The Patient-Centered Medical Home: Implications for Health Policy and Workforce Development

1. The Patient-Centered Medical Home: Implications for Health Policy and Workforce Development Paul A. Nutting, MD, MSPH Dir of Research, Center for Research Strategies Professor, University of Colorado Health Science Center

2. Today I want to do 4 things • Review some of the features of the Patient-centered Medical Home (PCMH) • Share findings of our evaluation of the first national demonstration of the patient-centered medical home (PCMH) • Review policy implications of the PCMH • Initiate a discussion about the workforce implications of the PCMH.

3. Patient-Centered Medical Home (PCMH) • Political construct that has gained traction among many primary care stakeholders • The PCMH is embedded in the Affordable Care Act • Four primary care physician organizations (AAFP, ACP, APA, AOA) agreed on 7 principles of the PCMH and promoting PCMH as a new model for primary care practice. • Many demonstration projects underway (including several in Colorado), and including a national Medicare demo • National Demonstration Project of the American Academy of Family Physicians was the first major test, and has recently been completed and evaluated.

4. The Patient-Centered Medical Home

5. PCMH brings together four compelling streams of reform • Four pillars of primary care • The chronic care model--proactive, population-based perspective • Emerging information and communication technology • Consumer-driven insistence on better service, partnership, and transparency

6. National Demonstration Project of the Patient-centered Medical Home • Two-year project supported by American Academy of Family Physicians • PCMH model developed and implemented by TransforMED • National sample of 36 practices--randomized into intervention and self-directed • Highly motivated small and midsize practices • High degree of HIT adoption at baseline • Independent evaluation team--multi-method assessment.* *Annals of Family Medicine. (Supplement) May, 2010

8. Intervention: Resources Available Facilitated Practices Self-directed Practices • Received assistance from a change facilitator • Access to on-going consultation from a panel of experts in practice economics, health information technology, and quality improvement • Discounted software technology, training, and support. • Four learning sessions and regular group conference calls • Given access to web-based practice improvement tools and services without on-site assistance • Self-organized their own learning session half-way through the two-year project and participated in the final learning session

9. NDP Intervention: Limitations The PCMH model and the NDP intervention strategy both emphasized information technology Implementation strategy emphasized getting model components in place more than using them Did not alter the reimbursement system and had limited connection to the PCMH neighborhood

10. QUANTITATIVE Patient surveys Clinician/staff surveys Medical chart reviews Practice finances QUALITATIVE Field Notes from observations of facilitators Field notes from observations by Qual Analyst Key informant & informal interviews Email strings between practices and facilitators Online discussions between practices Learning Sessions and Conference calls Data Sources

11. Trial Main Effects • Both groups implemented many PCMH model components (facilitated practices implemented more components) • No change in patient rated outcomes • Patient-rating of their practice as a PCMH went down in both groups • Modest increases in quality of care indicators from medical record review in both groups; no difference between groups • Quality indicators associated with number of model components in place

12. 9 Lessons Learned From the National Demonstration Project

13. 1. Building a PCMH is a monumental undertaking • Highly motivated practices can implement many of the model components. • Transformation to a PCMH requires more than two years. • Practices don’t have change management strategies--they generally use a ‘just do it’ approach. • On-site facilitation accelerates implementation.

14. 2. Capacity for change at baseline is a huge determinant of success • ‘Adaptive reserve’ includes a healthy relationship infrastructure, facilitative leadership, and a culture of learning and improvisation. • Despite being highly motivated some practices had serious dysfunctional problems within the relationship infrastructure that required significant time and energy on the part of the facilitator. • Sustained change efforts brought out dysfuntion not obvious at the beginning • This was manifest as “change fatigue” and included unresolved tension and conflict, staff turnover, burnout, and passive resistance. • ‘Adaptive reserve’ can be used up and must be replenished

15. 3. Model components vary in difficulty • Implementing discrete model components was easier than changing roles and work patterns to use them. • For example, many practices implemented disease registries, but were unable to reconfigure work processes to use them effectively for population management. • Same-day scheduling and e-prescribing were far easier than developing care teams and population management.

16. 4. Successful practices have shared leadership systems • The most successful practices seem to have shared leadership systems rather than an individual charismatic physician leader. • Distributed and facilitative vs centralized and autocratic • Many physicians lack effective leadership skills. • A critically important role of leadership is to assure adequate time and space for safe group reflection and rich conversation.

17. 5. Health Information Technology (HIT) is not ready for prime time • Currently available HIT, while showing important potential, is not a "plug and play" interface for primary care practices. • Resembles more a pile of jigsaw pieces than inter-operable components of an integrated system • Most unable to support population management within the practice • None able to support coordinating care across the health care neighborhood

18. 6. Transformation to a PCMH cannot be achieved by a series of incremental changes • Traditional QI processes (such as PDSA cycles) are inadequate for transformation--QI processes work well within a stable practice model • Every major change, when implemented, has ripple effects on processes and roles throughout the practice--including changes made previously • Transformation requires ongoing attention to maintain and adapt changes. • Transformation requires shifts in mental models and sense of identity of both individuals and groups

19. 7. Transformation challenges many physician’s professional identity • Hesitant to share their special patient relationship with other members of the team • Responsibility goes beyond face-to-face care in the exam room to proactive, population management. • May not always personally do everything for the patient--share this responsibility with team. • May not always be the team leader.

20. 8. Transformation to PCMH challenges the group’s vision of their work • From caring for one patient at a time to managing a population • From an assembly line for efficient patient flow to a nimble team able to identify and meet changing patient needs and preferences • From a visit-centered to a population-based approach • From an isolated, independent source of care, to a member of a coordinated health care neighborhood • In short, practices need to become organizations that learn and improvise

21. 9. Medical homes must be integrated into a health care neighborhood • Cannot reform health care by ‘fixing’ primary care in a broken system. • Rather than asking medical homes to keep patients out of the cracks, the health care neighborhood should eliminate the cracks. (start with mental health) • Health care neighborhood is more than the practice’s referral network. • The neighborhood should be seen as a coordinated network of resources for the patients.

22. 4 Policy Implications Derive from the PCMH

23. 1. Transforming primary care will take time and patience • Two years is not enough. • Transformation requires a concerted national effort and the political will to invest in long-term system development and not promising a quick, single-stroke fix. • Policy environment must provide adequate time, resources (e.g. training, tech assistance) and incentives to permit primary care models to further develop in collaboration with integrated health care neighborhoods. • Reimbursment reform should support the developmental stages of transformation to a medical home and incentivize innovative care teams.

24. 2. The PCMH model should continue to evolve • Current PCMH model is very physician-centric • The full range of primary care services has overgrown the capacity of any single discipline. • Actively seek new models, not simply modifications of existing models--encourage disruptive innovation.

25. 3. We need radical new thinking about health care teams • Seriously include the patient. • Recognize that insistence on exclusively physician-directed care constrains the range of ways we can think of care teams. • Configure care teams both within practice and within health care neighborhood • Teams must be nimble--form and reform as patient needs and preferences change • Explore the potential of teams that are virtual and asynchronous • Clearly these teams will present new challenges for health information technology

26. 4. Most practices will require assistance in the transformation • NDP Facilitators were change agents, coaches, consultants, negotiators • Not all practices need the same thing, nor do the necessarily need it continuously • Extension agent model for assistance in leadership, change management, innovative practice operations, and for leveraging health information technology resources.

27. PCMH brings 3 new challenges for Workforce Development • PCMH as currently envisioned is too physician-centric. We need a multi-disciplinary, collaborative approach to refining the PCMH within the context of a health care neighborhood • Need serious innovation around care teams • Small practices and care teams desperately need effective facilitative leadership.

28. Implications for Workforce Development • Strengthen primary care pipeline for all disciplines • It isn’t all about the numbers; it’s about what they do and how they work together in new ways • Strengthen pre-graduate training for new roles (e.g. innovative care teams, population management, care team leadership). • Serious program to retread existing primary care physicians for the same new roles. • Encourage disruptive innovation (e.g. retail clinics) that are coordinated within a health care neighborhood

29. What can we do in Colorado? • Step back from the current model(s) and our separate political agendas. Take a deep look at what’s possible, and jointly commit to a long term, collaborative and multi-disciplinary approach with willingness to thoughtfully listen to and respectfully question each other.

31. Chronic Care Model • The Community: Resources and Policies • The Health System: Organization of Health Care • Self-management Support • Delivery System Design • Decision Support • Clinical Information Systems

32. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

33. Four Pillars of Primary Care • Easily accessible first contact with the health care system • Comprehensive care for all health-related conditions • Coordination and integration of care across clinicians and settings • Personal care through sustained partnerships in the context of family and community

34. Payment Reform Options to Support Change and Transformation To A Medical Home

35. Bottom LineTransformation to a PCMH is more about discovering how to become a learning organization, which co-creates an emergent future, than it is about learning from experts on how to build something already known.

36. References • Cohen D, McDaniel RR Jr, Crabtree BF, et. al. A practice change model for quality improvement in primary care practice. J Healthc Manag. 2004 May-Jun;49(3):155-68. • Miller, W.L., Crabtree, B.F., McDaniel, R.A., and Stange, K.C. Understanding Primary Care Practice: A Complexity Model of Change. J Fam Pract, 1998 46(5):369-376. • Miller WL, McDaniel RR, Jr., Crabtree BF, Stange, K. Practice Jazz: Understanding variation in family practice using complexity science. J Fam Pract 2001; 50(10):872-878.

37. References • Stroebel CK, McDaniel RR, Crabtree BF, Miller WL, Nutting PA, Stange KC. How complexity science can inform a reflective practice improvement process. Joint Comm J Qual and Patient Safety. 2005; 31(8):438-446. • Lanham HJ, McDaniel, Jr RR, Crabtree BF, Miller WL, Stange KC, Tallia AF, Nutting PA. How Practice Relationships Can Improve Quality of Care. Jt Comm J Qual Patient Safety. 2009;36:457-466.

38. References • Crabtree BF, Miller WL, Tallia AF, Cohen DJ, DiCicco-Bloom B, McIlvain HE, Aita VA, Scott JG, Gregory PB, Stange KC, McDaniel RR. Delivery of Clinical Preventive Services in Family Medicine Offices. Ann Fam Med. 2005; 3(5): 430-435. • Miller WL, Crabtree BF. Healing landscapes: Patients, relationships and optimal healing places. J Complementary and Alternative Med. 2005, 11 Suppl 1:S41-9. • Nutting PA, Miller WL, Crabtree BF, Jaen RC, Stewart EE, Stange KC. Initial lessons from the First National Demonstration Project on practice transformation to a patient-centered medical home. Ann Fam Med 2009;7:254-260.

39. References • Jordan ME, Lanham HJ, Crabtree BF, Nutting PA, Miller WL, Stange KC, McDaniel RR. The role of conversation in health care interventions: enabling sensemaking and learning. Implementation Science 2009, 4:15 doi:10.1186/1748-5908-4-15 Solberg LI,

40. Properties of Complex Adaptive Systems(Cont.) Self-organization: systems generate new structures and patterns over time as a result of their own internal dynamics. Order emerges from patterns of relationships among agents. Emergence: process by which non-linear interactions among agents results in new patterns of behavior. The system that evolves over time is more than the sum of its parts. Co-evolution: process of mutual transformation of the agent and the environment in which it exists.

41. Properties of Complex Adaptive Systems (CAS) CAS consist of ‘agents’ with capacity to learn and freedom to act in unpredictable ways. Agents are often individuals, they may be teams, organizational processes, technical components Agents are connected in non-linear ways--one agent’s actions changes the context for other agents. The quality of the interactions among agents is more important than the quality of the agents

42. According to CAS principles, successful practices will: Move from an ‘organization as machine’ paradigm and begin to understand their practices as complex adaptive systems. Pay more attention to the quality of the interactions among staff than on the quality of the staff. Focus on staff learning rather than on what they know today. Encourage cognitive diversity among staff (and teams) and leverage diversity to foster learning and emergence Recognize that the practice is a social entity, and foster sense-making, learning, and improvisation Expect and celebrate surprise as opportunities to learn and grow Begin to understand the interdependence between the formal and informal organizations rather than making everyone conform to the formal organization L

43. Relationship Infrastructure • All of our work has emphasized the importance of the relationship systems within primary care practice. • Dysfunctional relationships will emerge in times of stress or rapid change. Lanham HJ, McDaniel, Jr RR, Crabtree BF, Miller WL, Stange KC, Tallia AF, Nutting PA. How Practice Relationships Can Improve Quality of Care. Jt Comm J Qual Patient Safety. 2009;36:457-466.

44. Summary of the Joint Principles of the PCMH • Personal Physician: Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. • Physician Directed Medical Practice: The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

45. PCMH Joint Principles (cont) 3. Whole Person Orientation: The personal physician is responsible for providing for the entire patient’s healthcare needs and taking responsibility for appropriately arranging care with other qualified professionals. 4. Care is Coordinated and/or Integrated: across all elements of the complex healthcare system (e.g. subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g. family, public and private community based services). Care is facilitated by registries, information technology, health information exchange and other means.

46. PCMH Joint Principles (cont) 5. Quality and Safety: are hallmarks of medical home by incorporating a care planning process, evidence based medicine, accountability, performance measurement, mutual participation and decision making. 6. Enhanced Access: to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.

47. PCMH Joint Principles (cont) 7. Payment: appropriately recognizes the added value provided to patients who have a patient-centered medical home beyond the traditional fee-for-service encounter.

49. Types of Teams CONTROL (Think Football) AUTONOMY (Think Baseball) COLLABORATION (Think Basketball) From R. Keidel, Corporate Players

50. Team-Based Care • The “Teamlet” • Primary care physician • Medical assistant 1 • Nurse • Nurse practitioner • Medical assistant 2 • The “Navigator” • Care manager/health coach • The “Team” • Primary care physician & practice nurse