Strengthen Core Stimulate Progress Assembling PatientCentered Medical Homes

Strengthen Core & Stimulate Progress: Assembling Patient-Centered Medical Homes

“Harnessing the Cascade of Change in Family Medicine: The Critical Role of Behavioral Science. ”

Agenda Setting ► #1 - Credibility ► #2 - Core Competencies ► #3 - Culture Transmission and Change

#1 - Credibility Behavioral Science Roots of a Family Physician Lessons Along a Journey

IA – Family Store, Sister’s Illness, “Other” Siblings, Mother’s MSW

MN – State Psychiatric Hospital, Adult Psychiatry Ward

IA – Philosophy Major, Child Psychiatry Ward, Group Therapy Observer

NC – Behavior Science, Group Therapy, Family Physician Identity

WA – Family Systems Research

NJ – Teaching Biopsychosocial Medicine, Genogram Research

TX – The Baylor Way, Family Therapy Training, Collaborative Care

Ich ben ein verhaltenswissenschaftler.

The Texas Medical Center Skills Assessment, Core Competencies

#2 - Core Competencies Strengthen Core & Stimulate Progress Why this theme?

Jim Collins - Built to Last § Visionary Organizations ►Preserve core ideology § Core values § Core purpose ►Stimulate ►Preserve progress toward envisioned future the Core & Stimulate Progress

Family Medicine Core Values ► “…continuing ► comprehensive, ► compassionate, ► personal and care ► provided within the context of family and community. . ”

Family Medicine Core Purpose ► “All family physicians will share a ► common commitment to ► provide or coordinate all care specified in ► the family physician’s basket of services, ► thereby serving as effective ► personal medical homes for their patients. ”

Core – Preserve or Strengthen? ► Terry Mc. Geeney CEO Transfor. MED § “Moving Family Medicine Forward: Making Vision a Reality” ►“Houston, ► James we have a problem. ” Mold § “Can Family Medicine Become a Learning Community? ” ► Institute Chasm of Medicine: Crossing the Quality

Strengthen Core Stimulate progress toward what envisioned future?

Patient-Centered Medical Home ► “The medical home serves as the ► focal point through which ► all individuals—regardless of age, sex, race, or socioeconomic status— ► receive a basket of acute, chronic, and preventive medical care services. ”

Strengthen Core & Stimulate Progress: Assembling Patient-Centered Medical Homes

Harnessing the Cascade of Change The Change…

Joint Principles of the Patient-Centered Medical Home February 2007 American Academy of Family Physicians American Academy of Pediatrics American College of Physicians American Osteopathic Association

Joint Principles of the Patient-Centered Medical Home ► Personal physician ► Physician directed medical practice ► Whole person orientation ► Care is coordinated and integrated ► Quality and safety are hallmarks ► Enhanced access ► Payment recognizes added value of patientcentered medical home

Patient-Centered Primary Care Collaborative AARP American Academy of Family Physicians American College of Physicians American Health Quality Association American Osteopathic Association Aurum Dx

Patient-Centered Primary Care Collaborative Bridges To Excellence The Center for Excellence in Primary Care The Center for Health Value Innovation CVS Caremark • CVS/pharmacy • Caremark Pharmacy Services • Minute. Clinic

Patient-Centered Primary Care Collaborative Disease Management Association of America e. Health Initiative The ERISA Industry Committee Exelon Corp Foundation for Informed Medical Decision Making

Patient-Centered Primary Care Collaborative General Motors HR Policy Association IBM Mc. Kesson Corporation Medco

Patient-Centered Primary Care Collaborative National Centers National Association of Community Health Business Group on Health Business Coalition on Health Care

Patient-Centered Primary Care Collaborative National Committee for Quality Assurance National Retail Federation New England Quality Care Alliance Partners In Care

Patient-Centered Primary Care Collaborative The Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public Health The Society of Teachers of Family Medicine Walgreens Health Initiatives Wyeth

Harnessing the Cascade of Change The Cascade…

Patient-Centered Medical Home ► Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care

Patient-Centered Medical Home ► Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients

Patient-Centered Medical Home ► Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.

Patient-Centered Medical Home ► Care is coordinated and integrated across all elements of the complex health care system and the patient’s community

Patient-Centered Medical Home ► Quality and safety are hallmarks of the medical home § Physicians accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement § Practices go through voluntary recognition process to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model

Patient-Centered Medical Home ► Enhanced access to care through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and office staff

Patient-Centered Medical Home ► Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home § It should reflect the value of physician and nonphysician staff management that falls outside of the face-to-face visit § It should pay for services associated with coordination of care within a given practice and between consultants, ancillary providers, and community resources

Harnessing the Cascade of Change Harnessing…

Harnessing by Teaching ► What? § Principles of Patient-Centered Medical Home ► How? § Clinical practice ►Teaching Practices § Why the emphasis here?

John Dewey – “we learn what we do” ► “Dewey stressed that the role an individual is assigned in an environment-what he is permitted to do-is what the individual learns. “ ► “It is not what you say to people that counts; it is what you have them do. ” ► Teaching as a Subversive Activity, 1969

Marshall Mc. Luhan – “The medium is the message. ” ►“ ‘Message’ here means the perceptions you are allowed to build, the attitudes you are enticed to assume, the sensitivities you are encouraged to develop-almost all the things you learn to see and feel and value. You learn them because your environment is organized in such a way that it permits or encourages or insists that you learn them. ”

The Medium “Hidden” curriculum or Unintentional curriculum Learning environment Culture

#3 - Culture Transmission and Change Teaching Practice Learning Environment and Philosophy of Education

Philosophies of Education ► Perennialism § Aim of education is to discipline the mind by developing the ability to reason and pursue truth ► Essentialism § Aim of education is transmission of cultural heritage to prepare learners for future ► Progressivism § Education is not a product to be learned but a process that continues throughout life ► Reconstructivism § School should be agency for solving political and social problems to achieve improvement in society

Teaching Practice ► What elements of Patient-Centered Medical Home are in place? § Personal physician § Physician directed medical practice § Whole person orientation § Care is coordinated and integrated § Quality and safety are hallmarks § Enhanced access § Payment recognizes added value of patientcentered medical home

Teaching Practice ► How are they taught? § Modeling § Experiential learning cycle ►Abstract conceptualization ►Active experimentation ►Concrete experience ►Reflective observation

Culture Transmission ► Selection of entry-level candidates ► Humility-inducing experiences ► Job mastery § Control systems and rewards for adherence to values ►Reinforcing folklore § Heroes, rites and rituals, networks ► Consistent role models

Teaching Practice ► What critical elements are missing? § Personal physician § Physician directed medical practice § Whole person orientation § Care is coordinated and integrated § Quality and safety are hallmarks § Enhanced access § Payment recognizes added value of patientcentered medical home

Teaching Practice ► Can they be developed? § Change management ►Learners as part of change process

Culture Change ► External enabling conditions, internal permitting conditions ► Precipitating pressures, triggering events ► Cultural visioning ► Culture change strategy § Culture change action plans, implementation of interventions § Reformulation of culture

Strategies for Change ► Four frames for organizations § Factory, jungle, family, theater ►Bolman ► Three & Deal: Reframing Organizations strategies § Empirical-rational strategies § Power-coercive strategies § Organizational self-renewal ►Normative/re-educative strategies

Organizational Self-Renewal ► Learning organization § Planned strategy § Systems approach § Focus on people § Educational strategy § Dealing with real problems § Involvement of top-level administration § Learning through experience § Change agent

Change ► “Change means movement. Movement means friction. ” ► “Why the struggle, the conflict, the heartbreak, the danger, the sacrifice. Why the constant climb? ” ► “Because life is there ahead of you and either one tests oneself in its challenges or huddles in the valleys in a dreamless day-to-day existence whose only purpose is the preservation of an illusory security and safety. ”

Rules for Radicals, 1971 Saul Alinsky Born Chicago 1909

Ideal Elements of “Organizer” ► Curiosity ► Imagination ► Irreverence ► Sense of humor ► Bit of blurred vision of a better world ► Organized personality ► Ego ► Free and open mind

Harnessing the Cascade of Change in Family Medicine: The Critical Role of Behavioral Science Strengthen Core & Stimulate Progress: Assembling Patient-Centered Medical Homes