HomePartners & Projects Evaluators' ReportsReport #5

Evaluators' Report on the National Demonstration Project (NDP)
to the Board of Directors of TransforMED

February 5th, 2008

by The Center for Research in Family Medicine and Primary Care
Elizabeth E. Stewart, PhD (NDP Qualitative Analyst)
Carlos R. Jaén, MD, PhD
Benjamin F. Crabtreee, PhD
Paul A. Nutting, MD, MSPH
William F. Miller, MD, MA
Kurt C. Stange, MD, PhD

Introduction:

The formal National Demonstration Project is moving toward the homestretch with a final April learning session and an ultimate push by facilitators to assist in practice change; however, it is important to realize that the learning from the NDP is far from over. The Evaluation Team will continue to collect data for the coming year, including Evaluation Team site visits to all facilitated practices (site visits to the self-directed practices already have been completed over the past 6 months). The Evaluation team recently had an analytic retreat in San Antonio to review thousands of pages of qualitative data and the initial quantitative analysis of surveys of patients and practice members.

This report will summarize some insights which are emerging about the change process in the facilitated and self-directed practices; practice finances; developing a personal medical home; and the potential of TransforMED as it goes forward. These thoughts may be helpful to TransforMED as it transitions to a for-profit company with the goal of assisting practices in transformative change efforts.

Practice Change
In earlier board reports, we refer to practice transformation as comparable to the midair conversion of a 1950's era DC-3 airplane into a futuristic Starship Enterprise. After almost two years, the analogy still holds true. Implementing the technical pieces of the TransforMED model of care has been enormously difficult, requiring heroic efforts and faith on the part of the practices. This includes the self-directed practices, each of whom has soldiered forward without the aid of facilitation.

Putting the model components in place (e.g., group visits, disease registries, same day scheduling, etc) has been the primary focus of the facilitated practices since the first learning session. In some practices, the facilitator had to address significant problems with practice relationship infrastructure before more technical work could be accomplished. However, the majority of facilitated practices dove right into plugging in the pieces, using the facilitator as a consultant, guide, information-gatherer, and support system. Despite this assistance, implementation of the model has strained even these exemplar practices because change is demanding and rife with unexpected setbacks. Staff turnover, embezzlement, death or illness in the family, financial worries, personal and personnel problems, inconsistent technology, and the bureaucratic systems moving at a glacial pace – these are just a few of the issues that have accompanied change. Many are precipitated by the change itself, and others are simply the background context of contemporary primary care practice. An important role of the facilitator has been helping the practices stay on course and manage change fatigue.

The self-directed practices brought their own sense of motivation and innovation to the project. Although some have expressed disappointment at the lack of formal instructions, almost all eventually used the freedom of being self-directed to implement certain components in ways uniquely suited to their patient population and community at large. For example, one self-directed practice holds non-traditional group visits, where anyone can come with any kind of problem, as a way to ease its access problem. Another practice saw a need for socialization in older, retired men at risk for depression, and it crafted group visits to fill that niche.

Many of the self-directed practices, like the facilitated practices, were already making changes when they applied to participate in the NDP. Without an external person to push them along, the self-directed practices appeared to move at a slightly slower pace during the study period; however, most have made substantial progress. In some ways, this slower pace was advantageous to mitigate the effects of "change fatigue." However, nearly all practice leaders said they would welcome a facilitator to step in the mix and provide third-party support and motivation, someone to provide structure, keep the practice on track, and hold people to deadlines. Otherwise, they report, it is too easy to get caught up in the daily grind.

A common theme is emerging in the data from both the facilitated and self-directed practices. Successful implementation of new model components does not automatically lead to the relationship-centered organization, necessary for sustained change and learning. This is understandable, as the hard work of implementing technology and revamping work flow means the difficult task of building practice relationships retreat to the backburner. We may find that having a relationship-centered organization is key in creating a patient-centered medical home (see related section in this board report). For the most part, the practices that are relationship-centered were so in the beginning. At the same time, the facilitators have had a huge effect in some of the practices that had overtly dysfunctional relationship systems at baseline.

Practices Finances
Practice finances are critically important, and it is clear that practices are less facile managing their finances than was initially assumed. The facilitators, with Jim Arend's leadership, have worked tirelessly to acquire details on practice finances, with some success on some practices, but not across the board. At times, simply filling out the financial reporting form required accounting intervention from Jim. For this reason, such detailed information has not been requested from the self-directed practices.

The Evaluation Team and facilitators have worked together to develop a plan to collect additional data from both sets of practices using a simplified financial form created by Jim and modified by the Evaluation Team.  Rather than acquiring specific details about a practice's finances, this form is intended to measure the practice's overall knowledge and understanding of their finances. It is a subtle difference, but one that might allow us to characterize practice facility with finances and make meaningful comparisons across all practices. We will collect these data in February 2008 and again in January 2009 (before the evaluation period expires).

Much credit goes to the NDP facilitators and their tireless effort to collect comprehensive financial data from the practices. However, the data which have emerged will simply not permit analysis of the financial implications of implementing either the components of or the total TransforMED model.

The Patient-Centered Medical Home
The term "patient-centered medical home" (PCMH) has gained considerable national attention, although there remains ambiguity in what it really means and particularly how to measure it. Early analysis from the NDP (using both qualitative data and the quantitative scores from two waves of Patient Outcome Surveys) does suggest that implementing components of the original TransforMED model does not automatically lead to a patient-centered medical home.  A primary focus of the NDP has been implementation of the TransforMed model components and to a certain extent, this focus on technical innovations has competed with efforts to address relationship-centered patient care within the practice. Over the past six months, the NDP facilitators have made concerted efforts to increase awareness of relationship-centered care and the effect on patient perceptions of care may emerge in the final round of patient surveys.

Early data from patient surveys suggest that some facilitated and self-directed practices are seen as PCMHs by their patients.  This is encouraging and suggests that a PCMH can be achieved, although it should be acknowledged that there are multiple pathways to get there. However, the data also suggest that this characteristic was largely in place in these practices at baseline. It is too early to say at this point whether the final push by facilitators to emphasize relationship-centered care will have an impact on the measures of PCMH.  Since there may be a time lag between implementation of TransforMED components and patients' perceptions, the final patient survey will be delayed as long as possible.

Creating a PCMH is much more than a sum of implementing discrete model components.  Such transformation is exceedingly difficult, and those who attempt it are heroic. To achieve transformation, full engagement of critical members of the practice is needed.  At the same time the practice needs to remain in charge of its own destiny.  They may need assistance in making the changes, but the decision what to change needs to be theirs. They also need to remain full partners in their learning and development process. In addition to implementing the TransforMED model components, the path to creating a PCMH requires particular attention to:

• The clinical process – the interaction between patient and practice clinicians and staff members. This is by no means limited to the exam room, although the patient-physician interaction begs for special attention.
• The relationships among all members of the practice.
• The relationships between the practice and the larger health system and community.
• The motivation and capacity of key stakeholders within the practice.

The NDP is to be commended for its leadership in understanding the PCMH. No other study in the country is exploring these issues in such a comprehensive fashion. No one knows what "makes" a patient-centered medical home, but TransforMED has the resources at hand to become leaders in this expanding yet elusive topic. It should be noted that in addition to the NDP practices, TransforMED also has access to the P4 residences, which serve as tremendous learning opportunities in precisely this area.

The Role of the NDP in TransforMED as a Commercial Venture
TransforMED is a knowledge company. The most critical ingredient for its success is its knowledge capital. Other additions, such as tailored marketing and strategic alignments, may be very helpful as TransforMED goes forward as a commercial enterprise. But the services themselves are solely based on the knowledge capital gained from actual work with real practices and continued respect to the ongoing learning process.  TransforMED has the opportunity to build and fortify this knowledge capital with three fundamental assets:

• First, the three NDP facilitators. These individuals are not just studying practice change; they are living it alongside their practices.  Their knowledge of what works and what doesn’t (e.g., pivotal strategies, stumbling blocks, missed opportunities, etc) should be discussed in a safe, supportive environment where honest assessment is the highest priority. While these three facilitators are no doubt needed to pursue future opportunities for TransforMed, they still need the time and space to work with their practices and share their learning with the rest of the TransforMED team.  The knowledge capital of the NDP is not based on success stories alone; rather, the strategies and insights gleaned from every degree of success and failure.
• Second, the 32 NDP practices. These clinicians and staff live and breathe practice change - they are the real experts.  Their combined experiences create a powerhouse of information and ideas which far exceeds the knowledge of any national speaker or consultant. The final learning collaborative will be an unprecedented opportunity to listen and learn from the practices as a united group.  The synergistic power of the group should not be underestimated, nor thwarted by the presence of other speakers. This is an incredible opportunity for TransforMED to listen to the core of the NDP and optimize their collective knowledge base. While many new companies have to research the needs of their target audience with focus groups and surveys, TransforMED can sit back, relax, and listen carefully.
• Third, Ongoing Learning from the NPD Evaluation. The ongoing, emergent learning from the NDP continues to generate hypotheses and push out the boundaries of what we know about practice transformation and the personal medical home. The data are viewed not simply as stand-alone occurrences, but through evaluation lenses built from decades of experience in practice-based research. We wish the findings could be neatly summarized and delivered overnight, but like most things of value, it will take time. The results are far too important to the discipline of family medicine – and the tens of thousands of physicians who subscribe to that discipline – to risk rushing to conclusions. We thank TransforMED and the board in its continued support of our efforts.

Learning from the NDP is far from over. Although looking ahead is essential to the future of TransforMED, it is equally important to maintain focus on the NDP and what can still be learned. The NDP is an organic wellspring of knowledge which will continue to provide TransforMed with its most valuable assets.