Facilitating Change: Lessons from the TransforMED National 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 Two-year project intended to ‘test’ the new model of family medicine as outlined in the FFM report. AAFP provided funding; TransforMED was created to design and implement the project. Independent evaluation team providing mixed-methods analysis for practice & patient outcomes.

NDP: Background & Timeline Presentation Information NDP: Background & Timeline 300 usable applications 500 practices applied 36 practices selected 18 randomized: FACILIATED SELF-DIRECTED 15 (SD) practices finished NDP start: July 2006 NDP finish: June 2008 17 (F) practices finished Touchstone Group Begins CONFIDENTIAL

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

Mixed Methods QUANTITATIVE QAULITATIVE Patient Health Outcomes (medical chart audits) Practice Finances (surveys – limited) Clinician/Staff Satisfaction (surveys) Patient Perception of Care (surveys) QAULITATIVE Field notes, interviews, observations, email communication logs, conference calls, Learning Sessions, facilitator debriefs, list serve, document of model components.

Presentation Information CONFIDENTIAL

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 Health Information Technology Electronic medical record Electronic orders and reporting Electronic prescribing Evidence-based decision support Population management registry Practice Web site Patient portal Care Management Population management Wellness promotion Disease prevention Chronic disease management Care coordination Patient engagement and education Leverages automated technologies Quality and Safety Evidence-based best practices Medication management Patient satisfaction feedback Clinical outcomes analysis Quality improvement Risk management Regulatory compliance 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

A new way of thinking… Transformation is more than a series of incremental changes; it requires requires epic whole practice re-imagination and redesign. Transformation to a PCMH requires substantial changes in the mental model of both physicians and practice staff. It is more than implementing sophisticated office systems… it is about adopting substantially different approaches to patient care.

A new way of thinking… Physicians will need to move towards facilitated leadership skills and away from authoritative ones. Physician-patient relationship will need more emphasis on partnership to achieve patients’ goals. 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? 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 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* Measure of 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)

The Role of Facilitation 1. Consulting 2. Coaching 3. Facilitating Adaptive Reserve

Facilitation: Consultant Huddles & Meetings Metrics, PDSA cycles Workflow analysis Specific projects HIT assistance – vendor liaison, implementation

Staff: Empowerment, task delegation Facilitation: Coach Physicians * Leadership * Finances * Delegation * Time Mgt * Communication * Support Practice Managers * Project Mgt * Personnel/HR * Finances * Communication * Empowerment * Support Staff: Empowerment, task delegation

Facilitation: Adaptive Reserve Conflict Resolution Staff Retreats With Pre-Work & Follow-up Rich & Lean Communication Intense Coaching Facilitated Learning Sessions w/other practices

Patient Outcomes Surveys Mailed to cross-section of 120 pts/practice, 3x Based on multiple validated surveys and intended to measure 7 attributes of patient-centered primary care.* Superb Access Patient Engagement Clinical Information Systems to Support Care Care Coordination Integrated & Comprehensive Team Care Routine Patient Feedback to Doctors 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 Responsiveness 10) Family Context (CPCI) 11) Organizational Access 12) Community Context (CPCI) 13) Usual Provider Continuity (CPCI) 14) Interpersonal treatment 15) Recommend Doctor 16) Rating of Doctor (1-10) 17) Med Home (PCPE) 18) Same Day Access Available 19) Overall health status (1-5)

Self-Directed Practices: Some Decreases Baseline 9 months 28 months Mean SD Empathetic Care .87 .20 .84** 0.20 Comprehensive Care .84 .16 0.82 0.16 .81** .15 Interpersonal Com. .81 .18 .78** 0.18 .80 Advocacy .82 .80* Health Promotion .14 .34 .24*** 0.34 .31 Only showing core elements with significant changes from baseline: * = p <.05; ** = p <.01; *** = p <.001

Self-Directed Practices: Some Decreases Baseline 9 months 28 months Mean SD Community Context .71 .22 .67** 0.22 .66*** Interpersonal treatment .91 .17 .89* .16 Recommend Doctor .94 .15 .91* .92 .14 Rating of Doctor .88* .88 Same Day Access .41 .48 .34* .40 .49 Overall health status 3.38 3.44 3.50* 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.