Although only 6 years have passed since the patient-centered medical home (PCMH) was first proposed to reinvigorate primary care, thousands of practices have engaged in formal and informal transformation activities. Strong evaluation activities supported by The Commonwealth Fund, the Agency for Health Care Research and Quality, and others have elucidated a coherent set of observations about the nature and difficulty of the process, the factors associated with successful change, and the challenges that must be overcome.1 All observers agree that practice transformation is difficult, even painful, and perhaps never-ending without a “Cinderella moment when the practice suddenly realizes it is a PCMH.”2 For most primary care practices, becoming a fully functioning medical home means wholesale changes to the way the practice organizes itself, serves its patients, and delivers care. Many peoples’ jobs change in ways that are challenging, even disorienting.
In this paper, we discuss lessons learned in the course of the Safety Net Medical Home Initiative (SNMHI), a 5-year demonstration project sponsored by The Commonwealth Fund that aimed to assist 65 safety net clinics in 5 states become PCMHs. Despite the high level of support made available to each practice, participating practices varied widely in their transformation success. Over the course of the SNMHI, project staff and practice facilitators frequently discussed the characteristics that enabled successful clinics to transform. These discussions often revolved around the following 3 questions: what motivates practices to disrupt old ways of organizing and delivering care; what changes enable practices to see a better future and sustain the effort; and how do successful practices go about making changes? To pursue these questions, we studied a small number of successful clinics in more depth to identify potentially promising avenues for future research.
The SNMHI has been described elsewhere.3,4 It was a 5-year (2008–2013) effort sponsored by The Commonwealth Fund to develop and test a replicable model for supporting acceleration of PCMH transformation among 65 safety net practices in 5 states. Participating practices in each state were supported by a Regional Coordinating Center, most commonly a Primary Care Association, which employed medical home facilitators (MHFs) who worked closely with individual clinics in their transformation efforts. In the first year of the initiative, we identified 8 domains in which practices would need to implement changes to become medical homes, and suggested 3–5 more specific and actionable key changes associated with each domain.4
Our objective for the case studies was to study 3 practices of different sizes, geographic locations, and organizational structures that had all made major progress in their transformation to PCMH. The primary tool used in the project to assess transformation progress was the Patient-centered Medical Home Assessment (PCMH-A), a self-assessment conducted by the practice team.5 This 33-item instrument assesses progress toward implementation of each of the key changes on a scale from 1 to 12. SNMHI practices completed the PCMH-A every 6 months between March 2010 and March 2013. Across the 65 sites, the mean overall score rose from 7 to 9 over the 3-year interval.
Because of limited resources, the case studies included 3 practices of different sizes, geographic locations, and organizational structures that had all made major progress in their transformation to PCMH. We wanted sites in different states, both rural and urban, that included a small, single-site rural clinic, an urban clinic, and a multisite community health center. We limited our candidate pool to sites that had made substantial transformation progress as measured by change in their overall PCMH-A scores. Using these criteria, we identified 8 sites and asked the MHFs working with each of the 8 for their assessment. With advice from the MHFs, 3 primary care organizations were selected: clinic A (an urban FQHC in Oregon), clinic B (a small single-site rural clinic in Colorado), and clinic C (a multisite urban and rural FQHC in Idaho). On average, the overall PCMH-A scores of our 3 clinics increased from 6.4 in March 2010 to 9.4 in March 2013.
We contacted leaders in each of the 3 clinics to identify those individuals in their clinic who played key roles in practice transformation. We then interviewed key staff either in person or by telephone. At clinic A, we interviewed the clinic medical director and the quality improvement specialist. At clinic B, we interviewed the CEO, RN clinical coordinator, and Business Manager. From clinic C, we interviewed the organization’s medical director and received input from the recently retired CEO. We conducted semistructured 1-hour long qualitative interviews during February and March 2013 with these practice leaders. Examples of interview topics and questions are listed in Table 1. Interviews were audio taped and transcribed for data analysis.
The 3 authors (E.H.W., R.G., and K.C.) collaboratively developed a coding system to aid in the location of content and potential quotations. Each author then independently coded each transcript, and disagreements in coding were resolved by discussion among the coders. Data analysis began with each of the 3 authors immersing themselves in the transcripts in an effort to identify recurring themes within and across cases.6 Through discussion, we arrived at a final set of themes.
What Motivates Practices to Disrupt Old Ways of Organizing and Delivering Care?
Unless a clinic comes to appreciate the difference between their current practice and a fully functioning PCMH and begins to visualize a better future, there is little motivation to change. Psychologists distinguish 2 sources of motivation—intrinsic and extrinsic.7 Motivation is intrinsic if one changes because the changes are personally desirable or rewarding; it is extrinsic if one changes primarily in response to perceived external rewards or threats. In most situations, intrinsic motivators are felt to be more powerful motivators of change. For PCMH transformation, intrinsic motivators would include concerns about the practice’s quality of care or patient experience, or the desire to be a community leader. Opportunities to obtain new payments or meet certification or recognition standards are common extrinsic motivators.
The 3 organizations studied generally saw change as the way to respond to internal concerns. In 1 clinic, the concern was provider excellence and accountability. One leader in a second clinic described change as a response to major organizational change and upheaval. “I think people just needed something to organize around and we also really needed to raise the quality of care.” External factors such as reimbursement or recognition were mentioned but did not appear to be the decisive motivators for these practices.
Armed with a desire for a better future, leaders in all 3 clinics made transformation an organizational priority, and often visibly drove change themselves. For instance, in 1 organization the CEO got up and said “We are going to do this and we’re not looking back.” However, the clinics seemed to have differing initial impressions of the magnitude of the undertaking. One clinic recognized that they had to “tear everything down…and build it from the ground up again.” Others were “just trying to get our feet wet,…figuring out what it all meant.” Eventually all 3 practices did recognize the magnitude of undertaking and it was not going to happen without a concerted effort across the entire organization.
For many SNMHI practices, building will among physician and nursing leaders was often a decisive next step. One clinic’s experience was not atypical. “We had one physician champion [but]…unfortunately he didn’t try real hard to sell the concept to his peers.” Three residents with prior exposure to the PCMH “helped get the momentum going much better.” In a second clinic, the Medical Director was the champion, and he went from clinic to clinic meeting with all staff “giving them a vision of what we were doing.” In the third clinic, 1 physician emerged as a “fantastic champion” who would identify work processes that needed fixing, and was willing to test ideas for change. Some providers and staff never “catch the vision” and in 1 clinic, a provider opposed to working in teams was let go; in another clinic, nurses uncomfortable with expanded clinical roles left the practice.
What Changes Enable Practices to See a Better Future and Sustain the Effort?
It is often said that a major characteristic of effective leadership is the ability to help their colleagues envision a better future. In our 3 clinics, the vision came as a result of their involvement in the SNMHI and hearing presentations of the PCMH model. One clinic leader described attending an SNMHI meeting with his CEO where the PCMH model was discussed. “Our CEO…caught the vision pretty quickly. We knew we needed to do this…It was going to be better patient care.” In the third clinic, staff “did the pilgrimage to South Central Foundation in Alaska and said we need to bring this [back home].”
The specific ideas for change in the SNMHI were the 8 change concepts and 33 more specific key changes described above. One major question about their implementation arose repeatedly throughout the SNMHI. Where should we begin, and is there any order in which we should work on changes? As 1 leader put it: “how you sequence the work in a primary care home is crucial, and we didn’t understand.” Over time, a logical sequence began to emerge as shown from the bottom up in Figure 1. Practices simply could not make progress if their leaders were unenthusiastic or not engaged, and/or they did not have a strategy and resources for making changes. Therefore, we considered 2 change concepts, Engaged Leadership and Quality Improvement Strategy, to be foundational.
Leadership visibility in the transformation process seems to be critical. For example, in 1 of our 3 organizations, the CEO and Medical Director personally led transformation. “We actually went around [to all clinics] and had a clinic meeting…so everyone was onboard at the same time and understood the same things.” SNMHI developed special sessions and resources for clinic leaders in an effort to increase their understanding of transformation. This proved to be pivotal for 1 of our 3 clinics whose CEO, after participating in an SNMHI meeting, decided “we needed to do this because it looked like it was going to be better patient care.” Because we primarily interviewed practice leaders and focused on their role, we have likely given inadequate attention to staff engagement and involvement in the transformation process. Staff involvement in planning and executing system changes played a critical role in clinics A and B.
Our interviewees, especially the leaders, discussed the factors that had influenced their clinic’s ability to change and improve. Having a trusted performance measurement system and explicit approach to identifying and testing practice changes were crucial. For example, 1 leader attributed her clinic’s earlier failures to create sustainable change to the lack of an infrastructure and culture to support change, what she called adaptive reserve.8 Although many SNMHI clinics had some quality improvement experience, relatively few had stable, trusted performance measurement systems in place. For 1 of our 3 clinics, hiring a quality improvement specialist who could produce meaningful performance measures and work with teams to interpret and improve those measures was a turning point. In addition to measures, practices struggled until they developed an organized approach to process change. One of our 3 clinics did not see real change until “we brought in a guy to help with Six Sigma, looking at the processes. I think that’s when we really got traction in terms of the real detail.”
Next, practices that had not linked patients with specific providers or care teams found it extremely difficult to begin to make many of the changes involved in becoming a PCMH. SNMHI practices that created explicit patient panels for the first time found that it paved the way for other PCMH changes. For example, explicit panels enable and encourage population management and continuity of care. They facilitate measuring and reporting performance at the provider level, which is more likely to spur change than organization-wide measures. As 1 interviewee put it: “once you can run data on your own panel, that’s really when medical home practice change happens.” In addition, having a panel defines a provider’s work in a very different way. Without panels, work is largely confined to managing and documenting visits. With panels, work extends beyond visits.
For many safety net practices, empanelment clarifies the need for high functioning patient care teams. The clinical champion in 1 practice asked “how am I able to perform in this new environment where I…have …an assigned panel of patients…, where I …simply couldn’t get all the work done?” Her response was to pilot working as a team and slowly developed the huddles, task delegations, and other elements of team care that enabled her “to figure out how she’d get her work done.” The clinical champion in another practice early on grasped “that with this medical home…it would be a team taking care of the patient.” His challenge was to convince his colleagues. They let each individual clinic define their team. Slowly nonphysician staff began to catch “the vision that what they did mattered,” and they started to see small successes. In all 3 clinics, the formation of teams that huddle each morning was decisive in changing the culture and freeing up time for providers and others to manage their population. SNMHI practices that developed effective clinical teams found it much easier to tackle the remaining elements of the PCMH.
How do Successful Practices go About Making Changes?
The 3 clinics found that change was slow and difficult until they found a way to create both a culture and infrastructure that encouraged and supported change. One clinic “got off to a slow start” as they struggled to find a way to make changes. This clinic made progress when they involved the folks and units relevant to the change, used process mapping to identify the kinks, and then planned and tested small changes. Another practice had been exposed to Plan-Do-Study-Act (PDSA) cycles and tried to implement them, but found that they “did a lot of P and D and not a lot of S.” As a result, change was difficult to sustain. Participation in an insurer’s pay for performance program encouraged the development of a more robust performance measurement system. To manage the measurement, the clinic hired a Quality Improvement coordinator who not only crunched the numbers, but started taking the reports to the team rooms encouraging the teams to “figure out a way that we can do better.” In this clinic’s view, “the practice of measurement, reviewing [the measures], discussing and understanding your patient population” is what enabled them to move forward. In our third clinic, leadership not only drove change, but became major implementers of change. The CEO systematically used his bully pulpit and data to educate and motivate management, staff, and the Board of Directors. The Medical Director met with all the providers, and brought the new vision to each clinic and “worked at all of these clinics as a training mechanism.”
Practice coaching or facilitation was an important SNMHI resource made available to all participating organizations, but interviewees all indicated that transformation accelerated in their organization when an individual within the practice began to help and coach QI and practice teams. The coaches—an outside consultant, an internal QI coordinator, and a Medical Director—varied widely in training, orientation, and experience, but all were deeply committed to transformation, clearly linked with leadership, and worked directly with the QI and practice teams planning and testing changes.
Practice organizations vary widely in their capacity to mount a sustainable transformation effort that promises to be successful. Nolan9 has proposed a simple framework for thinking about organizational improvement—Will-Ideas-Execution. To change and improve, practices need the will or motivation to uproot old processes and habits and try new ones. Change seems to be easier to sell and to implement if based on explicit ideas that have been tried and found to be successful elsewhere. Most PCMH models involve dozens of discrete changes across multiple aspects of a practice.10,11 However, motivation and good ideas are insufficient if the practice does not have a strategy and mechanisms for executing meaningful changes to practice systems and work processes.
Our case studies illustrate the importance of each of these 3 ingredients to successful practice transformation. For 2 of our case study organizations, the will to transform practice was not sufficiently strong until exposure to the SNMHI model and resources. In those cases, exposure to a new set of ideas for primary care generated a sense that the future could be better following change. The ability to visualize a better future increased the motivation to change. The third clinic had been involved in practice change learning communities for several years, but had failed to make major, sustained improvements in performance. The will and ideas were there; what had been missing was the capacity to execute. The experience of our 3 clinics and the SNMHI as a whole suggest that the relationships between will, ideas, and execution are not linear. Exposure to new ideas for organizing and delivering care helped build the motivation to change in 2 of our 3 sites. In our third site, hiring a quality improvement coordinator who could produce trusted, meaningful performance measures and help frontline teams plan and make changes to improve the metrics intensified the organization’s motivation to make transformational change.
Our case studies confirm that leadership involvement in transformation is necessary. Across the 65 sites involved in the SNMHI, we did not see a single site make significant progress if leaders were not motivated to change. In 2 of our case study sites, the intensification of commitment and involvement of CEOs, Medical and Nursing Directors was decisive. For our 3 practices and the SNMHI as a whole, extrinsic motivators were clearly not enough. Many sites had opportunities for enhanced payments or recognition, yet changed little, and many sites made substantial improvements in the absence of financial incentives.
Will cannot be restricted only to leaders; it ultimately has to be shared by the staff. The leaders of our 3 clinics used various strategies for increasing staff motivation to change. The following quote from the CEO of a rural clinic nicely summarizes what the leaders of successful practices were doing day to day:
“We [the leadership group] tried not to be on every task force…because you wanted the people that were doing the work to be the ones that were helping design the process…. So sometimes we were just a resource on the outside looking in and pushing from behind. From a CEO perspective, I discovered my role was when people got stuck on issues, I’d get invited to the meetings just to listen and sometimes ask the why questions.”
We learned a great deal about the ideas that motivated and guided change in the SNMHI. The 8 change concepts and 33 key changes seemed to make sense to frontline staff, but the participants needed help in deciding where to begin. It was no surprise that engaged leadership and an effective QI strategy needed to be in place. However, the experience of our 3 clinics and others in the SNMHI helped us see that linking patients to specific providers (empanelment) and having effective teams were turning points in their PCMH journey. Together these created the infrastructure, capacity, and relationships that enabled practices to make positive changes in patient-centered care, care delivery, care coordination, and access.
The major limitations of our case studies are clearly the small number of highly selected sites, and that they were part of a well-supported transformation effort initiative with a clear conceptual model. Some of our observations, as a result, may not apply to practices with different transformation experiences or models. Moreover, our interviews were largely with practice leaders; interviews with frontline staff would have produced a more complete picture of the factors involved in successful transformation. Although the interviews were limited to 3 sites, the conclusions are consistent with the observations and lessons learned by the practice facilitators and project staff working directly with the 65 SNMHI sites.
The authors very much appreciate the generosity of the interviewees with their time and thoughts. The authors are also grateful for the support and advice of the SNMHI technical assistance staff and practice facilitators, whose input was critical to selecting sites and developing hypotheses for this study.