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

Winter 2009

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 National Demonstration Project (NDP) officially ended May 31, 2008, about a month after the fourth and final Learning Session in Kansas City.  While this final Learning Session pulled together nearly two years of hard work by TransforMED and the NDP practices, the practices realized they were only mid-way through an intense transformational process.  For the past year most practices (from both facilitated and self-directed groups) have remained in contact by email and conference call as the Touchstone Group and many will attend a 'reunion learning session' in March, 2009.

The Evaluation Team has carefully observed the NDP journey towards a patient-centered medical home (PCMH) with both quantitative (medical record review, patient survey, staff survey) and extensive qualitative data (site visit notes, formal and informal interviews, direct observation).  During the active phase of the NDP, we shared interim findings with the NDP Board (posted on TransforMED website) to promote ongoing, real-time learning.  Anticipating that the effects of the changes involved in the NDP would not show up immediately in patient outcomes, we re-established the final medical record, patient outcomes survey and clinician/staff survey time frame from 01/01/2008 to 08/01/2008.  We are now collecting the last of the medical record review data and are planning a series of peer-reviewed presentations and publications, including a preliminary report to be published in Annals of Family Medicine in July, 2009, and a supplement to the Annals, tentatively scheduled for the spring of 2010. 

In order to more effectively disseminate our major findings to the rapidly growing communities of practices, payers, and professional organizations involved in PCMH demonstrations, we will continue to post brief reports to the TransforMED website.

Some initial learnings for current demonstration projects

1. Achieving a PCMH requires whole practice redesign, and is not merely the sum of many incremental changes.
Principles of quality improvement (QI) have long emphasized PDSA (Plan-Do-Study-Act) cycles as a fundamental underpinning of changes efforts within primary care practices.  Some NDP practices initially adopted this approach, addressing one change at a time and moving on the next.  While the traditional QI model works well for certain, clearly bounded process changes, transformation to a PCMH requires a continuous, unrelenting process of change.  Since the components of change are interdependent, subsequent changes may require that previous changes be revisited and modified. 

The principles of the PCMH bring together the core primary care principles, relationship-centered patient care, reimbursement reform, new information technology, and the chronic care model.  Most of the current demonstrations run the risk of overemphasizing technology and underemphasizing relationship-centered care.  They may or may not promote the changes in clinician and practice-level identity that are essential to transformation.  Our initial data suggest that many practices were able to implement many components of the NDP model.  We will soon have initial data from the patient surveys and medical record reviews and will be able to comment on the relationships among the model components and patient outcomes that include preventive services, disease management, and patients" perceptions of their care.

2. Achieving a PCMH requires more than 2 years
Preliminary data from the NDP suggest that many practices have implemented many of the more than 50 discrete components of the NDP model and are closer to becoming a patient-centered medical home (PCMH). However, at the end of the 2-year project, none had completed the transformation.

"My gut reaction is that it will take a bit more time to see an end product result from transforming a practice.  I think we are moving toward a better spot. The progress to date just does not instantly show up amongst the noise of the life of a practice. I am excited to think of what it will be like if hopes about the new skills and chemistry come to reality. Tools for making change are being installed and it is key that we now have a greater grasp on what to do with the tools and how to use them.  We see where we are going, and before we were just drifting."

(NDP physician, facilitated practice, April 2008)

"Sometimes I feel like we haven't come very far compared to where we would like to go; I feel that we are on the cusp of some significant change over the next two years however.  I'm starting to realize that this change process is more likely to be a five-year project as opposed to a two-year project.  It is so encouraging to see that TransforMED is interested in sticking with it for awhile.

(NDP physician, self-directed practice, May 2008).

3. The journey to the PCMH requires both personal and practice-level transformation.
As difficult as it is to implement the many "new model" components, the equally difficult hurdles to overcome are the individual and practice level change in mental models that must be adopted.  For example, physicians generally believe that doctoring involves a patient and a physician—including other members of the practice staff in meaningful patient interactions means expanding that special relationship and for many physicians this requires a substantial change in their identity as a physician.  At the practice-level, moving from a machine-like view of "processing patient visits" at the patient's discretion to a more proactive, population-based planned care model represents substantial change in how the practice views itself.  Strategies for assisting practices in the transformation should include attention to both implementation of specific model components and to shifts in mental models. 

4. Transformation also involves learning to be a 'learning organization.'
Critical to practice-level transformation is learning how to become a "learning organization."  Achieving a PCMH is less about relying on experts to follow a well-charted course, than it is to discover an emergent model that fits the characteristics of the practice, the patient population, and the surrounding community. Adopting this "learning organization model," in place of the conventional "expert model," will present challenges for change agents working in a medical community that expects to pay consultants to come in with the external expertise and simply build the PCMH.

"We expected TransforMED to be the Messiah...we were hoping it would come in and just fix everything. There were times when I wanted to give up, especially when we learned midway through that so many practices were losing money. [I thought] why is this happening? I thought TransforMED was supposed to SOLVE that problem! But you know, we hung in there, our facilitator hung in there, we all did, and we made it through. We"re not there yet, but I think we can do it. It's really up to us, the practices, to come up with the answers."

(NDP physician, facilitated practice, April 2008)

The NDP facilitated practices had access to consultants with national reputations on a variety of topics: group visits, e-visits, EMR implementation, workflow and efficiency, etc. Although these consultants were featured heavily in the first and even second Learning Sessions, the practices used them less and less as the project progressed.  As the practices connected with each other, they realized that they, not the consultants, were the grounded "experts" in putting the pieces together in real-life practice.

"Most organizations will benefit more from evaluating and working on themselves, you know, learning how to do things for themselves, rather than having a consultant come in and say "do this do that."  It is much more beneficial to have to figure things out for yourself, figure out how to do things better as a team... team management is so critical. In medical school you learn how to be an isolated king, what we really need to learn is how to manage and work with other people."

(NDP physician, facilitated practice, June 2008)

5. Change agencies should support multiple connections among practices
TransforMED supported the facilitated practices in several important ways, with opportunities to share and reflect among practices being particularly important in motivating and energizing participants who were suffering from change fatigue.  This was done in part with the construction of an Improvement Collaborative.  The intervention started with a 2-day learning session. that initially exposed the practices to the NDP model and introduced them to the tools, consultants,  and model components of the project.  The organic and egalitarian nature of these face-to-face retreats inspired and galvanized the practices in surprisingly profound ways.  Subsequent learning sessions provided ample time for sharing successes, frustrations, and learnings with each other.

"Overcoming isolation was a big thing for me.  What I was looking for from a facilitator was connections. I didn"t get a facilitator, but I found other practices."

(NDP physician, self-directed practice, April 2008)

"We are all self-directed practices, trying to overcome our isolation, frustration, and fatigue to do a better job. Coming together with people of like minds and similar experience is the most important thing we can do."

(NDP physician, self-directed practice, April 2008)

The Facilitators also created opportunities for their practices to support each other with monthly conference calls.  These provided a critical venue for sharing experience and venting frustration between Learning Sessions.

 


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