Ten critical elements appear necessary for transformation. Each element raises key policy questions.
Committed, competent and passionate leadership is a sine qua non of successful transformative efforts regardless of practice size. No different than leadership in areas outside of health care, leadership in practice transformation entails establishing and articulating a vision, building the relationships required to accomplish it, and allocating and prioritizing resources to enable it.
The key research question is how to scale up the development and promotion of this type of leadership beyond the innovators and early adopters who likely have composed most of the programs described to date. Do these leaders need to be physicians? Can leadership be a criterion for selection into health professional schools? Can this kind of leadership be taught? What types of training and support are needed to develop and strengthen practice leaders and how will this training be supported?
To achieve transformation, additional investments in primary care will be necessary. Existing primary care resources are dedicated largely to providing visits. Much of the activities described in transformed practices represent new, currently unfunded activities such as asynchronous interactions via e-mail, population health management and outreach, as well as care coordination. In that sense, a PCMH is a “new business” for primary care practices,1
one that will require both an up front investment to undertake the transformation and a reliable revenue stream for ongoing operation.
We need to understand the magnitude, timing and feasible financing models to support practice investments in new personnel, space, and systems. We also need to know how payments should be made in order to better align the priorities of the practice with the goal of transformation, as well as how non-cash supports (e.g., co-located case managers paid for by insurance companies as has been done at Geisinger in Pennsylvania and at Independent Health in Buffalo, or support for electronic health record (EHR) adoption/implementation) can affect the pace of change. A particular challenge is the development of feasible models to achieve multi-payer support for transformation; a number of pilot efforts undertaken by large insurers acting alone (including IBM/Aetna in Texas, United in Florida) failed to get off the ground because, in a fragmented payment system, one payer—even a large one—supporting only its share of practice patients could not provide sufficient financial resources to support comprehensive practice transformation. Given the importance of new payment systems for supporting transformation, this should be a high priority activity for research.
All types of transformation require skill in establishing and maintaining relationships. Transformation entails transforming from a provider/physician focused, autonomous practice to team-oriented practices maintaining productive relationships with patients and families, with the community and its resources, and with the medical neighborhood of specialists, hospitals, plans and agencies. Research might identify optimal methods and timing of training and supervision through the various stages of health professional training that can promote skills in building and maintaining such relationships.
- Patient and family engagement
One core element of the Patient Centered Medical Home is a changed relationship between health professional and family/patient, particularly concerning the management of chronic conditions. Substantial research supports the importance of engaging patients and families in their care, particularly in the care of chronic illness. New capacities created by health information technology—such as patient portals and personal health records—may help to engage patients directly in their care and to drive change in health care organizational performance. Research questions should address how and to what extent patient access to clinical information stimulates practice transformation, as well as which models of patient/family engagement work best in actual practices.
Several demonstration programs—such as the evolving Massachusetts Medical Home Demonstration—emphasize a strong role for patients and families in driving or at least directly informing transformation process itself. In our experience, the unique perspective that family members bring re-focuses transformation efforts away from provider concerns and toward bringing value for families and patients. Research is needed to identify the ways in which engaging patients and families in the transformation process influences the pace and nature of the transformation. Additional research can examine how to best provide training and support to patients and families so they can most productively participate in this transformative effort, and what training is needed to better enable health professionals to work with families. This research will be especially valuable since few of the major demonstration projects now underway include family participation as a critical component.
- Competent management and finances
Change is stressful and requires a base of organizational stability. Competent management, particularly but not only financial management, establishes the requisite foundation for transformation to occur. The TransforMED investigators have identified a capability of practices they term “adaptive capacity”27
that indicates, in their view, the ability of a practice to undertake rapid and ongoing change. Defining and implementing systematic ways to assess whether a practice is “well functioning” and, beyond that, whether it has “adaptive capacity” would be a high value research activity as it may provide tools to assess and improve the “readiness” of practices to undertake transformation.
All of the transformation projects of which we are aware used one or more specific techniques or models for practices to undertake change, although the specific change models (model for improvement, lean, six sigma, or a more home grown approach) vary. We would predict that the optimal technique to promote practice transformation will be context specific and depend on the size, leadership and organizational setting of the individual practice. Maintenance of certification programs now require physicians to measure and improve performance at the practice level on a population basis. These programs have had a large volume of participating physicians, many from small practices, and the role of this process in raising consciousness and engaging practicing physicians is worthy of further study. Overall, research should examine how context and technique interact to produce results.
- Expert and facilitated assistance
The practices with whom we spoke repeatedly emphasized the importance of external support for providing a) new ideas and approaches; b) access to the experience of others like them; c) a framework for change. Sometimes this support came through consultative work from trained in office facilitators or QI experts, sometimes it came through collaborative learning projects (e.g., Hogg et al.).27
We have seen successful support from professional societies (American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Academy of Family Medicine (AAFM), Improving Performance in Practice (IPIP)), from state government, from organizations with expertise in improvement (NICHQ, IHI, Quality Improvement Organizations (QIO’s), improvement partnerships).
A series of key research questions emerge: What form of support is most effective in promoting and sustaining transformation? What are the best coaching models? What are the optimal training and core skills of successful coaches? How critical are site visits/on site facilitation vs. collaborative learning programs? What is the role of virtual learning communities? Understanding the relative advantages and disadvantages of each of these approaches will inform state and federal policy choices
Health IT plays four critical roles in enabling transformation. Each can be accomplished without IT, but well designed IT systems can facilitate each:
- Registry functionality and population management—identifying and managing the population of patients within a practice as a population.
- Care planning—populating and sharing the content of care plans efficiently.
- Communication—effective health IT can facilitate primary care/specialty communication, patient-doctor communication, and in-office team communication.
- Monitoring and tracking change and improvement.
But HIT itself only creates a “necessary but not sufficient” platform on which transformation takes place; the human interaction with technology must be the focus of further research:
- How best to achieve capacity for registry functionality as an “effortless by-product” of contemporaneous care documentation28
- Since care plans, by their nature, will demand shared engagement of patients/families in the creation of a “care plan document”, what HIT tools, standards and work flows best support this activity?
- What are the respective roles of technical and work flow standardization in the facilitation of effective communication?
- What routine capacities for monitoring performance should be “hard-wired” into EHR products? And how can this be done without adding undue hassle and cost?
- Capacity to Deliver Care Coordination
Research is needed to identify the optimal scale for care coordination, i.e., at what point does it make sense for the coordination function to be within a practice vs. outside. In either setting, it will be critical to understand the appropriate health professional skill required for this activity, and the training and requisite support. If care coordination capacity is located outside the practice, as it is in models such as the Help Me Grow program in Connecticut now undergoing replication, how best to maintain connection to the practice and avoid the shortcomings of simply outsourcing disease management –as many failed insurance company programs appear to do- is another question of central import.29
- Professional and staff roles and training
Core principles of chronic care management and the general concept of transformation as articulated above entail the use of teams and more broadly shared responsibilities across health professionals and staff at a variety of levels and disciplines. Ample research confirms the capabilities of nurses and nurse practitioners to provide chronic care management and preventive services at levels at least comparable to that provided by physicians.30,31
Additional research is needed to determine appropriate mix of staffing and roles for health professionals and staff to achieve the desired outcomes and how to provide training to non-professional staff (e.g., medical assistants). It will be helpful to know what resources can help practices develop effective teams and what useful assessment instruments can be deployed to help practices measure and improve their team performance.