The Patient-Centered Medical Home Part III: Time to Play Ball!

This article is the third of three parts.

Change management is difficult in and of itself, and embarking on a lengthy transformation is even more challenging. The Patient-Centered Medical Home (PCMH) application will require roughly 12 months to complete for even the most dedicated of practices, and the care transformation process will take even longer. The odds of achieving success in care transformation can be multiplied by incorporating specific strategies and tactics outlined in this article. These best practices achieve buy-in, improve engagement, and increase the likelihood of sustainable financial and quality outcomes (e.g., reduced emergency department utilization(1) and increased patient panel sizes(2)).

In the first two parts of this three-part article, we examined the background of the PCMH and outlined the key steps of a gap analysis to help understand if a practice is ready for action. Now we will put everything into action—starting with completing the PCMH application and continuing through the care transformation process. We will cover the selection of multiple stakeholder groups, communication strategies, prioritization of tasks, and more.

More Than Just Documenting What You Do

“Pointless.” That is how a physician from a Midwestern family practice described the PCMH process. When pressed for additional details, he explained that the PCMH process was a directive from organizational leadership and merely consisted of documenting processes already established. The approach this practice took resulted in Level 2 recognition, but did not result in any positive quality or cost outcomes and ultimately decreased the trust physicians in the practice had in the organization’s leadership.

Two parallel paths on the journey toward becoming a PCMH must be traveled: (1) completion of the application; and (2) cultural and care transformation. These two paths should be followed simultaneously in order to avoid the feeling that becoming a PCMH is a pointless endeavor. Achieving staff buy-in is a very important and necessary first step. This may be accomplished in a few different ways. The first approach we discuss involves properly educating staff on why becoming a PCMH will improve the quality of care that is delivered to patients. Following this, we discuss the use of stakeholder groups, which allow equal staff representation for key work streams (Figure 1).

Figure 1. The five components of successful transformation will help a practice expedite its transition into a next-generation practice.

Education

Simon Sinek has an excellent book (and a very popular TED talk) called Start With Why (Portfolio, 2011). The premise is, essentially, that people have a desire for clarity surrounding the why of any new endeavor. When the why is clear, a true relationship can develop, and behavior moves from being motivated to being inspired. “Why” engages people emotionally, whereas the “what” and “how” serve as evidence of that belief.

At the start of the PCMH journey, it is vital that the staff be educated on the why. Why is it important and necessary that the practice commit to this tremendous change? What is going on in the healthcare landscape? How is it going to impact primary care practices now and in the future, and, ultimately, why does a primary care practice need to change in order to stay above water?

Once staff members are aware of the macro- and microlevel trends in healthcare, they will better appreciate the why surrounding the necessity of the change. The next important step is to educate them on the how: how the change will happen and how they will be an important, influential catalyst of the change. This is when an overview of PCMH should be communicated to staff.

Stakeholders

It takes a considerable amount of time, attention, and resources to successfully implement the application process and care transformation. Fortunately, the benefits from the transformation (discussed in Part I of this series) make up for the time and commitment needed to develop new workflows and complete the application. Due to the high-stakes nature of this process, it is important to form a number of stakeholder groups to ensure all staff members are involved throughout this initiative. These stakeholder groups are responsible for a range of tasks specific to each group and, therefore, must be empowered to make decisions on behalf of the practice. A few key stakeholder groups essential to long-term success are described here, such as the executive leadership team and the application team.

Executive Leadership Team

The first necessary stakeholder group is an executive leadership team responsible for overseeing all aspects of the PCMH application and transformation. The team includes staff from each major job function and typically is small in size. Recommended team members include a physician, an administrator/manager, a front-line staff member, a clinical support staff representative, and the person responsible for completing the application.

This small team will hold everyone accountable for working efficiently and effectively during and after the application cycle. In addition to being the group ultimately responsible for the success of the PCMH, additional functions include oversight of the timeline, decision making, and removing barriers. The meeting frequency for this group will depend on the pace of change, simultaneous initiatives, and current progress. In addition, the executive leadership team is integral in the sustainability of PCMH. This group should continue to meet on a regular interval after the application is complete. During postapplication meetings, this team should evaluate success, identify areas of improvement, and ensure that changes continue to be reinforced.

Application Team

An application team usually consists of two people: the administrator and a staff person. However, IT support will be crucial for the many factors that require reports from the electronic health record (EHR) system. This duo will collect all the documents, reports, and materials necessary for the submission of the application. They will take care either of documenting the policies or delegating that responsibility to ensure the work is being completed. The staff person on this team should be someone who is well organized and comfortable using Microsoft Excel and Microsoft Word, as well as their EHR and practice management applications.

Preparing all the requisite materials requires manipulating the data so that it is suitable for presentation, including removing all patient health information. In addition, the staff member will need to keep detailed notes on all the various files that must be submitted in the application. While working on the application, this team should keep track of how many points the practice has currently earned so they have a good idea of what level of recognition they will receive.

Care Transformation Team

The final stakeholder group is the care transformation team. This larger team will serve as advocates for team members’ respective colleagues and will help redesign workflows in accordance with the many requirements in the PCMH model. The stakeholders in this group should include physicians, the administrator/manager, representatives from the clinical staff, and frontline staff representatives. Involvement from this broad group is necessary to get staff buy-in, redesign workflows in more efficient ways (because, after all, the frontline staff responsible for the work often have the best understanding of how to improve the workflow), and communicate to their colleagues. The decision of which employees to include on the work team is important, because they are the face of change and are the ones supplying the ideas and providing the input. Due to their involvement in developing the ideas and encouraging staff buy-in, staff members chosen for this team should be organized, creative, positive thinkers, open to change, good communicators, and held in high regard by their colleagues.

The triad of stakeholder groups will allow the practice to efficiently lead change and redesign workflows in a way that will lead to improvement in access and quality. Different groups have different responsibilities, but they work together to help with change management in the practice. The size of the groups will vary depending on the size of each individual practice, but the idea is the same—unless employees are empowered, engaged, and willing to contribute to the workflow redesigns, the benefits associated with the PCMH model will not be realized.

The sheer number of changes that accompany true PCMH embodiment can be tough for employees to handle.

Occasionally an employee or leader is resistant to the concept and idea of a PCMH. When this happens, it is important to understand the source of his or her resistance. Is there a lack of understanding surrounding the importance of transformation? Perhaps this individual feels there are other areas that need to be improved, or he or she does not feel heard or understood. Therefore, the first, and most important, step is to understand the individual’s perspective.

Prioritization

In terms of the application, many factors need to be developed and submitted. Therefore, it is important to strategize regarding the best way to approach and complete the requirements. The gap analysis should have already addressed the policies, procedures, and reports currently in place and those that need to be developed. In addition, the gap analysis should have identified which reports are currently being produced and which have yet to be produced.

Policies and procedures must be active for three months prior to the final submission of the application. Therefore, it is vital to develop and implement these new policies first. Engaging with IT (or your software vendor) to build new reports is another important step in the beginning of the journey. New reports may be labor intensive and difficult to build, depending on the various technology platforms that are used at each practice. As these new reports are produced, a practice can realize immediate benefits by focusing on “easier” tasks to achieve some quick wins.

Beyond prioritizing new policies and reports, other factors should be prioritized based on how difficult it will be to implement them successfully. The sheer number of changes that accompany true PCMH embodiment can be tough for employees to handle. Therefore, achieving quick wins, establishing momentum, and creating buy-in from participating individuals through increased efficiency and standardization is crucial. This brings us to the next important piece, constant communication.

Communication

A true PCMH transformation involves constant change. Therefore, it is imperative that communication with staff is treated with the upmost importance. Transparency in regard to progress, challenges, and upcoming initiatives will help staff remain engaged and buy into the idea that PCMH is the worth the time and effort. Communicating each “win” will help sustain the excitement and reinforce the message that each employee plays a vital role in helping to shape a new path and improve the care they deliver for each and every patient.

Beyond setting the stage and educating the staff, frequent ongoing communication will maintain momentum throughout this process. This can happen through multiple channels, including daily huddles, which can serve as a good place to communicate progress and inform staff of upcoming changes. Communication during the huddles should not be done solely by management or physician leadership. To be most effective, this communication should come from those on the stakeholder committees. When peers inform each other of changes and the progress made, it helps build consensus and support for any initiatives that directly impact their work. In addition, the huddles can be an opportunity for committee members to seek input from their peers before making a decision.

Daily huddles, town halls, weekly update emails, and in-clinic and public tracking tools are all useful methods to communicate to the staff. Staff should be told how the transformation and application are going, along with the barriers that are being faced and the upcoming changes they will experience. All this communication is designed to improve staff buy-in and engagement. Once earned, the cultural and care transformation will be realized with greater success and sustainability.

Care Redesign

Having staff members work at the top of their licensure is important within the PCMH program. By optimizing care delivery, work is delegated in a downward fashion, removing unnecessary work from the physicians’ already full plates. This requires, first and foremost, trust. Physicians need to be able to trust their clinical support staff to deliver high-quality care in order to allow them dedicated time to make improvements in designated and focused areas of care improvement.

Once physicians are able to trust their clinical colleagues, the next step is systematically going through the various care plans and identifying opportunities for improvement. Standing orders are a great way to standardize care across the clinic, but this requires agreement among physicians and an understanding of expectations by the clinical support staff. Therefore, a quality committee should be formed that includes members of the clinical support staff and physicians. Bringing all the team to the table will provide transparent, clear communication and allow for more optimal improvements.

One strategy for improving quality is to continuously evaluate the data and conduct rapid process improvement tests. These rapid tests should be designed to make small changes to existing processes such that they will not take a lot of training to implement. In addition, rapid tests allow for a very quick understanding about whether the changes will result in positive improvements.

Final Words

Approximately 12 months—it’s a long commitment. However, good things come to those who wait and persevere. Research continues to show the benefits of becoming a PCMH, but those benefits will not automatically be there just because you have the PCMH recognition. Rather, the benefits are realized by those practices that are deliberate and intentional throughout this process. Empower the staff, communicate regularly and thoroughly, foster teamwork, and be smart about prioritization, and you’ll be surprised at the progress you will have made by the time the practice receives its PCMH recognition.

References

1. David G, Gunnarsson C, Saynisch PA, Chawla R, Nigam S. Do patient-centered medical homes reduce emergency department visits? Health Services Research. August 12, 2014; http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12218/abstract . Accessed August 7, 2016.

2. Reid RJ, Coleman K, Johnson EA, et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Affairs. 2010;29:835-843.