The PatientCentered Medical Home Realworld practicelevel transformational change

The Patient-Centered Medical Home Real-world, practice-level transformational change and initiatives to support these efforts Don Klitgaard, MD, FAAFP Medical Director Myrtue Medical Center Harlan, IA

Learning Objectives ¢ Gain an understanding of the capabilities, skills and processes required to implement transformational change in a practice, especially in the area of leadership. ¢ Be able to list at least five key learnings about PCMH implementation from the experiences of our practice and the Transfor. Med NDP practices. ¢ Describe examples of how various educational and practice support efforts can assist practices in transformational change.

What is the context for PCMH transformation? Why should we change how we deliver healthcare?

How do you start to fix the foundational issue around why our healthcare system is so expensive and yet so broken? ? Average spending on health per capita ($US PPP) Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U. S. Health Care Expenditures: What Are the Options? , The Commonwealth Fund, January 2007, updated with 2007 OECD data

USA ranked 37 th by WHO Countries’ age-standardized death rates, list of conditions considered amenable to health care Source: E. Nolte and C. M. Mc. Kee, Measuring the Health of Nations: Updating an Earlier Analysis, Health Affairs, January/February 2008, 27(1): 58– 71

Every generation needs a new revolution. — Thomas Jefferson

Thought of the day to consider – The PCMH will be our generation’s revolution! — Don Klitgaard, 11/08/09

PCMH practice capabilities – how does it differ from traditional care? ¢ ¢ ¢ Patient-centered, not physician-centered care Coordinated, not just episodic care Proactive, not just reactive care Emphasis on prevention as well as achieving and maintaining wellness, not just treating illness HIT support – EHR, registries, patient portal, e-rx, e-mail communication, result tracking, POC decision support, etc. Quality systems and measurements built in Team-based care Increased partnership with community resources Comprehensive care We need both high tech and high touch elements Some of this sounds familiar, like traditional Family Medicine, but certainly not all. Let‘s dig deeper by looking at a case study……

Myrtue Medical Center – Harlan, Iowa

A case study in transformation Myrtue Medical Center - Harlan, IA ¢ ¢ ¢ Critical access hospital/rural health clinic system, integrated since 1991 Medical staff – 7 Family Physicians, 1 Med/Peds, 1 general surgeon, 3 PAs, 2 ARNPs Nursing staff – 35, Office staff - 22 Main clinic in Harlan, community of 5200 in rural Iowa, and 3 satellite clinics in Avoca, Shelby and Elk Horn Full scope of practice – Inpatient, ER, NH, OB, procedures, clinic coverage

MMC Practice Demographics ¢ ¢ ¢ ¢ 20, 787 active patient e-records Newborns to 104 year olds Wellness to acute illness to chronic disease care – PCMH changes focused in the clinic 38, 000+ clinic visits in last year $6. 5 million gross clinic revenue $159, 000 net clinic income (~break-even) Main payers – 39% Medicare, 30% Wellmark BC/BS, 20% other commercial insurers, 7% Medicaid, 4% self-pay

Where we started in 2005 -06 - ripe for practice-level change Interim, then new CEO ¢ No clinic manager ¢ Nurses union turmoil – large nurse turnover ¢ Several failed practice improvement projects ¢ Failed EHR implementation/lost IT staff ¢ Stressed medical, office, and nursing staff ¢ ¢ Short version – WE NEED HELP!

You don’t have to change, survival is optional — C. Edwards Deming ¢

Enter the Transfor. MED National Demonstration Project in 2006 The mission of Transfor. MED in the NDP is to lead and empower family physicians in implementing the new model of care (which has evolved into the PCMH)

AAFP-funded National Demonstration Project - $8 million initial investment ¢ Applied January 2006 ¢ Selected April 2006 ¢ 24 month project began June 2006 and ended May 31, 2008 ¢ Evaluation period ended December 2008 ¢ Results now beginning to be published ¢

Transfor. Med NDP participants 36 sites from around the country were selected to study the new model. These practices were randomly assigned to one of two groups • • 18 facilitated practices were engaged in a transformative process to fully implement a new model of care 18 self-directed practices were provided the information to implement the model of care in a self directed manner.

Myrtue Medical Center

Goals of the NDP Evaluation ¢ To determine the effect of the New Model (PCMH) implementation on the following: Patient outcomes l Patient-centered care l Staff/physician working relationships l Financials of the practice l

What we agreed to: ¢ ¢ Implementation – all aspects of the New Model during the 24 month project Evaluation – staff/patient satisfaction surveys, clinical/chart reviews, financial reviews, etc. Dissemination – lessons learned during the NDP will be shared in many venues Staff commitment – lead physician and staff member for learning collaboratives in KC, monthly phone conferences, ongoing e-mails, on-site visits with Transfor. Med staff

What we received in return: ¢ ¢ ¢ ¢ A worthy vision – gets to the heart of why most of us chose family medicine/primary care as a career Practice Enhancement Facilitator – 1 for each 6 practices Ongoing, personalized consultant support Exposure to best practice ideas in all areas of practice redesign IT product selection assistance Perhaps most importantly, a collaborative learning environment to share ideas, reinvorgorate support the transformation process We did not receive any grant $ or increase in payments

Our PCMH Blueprint

First steps in transformation – Understanding the blueprint and coming up with a construction plan Team building/Vision sharing l “soft”, but critical l main focus in the first months ¢ Honest Self-Assessment l brutal reality “gut check” l first month ¢ Goal development/Timeline setting l started thinking about and discussing right away l details gradually took shape over 2 -3 months ¢

Using the blueprints to develop the specific projects ¢ Projects are how you break down extensive changes into manageable pieces l l l l Staff empowerment/redesign Clinic process review Advanced Access Scheduling EHR Implementation – Important, but most disruptive Chronic Disease Management Enhanced communication/Patient portal Clinical decision support/Point of care reports Wellness integration

Myrtue Medical Center Clinics project details ¢ Staff redesign/empowerment – l Daily nursing huddles – easy/effective l Lead nurse selection and development l Clinic manager – critical missing element l Immunization nurse – improved efficiency l Health coaches/Chronic Disease Management nurses – manage registries, proactive care, expand the team l Everyone should always be working at the top of their license!

Myrtue Medical Center Clinics project details ¢ Clinic process review Workflow analysis – look for inefficiencies, prepare to automate processes (Lean, process mapping, etc. ) l Appropriate use of professional resources l Organize and implement training, coaching for the clearly defined, delegated responsibilities Advanced access scheduling l Accurate matching of supply/demand – demand survey l Huge impact on patient satisfaction if done well! Implementation of EHR – Go live 2/07, HUGE change! l Allows more effective communication – in office and with patient l E-prescribing, real-time documentation l Organizes data in searchable form for CDM, population mgmt. l ¢ ¢

Myrtue Medical Center Clinics project details ¢ ¢ l ¢ Chronic disease management/Population management teams l Registries – not easy, but absolutely necessary for the next level of care. Started with CDM, but moving more into prevention l RN health coaches crucial - foster team approach for proactive care l HUGE potential for improvements in care Patient Portal l View medical record, appt/refill requests, lab results, e-visits ¢ Enhanced communication with hospitals/specialists Referral, lab and radiology tracking l Enhanced information sharing and closing the communication loops Clinical decision support tools – in development Point of Care report EHR data run through a protocol engine l Identifies needed care, enables delegation, makes visits more productive l l

Myrtue Medical Center Clinics project details ¢ Wellness integration 2010 – the newest “room” in our medical home l Hardwire community, corporate and individual wellness/fitness into our clinical practice

Lessons learned – at MMC and in the NDP in general ¢ Change is hard and slow l Transformation has to happen on many levels • of practices – culture change • of physicians – personal change • of patient expectations – community change l l l Practices typically not used to system-level changes Significant, practice-wide transformation will be at least a 3 -5 year process, even with a motivated, unified practice with adequate resources However, many significant incremental benefits occur for patients and the practice along the way

Success is going from failure to failure without losing enthusiasm. — Abe Lincoln

Transformation happens in the midst of a busy clinical practice How does this type of change feel to physicians, staff, and patients? http: //www. youtube. com/watch? v=L 2 zq. TYgcpfg

Lessons learned ¢ Relationships matter l l l A practice’s capacity for change and ability to follow through with projects is heavily-dependent on strong personal relationships within the practice Need to build and foster strong relationships on all levels to be successful with transformative changes Like in all other areas of life, this becomes especially important during times when the practice is under increased stress • EHR implementation, major process changes, etc.

Innovation—the heart of the knowledge economy—is fundamentally social. — Malcolm Gladwell

Lessons learned ¢ Medical practices are extraordinarily complex l l l Small changes often have large impacts • Daily huddles • Immunization nurse • Improving access – Advanced Access scheduling, extended clinic hours Large, difficult changes may be necessary but can have relatively smaller impacts overall, at least short-term • Full-scale EHR implementation – allowed for many new opportunities, but on balance had less initial positive impact than some of our other changes Change management is an essential skill that practices need to be successful

There is a certain relief in change, even though it be from bad to worse; as I have found in traveling in a stagecoach, that it often a comfort to shift one's position and be bruised in a new place. — Washington Irving Tales of a Traveler (1824) Pearl – be sure to find some humor in the midst of a challenging journey!

Lessons learned ¢ Transformation has to happen on the personal level as well as the practice level l l Is a gradual change from physician-centered thinking and practice to true team-based, patient-centered care This is just as hard as (and honestly much harder than) the practice-level transformation Physician’s perception of their role is challenged and the comfort of daily practice flow is interrupted • Takes time to readjust to new practice dynamics and daily workflow routines Important to remember in the midst of stressful changes, that an important aspect of PCMH transformation is to reconnect with the joy of practicing family medicine!

Don’t mess with my groove! — my son Jack’s favorite philosopher Cusco, Disney’s The Emporer’s New Groove

Lessons learned ¢ Technology has great potential, but several problems limit it’s current usefulness and widespread implementation. l l lack of interoperability - biggest hurdle lack of comprehensive functionality • EHR, registry, patient portal, POC reporting, e-rx, test result and referral tracking, communication l l expense – HITEC $ will hopefully help here amount of resources and energy needed to make things work together

Nothing talks to anything else like it should. It’s like putting together a huge puzzle, but the pieces are all from different boxes. — Khristine Jacobsen MMC CIO and puzzlemaster

Lessons learned (reaffirmed) ¢ ¢ The PCMH is more than the sum of its individual parts Measurements (practice metrics, NCQA, etc. ) are important and can measure many aspects of the PCMH, but will never be able to fully capture the essence of what we do as family physicians Patients want wellness and healing, not just diagnosing and curing illness Since the practice of medicine is by definition human beings interacting with other human beings, medicine will always be an art as much as a science

Not everything that counts can be measured, and not everything that can be measured counts — Albert Einstein

What have we learned with regards to leadership? ¢ Effective leadership is absolutely critical!!! l Need strong leaders in all areas • • l l Physician champion Clinic manager/nursing IT leader Administration/financial If we are not all on the same page during transformation, the ability to make changes is hampered or halted The leadership team needs to shape the new culture of the organization

Culture does not change because we desire to change it. Culture changes when the organization is transformed; the culture reflects the realities of people working together every day. — Frances Hesselbein

Leadership ¢ Physician champion l l l Crucial that someone assumes this role to take the lead on change efforts Needs good communication skills and be willing to function as part of a team Will take time away from clinical practice, and this needs to be recognized and supported/rewarded Will establish the vision and lead the physician group by both example and making the case for change Sets the overall tone for both the leadership team and the practice transformation project

One key to successful leadership is continuous personal change. Personal change is a reflection of our inner growth and empowerment. — Robert E. Quinn

Leadership ¢ Clinic manager/Nurse lead l l l May be one person in smaller practices or may need to be two separate individuals in larger practice Much of the true day to day work of practice transformation will fall to them - Linchpin for success of the project Needs to have the respect of and excellent rapport with office, nursing and medical staff Important to have or develop solid organizational and project management skills Must understand both the office/business side of a practice as well as the clinical needs of patients and providers, including daily workflow

Just keep slogging through, things are going to get better! — Janelle Nielsen, RN wise MMC clinic manager, in the midst of an exhausting spell of EHR change fatigue

Leadership ¢ HIT leader l l Depending on the size of the practice, this may be one of the other team members, or a separate person Critical that the practice understand the full capabilities and limitations of its various technologies This role becomes more crucial as new layers of technology are added to support new processes and capabilities important to the PCMH – EHR, portals, websites, registries, POC reports, etc. Plays a crucial role in a PCMH practice

I’m all for progress. It’s change object to. — Mark Twain I

Leadership ¢ Administration/Financial leader l l l May be the clinic manager, or may include CEO or CFO-type representation in a larger system Less involved with day to day changes, but must understand be supportive of the transformation, as the finances of the practice are directly and indirectly affected • Expanded hours, technology costs, staffing additions for in -office health coaching/CDM Bring useful perspective on the “in the box” thinking • Business practices often to be addressed initially to set the practice up for success with transformation projects • Co-pay collections, appropriate coding, office efficiencies l They need to be educated and start to understand the fundamental shift that is developing - from volume-based reimbursement under strict FFS to a blended model that recognizes quality, patient-centeredness, and cost savings

If you want to make enemies, try to change something. — Woodrow Wilson

Leadership Team skills ¢ ¢ To avoid making enemies (and instead make lots of friends as things improve), you have to actively manage change through effective leadership Need regularly scheduled meetings (weekly at first) of the leadership team, with minutes taken and distributed timely, clear duties defined, and timelines established and maintained as closely as possible If not already adept at project management and change management, these skills need to be developed and honed by the leadership team l Team formation, LEAN, process mapping, PDSA cycles, change fatigue, etc. Most of all, the leadership team needs to grab hold tightly of the vision, work purposefully towards this goal, and tap into the desire to everyone on the team to improve the lives of those we serve l l Almost everyone in our organization is there because they want to help and serve others, although some have to be periodically reminded of it! These are not necessarily skills taught well in medical school or residency, but absolutely essential for effective practice transformation

Our chief want is someone to inspire us to be what we know we could be. — Ralph Waldo Emerson

Examples of efforts to support practice-level transformation ¢ Set a Goal - Create a PCMH movement! l Educational programs – IAFP and others • Transformed/PCMH workshop at annual meeting • Lectures at scheduled CME meetings • Online resources • Bring in outside resources, but remember to use local innovators also • Stories are important for us as well as our patients l Collaborative efforts – IAFP/IHC Medical Home Learning Community • 3 sessions, more hands-on, educate and equip • Basically trying to take meetings like the Practice Improvement Conference to local practice teams • Use opportunities to motivate early adopters and early majority – don’t worry about laggards! • Future plans – 2010 and beyond

Examples of efforts to support practice-level transformation l l State-level multi-stakeholder meetings • UI PCMH forum – 9/18/09 • Bring together wide coalition of stakeholder share the PCMH vision together Legislative efforts – drive change in states • All Iowans must have a medical home • Medical Home Advisory Council - family physician driven policy change to support PCMH Work with payers • Wellmark BC/BS - Collaboration On Quality (P 4 P) • Discussions with Medicaid • Ideally, form a multipayer pilot to support PCMH Pay attention to national opportunities • CMS pilot and/or demonstration projects • HITEC

Examples of efforts to support practice-level transformation l Identify other key players/resources in your area • HIT regional extension centers are currently being selected • HITEC opportunities many $ on the table to support IT • Medical schools – educate administration on PCMH and current/future workforce needs (IAFP leaders met with Dean, VP) • Residency efforts – transform residencies into PCMHs (walk the walk), send residents to innovator practices, strengthen ties with state academies (IAFP president meeting with residency directors) for mutual support l www. Transfor. Med. com – use the MHIQ and the many other extraordinary tools created by our academy

Two final thoughts: Change is an ongoing process, not an event.

Never doubt that a small group of thoughtful, concerned citizens can change the world. Indeed, it is the only thing that ever has. — Margaret Mead

Contact information Don Klitgaard, MD ¢ 1220 Chatburn Avenue ¢ Harlan, IA 51537 ¢ 712 -755 -5130 (PCMH) ¢ 712 -579 -1911 (cell) ¢ Dklitgaard@myrtuemedical. org ¢