Transforming Residency
Practices into Medical Homes
Perry Dickinson, MD
Department of Family Medicine
University of Colorado School of Medicine
Outline
• What is the Patient Centered Medical
Home?
• Colorado FM Residency PCMH Project
• Lessons learned
• Questions and (hopefully) answers
What is the Patient Centered
Medical Home?
• The PCMH is an approach to providing
enhanced, comprehensive primary care
for children, youth, and adults.
• Has gained a great deal of traction as a
platform for improving care and
decreasing costs
• Builds on core family medicine principles,
but with some key changes
Why Do We Need to Change? –
Health Care System Perspective
• Spending incredibly too much for health care
– Increasing recognition that current system
unsustainable
• Mediocre quality in multiple areas
• Increasing recognition of the potential role of
primary care to increase quality and
decrease costs
Cost per capita
vs healthy life years
Best
Organization for Economic Cooperation and Development data, 2000
International Quality Comparison
Need for Change – Primary
Care Perspective
• Primary care clinicians – on a treadmill
– Reimbursement system slanted against
primary care, toward procedures, specialists,
hospitals
– Very tight financial margin
– Have to see more and more patients to
survive
– Can’t deliver the type of care we want and
need to do
What’s Different with PCMH?
• Builds on strengthening the pillars of primary
care (continuity, comprehensive care,
coordination of care, initial access to care)
• Adds different approaches to organizing
care based on the Chronic Care Model
• Adds use of Information Technology tools
• Expanded importance of teamwork – among
clinicians, staff, patients, families,
specialists, hospital, community
Core Features of the PCMH
• Centered around continuity relationship with
a personal physician – but team-based care
• Integrated mental, behavioral health
• Patient’s care coordinated by the practice
• Patient-centered; self-management support
• Ongoing quality improvement
• Population-based care
• Enhanced access
• Payment reform
Payment System
• Several models proposed
• Most prevalent – blended payment model:
– Traditional fee for service, plus…
– Per member per month care
management fee based on level of
services provided, plus…
– Pay for performance
• Multiple pilots underway, including
Colorado
Day in the life of Primary Care
• Mid afternoon. Running behind. Has already
seen 22 patients.
• 55 y/o man with dizziness, rash and chronic
rhinorrhea
• Has DM, requesting refills. Last seen 9 mos ago
• No labs for over a year – not well-controlled then
• Info scattered through chart, hard to find
• Last retinal exam unclear – no record
• You evaluate the acute symptoms, order labs,
refill meds. No time for diabetic education. Ask
to return in a month, but will he return then?
Day in the Life of a PCMH
• The MA checks the next day’s schedule at 4 PM
and identifies chronic care patients.
• Same patient - 55 y/o with uncontrolled diabetes
• Recently was seen for dizziness and now
returning for a planned care visit
• She notes that he needs a Pneumovax, lipid
test, & retinal exam and prints his flow sheet.
• Patient goes straight to exam room, MA checks
the patient in, checks BP & foot exam, screens
for depression, makes referral for eye exam,
orders lipids and Hgb A1c, gives Pneumovax
Day in the Life of a PCMH
• Physician performs assessment, begins selfmanagement discussion, adjusts meds, and
plans next visit.
• Patient sent to nurse care manager who helps
patient to develop personal care plan, sets up
for a diabetes education group in the community
• MA calls patient in 2 weeks to see if he has
questions or problems, makes sure no problems
with med change, reconfirms next visit.
• Reality? This comes from one of our PCMH
Demonstration Project practices
The Colorado Family Medicine
Residency PCMH Project
• 3-year grant from the Colorado Health
Foundation; began in December 2008
• Goal: To transform the 10 Colorado FM
Residency Programs into medical homes
through practice improvement and
curriculum redesign
What is Involved?
Initial Engagement
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Engagement of leadership, residents, staff
Start working on forming improvement teams
Assistance with initial IT issues
Practice/program discussions of PCMH to
help form the vision
• Sponsoring organizations – look for support,
try to remove barriers
Improvement Teams
• Practice improvement is a team sport
• Have to make time and space for reflection on
areas needing change, planning
• Best way of doing this - practice “Improvement
Team” with regular meetings to consider and plan
improvement efforts
• Should include people from all major parts of the
practice – diversity, teamwork is crucial
• Takes time and persistence for team to become
optimally functional
Practice Coaching
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Assessment of current status in practice
Feedback assessment to practice
Help form improvement teams
Initially facilitate improvement team process
but transition to practice taking over
• Serve as connection to resources, best
practices
• Goal is to establish a sustainable change &
improvement process in the practice
Curriculum Redesign
• Facilitation and consultation for PCMHrelated curriculum changes
• Changes to free up residents to participate
in PCMH and QI efforts
• Shared resource development across
programs (lectures, modules, etc)
• Active involvement of residents in practice
redesign process
• PCMH practices for residents to experience
Collaboratives
• Meetings of representatives of all practices
and programs
• Planning, sharing, educational – highly
interactive
• Two collaboratives per year
– First one May 2009 – 105 people from the
residency programs and practices
– Second - October 2009 – 135 from programs
– Third – May, 2010 – 160 from programs
Practice Goals
• Achieve NCQA PPC-PCMH recognition
• Improve level of medical homeness:
– PCMH Clinician Assessment
– Practice Staff Questionnaire (practice
culture)
– Practice PCMH Monitor (recently
developed)
• Improve quality measures in two clinically
important areas chosen by the practice
Curricular Goals
• Revision of curricula to allow resident
participation in PCMH and QI efforts
• Improved resident achievement of PCMH
competencies
• Improved resident use of PCMH elements as
measured by PCMH Clinician Assessment
• Implementation of PCMH curricular elements
Challenges for Residency
Practices
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Inconsistent resident availability
Lots of part-time faculty and resident providers
Large practices – most have 40-90 employees
Goals and beauracracy of sponsoring hospitals
Staff often controlled by hospital
Hierarchical management structures
Rigid and extensive residency curricular and
structural requirements
Lessons Learned –
Practice Transformation
• Becoming a medical home takes time,
requires fundamental change in multiple areas
• Change is difficult, and this is a lot of change
• Have to have a robust change management
and quality improvement process
• Outside support (from a practice coach) can
really help – but practice needs to be open to
having a coach
Lessons – Structure of Support
• No established road map to the medical home
• NCQA PCMH standards provide some framework –
but incomplete, insufficient
• Some things need to be done early to enable later
changes (vision, team formation, staff engagement,
registry implementation)
• Moving toward more structured approach, but have
to balance with practice choice
• Lack of payment reforms limit changes in some
areas, but not others
Lessons - Curriculum
• Residents are more energized and ready to
change than faculty
• Difficult but crucial to involve residents on a
regular basis in the change process
• Developed PCMH competencies – will evolve
• Curriculum issues may change over time
– Initial need for didactics & projects in key
PCMH areas
– Gradual shift to more experiential learning
Lessons - Sustaining Change
• Identified a need to more formally train internal QI
Team Leaders to create sustainability
– Mix of didactic, discussion, experiential with
support by our project team
– Varies according to audience (staff, physicians)
• Creating a Learning Community
– Learning Collaboratives working well to promote
sharing
– Project staff creating connections between
programs working on similar areas
PCMH – Huge Cultural Issues
• Three key areas for practice cultural change:
• Leadership
– Change process requires a shift toward less
hierarchical management
• Team-based care and improvement process
– Clinicians and staff not used to working in teams
• Patient-centeredness
– Traditional care practice and physician centered;
requires a shift for everyone
PCMH is a Team Sport
• No way for primary care clinicians to do
everything their patients need themselves
• Multiple studies showing that delegating
responsibilities to the staff has very positive
results – patient, staff, clinician satisfaction,
quality and efficiency of care
• Goal is everyone working at the top of their
license and skills
• We physicians have difficulty delegating
• Staff not trained for some of these tasks
Effective Leaders for Change
• Provide an initial vision – but engage
everyone in further developing the vision
• Refer to the vision regularly to focus work
• Help everyone figure out how they can
contribute to the vision
• Make time for reflective, interactive team
meetings
• Encourage an open exchange of ideas
• Value and nurture diversity of people, ideas,
and experiences
Effective Leaders
• Empower people to work at highest level
• Hold people (and self) accountable
• Help show a way forward when things are
stuck
• Are not afraid of failure
• Share information freely
• Create a true shared leadership model
• Often work through others to achieve goals
• Give recognition and awards
Reality
Even if you are on the right track, you’ll get
run over if you just sit there
~ Will Rogers
Thank You!
• Contact Information:
– Perry Dickinson:
perry.dickinson@ucdenver.edu