Facilitating Change: Lessons from the TransforMED National Demonstration Project Facilitating...
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Transcript of Facilitating Change: Lessons from the TransforMED National Demonstration Project Facilitating...
Facilitating Change:Facilitating Change:Lessons from the TransforMED Lessons from the TransforMED National Demonstration ProjectNational Demonstration Project
AHRQ 2009 Annual Conference Sept. 14, 2009
Elizabeth E. Stewart, PhD
Independent Evaluation Team
from Center for Research in Primary Care & Family Medicine
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
National Demonstration Project
o Two-year project intended to ‘test’ the new model of family medicine as outlined in the FFM report.
o AAFP provided funding; TransforMED was created to design and implement the project.
o Independent evaluation team providing mixed-methods analysis for practice & patient outcomes.
NDP: Background & TimelineNDP: Background & Timeline
17 (F) practices finished
300 usable applications
500 practices applied
36 practices selected
18 randomized:FACILIATED
18 randomized:SELF-DIRECTED
15 (SD) practices finished
NDP start: July 2006
NDP finish: June 2008
Touchstone Group Begins
Real Practices… Real Stories
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
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 $$ for self-organized
retreat midway through NDP
Self- Directed• List serve & website access• 1 final NDP Learning Session• Some $$ for self-organized
retreat midway through NDP
Mixed Methods
QUANTITATIVEo Patient Health Outcomes (medical chart audits)o Practice Finances (surveys – limited)o Clinician/Staff Satisfaction (surveys)o Patient Perception of Care (surveys)
QAULITATIVEo Field notes, interviews, observations, email
communication logs, conference calls, Learning Sessions, facilitator debriefs, list serve, document of model components.
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
Care Management
• Population management
• Wellness promotion
• Disease prevention
• Chronic disease management
• Care coordination
• Patient engagement and education
• Leverages automated technologies
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
Quality and Safety
• Evidence-based best practices
• Medication management
• Patient satisfaction feedback
• Clinical outcomes analysis
• Quality improvement
• Risk management
• Regulatory compliance
Health Information Technology
• Electronic medical record
• Electronic orders and reporting
• Electronic prescribing
• Evidence-based decision support
• Population management registry
• Practice Web site
• Patient portal
A new way of thinking…o Transformation is more than a series of
incremental changes; it requires requires epic whole practice re-imagination and redesign.
o Transformation to a PCMH requires substantial changes in the mental model of both physicians and practice staff.
o It is more than implementing sophisticated office systems… it is about adopting substantially different approaches to patient care.
A new way of thinking…
o Physicians will need to move towards facilitated leadership skills and away from authoritative ones.
o Physician-patient relationship will need more emphasis on partnership to achieve patients’ goals.
o 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.
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.
What is Adaptive Reserve?
o 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
o 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
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)
Mea
sure
of A
dapt
ive
Res
erve
The Role of Facilitation
1. Consulting
2. Coaching
3. Facilitating Adaptive Reserve
Facilitation: Consultant
Huddles & Meetings
Workflow analysis
HIT assistance – vendor liaison, implementation
Metrics, PDSA cycles
Specific projects
Facilitation: Coach
Physicians
* Leadership* Finances* Delegation* Time Mgt* Communication* Support
Staff: Empowerment, task delegation
Practice Managers
* Project Mgt* Personnel/HR* Finances* Communication* Empowerment* Support
Facilitation: Adaptive Reserve
Rich & LeanCommunication
IntenseCoaching
Facilitated Learning Sessions w/other practices
Conflict Resolution
Staff RetreatsWith Pre-Work& Follow-up
Patient Outcomes Surveys
o Mailed to cross-section of 120 pts/practice, 3x o Based on multiple validated surveys and intended to
measure 7 attributes of patient-centered primary care.*1. Superb Access2. Patient Engagement 3. Clinical Information Systems to Support Care4. Care Coordination 5. Integrated & Comprehensive Team Care6. Routine Patient Feedback to Doctors7. Publicly available information• Also assess patient enablement & patient satisfaction.
*Commonwealth Fund
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 Responsiveness10) Family Context (CPCI)
11) Organizational Access12) Community Context (CPCI)
13) Usual Provider Continuity (CPCI)
14) Interpersonal treatment15) Recommend Doctor 16) Rating of Doctor (1-10)
17) Med Home (PCPE)
18) Same Day Access Available19) Overall health status (1-5)
Self-Directed Practices: Some Decreases Baseline 9 months 28 months
Mean SD Mean SD Mean SD
Empathetic Care .87 .20 .84** 0.20 .84** .20Comprehensive Care .84 .16 0.82 0.16 .81** .15
Interpersonal Com. .81 .18 .78** 0.18 .80 .18
Advocacy .82 .16 .80* 0.16 .80* .16
Health Promotion .14 .34 .24*** 0.34 .16 .31
Only showing core elements with significant changes from baseline: * = p <.05; ** = p <.01; *** = p <.001
Self-Directed Practices: Some DecreasesBaseline 9 months 28 months
Mean SD Mean SD Mean SD
Community Context .71 .22 .67** 0.22.66**
* .22Interpersonal treatment .91 .17 .89* .17 .91 .16
Recommend Doctor .94 .15 .91* .15 .92 .14
Rating of Doctor .91 .15 .88* .15 .88 .15Same Day Access .41 .48 .34* .48 .40 .49Overall health status 3.38 .94 3.44 .94 3.50* .92
Only showing core elements with significant changes from baseline: * = p <.05; ** = p <.01; *** = p <.001
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.
Thank you.