Transforming the Primary Care Practice
June 10–12, 2014 · San Francisco, CA
Table of Contents
Section 1: Program Overview……………………………………………………………2
Section 2: Curriculum Design…………………………………………………………..2
Purpose of the System…………………………………………………………………………………………………….3
Leadership for Change……………………………………………………………………………………………………3
Partner with Patients……………………………………………………………………………………………………..4
Team-Based Care…………………………………………………………………………………………………………..4
Information Systems………………………………………………………………………………………………………4
Access…………………………………………………………………………………………………………………………..5
Underlying Capacity: Improvement for Quality……………………………………………………………….5
Section 3: Diagnostic Assessment and Reading List (To Do List)………………5
¨ Patient-Centered Medical Home Assessment (PCMH-A), Part 3…………………………………..5
¨ Primary Care Provider (PCP) Panel Worksheet…………………………………………………………..5
¨ Delay for a Routine Appointment, also known as “Third Next Available”………………………5
¨ Continuity Rate……………………………………………………………………………………………………….6
¨ Clinical Quality Measures…………………………………………………………………………………………6
¨ Accessing Patient-Centered Care Using the Advanced Access Model…………………………….6
¨ A Systems Approach to Patient-Centered Care……………………………………………………………7
¨ Building Teams in Primary Care: Lessons Learned………………………………………………….….7
¨ Building Teams in Primary Care: 15 Case Studies………………………………………………….……7
Patient Centered Medial Home Assessment (PCMH-A)…………………………………………………………….….8
Primary Care Provider (PCP) Panel Worksheet……………………………………………………………………………11
Continuity Rating Grid……………………………………………………………………………………………………………..12
Welcome to IHI’s
Transforming Primary Care Practice Program
Section 1: Program Overview
In this rapidly changing health care environment, now is the time for primary care practices to rethink their approaches to providing care. Doing things “the way we’ve always done it” is no longer enough; primary care organizations must learn how to transform their systems of care in a way that will lead to better, sustainable results. Meaningful use, the patient-centered medical home, advanced primary care, person- and family-centered care, and electronic health records all constitute new challenges for office practices, yet they also present new opportunities. When equipped with foundational skills and knowledge, organizations that have a will to change and improve can thrive in this new environment.
This intensive program is designed to help primary care practices adapt and succeed, by bringing together the best knowledge available on high leverage changes for primary care transformation. During the three-day intensive program, participants will engage in an interactive environment to learn about and share experiences relating to accessible, continuous, and coordinated family-centered care using a team approach, health information technology, and shared decision making. The vision is that the program will lay the foundation for ongoing improvement, while also providing the opportunity for practices to immerse themselves in key changes that will propel them towards a system that works better, is more cost effective, and meets the needs of the community.
The program will consist of improvement-minded organizations working together with The Institute for Healthcare Improvement (IHI) staff and faculty to explore effective designs and approaches to foster relationships between the customer, families, community, and care team for optimal health and wellness, while responsibly managing resources.
Section 2: Curriculum Design
Major change in the system of care will not happen easily for a long list of reasons. Comprehensive models exist to guide organizations on their improvement journey, yet the diagrams tend to oversimplify the reality and magnitude of the change. The same applies to the following visual of the curriculum offered for this intensive program to transform the primary care practice, but it does give us a starting point.
The model of the curriculum is not intended to replace any of the comprehensive models that pervade our healthcare “universe” at this time (such as the Chronic Care Model, the Patient Centered Medical Home, etc.), but instead is intended to actually use the success and effectiveness of such models to identify high leverage changes that might accelerate progress toward a system of advanced primary care.
The Transforming Primary Care Practice Curriculum can be depicted as follows:
Purpose of the System
We started at the top of our model with the purpose of the system in its ideal state: to foster relationships between the patient, families, community, and care team for optimal health and wellness, while responsibly managing resources.
Your practices exist to provide great service and care for your community that emphasizes not only the prevention of disease and injury, but also self- responsibility for nutrition, exercise, and other aspects of lifestyle that promote wellness. To do that effectively, you must foster positive relationships and partnerships with the patients, their families, and other community entities, providing those services and developing those relationships in a cost effective manner.
The outcome that everyone is working toward is optimal health (medical outcomes) and wellness (taking us away from simply the medical model, but also the mind and spirit of each patient as well as their ability to function at the level that they desire).
Responsibly managing resources refers to the need for a business case and preservation of organizational financial viability.
Leadership for Change
The element of creating a Will to Change, eliminating complacency, and communicating and interacting with the community falls in the leadership domain. We will help leaders of organizations understand that they have to define what the future should look like, align people with that vision, then inspire them to make it happen. They have responsibility for leading and spreading improvement, while also paying attention to the need to build systems and processes to sustain that spread.
Partner with Patients
To the casual observer, it might seem that health care has always been person- and family-centered, but in many ways, the health care system is more about serving the needs of itself rather than those it serves. How often do we take the time to really listen to what our patients need and want and what really matters to them? Organizations will understand the value and importance of listening to their customers about their experience and the impact of moving from simply being a recipient of care to be a partner in care.
The curriculum focuses on opportunities for engaging persons and families in the design and functioning of a practice that is person and family centered in three contexts: care for the individual, practice improvement, and policy design and implementation. More than a full day of activity will be available relating to this aspect of the curriculum.
Team-Based Care
The process of developing a care team within primary care practices is not something that you can “take off the shelf.” It needs to be individualized for each practice, their patients, and their community. The curriculum will address how to take a close look into the practice to develop a greater understanding of the patient population that is served and the processes that are used to meet the needs of the patient and family.
The specific mix of staff (number of physicians, nurses, assistants, technicians, clerks, etc.) may vary from clinic to clinic and determines the extent and type of work that can be driven away from any constraints in the system. The care team composition of each clinic will emerge from an understanding of the types of services it provides, the most common diagnoses, referral patterns, clinical outcomes, etc. Once the care team composition is determined, there are many ways to optimize the care team. This aspect of change—becoming an optimized care team—is vital in your transformation journey.
The curriculum model addresses the importance of care coordination in today’s complex environment. With an exposure and understanding of evidence-based principles for systems of care coordination and care management, the curriculum will help organizations understand how to identify the populations most appropriate for care/case management and will recognize what constitutes successful programs. As primary care practices serve as the focal point of care coordination across health care delivery, methods to facilitate, coordinate, and track care and services with other clinical and community entities will be identified.
Information Systems
Health information technology (HIT) has the potential to enable better care for patients, and to help clinicians achieve continual improvements in the quality of care in primary care settings, but simply implementing current health IT tools will not bring about these results. To generate substantial and ongoing improvements in care, health IT adoption must go hand in hand with the implementation of a robust change package and the routine use of solid improvement methods and data by clinicians and other staff.
Access
Long waits and delays for care and discontinuity are epidemic in our health care system. As we struggle to get through today, and cope with what seems to be insatiable demand we inevitably push some work into the future. This further mortgages future capacity and continuity is sacrificed. The curriculum solidly addresses the importance of breaking this cycle and moving to models that reliably provide improved Access and Continuity. The second day of the current curriculum model provides an opportunity for an intensive session on access, with an introduction to advanced access on Day 1.
Pragmatic ideas will be provided to accomplish the following:
• Match Demand and Supply Daily
• Work down the Backlog
• Decrease appointment types and times
• Develop Contingency Plans
• Reduce Demand for Unnecessary Visits
• Optimize the Care Team
Underlying Capacity: Improvement for Quality
The list of capabilities required to drive system-level improvement is long, but includes, at a minimum, the Model for Improvement, a simple, yet powerful tool for accelerating improvement. Building the capacity and capability for improvement is vital in any organization that is interested in transformation.
Participants will leave with an understanding how to develop an aim, set goals, and establish measures for improvement, using some of their own data to develop an action plan for improvement.
Section 3: Diagnostic Assessment and Reading List (To Do List)
A checklist of assessments to be completed and brought to the seminar and articles to be read include:
¨ Patient-Centered Medical Home Assessment (PCMH-A), Part 3
Complete the assessment on Page 8-10 and bring a 2 copies with you to the seminar. Turn one copy in at the registration desk when checking in for the seminar.
¨ Primary Care Provider (PCP) Panel Worksheet
Located on Page 11 of this document, please complete and bring the results with you to the seminar.
¨ Delay for a Routine Appointment, also known as“Third Next Available”
Access to care is a key determinant of patient satisfaction and will be one area of the focus on Day 2 of the seminar. The recommended measure of access is the number of calendar days to third next available routine appointment. To understand current access to your PCPs or specialists, we are asking you to focus on one specific appointment type, a request for a routine appointment. The delay for the third available appointment is used (rather than the first or second) because it is a more reliable reflection of your system’s availability. It more closely reflects the patient experience in terms of delay. The first or second appointment available is often due to a cancellation or some other random event.
Use your scheduling system (whether it is computerized or manual) to count the number of days from today to the day when the third next appointment is available. Experience shows that measuring the 3rd next available appointment first thing on Monday morning, before the phones are open, is a great way to reliably capture this data.
Do not count appointments that have been held or reserved for same day urgent needs as these are generally not available to patients unless they qualify with specific clinical criteria. Remember, we want to understand the delay patients experience for routine care.
Measure the third next available routine appointment for each PCP or each specialist on your clinical team. Make this measurement the same day and time each week, every week prior to the seminar. If you already collect and have this data readily available, bring historical data and graphs with you! Please remember to bring this data with you to the seminar.
¨ Continuity Rate
Continuity is the rate at which your patients see their PCP when coming in for primary care. It is a retrospective look at the patient experience in your system and should be measured monthly.
If you are already regularly measuring and reporting this data, please bring that information with you to the seminar. If you are not regularly collecting the data, please do at least a one-month review of visits and determine the rate of continuity. Ideally, it would be continuity for each PCP in your organization, but we would be happy with a subset or team or average, if that is more do-able.
A worksheet is included on Page 12
¨ Clinical Quality Measures
Bring the results of some clinical quality measures that you have identified for improvement for the session on Day 2: Identifying Improvement Opportunities.
Reading List
Please read the following articles prior to participation in the seminar. They will help provide a foundation for some of the content we will be discussing at the seminar.
¨ Accessing Patient-Centered Care Using the Advanced Access Model
Access the article at: http://journals.lww.com/ambulatorycaremanagement/Fulltext/2009/01000/Accessing_Patient_Centered_Care_Using_the_Advanced.6.aspx
Abstract: Waits and delays for healthcare are legendary. These delays are not only frustrating and potentially hazardous for patients and providers but also represent significant cost to office practices. The traditional medical model that defines urgent care versus routine care is a vain and futile attempt to sort demand. This approach is at constant odds with patients' definition of urgency. Trusting patients to determine when and how they want to access care makes sense from a customer service perspective. If approached systematically using the principles of Advanced Access, patient demand patterns can be tracked to forecast demand. These demand patterns become the template for deploying the resources necessary to meet patients' needs. Although not a simple journey, the transformation to Advanced Access provides an entree to patient-centered care where patients can say, I get exactly the care I want and need, when I want and need it. There are some article tools in the right hand column of the website that will allow you to change the format to PDF and print off the article if desired.
¨ A Systems Approach to Patient-Centered Care
Access the article at:
http://azlend.peds.arizona.edu/sites/azlend.peds.arizona.edu/files/care2.pdf
Summary: Providing care centered on patients' needs and expectations is a key attribute of quality care. Unfortunately, despite the intent and efforts of many to improve patient centeredness, the quality of patient- clinician relationships, patient access, and continuity of care appear to be worsening in the US and lag behind other countries. Clinicians do not consistently address patients’ concerns, do not always assess patients’ beliefs and understanding of their illness, and often do not share management options with patients. In this Commentary, the authors propose four specific changes that should help the medical profession meet patients' needs.