AHRQ-funded journal supplement offers lessons on primary care practice transformation

(Press-News.org) LEAWOOD, Kan. – Primary care practice transformation on a large scale is the cornerstone of current health care reform efforts aimed at achieving better outcomes, better value and better experience of care. Amid emerging evidence that transformation toward the patient-centered medical home model offers a viable solution in today's health care environment, the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality funded 14 studies to learn more about the processes and determinants of successful change from practices that had already demonstrated successful transformational activities and improved outcomes. Key findings of these 14 projects, which the funders hope will inform more widespread change efforts, are published in a special supplement of Annals of Family Medicine.

The supplement, Transforming Primary Care Practice, features insights from 14 natural experiments undertaken in a wide variety of settings across the United States including independent practices, integrated delivery systems, community health centers and large government systems. The projects, which were funded by AHRQ grants awarded in 2010 totaling more than $4.1 million each year for two years, begin to identify the approaches and methods for transforming the structure, characteristics and function of primary care that are likely to be successful in a wide variety of practice types and settings.

"The lessons learned from these analyses demonstrate that true transformation toward the patient-centered medical home model is not only possible, but desirable, although not without its challenges," writes Robert J. McNellis, MPH, PA, AHRQ [insert title] and colleagues, in a commentary about the lessons learned that cut across all the projects.

In the editorial, McNellis and colleagues outline five overarching thematic findings that emerged from the projects despite the wide variety of practices studied, geographic locations, sizes, structures and motivations:

1) A strong foundation is needed for successful redesign. Existing baseline capabilities of a practice are important determinants of successful transformation. Practices must accurately assess their readiness for change and their ability to handle the change process before undertaking substantive change. 2) The process of transformation can be a long and difficult journey. The process of transforming is complex, challenging and ambitious. It takes time and is constantly evolving. Progress is a process that ebbs and flows, and practices should prepare for a taxing journey. 3) The approaches to transformation vary. The ingredients of a successful change process vary, but a few key elements seen across the projects include: integration of more team-based care, expanded access to care, use of measurement and feedback tools and the use of learning collaboratives to facilitate team communication. 4) Visionary leadership and a supportive culture ease the way for change. Having strong internal change drivers is an important facilitator of successful transformation. The two internal drivers seen to have the most influence on change were leadership and culture. 5) Contextual factors are inextricably linked to outcome. The context within which transformation occurred is critical to understanding a practice's success.

In addition to the overarching findings above, the articles raise several potential cautions, including the difficulty of measuring the financial impact of transformation on a practice. Overall, the teams found it was very difficult to understand the ultimate impact of transformation on the bottom line of the practices. Additionally, many investigators noted a difference between a true PCMH and external recognition as one, concluding that a practice could be a true PCMH without having received recognition, and a practice that has received PCMH recognition may not be a true PCMH. They warn that the journey to recognition, in contrast to true transformation, can create a culture of "box checking" rather than making the deep changes necessary to become truly patient-centered.

"Annals is excited to publish these important findings, and we hope they will inform efforts to improve health care systems' ability to support changes to improve the effectiveness and sustainability of primary care practices to better meet patient needs across the country," said Kurt Stange, MD, PhD, Annals of Family Medicine editor and corresponding author of a supplement article on the importance of reporting contextual factors. "We especially hope the grantees' innovative reporting of relevant contextual factors – information critical to understanding what happened and why in the studies – will help other practices as they attempt to transport these findings to their unique settings and circumstances."

"Few practices realize or are prepared to make the substantive changes necessary for true transformation. However, this research demonstrates that change is possible even in the face of payment systems that do not yet adequately support transformative efforts within a deeply fragemented health care system," McNellis concludes. "Research like that presented in this supplement can serve as a roadmap, if not a how-to manual on achieving transformation."

Supplement articles include: Lessons Learned from the Study of Primary Care Transformation
Robert J. McNellis, MPH, PA, et al
This editorial summarizes the interventions studied by the 14 grantees and synthesizes the major findings and lessons learned about the process of transforming. Support and Strategies for Change Among Small Patient-Centered Medical Home Practices
Sarah Hudson Scholle, MPH, DrPH, et al
Financial support, practical training, and other help are important in spreading the adoption of the PCMH model among small practices. Recognition as a Patient-Centered Medical Home: Fundamental or Incidental?
Daniel Dohan, PhD, et al
Becoming patient centered and seeking NCQA recognition as a PCMH run along separate but parallel tracks in this case study. Spreading a Medical Home Redesign: Effects on Emergency Department Use and Hospital Admissions
Robert J. Reid, MD, PhD, et al
It is possible to reduce emergency department use with PCMH transformation across a diverse set of clinics using a clear change strategy and sufficient resources and supports. Facilitators of Transforming Primary Care: A Look Under the Hood at Practice Leadership
Katrina E. Donahue, MD, MPH, et al
Certain aspects of leadership help move practices forward in primary care transformation, including setting strategic direction and implementation. Cultivating Engaged Leadership Through a Learning Collaborative: Lessons from Primary Care Renewal in Oregon Safety Net Clinics
Carmit K. McMullen, PhD, et al
A group of safety net organizations cultivates engaged leadership with scarce resources by partnering with organizational leaders in design of transformation efforts, sharing lessons and overcoming implementation hurdles. Process and Outcomes of Patient-Centered Medical Care With Alaska Native People at Southcentral Foundation: Findings From a Mixed Methods Evaluation
David L. Driscoll, PhD, MPH, MA, et al
In this study of a tribally owned and managed primary care system, all reported measures of emergency care use showed a decreasing trend after PCMH implementation. Quality, Satisfaction and Financial Efficiency Associated With Elements of Primary Care Practice Transformation: Preliminary Findings
Julie Day, MD, et al
A study of multiple outcomes in a redesigned model of care underscores the importance of team-based-care and continuity of care. Contrasting Trajectories of Change in Primary Care Clinics: Lessons From New Orleans Safety Net
Diane R. Rittenhouse, MD, MPH, et al
The PCMH model can successfully address the needs of safety-net populations, particularly with the support of stable, committed leadership and deep community ties. Becoming a Patient-Centered Medical Home: A 9-Year Transition for a Network of Federally Qualified Health Centers
Neil S. Calman, MD, et al
This study, set in a large FQHC network serving a diverse population, reports on complex system change, including its component parts and the processes by which it was facilitated. Assessment and Measurement of Patient-Centered Medical Home Implementation: The BCBSM Experience
Jeffrey A. Alexander, PhD, et al
Approaches to PCMH measurement should be driven by the intended uses and users of the measure. Patient-Centered Medical Home Among Small Urban Practices Serving Low-Income and Disadvantaged Patients
Carolyn A. Berry, PhD, et al
Small practices can achieve important aspects of the PCMH model of primary care, often with informal rather than formal mechanisms and strategies. Medical Home Transformation in Pediatric Primary Care—What Drives Change?
Jeanne W. McAllister, MHA, et al
In pediatric primary care practices, medical home transformation requires continuous development, ongoing quality improvement, family partnership skills, teamwork and strong care coordination. A Positive Deviance Approach to Understanding Key Features to Improving Diabetes Care in the Medical Home
Robert A. Gabbay, MD, PhD, et al
Key factors in primary care practices' performance improvement during medical home transformation include baseline structural capabilities and ability to buffer the stresses of change. Medical Home Transformation: A Gradual Process and a Continuum of Attainment
Leif I. Solberg, MD, et al
Medical homes are not similar, change in outcomes is slow, and transformation occurs on a continuum. Context Matters: The Experience of 14 Research Teams in Systematically Reporting Contextual Factors Important for Practice Change
Andrada Tomoaia-Cotisel, MPH, MHA, et al
This study offers a feasible, systematic approach for research teams to identify and convey contextual factors for understanding and transporting findings from health care research.

### Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article, including those in the supplement, can be accessed free of charge on the journal's website, http://www.annfammed.org.