Facilitating Change:Facilitating Change:Lessons from the TransforMED Lessons from the TransforMED National Demonstration ProjectNational Demonstration Project

AHRQ 2009 Annual Conference Sept. 14, 2009

Elizabeth E. Stewart, PhD

Independent Evaluation Team

from Center for Research in Primary Care & Family Medicine

Evaluation Team

Carlos R. Jaen, MD, PhD

Paul A. Nutting, MD, MSPH

Benjamin F. Crabtree, PhD

William L. Miller, MD, MA

Kurt C. Stange, MD, PhD

Elizabeth E. Stewart, PhD

National Demonstration Project

o Two-year project intended to ‘test’ the new model of family medicine as outlined in the FFM report.

o AAFP provided funding; TransforMED was created to design and implement the project.

o Independent evaluation team providing mixed-methods analysis for practice & patient outcomes.

NDP: Background & TimelineNDP: Background & Timeline

17 (F) practices finished

300 usable applications

500 practices applied

36 practices selected

18 randomized:FACILIATED

18 randomized:SELF-DIRECTED

15 (SD) practices finished

NDP start: July 2006

NDP finish: June 2008

Touchstone Group Begins

Real Practices… Real Stories

Implementation Assistance

Facilitated• 6 practices/facilitator • Access to facilitator (site visits,

phone calls, emails)• 4 NDP Learning Sessions• Monthly conference calls• Discounted technology • Access to national consultants • List serve & website access

Facilitated• 6 practices/facilitator • Access to facilitator (site visits,

phone calls, emails)• 4 NDP Learning Sessions• Monthly conference calls• Discounted technology • Access to national consultants • List serve & website access

Self- Directed• List serve & website access• 1 final NDP Learning Session• Some $$ for self-organized

retreat midway through NDP

Self- Directed• List serve & website access• 1 final NDP Learning Session• Some $$ for self-organized

retreat midway through NDP

Mixed Methods

QUANTITATIVEo Patient Health Outcomes (medical chart audits)o Practice Finances (surveys – limited)o Clinician/Staff Satisfaction (surveys)o Patient Perception of Care (surveys)

QAULITATIVEo Field notes, interviews, observations, email

communication logs, conference calls, Learning Sessions, facilitator debriefs, list serve, document of model components.

Access to Care & Information

• Health care for all

• Same-day appointments

• After-hours access coverage

• Lab results highly accessible

• Online patient services

• e-Visits

• Group visits

Practice Management• Disciplined financial management• Cost-Benefit decision-making• Revenue enhancement• Optimized coding & billing• Personnel/HR management• Facilities management• Optimized office design/redesign• Change management

Practice Services

• Comprehensive care

for both acute and chronic conditions

• Prevention screening and services

• Surgical procedures

• Ancillary therapeutic & support services

• Ancillary diagnostic services

Care Management

• Population management

• Wellness promotion

• Disease prevention

• Chronic disease management

• Care coordination

• Patient engagement and education

• Leverages automated technologies

Continuity of Care Services

• Community-based services• Collaborative relationships

Hospital care

Behavioral health care

Maternity care

Specialist care

Pharmacy

Physical Therapy

Case Management

Practice-Based Care Team

• Provider leadership

• Shared mission and vision

• Effective communication

• Task designation by skill set

• Nurse Practitioner / Physician Assistant

• Patient participation

• Family involvement options

Quality and Safety

• Evidence-based best practices

• Medication management

• Patient satisfaction feedback

• Clinical outcomes analysis

• Quality improvement

• Risk management

• Regulatory compliance

Health Information Technology

• Electronic medical record

• Electronic orders and reporting

• Electronic prescribing

• Evidence-based decision support

• Population management registry

• Practice Web site

• Patient portal

A new way of thinking…o Transformation is more than a series of

incremental changes; it requires requires epic whole practice re-imagination and redesign.

o Transformation to a PCMH requires substantial changes in the mental model of both physicians and practice staff.

o It is more than implementing sophisticated office systems… it is about adopting substantially different approaches to patient care.

A new way of thinking…

o Physicians will need to move towards facilitated leadership skills and away from authoritative ones.

o Physician-patient relationship will need more emphasis on partnership to achieve patients’ goals.

o Practice will need to change from a machine that processes patients for the doctors to a team that proactively manages a population of individual’s health.

What helps a practice transform?

“Core Structure” – includes ability to manage basic finances, clinical & practice operations during times of stability & modest change.

“Adaptive Reserve” - ability of practice to be resilient, to bend & survive under force. Facilitates adaptation during times of dramatic change.

What is Adaptive Reserve?

o Measured with the Clinician/Staff Questionnaire• Anonymous questionnaire - 3x during project• Based on validated PSQ and ‘The Magnificent 7’• Represents the perceptions of those living in the practice

o 89 questions total, pared down to 9 final categories through factor analysis:

Respectful Interaction Strong Leadership

Learning Culture Sense making

Reflection Diversity

Work Environment Mindfulness

Communication

Change in Adaptive Reserve*

*Adaptive reserve includes measures of leadership, sensemaking, diversity, mindfulness, communication, respectful interaction, learning culture, reflection and general work environment. Baseline vs. 28 months for facilitated group is statistically different. (p<0.01)

Mea

sure

of A

dapt

ive

Res

erve

The Role of Facilitation

1. Consulting

2. Coaching

3. Facilitating Adaptive Reserve

Facilitation: Consultant

Huddles & Meetings

Workflow analysis

HIT assistance – vendor liaison, implementation

Metrics, PDSA cycles

Specific projects

Facilitation: Coach

Physicians

* Leadership* Finances* Delegation* Time Mgt* Communication* Support

Staff: Empowerment, task delegation

Practice Managers

* Project Mgt* Personnel/HR* Finances* Communication* Empowerment* Support

Facilitation: Adaptive Reserve

Rich & LeanCommunication

IntenseCoaching

Facilitated Learning Sessions w/other practices

Conflict Resolution

Staff RetreatsWith Pre-Work& Follow-up

Patient Outcomes Surveys

o Mailed to cross-section of 120 pts/practice, 3x o Based on multiple validated surveys and intended to

measure 7 attributes of patient-centered primary care.*1. Superb Access2. Patient Engagement 3. Clinical Information Systems to Support Care4. Care Coordination 5. Integrated & Comprehensive Team Care6. Routine Patient Feedback to Doctors7. Publicly available information• Also assess patient enablement & patient satisfaction.

*Commonwealth Fund

POS Core Elements to Measure

1) Patient Enablement (PEI)

2) Empathetic Care (CARE)

3) Comprehensive Care (CPCI)

4) Accumulated Knowledge(CPCI)

5) Inter Personal Com (CPCI)

6) Coordinated Care (CPCI)

7) Advocacy (CPCI)

8) Health Promotion (ACES)

9) Cultural Responsiveness10) Family Context (CPCI)

11) Organizational Access12) Community Context (CPCI)

13) Usual Provider Continuity (CPCI)

14) Interpersonal treatment15) Recommend Doctor 16) Rating of Doctor (1-10)

17) Med Home (PCPE)

18) Same Day Access Available19) Overall health status (1-5)

Self-Directed Practices: Some Decreases Baseline 9 months 28 months

Mean SD Mean SD Mean SD

Empathetic Care .87 .20 .84** 0.20 .84** .20Comprehensive Care .84 .16 0.82 0.16 .81** .15

Interpersonal Com. .81 .18 .78** 0.18 .80 .18

Advocacy .82 .16 .80* 0.16 .80* .16

Health Promotion .14 .34 .24*** 0.34 .16 .31

Only showing core elements with significant changes from baseline: * = p <.05; ** = p <.01; *** = p <.001

Self-Directed Practices: Some DecreasesBaseline 9 months 28 months

Mean SD Mean SD Mean SD

Community Context .71 .22 .67** 0.22.66**

* .22Interpersonal treatment .91 .17 .89* .17 .91 .16

Recommend Doctor .94 .15 .91* .15 .92 .14

Rating of Doctor .91 .15 .88* .15 .88 .15Same Day Access .41 .48 .34* .48 .40 .49Overall health status 3.38 .94 3.44 .94 3.50* .92

Only showing core elements with significant changes from baseline: * = p <.05; ** = p <.01; *** = p <.001

No Significant Change in Facilitated Practices

• Facilitated practices showed relatively small, if any, changes in any of the 19 categories over time.

• Despite tremendous changes going on at the practice, the core elements of the patient experience appeared unchanged.

• This may suggest that facilitation had a buffering effect. Patients in the SD practices may have felt the chaos of change but pts in the facilitated practices did not.

Thank you.