Evaluation Team

1. Facilitating Change:Lessons from the TransforMED National Demonstration ProjectAHRQ 2009 Annual Conference Sept. 14, 2009Elizabeth 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. 500 practices applied • 300 usable applications 36 practices selected 18 randomized: SELF-DIRECTED 18 randomized: FACILIATED 15 (SD) practices finished NDP: Background & Timeline NDP start: July 2006 NDP finish: June 2008 17 (F) practices finished Touchstone Group Begins

6. Real Practices… Real Stories

7. 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

8. Mixed Methods QUANTITATIVE • 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.

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* *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) Measure of Adaptive Reserve

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

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

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 Only showing core elements with significant changes from baseline: * = p <.05; ** = p <.01; *** = p <.001

23. Self-Directed Practices: Some Decreases 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.