1. Facilitating Change: Lessons from the TransforMED National Demonstration Project AHRQ 2009 Annual Conference Sept. 14, Elizabeth E. Stewart, PhD Independent Evaluation Team from Center for Research in Primary Care & Family Medicine

2. 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

3. 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.

4. 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

6. Real Practices… Real Stories

7. Implementation Assistance
Facilitated
6 practices/facilitator
Access to facilitator (site visits, phone calls, s)
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

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

9. Presentation Information
CONFIDENTIAL

10. 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

11. 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.

12. 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.

13. 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.

14. 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

15. 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)

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

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

18. 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

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

20. 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

21. 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)

22. 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

23. 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

24. 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.

25. Thank you.