series). Facilitators can provide online consultation, "spot" solutions or the full transformation package. Prices start in the $100s and can go up to the $10,000s, depending on services, facilitator and practice size.
The most important thing with medical home transformation is to realize that it is a journey, not a destination. Building the team's capacity to change and adjust to outside forces is the most important task in the transformative process. Most practices will likely need some outside help to do this. If not, consider yourself one of the lucky few.
Six ways to communicate better with your administrator
The TransforMed medical home National Demonstration Project (NDP) had a breadth of practice types. Our practice is a "satellite" family medicine clinic with three family physicians. We are part of a regional 250-provider multispecialty clinic. This gave us some advantages (such as already having an electronic medical record) and some disadvantages (like having to go through a lot of bureaucracy to get new projects approved). Communicating effectively with other members of the health system, particularly administrators, became crucial during the NDP. We found some simple steps to help us:
1. Do as much as you can locally without involving the system. By this, I do not mean be deceptive. We simply found that if we could do easy things -- like scheduling team meetings, running an ad in the local paper or surveying patients -- without involving our marketing department or directors, things would get done much faster. This often meant that more physician time was spent on the task, but in the end, the overall efficiency warranted the time spent.
2. Be direct when asking for approvals. Like physicians, administrators are busy people. It is often helpful to have a quick "elevator speech" ready to deliver when you find yourself crossing paths with your administrator. The elevator speech is essentially a 2-minute pitch that summarizes your service or project request, why it is important to the administrator and what action the administrator needs to take. The speech should be very specific, and you should always follow up on the action to ensure it gets done.
3. Listen and establish common ground. Listening requires you to clear your mind and really hear what the other person is saying. Too many times, we are busy formulating a response to the speaker and don't truly listen. It is by listening that physicians can understand better the administrator's operating premise, which is usually quite different from the physicians' perspective. Physicians tend to operate by doing what is best for patients, where administrators are charged with doing what is best for the business. These two basic operating premises are often at odds, but we can learn from one another and find common ground if we truly listen and seek to understand one another's perspectives.
For instance, in studying our immunization rates for patients with diabetes, we were stunned to discover that more than 50 percent of eligible diabetics had not received recommended immunizations. Other NDP practices were using a registry software product that mined the electronic medical record for such data and printed a point-of-service list of services due. We thought using this software would easily solve our immunization problem. We approached our IT administrative team with the request. Five meetings later, we came to understand that the administrative team was blocking our request due to concerns over software incompatibility and cost. From our perspective, the most important consideration was patient care. We did not want one of our patients with diabetes to contract pneumonia and land in the hospital. However, from the administrative side, the most important consideration was that our little project did not crash the system. Once we came to this understanding of each other's perspectives, the IT team was able to show us how to use our existing EMR to perform the registry function we needed.
4. Reserve adequate time for communicating. Good communication takes focused time. Physicians are notorious for running on a continuous, unfocused, multi-tasking hamster wheel. However, we need to slow down from time to time and spend time together listening and problem-solving, at least for large issues. Though most physicians I know dread being summoned to an administrative meeting, these meetings should give both administrators and physicians time to focus on the matter at hand. An even better scenario to allow increased focus would be to ban cell phones and pagers from these meetings. (I'm dreaming.)
5. Run meetings effectively. Respect all meeting attendees' time by sending out an agenda and supporting materials for consideration prior to the meeting. Start the meeting on time, and follow the agenda. Make sure to delegate tasks or action items that come out of the meeting, and follow up on those items with progress reviews at pre-determined intervals. Also, take good notes. You don't want discussion items or actions from one meeting to be forgotten by the next. A lack of follow-through will send a message that members' time and efforts are not respected and appreciated.
6. Take immediate responsibility. Problems should be identified, explored and resolved immediately. Ignoring problems and letting them fester leads to passive-aggressive and counter-productive behaviors. Physicians and administrators both need to own up to problems or failed initiatives and work together using good communication techniques to change course or correct problems.
You don't have to do it all: Connecting patients with community resources
When our practice was first introduced to the medical home concept, we were overwhelmed by the amount of services we should be providing to our patients. For example, the medical home model emphasizes patient self management, especially for chronic diseases. That means that patients with diabetes need guidance on diet, exercise, medications, injections and lifestyle changes. While we thought we were doing a pretty good job at this, fitting all this guidance into four 15-minute visits per year was probably not enough. How could we provide this care better – without adding FTEs? The answer became linking patients to existing resources in the community to supplement our in-office care.
Treating your patients as part of a larger population or community was an important part of the National Demonstration Project (NDP). Practices in the NDP soon discovered that they could not by themselves provide all the services implicit in a medical home. Financial, time and geographic barriers prohibited the provision of all services to all patients.
Dietary counseling, pharmaceutical services and therapy are some of the elements that may best be provided by facilities outside the medical home office. Costs of providing these services can be defrayed if practices tap outside sources to provide these services. We have a diabetic educator in our larger health system who does a very good job educating patients about their diet. The problem is that there is only one of her, and we have a LOT of diabetics. Furthermore, patients have to travel 20 minutes and navigate a large medical complex to get to her. Compliance with recommendations and follow-up suffers. But then we became aware that one of our favorite local pharmacists had become a certified diabetic educator, so we began having patients see him for diet and exercise advice. He also threw in medication advice. Since the pharmacy is in our town, patient compliance and follow-up was terrific.
If your practice does not have diabetic educators nearby, there are other resources. Visit http://www.diabetes.org/ for a plethora of free patient education ideas and support for professionals.
Our practice also utilizes home health to supplement our services to patients, and we have had some very good results reducing hospitalization rates for patients with CHF by educating them on diet and the importance of daily weights, with standing instructions for diuretic dosing based solely on daily weight changes. Many insurance companies will give patients a free scale. Recently, Optima Health has been offering scales and a daily phone consultation for CHF patients to assist with managing their fluid status and to recognize, report and treat early signs of an exacerbation. Now, we all know it would be terrific if payers would pay primary care physicians and their offices to provide such intensive management right from the office, but this is not yet a reality in most markets. Taking advantage of other resources can provide patients with much-needed services at no additional cost to the practice.
Another area where community resources are useful is with dementia. This devastating group of illnesses is very time and labor intensive for the family physician's practice. Many communities have Alzheimer’s programs, such as the one in our county: http://www.alzalliance.org. The Alliance offers a wealth of services to help both patients and their families cope with this devastating illness. I have referred several patients to this group and have been thanked for doing so. Helping patients find other individuals in the community who are dealing with similar health issues is very valuable for their overall care. Having a reliable resource to simply answer questions can save time and money in the care of individuals with dementia.
Hopefully these examples will help you explore ways you can connect patients with community resources. This networking approach shifts the cost of complicated care off the practice and encourages the patient to take more responsibility for self-management, core goals of care in the patient-centered medical home.