1. Transforming Residency Practices into Medical Homes
Perry Dickinson, MD
Department of Family Medicine
University of Colorado School of Medicine

2. Outline What is the Patient Centered Medical Home?
Colorado FM Residency PCMH Project
Lessons learned
Questions and (hopefully) answers

3. What is the Patient Centered Medical Home?
The PCMH is an approach to providing enhanced, comprehensive primary care for children, youth, and adults.
Has gained a great deal of traction as a platform for improving care and decreasing costs
Builds on core family medicine principles, but with some key changes

4. Why Do We Need to Change? – Health Care System Perspective
Spending incredibly too much for health care
Increasing recognition that current system unsustainable
Mediocre quality in multiple areas
Increasing recognition of the potential role of primary care to increase quality and decrease costs
There is compelling, widely available evidence coming from academic centers, think tanks, plans, and government studies that find unexplainable disparities in healthcare quality, cost, and outcome.
I’m sure you’re all familiar with the problems:
IOM Quality Chasm - Difference between what healthcare should be and what it is now is not a gap, it’s a chasm….
Mediocre quality – Rand Study - with the current - giving 55% of recommended care - Nation / World news: Mediocre doctoring the norm: Study: Proper care given just 55 percent of the time – June 2003 and March 2006 – NOW HIT THE LAY PUBLIC AND BUSINESS JOURNALS
NEW STUDY PROVIDES ROAD MAP TO PREVENTIVE SERVICES WITH GREATEST HEALTH IMPACT, BEST COST VALUE - More than Half of Americans Who Need Valuable Preventive Services Continue to Go Without Them (by Partnership for Prevention - Sponsored by the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ)) - Sheds light on the startling fact that more than 50 percent of Americans who need these valuable preventive services continue to go without them.
The three most valuable preventive health services that can be offered in medical practice today, each of which save more money than they cost and provide enormous health benefits are:
Discussing daily aspirin use with at-risk adults to prevent cardiovascular disease
Immunizing children
Intervening with smokers to help them quit
Developed a ranking of 25 recommended services based on those that provide the greatest health benefits, both in terms of saving lives and improving quality of life, while offering the most value for the health care dollars
According to the study, five of the highest ranking services are being utilized by less than half of the people who need them.
These are: 1.) discussing daily aspirin use with at-risk adults; 2.) screening adults age 50+ for colorectal cancer; 3.) intervening with smokers to help them quit; 4.) vaccinating older adults against bacterial pneumonia; and 5.) screening young, sexually active women for Chlamydia.
Killing 44K - 98K people every year from medical errors
It’s not bad doctors – we need to move from a blame and shame culture – but as physicians, we can no longer accept the status quo. There is compelling, widely available evidence coming from academic centers, think tanks, plans, and government studies that find unexplainable disparities in healthcare quality, cost, and outcome. Even after disputes regarding methodology, severity adjustments and peer reviewed critiques rinse the data and findings, the evidence demonstrates that value of the health care purchased is hardly uniform. (for the money being spent on healthcare, the quality needs to be improved). Part of the issue is we are taught to take care of each patient individually – but when you look at the POPULATION of patients as a whole, the numbers look very mediocre
We certainly want to keep the good relationships with our patients – but we also need NEW and Better Systems to get this job done.

5. Cost per capita vs healthy life years
Best
Organization for Economic Cooperation and Development data, 2000

6. International Quality Comparison

7. Need for Change – Primary Care Perspective
Primary care clinicians – on a treadmill
Reimbursement system slanted against primary care, toward procedures, specialists, hospitals
Very tight financial margin
Have to see more and more patients to survive
Can’t deliver the type of care we want and need to do

8. What’s Different with PCMH?
Builds on strengthening the pillars of primary care (continuity, comprehensive care, coordination of care, initial access to care)
Adds different approaches to organizing care based on the Chronic Care Model
Adds use of Information Technology tools
Expanded importance of teamwork – among clinicians, staff, patients, families, specialists, hospital, community

9. Core Features of the PCMH
Centered around continuity relationship with a personal physician – but team-based care
Integrated mental, behavioral health
Patient’s care coordinated by the practice
Patient-centered; self-management support
Ongoing quality improvement
Population-based care
Enhanced access
Payment reform

10. Payment System Several models proposed
Most prevalent – blended payment model:
Traditional fee for service, plus…
Per member per month care management fee based on level of services provided, plus…
Pay for performance
Multiple pilots underway, including Colorado

11. Day in the life of Primary Care
Mid afternoon. Running behind. Has already seen 22 patients.
55 y/o man with dizziness, rash and chronic rhinorrhea
Has DM, requesting refills. Last seen 9 mos ago
No labs for over a year – not well-controlled then
Info scattered through chart, hard to find
Last retinal exam unclear – no record
You evaluate the acute symptoms, order labs, refill meds. No time for diabetic education. Ask to return in a month, but will he return then?

12. Day in the Life of a PCMH
The MA checks the next day’s schedule at 4 PM and identifies chronic care patients.
Same patient - 55 y/o with uncontrolled diabetes
Recently was seen for dizziness and now returning for a planned care visit
She notes that he needs a Pneumovax, lipid test, & retinal exam and prints his flow sheet.
Patient goes straight to exam room, MA checks the patient in, checks BP & foot exam, screens for depression, makes referral for eye exam, orders lipids and Hgb A1c, gives Pneumovax
All done before seeing the physician. A transformed practice requires additional time for MA, advanced training of MA and Standing Orders.

13. Day in the Life of a PCMH
Physician performs assessment, begins self-management discussion, adjusts meds, and plans next visit.
Patient sent to nurse care manager who helps patient to develop personal care plan, sets up for a diabetes education group in the community
MA calls patient in 2 weeks to see if he has questions or problems, makes sure no problems with med change, reconfirms next visit.
Reality? This comes from one of our PCMH Demonstration Project practices
Physician has time to activate patient because of bidirectional information and delegates duties.

14. The Colorado Family Medicine Residency PCMH Project
3-year grant from the Colorado Health Foundation; began in December 2008
Goal: To transform the 10 Colorado FM Residency Programs into medical homes through practice improvement and curriculum redesign

15. What is Involved? Initial Engagement
Engagement of leadership, residents, staff
Start working on forming improvement teams
Assistance with initial IT issues
Practice/program discussions of PCMH to help form the vision
Sponsoring organizations – look for support, try to remove barriers

16. Improvement Teams Practice improvement is a team sport
Have to make time and space for reflection on areas needing change, planning
Best way of doing this - practice “Improvement Team” with regular meetings to consider and plan improvement efforts
Should include people from all major parts of the practice – diversity, teamwork is crucial
Takes time and persistence for team to become optimally functional

17. Practice Coaching Assessment of current status in practice
Feedback assessment to practice
Help form improvement teams
Initially facilitate improvement team process but transition to practice taking over
Serve as connection to resources, best practices
Goal is to establish a sustainable change & improvement process in the practice

18. Curriculum Redesign
Facilitation and consultation for PCMH-related curriculum changes
Changes to free up residents to participate in PCMH and QI efforts
Shared resource development across programs (lectures, modules, etc)
Active involvement of residents in practice redesign process
PCMH practices for residents to experience

19. Collaboratives
Meetings of representatives of all practices and programs
Planning, sharing, educational – highly interactive
Two collaboratives per year
First one May 2009 – 105 people from the residency programs and practices
Second - October 2009 – 135 from programs
Third – May, 2010 – 160 from programs

20. Practice Goals Achieve NCQA PPC-PCMH recognition
Improve level of medical homeness:
PCMH Clinician Assessment
Practice Staff Questionnaire (practice culture)
Practice PCMH Monitor (recently developed)
Improve quality measures in two clinically important areas chosen by the practice

21. Curricular Goals
Revision of curricula to allow resident participation in PCMH and QI efforts
Improved resident achievement of PCMH competencies
Improved resident use of PCMH elements as measured by PCMH Clinician Assessment
Implementation of PCMH curricular elements

22. Challenges for Residency Practices
Inconsistent resident availability
Lots of part-time faculty and resident providers
Large practices – most have employees
Goals and beauracracy of sponsoring hospitals
Staff often controlled by hospital
Hierarchical management structures
Rigid and extensive residency curricular and structural requirements

23. Lessons Learned – Practice Transformation
Becoming a medical home takes time, requires fundamental change in multiple areas
Change is difficult, and this is a lot of change
Have to have a robust change management and quality improvement process
Outside support (from a practice coach) can really help – but practice needs to be open to having a coach

25. Lessons – Structure of Support
No established road map to the medical home
NCQA PCMH standards provide some framework – but incomplete, insufficient
Some things need to be done early to enable later changes (vision, team formation, staff engagement, registry implementation)
Moving toward more structured approach, but have to balance with practice choice
Lack of payment reforms limit changes in some areas, but not others

26. Lessons - Curriculum
Residents are more energized and ready to change than faculty
Difficult but crucial to involve residents on a regular basis in the change process
Developed PCMH competencies – will evolve
Curriculum issues may change over time
Initial need for didactics & projects in key PCMH areas
Gradual shift to more experiential learning

27. Lessons - Sustaining Change
Identified a need to more formally train internal QI Team Leaders to create sustainability
Mix of didactic, discussion, experiential with support by our project team
Varies according to audience (staff, physicians)
Creating a Learning Community
Learning Collaboratives working well to promote sharing
Project staff creating connections between programs working on similar areas

28. PCMH – Huge Cultural Issues
Three key areas for practice cultural change:
Leadership
Change process requires a shift toward less hierarchical management
Team-based care and improvement process
Clinicians and staff not used to working in teams
Patient-centeredness
Traditional care practice and physician centered; requires a shift for everyone

29. PCMH is a Team Sport
No way for primary care clinicians to do everything their patients need themselves
Multiple studies showing that delegating responsibilities to the staff has very positive results – patient, staff, clinician satisfaction, quality and efficiency of care
Goal is everyone working at the top of their license and skills
We physicians have difficulty delegating
Staff not trained for some of these tasks

30. Effective Leaders for Change
Provide an initial vision – but engage everyone in further developing the vision
Refer to the vision regularly to focus work
Help everyone figure out how they can contribute to the vision
Make time for reflective, interactive team meetings
Encourage an open exchange of ideas
Value and nurture diversity of people, ideas, and experiences

31. Effective Leaders Empower people to work at highest level
Hold people (and self) accountable
Help show a way forward when things are stuck
Are not afraid of failure
Share information freely
Create a true shared leadership model
Often work through others to achieve goals
Give recognition and awards

32. Reality
Even if you are on the right track, you’ll get run over if you just sit there
~ Will Rogers
We do not have a lot of time. Other agents will fill the void.

33. Thank You!
Contact Information:
Perry Dickinson: