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American Academy of Family Physicians
Wednesday Jun 23, 2010

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.

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