Transformation Is an Ongoing Process, and Does Not End With PCMH Recognition
As discussed in the McNellis paper, primary care transformation is an ambitious and complex undertaking, and implementation generally does not follow a clear, linear trajectory. In addition, transformation is an ongoing process that practices or health systems choose to engage in, rather than a goal to be achieved. A primary care provider interviewed for one of the studies explained it this way: 鈥渕edical home is a process, I don鈥檛 think it鈥檚 an endpoint. It is constantly evolving; if you get one thing going, there is always something else you can tweak or improve upon.鈥11 A paper by Solberg et al found substantial variation in the performance of PCMHs and that many had significant room for improvement. This indicated to the investigators that there is a continuum of transformation and performance among medical homes, even after they have achieved recognition.12
Other investigators pointed out that achieving recognition or certification as a PCMH (by the NCQA, The Joint Commission, a State health department, or another group) was a useful marker of progress in the process and helped motivate transformation efforts, but recognition itself did not necessarily signify being a 鈥渢rue鈥 medical home or the end of the process of transformation. Solberg reported that the Practice Advisory Group for 120 health care homes in Minnesota realized only after they had been certified as a PCMH for a while that becoming certified was 鈥渏ust the start of the journey鈥 (oral interview, December 2014), and that successful transformation required not just meeting recognition standards, but rather a change in overall practice culture. Most of the TPC PIs agreed that 鈥渁 practice could be a true PCMH without having received recognition, and a practice that has received recognition may not be a true PCMH.鈥1 However, the standards that are required for PCMH recognition, particularly those of NCQA, have evolved over time to encompass important elements of practice transformation that were not included in earlier versions.
Of the 14 TPC grants, eight reported that all of the participating practices had already achieved PCMH recognition by the time the study ended鈥攕ix by NCQA, one by Oregon鈥檚 Patient-Centered Primary Care Home Program, and one by the Minnesota Department of Health. (For two of these eight grants, recognition or certification as a PCMH was a condition for inclusion in the study). In four grants, some of the practices were recognized as a PCMH while others were not. Of these four, two were actively seeking recognition as a PCMH at the time the study ended, while the other two had chosen not to seek recognition. In one study, none of the practices sought recognition, and another study did not report information about recognition status of involved practices. Appendix A provides details about the PCMH recognition status of practices across TPC grants.
While most of the practices studied in the TPC grants had either already attained or sought recognition as a PCMH, some determined that attaining and maintaining PCMH recognition was not worth the effort or cost required. The time and cost required to apply for PCMH recognition/certification can be significant because of the documentation that is required, and financial benefits for being a recognized PCMH are not available in all locations and are often minimal. For example, the 10 primary care practices run by the University of Utah did not seek recognition or certification as PCMHs despite their participation in a primary care transformation effort because they determined that there was no business case in their market to justify the necessary investment (M Magill, oral interview, December 2014). The Palo Alto Medical Foundation allowed its PCMH recognition from NCQA to lapse after only 2 years because the organization decided that transformation into a PCMH was important for its mission, but formal recognition was not.13 Berry and colleagues found that many small practices simply did not have the time or capacity to seek formal PCMH recognition.14
Motivation and Readiness to Transform Vary Across Practices
The motivations for undertaking primary care transformation, and the readiness to do so, varied across practices. The desire to improve patient care was mentioned by most of the TPC investigators as the key motivator for the primary care transformation efforts they studied. However, a number of other motivations were also mentioned, including intellectual curiosity, wanting to be involved in cutting-edge health care, and a desire to be ahead of the curve on something practices believed would ultimately become a requirement. In addition, a number of financial incentives were reported as motivating transformation initiatives, including financial assistance through PCMH pilot and demonstration projects, which practices used to improve clinic infrastructure (e.g., to implement EHRs) or to provide training or support (e.g., practice facilitators); by gaining a competitive edge in the health care market by becoming a recognized PCMH; and through direct payments for being a recognized PCMH from some State and private insurance payers. While not directly related to the PCMH, incentives are also available for practices that can demonstrate 鈥渕eaningful use鈥 of certified EHR technology by the Centers for Medicare & Medicaid Services though authorization from The American Recovery and Reinvestment Act of 2009.15 Even when strong financial incentives were offered, however, not all practices were ready to transform. For example, a study of safety net clinics by Rittenhouse and colleagues found that practices with insufficient organizational capacity were either slow to implement changes or unable to do so altogether.16
Changes in Practice Culture and Mental Models Are Often Required
For some practices, transformation to a PCMH built upon years of previous practice improvement, including quality improvement efforts, the adoption of EHRs, or a focus on shared decisionmaking. For the more advanced practices, these efforts often began before the concept of PCMH was fully developed or even had a name. Becoming a certified PCMH for these practices was relatively easy and was viewed by staff as another step in the process. Other practices found that even if they did not have previous initiatives to build upon, the concept of a PCMH fit within the practice鈥檚 existing ethic for providing care. For example, Federally Qualified Health Centers already used a family-centered approach to care before transformation to PCMH efforts began. Therefore, investigators found that it was fairly easy for staff in these practices to embrace the PCMH model.17
For other practices, however, transformation to PCMH marked a big change and required a dramatic shift in mental models (i.e., how people think) about primary care at the individual level, as well as culture change, including staff buy-in to new roles and responsibilities, at the practice level.18 Gabbay and colleagues, who studied the Chronic Care Initiative in Pennsylvania, identified three main areas where shifts in mental models and practice culture were necessary for successful transformation to PCMH: 1) shifting toward proactive population-based care in the practice-patient relationship; 2) creating a culture of self-examination (i.e., routine review of clinical and quality improvement data at both the individual and practice level); and 3) the redistribution of responsibilities and adoption of a team-based care approach.18 One physician described this process as 鈥渢aking your head out of the sand鈥 and recognizing that you are not managing your population of patients as well as you thought you were.19 The Practice Advisory Group of a study examining 120 health care homes in Minnesota (PI: Leif Solberg) found that the most important factors for successful practice transformation were having a clear vision for change and an understanding of the 鈥渂ig picture鈥 on the part of practice leaders (i.e., visionary leadership), and an overall change in practice culture (L Solberg, oral interview, December 2014).
Contextual Factors Play an Important Role in the Success of Transformation Efforts
As discussed by Tomoaia-Cotisel et al,20 contextual factors affected the success and sustainability of primary care practice changes at the practice level (e.g., practice characteristics), the organizational level (e.g., leadership structure and payment model), and in the external environment (e.g., sources of financing). The contextual factors discussed below were raised by the TPC investigators as particularly important in the efforts they studied.
Leadership and Communication
Strong leadership committed to primary care transformation at both the practice and systems levels was identified by multiple investigators as vital to the success of transformation efforts. In fact, Donahue and colleagues found that practices with higher leadership scores were significantly more likely to make practice changes.21 Calman and colleagues found that in addition to facilitating IT changes and process redesign, support from those in leadership positions helped to create a culture that encouraged innovation and early adoption of new policies and methods related to transformation (N Calman, oral interview, December 2014). Donahue et al reported that a committed mid-level manager in addition to strategic or visionary leaders was essential for successful practice change.21 These mid-level managers serve as the operational link between the strategic leaders and the practice staff responsible for day-to-day implementation activities.
To support transformation efforts, organizational leaders also needed to communicate effectively with frontline staff. Driscoll and colleagues found that to do so, it was necessary for leaders to communicate in a clear and transparent way about what changes were expected from the staff and how long the changes were expected to take.22 After that, leaders needed to be open to feedback from clinic staff about what worked in practice and what did not (R Meenan and C McMullen, oral interview, December 2014). Effective communication was also found to facilitate practice buy-in to PCMH transformation.23 Clinics with leaders who provided excellent communication and supported staff throughout implementation of primary care changes with hands-on, side-by-side training were found to have the highest functioning teams.2
Leadership stability was also identified as a key factor for achieving and maintaining successful practice transformation.24 For example, a change in leadership at a university health system studied by one of the TPC investigators led to fundamental changes in the understanding of primary care transformation. As a result, previous efforts toward PCMH transformation were no longer seen as an organizational priority (M Magill, oral interview, December 2014.) The loss of a mid-level champion can also be devastating to a transformation effort, particularly for smaller practices where just one or two individuals are leading the work (R Meenan, oral interview, December 2014). As one investigator explained, 鈥渜uality improvement efforts would stop if the one person who championed it left the practice鈥 (K Donahue, oral interview, December 2014).
Practice Size
Small, independent practices were disproportionately affected by the costs and time required for implementation of the PCMH because they did not have the same resources and infrastructure that larger practices had to help offset the costs of implementation.25, 14, 4 Small practices also could not benefit from the same economies of scale as larger practices3 and often did not have the necessary funds to bring in outside experts or develop infrastructure to help with primary care practice changes (C Berry, oral interview, December 2014). The effect of practice size and resource constraints on PCMH transformation was underscored by a finding by Fetters and colleagues that overall mean PCMH implementation scores were highest in practices with six or more physicians and decreased as the number of physicians in the practice decreased,25 as well as a finding by Rittenhouse that higher levels of NCQA recognition were associated with larger clinic size and ownership by a large health care system.26
Small practices, did, however, find innovative ways to implement important aspects of the PCMH model. In fact, Berry and colleagues found that the small practices they studied were able to achieve substantial implementation even though they faced numerous potential challenges, and they were able to do so by using more informal strategies for team-based care and care coordination.27 For example, although these clinics did not have the funds to hire an official 鈥渃are manager,鈥 a front office staff member was often trained to take on this role (C Berry, oral interview, December 2014).
Electronic Health Records
Existing infrastructure, especially having EHRs in place, was identified by investigators as an important contextual factor for primary care transformation. For example, Calman and colleagues found that the EHR at the Institute for Family Health Network, implemented just prior to PCMH transformation, was integral to PCMH transformation because it allowed the network to more easily develop and implement patient registries, a patient portal, visit summaries, care guidelines, screening reminders, and other components of patient management.17 Gabbay and colleagues found that the practices with the most improved clinical outcomes were the ones that had greater structural capabilities at baseline, such as EHRs and stable financial systems, compared to lower performing practices.19
However, there was considerable variation in EHR systems in place across the practices evaluated by the TPC investigators. While a few larger health systems, such as Group Health and the Palo Alto Medical Foundation, had well-established EHR systems in place when they began PCMH transformation, many practices had only recently implemented EHR systems or did so during primary care transformation, and other practices did not have an EHR in place during PCMH transformation. (Appendix A provides comparative details across studies). Although practices can qualify for the lowest level of NCQA recognition as a PCMH without an EHR system in place, an EHR allows practices to implement population management and quality reporting and can help manage the volume of documentation required to establish and sustain a PCMH.
Kraschnewski and Gabbay reported that despite the numerous advantages of health IT, many of the practices they studied did not use EHRs at all because of multiple barriers to adoption. These barriers included issues with information exchange and interoperability between systems, challenges with technical implementation, low acceptance rates by both physicians and patients, and issues related to patient access. They also found that implementing health IT was a complex undertaking and required a large upfront expense, representing a significant financial risk for practices.1
The capabilities of existing EHR systems also varied widely across practices. Solberg and colleagues identified the limitations of existing EHRs as a key barrier to practices in meeting the PCMH documentation requirements of the Minnesota Department of Health.28 Of the safety net practices studied by Meenan and colleagues, those that did have an EHR in place were often not set up to do data extraction for quality improvement purposes. Therefore the data extraction required for conducting quality improvement activities was very time consuming for these practices and imposed a significant resource burden.29 Cooley and colleagues found that, because of limited capabilities, EHRs were both a driver and restrainer of transformation.11 While two of the 12 practices his team studied reported success in using EHRs to develop care plans and were close to using them for reporting purposes, none had yet been able to use EHRs for data and report retrieval, immunization management, or medication dosing.11
Competing Priorities
Many institutions (particularly larger ones) had multiple initiatives going on at any one time, all of which vied for the limited time and attention of clinicians and administrators, and PCMH transformation was only one of these initiatives. Front-line staff at Palo Alto Medical Foundation reported feeling overwhelmed by the number of changes that were required of them across initiatives, and experienced change fatigue (M Tai-Seale, oral interview, November 2014). At Group Health, a large upgrade of practice management software took place at the same time as the implementation of PCMH transformation, and this disrupted the collection and distribution of quality of care data, frustrated staff, and hampered quality improvement activities related to transformation.2
Other types of competing priorities were also mentioned by TPC investigators. For example, Rittenhouse and colleagues identified the need for medical school鈥揳ffiliated clinics to balance transformation efforts with their mission to train future health professionals in their study of safety net clinics in the New Orleans area.24
Care Coordination and Team-Based Care Are Key Elements of Transformation
Care coordination and team-based care were identified by multiple PIs as key elements of successful primary care transformation. In a study led by Cooley and McAllister, care coordinators were identified as integral to a practice鈥檚 ability to provide proactive care, support families, and reach out to communities. In fact, many physicians in this study reported that they would not be willing to go back to their previous care model without care coordinators.11 Gabbay and colleagues found that practices with the most improvement in diabetes care reported greater involvement of a patient-centered care manager and greater integration of the care manager into the overall care team compared to practices with the least improvement.30 The investigators concluded that care managers should meet with patients, support self-management, leverage the EHR for managing care, and integrate with the care team through office huddles and other ongoing communications.30
Implementing team-based care also improved patient and provider satisfaction.10 Training clinical team members other than nurses and physicians to work with patients on self-management activities was found to increase patient involvement in care.31 Members of the clinical staff who were given expanded roles in providing care reported that acquiring the authority to make decisions empowered them to be more involved in patient care and led to better team relationships.4 In particular, utilizing MAs in expanded roles helped clinicians be more efficient,10 made office visits more productive,19 and allowed physicians more time with patients.4 With support and some additional training, MAs could be trained to support population management, care management, and quality improvement activities, as well as serve as health coaches.32 Expanding the role of MAs was also found to enhance teamwork, improve workflow, and improve patient safety.32
Cronholm et al (PI: Gabbay) reported that the greatest tension from shifts in mental models arose between clinicians and MAs, suggesting that there were significant barriers to moving away from clinician-centered care to a team-based model.18 Driscoll and colleagues found that transition to a coordinated, team-based model was challenging for some physicians who were used to a private practice model and for clinicians who were unfamiliar with the role or abilities of clinicians from other disciplines.33 However, they also found that most clinicians adapted to the team model and quickly became comfortable triaging patient care needs to the appropriate team member.33 Gabbay and colleagues found that many of the MAs enjoyed their new role helping patients set self-management goals and ensuring that patients received needed care; however, a few thought they should be paid more for this new role, resented the extra work, or found the documentation tasks to be tedious.19
Practice Transformation Involves Inherent Tradeoffs
Transformation efforts aimed at implementing one aspect of the PCMH often involved a tradeoff with other aspects of care. These tradeoffs highlight the complex nature of PCMH transformation and the importance of weighing and evaluating the effect of system changes on diverse outcomes, including the patient and provider experience.
For example, Magill and colleagues pointed out that an emphasis on improving access can have a negative impact on continuity of care because appointments can be made available more quickly, but not necessarily with a patient鈥檚 regular primary care provider.10 The study of safety net practices led by Rittenhouse found that it was challenging to provide comprehensive care to patients while maintaining accessible services under conditions where there was a high demand for services from patients seeking care.24
Other transformation-related activities required tradeoffs between patient and provider satisfaction. For example, Magill and colleagues found that a more efficient visit improved patient satisfaction because of reduced wait time, but decreased provider satisfaction because they had less time with each patient.10 Increased access to primary care services and same-day appointments for patients at Southcentral Foundation in Alaska (PI: Driscoll) had the unintended effect of causing high levels of stress and frustration for clinicians because of the large number of patients they were often required to see per day, requiring them to work extremely long hours, often without any prior notice.22 Magill and colleagues recommended that practices monitor both the intended and unintended consequences of redesign efforts to identify and address tradeoffs that come with practice change.10
Transformation Requires Supplemental Funding, and Sustainability Will Require Payment Reform
Implementing a PCMH represents a significant investment of time and money; therefore, ongoing access to adequate funding for transformation efforts was reported as a concern for many practices25, 16, 34 and as a barrier to implementation.6 Reiter et al (PI: Donahue) reported that transformation costs were a burden for practices, even when practices made cost-saving efforts such as leveraging existing resources and scheduling meetings during slower patient care periods.34
Scholle and colleagues found that a large majority (69.5%) of the 249 practices they studied received some financial payment for PCMH transformation, either from participation in a pilot or demonstration project or through direct payments from State or private insurance payers (for recognized PCMHs) or other entities.6 Gabbay and colleagues reported that supplemental financial support was critical for primary care transformation because it allowed practices to acquire needed resources such as EHR systems and additional staff (e.g., MAs and care coordinators), pay for the staff time needed for education and quality improvement efforts, and to make physical modifications to clinic space.19 Berry and colleagues found that even modest financial assistance could go a long way in making PCMH transformation possible for smaller practices (C Berry, oral interview, December, 2014). Fetters and colleagues warned that requiring primary care practices to shoulder the investment alone could severely limit PCMH implementation, and they and others recommended that payers, purchasers, and policymakers explore methods to help support the costs of primary care transformation.25, 34
Rittenhouse and colleagues reported that financial support must be stable over time to ensure that PCMH changes are sustained. In their study of safety net clinics in New Orleans, declines were observed in the areas of access, quality and safety, and care coordination and integration once clinics were no longer eligible for redesign bonus payments and faced the loss of funding for patient care services. In light of new financial realities, investigators found that clinics shifted their priorities from growth and transformation to consolidation and financial survival.16
Other investigators noted that current fee-for-service reimbursement strategies do not cover PCMH-related costs,28 such as an expanded health care team and services, including new roles for MAs, care managers, and clinical pharmacists (M Magill and D Scammon, oral interview, December 2014). Additionally, traditional payment systems, which reward quantity rather than quality of health services, do not account for care complexity and may compromise a practice鈥檚 ability to sustain a PCMH.11 Reiter et al (PI: Donahue) recommend that policymakers consider reimbursement and other strategies to help practices manage the costs of primary care transformation.34
To address the need for a change from quantity-driven payment to more 鈥渧alue-based鈥 payment, the Department of Health and Human Services has set a goal for Medicare payments through alternative payment models to reach 30 percent by 2016 and 50 percent by 2018. These alternative payment models include advanced primary care medical home models, as well as Accountable Care Organizations, new models of bundling payments for episodes of care, and integrated care demonstrations for beneficiaries that are dual Medicare-Medicaid enrollees.35
