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The Practice Perspective on Transformation: Experience and Learning from the Frontlines

Stout, Somava MD, MS*; Weeg, Stephen MEd

doi: 10.1097/MLR.0000000000000239
Brief Report

Background: The transition of a primary care practice to a patient-centered medical home can be arduous. It requires time and resources from staff and leaders. Evidence to date suggests that not all medical homes are equally successful and that there is a substantial difference between the achievement of medical home recognition and meaningful transformation. However, little information is available to help a practice understand which approaches or strategies it might employ to prepare itself for successful transformation.

Objectives: Leaders in 2 very different primary care practices that participated in the Safety Net Medical Home Initiative (SNMHI) offer their impressions, contextualizing the experience of practice transformation from the perspective of the medical practice and providing insight on approaches that may support success.

Design: The authors self-identified a set of shared approaches they believe allowed their organizations to successfully implement and sustain changes consistent with the PCMH Model of Care.

Results: The approaches are: (1) harness the power of meaning; (2) approach PCMH implementation as a large-scale cultural transformation; (3) engage frontline staff and patients in the change process; (4) develop leadership’s capacity to manage and support the change process; (5) consider sustainability from the beginning.

*Cambridge Health Alliance and the Harvard Medical School Center for Primary Care, Somerville, MA

Portneuf Health Care Foundation, Pocatello, ID

Supported by a grant from The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The Harvard Center for Primary Care also supports one of the authors (S.S.) with academic time to pursue writing and scholarship related to primary care.

The authors declare no conflict of interest.

Reprints: Somava Stout, MD, MS, Cambridge Health Alliance and the Harvard Medical School Center for Primary Care, 230 Highland Ave, Somerville, MA 02143. E-mail: sstout@challiance.org.

Implementation of the Patient-Centered Medical Home (PCMH) Model of Care requires changes to nearly every aspect of the primary care practice—clinical care, operations, administrative processes, and staff relationships.1 For most primary practices, adopting the PCMH Model of Care will entail not only significant redesign but also a fundamental shift in orientation. Most evaluations of PCMH implementation have emphasized the technical aspects of practice redesign, providing scant information on the experience of transformation from the perspective of the medical practice. Evidence to date suggests that not all medical homes are equally successful and that there is a substantial difference between the achievement of medical home recognition and meaningful transformation.2–4 However, little information is available to help a practice understand which approaches or strategies it might employ to prepare itself for success.

This article, written by leaders in 2 very different primary care practices, offers impressions from the perspective of the medical practice. These impressions contextualize the experience of practice transformation and provide insight on approaches others might use as they begin or continue the medical home journey.

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BACKGROUND

Health West (HW), based in Pocatello, ID, is a geographically dispersed, rural health system with 6 clinics serving 9000 patients. Cambridge Health Alliance (CHA), located in Cambridge, MA, is an urban alliance of 2 hospitals, several specialty practices, and 12 community health centers serving 100,000 patients (Table 1).

TABLE 1

TABLE 1

Both organizations participated in the Safety Net Medical Home Initiative (SNMHI), a national demonstration of the PCMH Model of Care that used a specific framework for practice transformation and provided robust, multi-modal technical assistance to 65 primary care safety net sites in 5 states. The Initiative, its technical assistance program, and its outcomes are described in detail elsewhere.5,6

These 2 organizations, from different environments and with different organizational structures, both successfully implemented the PCMH Model of Care as evidenced by SNMHI program monitoring data, including data from the Patient-Centered Medical Home Assessment (PCMH-A), described elsewhere.5 Both organizations also demonstrated improvements in clinical processes (eg, some care teams at HW improved performance on medication reconciliation from 30% to 90% within 2 months), quality of care, patient experience, and employee experience measures.7–9 The authors were invited to contribute their impressions after being identified as exemplar sites by the SNMHI National Program Team, also described in detail elsewhere.5

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RESULTS

The authors self-identified a set of shared approaches they believe allowed their organizations to successfully implement and sustain changes consistent with the PCMH Model of Care. They are: (1) harness the power of meaning; (2) approach PCMH implementation as a large-scale cultural transformation; (3) engage frontline staff and patients in the change process; (4) develop leadership’s capacity to manage and support the change process; (5) consider sustainability from the beginning. Additional learnings from other SNMHI sites that may be of interest to readers are presented in a companion piece by Wagner et al.10

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Harness the Power of Meaning

Real transformation requires hundreds of changes, which can be daunting for staff already overburdened in primary care practice. CHA and HW recognized meaning as a powerful source of emotional energy that could fuel and sustain their transformation efforts, even in the face of overwhelming environmental challenges and change fatigue—and both took specific steps to harness it.

First, leaders invested time upfront to ensure staff understood the PCMH Model of Care, particularly how it aligned with their organization’s mission. Critically, they emphasized that pursuing PCMH was not about meeting a regulatory requirement but rather about providing quality and compassionate care. This positioning resonated with staff’s intrinsic desire to provide the types of care that would meet patients’ needs.

Second, both organizations encouraged staff to participate in creating a vision for the transformation effort. CHA, for example, asked hundreds of staff, in small groups, to assume the role of patients and to describe what the CHA health care system should look like. Repeatedly, staff named the principles of the PCMH Model on their own. Personally identifying the reasons to change made the work of testing and implementing PCMH personally rewarding.

Both organizations further reinforced the meaning of PCMH by consistently demonstrating their commitment to patient centeredness. CHA added patient partners to every site improvement team and at major design steps, examined standardized patient cases to ensure the right approach was being undertaken. In partnership with its Board of Directors and its staff, HW created a new mission to better emphasize its focus on patient-centered care: “Empowering our patients and communities by proactively providing quality, affordable patient-centered healthcare.”

Both organizations also used stories to demonstrate the benefits of PCMH for patients and families, and both celebrated “wins”—for example, acknowledging a receptionist who had scheduled a mammogram when a patient came in for a cold (resulting in an earlier diagnosis of breast cancer) and celebrating a medical assistant who helped a woman with insulin-dependent diabetes quit smoking. Through these exercises, staff came to identify PCMH care as the type of care they would want for their own families and to believe that implementing the PCMH Model would result in a more positive workplace—improving their own professional and personal satisfaction.

Ultimately, a shared belief in the meaning of the transformation effort led to a shared responsibility for the transformation effort.

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Engaged Frontline Staff and Patients in the Change Process

Leaders at both organizations fostered engagement and built ownership by empowering staff to use their expertise to make and test change and spread improvements. CHA created a process improvement team at each site, which included one receptionist, medical assistant, nurse, provider, and leadership team member, and 2 patients. These teams were charged with spreading innovations between care teams and developing workflows. A primary care-wide team, made up of representatives from the various sites, was established to spread innovations across sites and to improve standardization. Gaining input from frontline staff and patients resulted in the accelerated development of workflows and tools that were accepted by, and worked for, care teams. This allowed solutions to take hold more rapidly than in previous improvement efforts.

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Approach PCMH Implementation as a Large-scale Cultural Transformation

Both organizations had been through large technical changes related to the adoption of an electronic health record (EHR) and understood the importance of attending to human factors. Leaders realized that PCMH would require every health care worker to change her approach to patient care and would require the organization to change the roles and relationships of every stakeholder, including Board members, clinical staff, support staff, and even patients. This was not a technical or incremental effort but rather a large-scale “cultural transformation” unlike anything they had navigated before. Leaders’ explicit acknowledgment of this difference helped prepare staff for the work that lay ahead.

In addition, both organizations acted to make their new expectations known and transparent to all staff. For example, HW revised job descriptions and recruiting processes to clarify its expectations for staff commitment to patient-centered care. Both organizations provided training to build the confidence of care teams to assume new responsibilities and function in new roles.

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Develop Leadership’s Capacity to Manage and Support the Change Process

Both organizations realized that leaders themselves would need training and support to function effectively in their new roles. CHA established a multidisciplinary leadership academy, which provided skills-based training and a supportive community. HW sent multiple leaders to SNMHI learning sessions and other training events for similar support. As a result, both administrative and medical leadership were engaged and visible throughout the transformation process. This presence further energized the teams by brining attention and focus to their work. Both organizations’ commitment to developing effective leadership and to supporting leaders as people resulted in environments that were conducive to change.

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Consider Sustainability From the Beginning

Development of a medical home takes time, energy, and resources—it is a marathon, not a sprint. Both CHA and HW thought about how to sustain themselves for the long haul at the beginning of their journey and employed specific strategies to support their efforts. They adapted existing organizational structures and processes wherever possible, created toolkits to hardwire key changes, and created a multi-year map of the transformation to assist with planning.

Leaders intentionally positioned PCMH as the beacon toward which all efforts led so that PCMH remained the central focus for all stakeholders. For example, the HW Board of Directors updated its strategic plan to make PCMH a major organizational goal. In response, leaders at every level focused communications on PCMH, redefined work in terms of how it would help achieve PCMH, and began to use the medical home as a guide to solutions for everyday problems, for example, using the principle of continuity to guide difficult decisions about the patient empanelment and provider assignment process in rural clinics.

Knowing that turnover could be a risk, both organizations invested in cultivating champions at every level. As a result, at both organizations, there is now a deep bench of people, from medical assistants to nurses to provider leaders to administrators, who understand the principles of PCMH and can describe how to implement its elements in detail to their peers.

Although both organizations received critically important technical assistance from the SNMHI, neither organization received significant funding or new staff to support their transformation efforts. Both organizations overcame this challenge by realigning or redeploying existing resources or investing strategically to give teams the tools (such as an EHR to provide actionable data) and time they needed to do new work.

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SUMMARY

These 2 organizations made significant changes on their journeys to become medical homes for vulnerable and underserved patients. Despite the substantial variation in the structure of these organizations, their paths to successful transformation proved to be largely the same, indicating there may well be common approaches to successful implementation. For both, full organizational commitment—powered by meaning, informed by data, and fed by relationships—led to empowered care teams able to use their skills and resources to meet the needs of patients.

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ACKNOWLEDGMENTS

The authors gratefully acknowledge the editorial support of Kathryn Phillips (Qualis Health) and the dedicated work of the leadership and frontline teams of Health West and Cambridge Health Alliance.

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REFERENCES

1. Nutting PA, Millwer WL, Crabtree BF, et al.. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7:254–260.
2. Ewing M. The patient-centered medical home solution to the cost-quality conundrum. J Healthc Manag. 2013;58:258–266.
3. Fifield J, Forrest DD, Burleson JA, et al.. Quality and efficiency in small practices transitioning to patient centered medical homes: a randomized trial. J Gen Intern Med. 2013;28:778–786.
4. Friedberg MW, Schneider E, Rosenthal M, et al.. Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care. JAMA. 2014;311:815–825.
5. Sugarman JR, Phillips KE, Wagner EH, et al.. The Safety Net Medical Home Initiative: transforming care for vulnerable populations. Med Care. 2014;52suppl 4S1–S10.
6. Coleman K, Phillips KE, Van Borkulo N, et al.. Unlocking the black box: supporting practices to become patient-centered medical homes. Med Care. 2014;52suppl 4S11–S17.
7. Hacker K, Mechanic RE, Santos P. Accountable Care in the Safety Net: A Case Study of the Cambridge Health Alliance. 2014.New York, NY: The Commonwealth Fund.
8. Hacker K, Santos P, Thompson D, et al.. Early experience of a safety net provider transforming to an Accountable Care Organization. J Health Polit Policy Law. 2014;39:901–917.
9. Self-collected, Internal documents. Health West, Inc. 2009-2013.
10. Wagner EH, Gupta R, Coleman K. Practice transformation in the Safety Net Medical Home Initiative: a qualitative look. Med Care. 2014;52suppl 4S18–S22.
Keywords:

PCMH; transformation; primary care practice; success approaches; safety net

© 2014 by Lippincott Williams & Wilkins.