LEAWOOD, Kan. Primary care practice transformation on a large scale is the cornerstone of current health care reform efforts aimed at achieving better outcomes, better value and better experience of care. Amid emerging evidence that transformation toward the patient-centered medical home model offers a viable solution in today's health care environment, the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality funded 14 studies to learn more about the processes and determinants of successful change from practices that had already demonstrated successful transformational activities and improved outcomes. Key findings of these 14 projects, which the funders hope will inform more widespread change efforts, are published in a special supplement of Annals of Family Medicine.
The supplement, Transforming Primary Care Practice, features insights from 14 natural experiments undertaken in a wide variety of settings across the United States including independent practices, integrated delivery systems, community health centers and large government systems. The projects, which were funded by AHRQ grants awarded in 2010 totaling more than $4.1 million each year for two years, begin to identify the approaches and methods for transforming the structure, characteristics and function of primary care that are likely to be successful in a wide variety of practice types and settings.
"The lessons learned from these analyses demonstrate that true transformation toward the patient-centered medical home model is not only possible, but desirable, although not without its challenges," writes Robert J. McNellis, MPH, PA, AHRQ [insert title] and colleagues, in a commentary about the lessons learned that cut across all the projects.
In the editorial, McNellis and colleagues outline five overarching thematic findings that emerged from the projects despite the wide variety of practices studied, geographic locations, sizes, structures and motivations:
1) A strong foundation is needed for successful redesign. Existing baseline capabilities of a practice are important determinants of successful transformation. Practices must accurately assess their readiness for change and their ability to handle the change process before undertaking substantive change.
2) The process of transformation can be a long and difficult journey. The process of transforming is complex, challenging and ambitious. It takes time and is constantly evolving. Progress is a process that ebbs and flows, and practices should prepare for a taxing journey.
3) The approaches to transformation vary. The ingredients of a successful change process vary, but a few key elements seen across the projects include: integration of more team-based care, expanded access to care, use of measurement and feedback tools and the use of learning collaboratives to facilitate team communication.
4) Visionary leadership and a supportive culture ease the way for change. Having strong internal change drivers is an important facilitator of successful transformation. The two internal drivers seen to have the most influence on change were leadership and culture.
5) Contextual factors are inextricably linked to outcome. The context within which transformation occurred is critical to understanding a practice's success.
In addition to the overarching findings above, the articles raise several potential cautions, including the difficulty of measuring the financial impact of transformation on a practice. Overall, the teams found it was very difficult to understand the ultimate impact of transformation on the bottom line of the practices. Additionally, many investigators noted a difference between a true PCMH and external recognition as one, concluding that a practice could be a true PCMH without having received recognition, and a practice that has received PCMH recognition may not be a true PCMH. They warn that the journey to recognition, in contrast to true transformation, can create a culture of "box checking" rather than making the deep changes necessary to become truly patient-centered.
"Annals is excited to publish these important findings, and we hope they will inform efforts to improve health care systems' ability to support changes to improve the effectiveness and sustainability of primary care practices to better meet patient needs across the country," said Kurt Stange, MD, PhD, Annals of Family Medicine editor and corresponding author of a supplement article on the importance of reporting contextual factors. "We especially hope the grantees' innovative reporting of relevant contextual factors information critical to understanding what happened and why in the studies will help other practices as they attempt to transport these findings to their unique settings and circumstances."
"Few practices realize or are prepared to make the substantive changes necessary for true transformation. However, this research demonstrates that change is possible even in the face of payment systems that do not yet adequately support transformative efforts within a deeply fragemented health care system," McNellis concludes. "Research like that presented in this supplement can serve as a roadmap, if not a how-to manual on achieving transformation."
Supplement articles include:
|Contact: Angela Sharma|
American Academy of Family Physicians