“The key questions raised here are how to move [primary care transformation] from an intensive, boutique effort in hothouse demonstration programs to the mainstream.”1
In an effort to improve patient care, retain high-quality primary care providers, and qualify for payment reform, primary care practices across the United States are increasingly seeking patient-centered medical home (PCMH) recognition.2 Becoming a PCMH is a major undertaking.3 PCMH redesign requires changes to almost every process and system in a primary care practice to put patients at the center of care, from improving phone access to collecting and monitoring data for population-based care and redesigning referral systems with hospitals and specialists.4 PCMH recognition (ie, the process of documenting those changes for the purpose of external validation) differs from practice transformation to redesign care. Therefore, practice transformation often remains challenging for practices even after practice recognition has been achieved.
Practice facilitation, also called “coaching,” is a proven way to support practices to increase the motivation and quality-improvement skills of a practice to improve health outcomes.5 Coaching can include individualized consultation, as well as organizing peer-to-peer learning opportunities. Larger primary care health systems are increasingly developing their own internal coaching programs, whereas primary care associations and similar organizations are offering coaching to other practices.6–14 These coaching programs vary widely in terms of content, scale, and staffing.5,15 Many are relatively new or are expansions of more limited quality-improvement operations. In light of the limited guidance that is publically available about how to best support the transformation of practices, we crafted our own curriculum that draws on proven effective approaches. In this paper, we describe the Coach Medical Home curriculum and the evidence on which it was based.
We developed the curricular content by synthesizing evidence and experience from User Group consultation, a literature review, key informant interviews, and the Safety Net Medical Home Initiative (SNMHI). Each of these components is described in more detail in the following sections.
We convened a User Group to guide curriculum development in line with the needs of potential users. The User Group’s 12 members included leaders of primary care associations, community health centers, and national primary care organizations. They were selected by invitation based on our experience with leading-edge efforts and nominations by the funder. The User Group met 3 times over 18 months and meetings were facilitated by the authors. At the first meeting, the User Group provided feedback on our proposed modules (Table 1), which drew on the evidence described below. They reviewed learning objectives at the second meeting and reviewed draft content at the third meeting.
In fall 2011, we (E.W., B.T.A., K.C.) interviewed 8 leaders of large-scale primary care practice transformation initiatives. These medical and administrative directors of health care systems and primary care associations represented novel programs identified from the peer-reviewed and gray literature and snowballing techniques. The 30- to 45-minute individual interviews used a semistructured template that asked about: strategies to recruit and engage practices, including making the business case for participation and assessing readiness, and capacity to participate. We also asked how their programs sequenced the work, measured progress, and used peer-to-peer learning, practice facilitation, patient involvement, community linkages, and formal spread and sustainability planning. The interviewers reviewed detailed notes from the interviews together to identify themes.
Using PubMed, we searched for articles published in English between October 2006 and September 2011 that described the mechanics of how coaching programs were designed and implemented to support transformation. Search terms included: medical home; patient centered medical home; primary care medical home; patient-centered medical home; health home; chronic care model; collaborative; and practice transformation. We also reviewed Web sites that profile PCMH transformation initiatives that may not have been published yet, including: Pacific Business Group on Health; Patient-Centered Primary Care Collaborative; The Institute for Healthcare Improvement (IHI); AHRQ Innovations Exchange; Commonwealth Fund; The Robert Wood Johnson Foundation; Kaiser Family Foundation; and Center for Medical Home Improvement.
Figure 1 summarizes the search strategy and results. We found details about how transformation was supported for 25 different programs (Table 2) in 70 articles and reports. Most results are from US-based programs, many from the National Demonstration Program.35 We recorded program details using a structured abstraction tool (available upon request), including the quality improvement and payment approach and how programs addressed curriculum emphasis areas such as measurement, coaching, and peer-to-peer learning; and overall facilitators and barriers. The articles were largely described evaluation methods and outcomes but included limited information about specific intervention activities that could guide facilitation programs, so it was critical to supplement the results with findings from the other sources.
The SNMHI was a national demonstration implemented between 2008 and 2013 by The Commonwealth Fund, Qualis Health, and the MacColl Center for Health Care Innovation. The goal of the SNMHI was to help 65 primary care safety net sites become high-performing medical homes and to develop and demonstrate a replicable and sustainable implementation model for medical home transformation.4,15,51 Our applied experience as the National Program Team for the SNMHI, including participating in regional peer-learning groups for practices and coaches as expert faculty, provided additional insights. SNMHI coaches met regularly and their discussions were particularly valuable for surfacing specific challenges of PCMH transformation and prioritizing practices’ needs. For example, these sessions raised issues about the challenges of meshing practice transformation activities with a practice’s desire to seek NCQA recognition—a labor-intensive activity.
The best practices and issues identified from the above sources fit into the module topics developed with the User Group. With the User Group, we then developed corresponding learning objectives and outlined curricular content for each module (Table 1). Each module had 1 or 2 lead authors who used the available findings from the literature review, expert interviews, and SNMHI experience to develop content. Each module includes action steps and tools coaches could use to support these steps, for example, a companion slide deck that coaches and practice leaders could present at trainings. Individual modules were reviewed by the writing team, including a professional editor with expertise in plain language writing, and then by one of the User Group members.
In this section, we describe the key content presented in each of the 6 Coach Medical Home modules.
Getting Started: Selecting Sites, Structuring Interventions
As coaching programs get started, they need to identify how to best structure interventions. Ultimately, the success of any practice transformation initiative depends on the practice’s motivation to change and ability to continuously make changes to their systems.9,35,36,38,42,52 Practices begin transformation for reasons ranging from internal improvement goals (eg, Group Health,26 Harvard Vanguard28) to external incentive programs requiring formal proposals (eg, CareOregon12).
The readiness of a practice to engage in practice redesign—both in terms of its organizational stability and in terms of its will and ability to change—can be assessed by a structured visit to the practice.36,38 These initial visits help develop good relationships and provide a basis for program planning.39 To proceed and build a shared vision for success, practices, particularly leadership, need to understand the time and resources they will be expected to put into the work and what benefits they can expect to see as a result. PCMH assessments are 1 way to evaluate a site’s core functioning and can measure progress towards implementing specific PCMH processes as well.24 Having engaged the practice and established a relationship, the coaching program can implement specific technical support tailored to the practice and help foster and maintain motivation to change.35,36 Coaching relationships typically begin with intense upfront interactions between the coach and practice leadership. Thereafter, follow-up coaching occurs over a period of months to years, depending on objectives and available resources, and generally involves quality-improvement staff and committees. The information below provides more detail about implementing the technical support program.
Recognition and Payment
In the United States, there are diverse PCMH recognition and payment initiatives.53 Practice leaders often have questions about PCMH costs and payment opportunities and wish to understand the business case for PCMH before investing resources in transformation and recognition. Although coaches are not expected to be payment or policy experts, or advise on financial management strategies, coaches should be able to understand and articulate the business case for PCMH and to connect practice teams with the resources (internal and external) that can help them achieve their goals.
Coaches play a critical role in helping practices understand PCMH costs as investments rather than just expenses. In crafting the business case, coaches should be prepared to share evidence and examples of how PCMH can improve patient outcomes and reduce costs (eg, Geisinger, Group Health, Wellmed, and CareOregon).12,26,50,54 Coaches should also be prepared to describe outcomes that may be particularly attractive to practice staff, such as improved operational functioning, work-life balance, and professional motivation and career growth—including through training and continuing education credit.26,40,55
Coaches can also help practice teams understand how to advocate for and leverage internal resources to provide protected time for team huddles or funds to support practice change. Helping a practice learn how to identify, leverage, and prioritize resources is an essential component of building a practice’s capacity for effective change management. In addition, coaches can help practice teams identify external resources that may be available through pilots or programs that offer enhanced reimbursement, incentives, or other financial benefits to practices that meet requirements such as attaining PCMH recognition, implementing specific PCMH functions (eg, after-hours access), or meeting specific performance targets (eg, quality, cost, utilization).
Finally, coaches can help practices understand the difference between practice transformation and PCMH recognition. Some practices either conflate recognition with transformation (failing to understand how they are different or why transformation must precede recognition); or conversely, see transformation and recognition as separate goals that compete with each other for time and resources.51 A skilled coach can clarify the distinction, and establish a stepwise work plan to help the practice achieve both goals in a synergistic way.
Fundamentals First: Sequencing Changes
The SNMHI approach to PCMH transformation is guided by the 8 Change Concepts for PCMH Practice Transformation that define the attributes of a PCMH.4 Interactions with SNMHI coaches15 and practice leaders55 indicated that some changes were necessary before others could be made, suggesting a pragmatic sequence for addressing the change concepts: (1) laying the foundation: engaged leadership and quality-improvement strategy; (2) building relationships: empanelment and continuous, team-based healing relationships; (3) changing care delivery: organized, evidence-based care and patient-centered interactions; and (4) reducing barriers to care: enhanced access and care coordination. Without engaged leaders and an effective quality-improvement strategy, practices struggled to make changes. Without linking patients with specific providers, it is difficult to deliver organized, evidence-based care that relies on continuity and population management. And without team-based healing relationships, providers do not have the time or resources to change care delivery or improve care coordination and access. The sequencing helps practices identify where to start. Once this is established, sites can try key changes that fall under each change concept—specific action steps they can adopt and adapt in their practice. Coaches can use the sequencing to guide practices, taking into account each practice’s strengths and weaknesses and the system interdependencies involved in transformation.3,7,20,35,36,38,40,48
Measurement Matters: Setting up an Efficient and Effective Strategy for Assessing Progress and Detecting Success
Measurement for improvement—distinct from measurement for achieving specific recognition or evaluation objectives—is a critical part of PCMH transformation. Nothing builds traction like seeing improved measures that relate to changes made by staff. An improvement-focused measurement and reporting strategy aligns practice goals and external reporting requirements and helps the practice build momentum.
In the program results we reviewed, measurement was widely used to guide quality-improvement efforts, often through a dashboard of measures selected to inform goal setting and progress tracking.7,19,25,28,42,45,46,50 Patient care process measures and clinical outcomes were the most commonly used. Examples include third next available appointment; continuity; care management activity; phone access; outreach; patients called within 48 hours of hospital discharge; count of eligible process measures completed; and clinical process measures like immunization rates; and percent of eligible patients in prenatal care in the first trimester. The literature and our experience both suggest that effective reporting should draw from real-time systems (eg, electronic health records) so that it is meaningful to the practice, and include balance measures to identify any unintended consequences.56,57
An effective measurement and reporting strategy involves regular team discussion and action around the selected measures.58 Implementing and routinizing measurement requires careful communication to ensure accurate interpretation and avoid mistrust or resentment.59 Therefore, coaches should start measurement discussions by helping the practice understand the many ways that measurement reporting can support practice goals for improvement and funding. Practices often express frustration with measurement programs that are required for external purposes but not used internally. A coach can help practices reconcile the many needs for measurement data by identifying sets of variables that allow a practice to track clinical care and population management quality while meeting specific reporting requirements.60 Practices where all clinicians and staff are comfortable using data to set and track goals are well positioned for achieving improvement. Coaches can encourage this by making connections between strategic goals and reporting requirements, advising on attainable goals, recommending processes that engage staff in discussing data, troubleshooting challenges, and celebrating success.
Learning Communities: Building Excitement, Sharing Learning
Learning communities enable practices to actively learn from each other’s information and experiences. Learning communities provide a forum for practices to test and share resources and tools with one another, promoting the use of best practice tools, and reducing the time a practice might otherwise spend “recreating the wheel.”
Coaches may direct and often coordinate the activities of learning communities. Common mechanisms for promoting engagement and cross-site sharing successfully used by the IHI and the SNMHI include conference calls and webinars, individual and group site visits, newsletters and listservs, and in-person meetings.15,61 Experience from formal breakthrough series model collaboratives has identified 3 best practices: use prework to orient participants; encourage teams to track and record their quality measures to inform senior leaders, guide work with practice coaches, and compare with peers; and make suggestions for what practices should do between learning sessions.23,31,32,61
Scaling learning and enthusiasm requires careful attention to how information is shared: in the National Demonstration Program, learning sessions were energizing for participants but they found it challenging to pass this energy on to colleagues when they returned home.40 Some options which coaches can use to address these challenges are virtual learning communities, which participants can attend remotely, as well as ongoing support over time such as a listserv and periodic check-ins by the practice coach.41,45
Sustaining and Spreading Changes in Practice
Practice transformation is an ongoing process, not a destination. So it is important to consider how to design the program for sustainability, especially after the active coaching period ends. In addition, participating practices may wish to spread similar changes to other locations. Many PCMH programs, especially those within multipractice provider organizations (eg, Group Health; Harvard Vanguard), began with a pilot practice before spreading the program further. This approach allows for the model to evolve iteratively.28 Through testing, teams can identify which changes should be implemented consistently, as part of standard work. Leadership support is critical to maintain the vision and resources for transformation sustainability, such as documenting, routinizing, and refining new processes.36,42,48,62,63
To spread promising innovations, either within a single organization or between entities in a community, implementation science theory advises that potential adopters need to implement essential core components but also be allowed to refine and modify the innovation to fit their internal and external environment as the pilot site may differ significantly from the subsequent adopters. Spread can happen in different ways, ranging from a top-down directive to passive diffusion dependent on social networks.64,65 When choosing a method, systems should consider the amount of time they have to spread the innovation, and the degree of fidelity they require to maintain consistency among locations. Coaches can support spread by highlighting the benefit and feasibility of innovations, emphasizing how the new way is compatible with existing norms and values, and providing training and opportunities for testing.
Coach Medical Home draws on available evidence and experience with a larger transformation initiative to support practice coaching programs’ efforts to guide practice transformation. Across the modules, the curriculum emphasizes 3 main cross-cutting themes. First, transformation requires leadership commitment to support culture change. Second, strategies to engage and transform practices must be tailored to organizational context. Third, effective use of measurement and reporting, especially when bolstered by practice facilitators and peer-to-peer learning, supports both the conduct of PCMH activities and the transformation process. Therefore, supporting or facilitating PCMH transformation requires that coaches understand PCMH components and improvement approaches, as well as how to motivate practices to build and implement a transformation program.
The curriculum includes instructional material and tools that support application of the material with practices, such as slide decks, talking points, and a return on investment calculator. Coach Medical Home is publically available at http://www.coachmedicalhome.org. The site launched January 28, 2013 and 2019 unique visitors made 3137 visits in its first year.
A limitation of our effort to create an evidence-based curriculum, as confirmed by our literature review, is that that there is little published evidence to guide specific approaches to coaching practices to achieve broad-scale transformation in primary care. Therefore, Coach Medical Home draws heavily on our experience in the SNMHI in which we created an operational and evidence-based model for PCMH transformation, including the Change Concepts for Practice Transformation.4
Coach Medical Home contributes to the field by providing a curriculum coaches can use to support primary care transformation. As the bolus of medical home evaluations continue to be conducted and published, the field would benefit greatly from enhanced descriptions of the associated coaching interventions: What changes did the practices make? How did they make them? And what kind of support did those practices need to achieve the results they did? The field of PCMH is rapidly evolving, so we encourage testing and adaptation of Coach Medical Home as new models, evaluation findings, and contextual factors in the practice and policy environments emerge.
The authors are grateful for the time and insights of the practice transformation facilitators and program organizers who provided input on Coach Medical Home.
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