CONTRIBUTIONS

1. Journey Toward a PCMH:What are the barriers and how are they being addressed?Christopher G. Wise, Ph.D., M.H.A.Jeffrey A. Alexander, Ph.D.Lee Green, M.D.Genna CohenChristina Koster

2. CONTRIBUTIONS • Funding from Robert Wood Johnson Foundation • CHRT: oversight & support • BCBSM: oversight, PGIP

3. Lessons from First Demonstration Project on Practice Transformation to a Patient–Centered Medical Home • 36 Primary Care sites applying for PCMH • Intensive qualitative study over 3 yrs • Finding: “Change is hard” • - Limited ‘Adaptive Reserve’ for change in primary care Nutting PA et al., AnnFam Med 2009; 7:254-260

4. Lessons from First Demonstration Project on Practice Transformation to a Patient–Centered Medical Home “Our early analysis raises concerns thatcurrent demonstration designs seriously underestimate the magnitudeand time frame for the required changes, overestimate the readinessand expectations of information technology, and are seriouslyundercapitalized. We fear that with current assumptions, manydemonstrations place participating practices at substantialrisk and may jeopardize the evolution of the PCMH.” Nutting PA et al., AnnFam Med 2009; 7:254-260

5. Study Purpose • What factors are related to a primary care practice’s readiness for PCMH transformation? • What approaches have been used?

6. Methods: Scoring PCMH • June 2009 PCMH self-assessment responses for BCBSM PGIP program • 7 PCMH domains (agreement, registry, EBCR, coordination, test track, access , e-prescribe) • 57 total tasks • ~6,300 responding practice units • 0 pts for ‘not in place’ • 0.5 pts for ‘partially in place’ • 1.0 point for ‘fully in place’

7. Methods: Scoring PCMH • Standardize PCMH progress within each domain (actual pts/total possible pts) = % of domain complete • Took mean of PCMH % complete of all domains

8. Methods: Site Selection • Eliminated cases with no PCMH progress • Practices located in PGIP & AF4Q areas • Stratified by hospital affiliation (yes/no) • Ranked by %PCMH score (low to high) • Sorted by quartile • Randomized sites in highest & lowest quartiles

9. Methods: Site Selection

10. Methods: Site Selection • Different physician organizations • Regional variation • Size of practice

11. Methods: Interview • Developed semi-structured interview protocol • Interviews: • Physician • Practice Manager • Nurse • Medical Assistant • P.O leadership

12. Interview Counts

13. Methods: Analysis • Transcribed interviews • Team developed ‘codebook’ • Coded all interviews • Entered into Atlas T1 software • In-depth review for ‘Themes’ • Initial focus on ‘Readiness’ & ‘Approach’

14. Readiness • Readiness: Critical precursor to complex change (Weiner, 2009) 1. Motivation: Willingness & commitment to implement change. Trying to make sense of uncertainty. 2. Capability: Perceived ability to act on change – NOT capacity, resources

15. MOTIVATION : Perceived Value of PCMH “The key to success is getting everybody to focus on the patient. It truly needs to be patient-centered. For many years, I think we’ve been physician-centered not patient-centered.” (physician) • Intrinsically driven (pt., flow, team) • High penetration in practice • Already doing PCMH; want to do it better

16. MOTIVATION : Perceived Value of PCMH “I would bet you that almost every office has said it’s no different than what we’ve been doing.” (physician) • Extrinsically driven (insurer) • More hoops to jump through • Variable penetration in practice • Already doing PCMH; nothing more to do • Pulled in multiple directions; affects pt. care • What’s in it for my office?

17. MOTIVATION : Understanding PCMH Requirements “I did all these webinars, TransforMED, Med Fusion, all of them, to find out what I could get for PCMH. I’m sure my staff is sick to death of all these webinars.” (practice Mgr.) • Active learning • Thorough comprehension of PCMH tasks • Physician / Practice Mgr. catalyst • Stimulated by perceived value

18. MOTIVATION : Understanding PCMH Requirements “You look at all these different measures ...Some of them are pretty difficult to understand. What in the world are they asking for, and what’s the logic behind it?” (Practice Mgr.) • Passive learning – want external support • Practice Mgr. ‘needs to teach’ others • Interested, but overwhelmed by daily work • Variable PCMH requirements among payers

19. MOTIVATION : Commitment to Change “That’s just the way we do things here. We’re always the first one to raise our hand and say we’ll do it.” (Medical Assistant) • Near universal commitment • Approached with enthusiasm vs. trepidation • Opportunity to work together

20. MOTIVATION : Commitment to Change “I have three physicians who are not on the same page. It’s hard to have a front desk staff that is doing things differently for each of the physicians.” (Practice Mgr.) “When the doctor tells me to do this, I’ll do it.” • Uneven commitment • Small, independent practice – physician(s) own the business

21. MOTIVATION : Financial Incentives “The physicians are realizing, ‘I’m doing more medical care. I’m doing less paperwork because I have more helpers, and I’m making more money.’ What’s wrong with that picture?” (practice manager) • $ necessary, but not sole motivating purpose • Multiple incentives starting to add up • Reinvest into practice

22. MOTIVATION: Financial Incentives “They say we will get some more money for this (PCMH), but I’ll believe it when I see it.” (practice manager) • Skepticism – will payment be sustained? • Sticker shock – especially technology • Operating on low margins already • Need assurance of ROI

23. CAPABILITY (Is PCMH Attainable?):Time Demands • Identified by both high and low scoring • ‘We need to do something different’ vs. ‘Can’t get off the hamster wheel’ • “We’re caught between a rock and a hard place.” – Trying to fix plane while flying • Availability of internal resources • Documentation • Will benefit care in the long run • Too much in too many places

24. CAPABILITY: Prospects of Changing Patient Behavior “The patient is at the center of this, but really, how engaged are the patients?” • High scoring • Good platform to engage with patients • Low scoring • Implausible • May negate PCMH gains the practice makes • Possible influence of socioeconomic environment?

25. CAPABILITY: Health Information Technology “HIT is a huge expense on the practice, and a gigantic piece of PCMH” • High scoring • Support from P.O. and/or hospital • Over the hump with implementation • Low scoring • Catch 22: Need HIT to reduce paperwork, but not ready or can’t afford or don’t understand HIT • ALL: Age of users has impact

26. CAPABILITY: Setting Implementation Expectations • Needs to be quick • “I’ll try this for a couple months” • First, need HIT to be more user friendly • Persistence, persistence, persistence Life = Risk Video

27. APPROACHES • Translating the value of PCMH • Activate physician + practice manager • “Clinical Advocacy Team” created by a PO • Translating PCMH steps into value • Link specific PCMH requirements to benefits • Organizational ‘translator’ helps • Celebrate small successes

28. APPROACHES • Incrementalism • One-step-at-a time reduces fear • Learn PCMH 1st, then have the practice decide where to start (registry…wherever makes sense) • Using data • Helps ID opportunities & goals • Formal approaches to review data • Variable needs: external and internal approaches

29. APPROACHES • Define & refine roles of practice team • Engages and empowers all • Improves efficiencies: no more 3 different ways • Aids sustainability & spread • Leadership • System executives + physician(s) + pract. Mgr. • Support time for change • Desire to learn more from others

30. Discussion • These findings both confirm and extend the NDP • Our sample less highly selected, suggesting the lessons are general • Resources necessary but not sufficient • Adaptive reserve critical

31. "Adaptive Reserve" • Central elements include relationship infrastructure, facilitative leadership, and teamwork • These to differ markedly between our high- and low-scoring practices • Found that office staff tended to be on board, it was physicians who were sometimes not • Do these findings merely predict who will do well, or can intervention help? • Of what sort and at what cost?

32. QUESTIONS?

33. Lessons from First Demonstration Project on Practice Transformation to a Patient–Centered Medical Home Becoming a PCMH requires transformation Technology needed for PCMH is not ‘Plug and Play’ Transformation to PCMH requires personal transformation of physician Change fatigue is a serious concern Transformation to a PCMH is a developmental process Transformation is a local process Nutting PA et al., Ann FamMed 2009; 7:254-260