Strategic Planning for Patient-Centered Medical Home Implementation

Introduction to the Patient-Centered Medical Home Model

In 1967, the American Academy of Pediatrics (AAP) introduced the concept of Medical Homes. These homes were initially established for the purpose of maintaining children's medical records. Several decades later, in 2002, the Academy expanded its policy statement on the concept, making it more comprehensive, accessible, compassionate, and culturally effective. The new policy also shifted the focus of the medical home from the child to the family. The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) have also developed their own patient-care models, which they refer to as the "advanced medical home" and "medical home," respectively (PCPCC, 2007).

Many healthcare experts agree that the basic components of the medical home definition include accessibility, teamwork, comprehensive care, patient-centered care, and a focus on safety and quality. The medical home model is now accepted universally as a framework for how primary care ought to be structured and delivered. Some have described the medical home concept as a philosophy of care delivery that allows physicians and other Health Care Providers (HCPs) to meet clients and patients at their place of residence. Medical homes have become places where patients are treated with compassion, respect, and dignity, enabling the building of strong relationships based on mutual respect between patients and providers. Though initially some individuals thought of Medical Homes as final destinations or resting places, the model has evolved to the point where it is now considered a framework for efficient primary care in which patients can receive the right care at the right time. In recognition of the important role played by medical homes in healthcare provision, the major American physician associations jointly developed and published the Joint Principles of the Patient-Centered Medical Home. This jointly released framework has been revised and is now referred to as the PCPCC (PCPCC, 2015).

The medical home concept has the power to transform how healthcare is delivered in the United States. Using data from many different medical homes across the country, the Agency for Healthcare Research and Quality (AHRQ) described medical homes as a concept for structuring and delivering the essential functions of primary care. Primary care medical homes have five unique characteristics.

1. Comprehensive Care

Many medical homes are responsible for providing nearly all of their clients' mental and physical healthcare needs, including chronic care, acute care, wellness, and preventive services. For a medical home to effectively offer comprehensive care, a multidisciplinary team of care providers is required. Such a team may include medical doctors, care coordinators, educators, social workers, nutritionists, pharmacists, nurses, physician assistants, and nurse practitioners. Even though medical homes may employ large teams to provide the best and most comprehensive care, many practices have also formed virtual (contractual) teams that can combine efforts as needed to offer clients the right care at the right time and at comparatively lower costs.

2. Patient-Centered

Many medical homes provide care focused on the whole person. Such care is often grounded in strong working relationships with patients that are built on respect and dignity. Partnering with medical home clients and their families entails understanding and respecting the unique preferences, values, cultures, needs, and beliefs of every individual patient. Medical homes also actively support their clients in organizing and managing their personal care at whatever level the clients choose. Recognizing that both patients and their loved ones are core members of the care team, the medical home concept ensures they are fully informed when care plans are developed.

3. Coordinated Care

The medical home model ensures that all components of the broader healthcare system—including community support, home healthcare, medical facilities (hospital care), and specialty care—are coordinated. Such coordination is essential for continuity of care during transitions between different healthcare settings, such as when patients are discharged from hospitals. The medical home model also advocates for the establishment of open and clear communication channels among patients, the care team, the patient's family, and the medical home.

4. Accessible Services

Medical homes have been known to provide more accessible services for individuals with urgent needs, including phone access to selected members of the care team, 24/7 telephone access to the home, extended in-person hours, and alternative communication channels such as email or video calls. In short, medical home practices are highly responsive to their clients' preferences regarding how they wish to access their care providers.

5. Quality and Safety

Medical home practices are committed to providing the highest quality services. Many such institutions have continuous quality improvement initiatives that use tools such as clinical decision-support systems and evidence-based care to guide their interactions with patients and families. For instance, many medical home practices conduct performance measurement surveys and other forms of performance evaluation to assess clients' experiences and satisfaction levels. Some practices even publicly share their safety data and quality improvement measures. Such homes are often regarded as the most committed to quality and safety (AHRQ, n.d.).

Strategies for Achieving Primary Care Medical Home Transformation

Effective leaders create and manage system-level objectives at the executive level. They develop practical and realistic plans for attaining those objectives and drive these strategies from the top down. They direct leadership focus toward system-level enhancements in transparency, leadership systems, and personal leadership, and they incorporate the input of both patients and their families into the improvement plan. They also make their Chief Financial Officers (CFOs) quality champions and engage physicians and other providers in order to build the organization's capacity for improvement.

Leaders establish regular improvement meetings that highlight progress and the challenges being faced. They ensure that their organizations have data reporting capabilities to assess whether changes are having any meaningful effect on care provision. They use data to report successes and continue pushing for further transformation. Publishing reports must take into account the different needs of the audiences for whom the data is intended; understanding the audience and helping them interpret what is happening can increase the impact of transformation projects.

Most importantly, leaders ought to encourage their followers to continuously improve and innovate to transform their medical homes. To be successful in managing medical homes, a leader must be visionary and motivational, capable of helping staff move collaboratively toward desired performance and service-provision levels (SNMHI, 2010).

Start with a Team

Leaders ought to begin assembling their Primary Care Medical Home teams immediately. A strong team should include a Chief Compliance and Quality Officer (CCQO), Chief Medical Officer (CMO), Chief Financial Officer (CFO), Chief Operating Officer (COO), deputy COO, practice managers, and the Chief Executive Officer (CEO). The team should immediately begin transforming their practice in order to meet CMS benchmarks.

Commitment

Commitment is much more than making declarations of loyalty. Commitment must be demonstrated in the drafting of strategic plans through the allocation of funds to improvement projects. For instance, a more meaningful show of commitment would be the creation of profit-sharing plans based on quality performance indicators—plans that reward workers for meeting specific patient care milestones. This would not only improve quality throughout the practice's services but would also motivate workers to contribute more in their day-to-day activities.

Electronic Health Records

One of the best ways to improve performance is to train workers in the use of Electronic Health Records (EHR). Purchasing the Care Coordination Medical Record (CCMR) system, which is a form of electronic health record, can also improve performance. The CCMR can increase documentation efficiency and reduce data redundancy. Once a leader explains the value of such a system and staff begin seeing improvements in their work processes, providers will join in and begin using these systems to help improve care delivery.

Staff Engagement and Buy-In

Securing staff buy-in is critical, particularly when making changes in primary care medical homes. Convincing staff to come on board and work together in the implementation of transformation projects plays a key role in determining whether the transformation process will succeed.

Comprehensive and Seamless Service Coordination

To enhance the provision of healthcare, it is important for service providers to offer a comprehensive care package. Care providers from different disciplines must be hired or contracted to ensure that the most comprehensive healthcare is available at the homes. However, comprehensive care alone is not sufficient; team members must also act with initiative and flexibility to provide the best care.

Quality Focus

The aim of PCMH approaches is to improve patient health outcomes. Thus, in any PCMH service improvement process, it is important to hire or assign duties to individuals with the right talents and skills to deliver the best quality care.

Effective Use of Technical Assistance Resources

Cooperating with Technical Assistance (TA) resources provided by organizations such as the American Institutes for Research (AIR) can help provide learning resources, coaching strategies, documentation reviews, and support for the implementation of National Committee for Quality Assurance (NCQA) standards (Indiana Health Centers, Inc., 2014).

Engaged Leadership in PCMH Transformation

Transforming any organization into a PCMH requires broad organizational change. Different system leaders—including clinical managers, C-suite executives, and governing boards—must be engaged and assigned specific responsibilities to support effective implementation. Employees at all levels of the organization must also integrate the new care delivery model. Any kind of change is difficult, and the most common reason such changes do not succeed is a lack of effective leadership. Since patient-centered medical home transformation is an organizational-level change, it cannot be achieved without the continuous engagement of leaders throughout the entire process.

Leaders and managers must articulate to their staff how PCMH makes business sense and how implementing it would enhance health outcomes, patient satisfaction, and organizational efficiency (SNMHI, 2010). Leaders must be committed to the transformation process for it to succeed. They must believe in the process and believe that the practice is doing the right thing. The right leader to oversee a transformation process believes in teamwork and encourages staff to invest every effort into the process. Such a leader ensures that staff are constantly engaged and that their opinions on the changes are taken into account (Indiana Health Centers, Inc., 2014).

Leaders facilitate patient-centered medical home transformation by mapping the path for change and sustaining new practices over time. One of the most important responsibilities for leaders during transformation is allocating the right amount of funding, technology, equipment, staffing, and time to support the change. Adequate resources help staff integrate and sustain key organizational changes. The key responsibilities for leaders during the change process include:

• Ensuring that the transformation process has the right amount of resources to succeed.
• Offering visible and continuous leadership by being physically present to ensure that strategies are implemented as planned and that change is sustained.
• Making sure that providers and other staff are given sufficient time to engage in activities prescribed by the medical home model.
• Ensuring that new training processes and hiring policies reflect the values of the patient-centered medical home (SNMHI, 2010).

Role of Leaders During PCMH Transformation

Leaders must manage the transformation process effectively for it to succeed. This management process involves motivating employees, removing obstacles, and providing the necessary resources. Key roles and responsibilities for leaders during the transformation process include the following.

Identify and Allocate Resources

Resources include money, technology, time, equipment, staffing, and other forms of support used to integrate and sustain key transformation changes.

Staff: Sourcing the right employees for a patient-centered medical home may involve hiring new staff or retraining existing employees. Clearly communicating the purpose of retraining or role changes within the organization can increase buy-in and self-confidence among staff. In some cases, it may be necessary to let go of employees who cannot adapt to the new model. New roles that may be added include care managers and social workers to coordinate care for high-risk clients; health IT specialists; health coaches to support patient self-management; medical assistants serving as outreach personnel or patient trackers; medico-legal experts; and office managers or program consultants to help oversee the transformation process.

Funding: Funding for patient-centered medical homes is widely regarded as necessary, even though not every health service provider pursuing this transformation will have access to multi-payer, state-supported initiatives. Other funding sources include grant applications and maximization of incentives such as pay-for-performance programs. In many practices, most funds are allocated to education, training, and support (Bleser et al., 2014). A study conducted in Pennsylvania found that participants from different disciplines reported that joint training and education processes increased their buy-in to the transformation (Pupillo, 2014).

Types of Support That Help Staff Implement PCMH Changes

The most important lesson is that only through effective communication can a leader secure staff buy-in to the transformation process.

1. Communicate Clearly and Effectively: Clearly communicating objectives helps individuals direct greater effort toward achieving desired outcomes. Leaders should also provide visible support for teamwork, which helps employees work collectively toward the organization's goals. Leaders should frequently meet with employees and solicit their opinions on ongoing transformations and on what could be improved with respect to the practice, the new changes, roles, and policies.

2. Teach About the Patient-Centered Medical Home: Educating staff and other stakeholders about the importance of the PCMH model facilitates additional buy-in. Explaining the benefits of this optimal care model and comparing it to the current model can help staff recognize it as more effective, more financially beneficial to the organization, and more likely to produce better patient health outcomes. More complex elements of the PCMH changes—such as the use of new health IT systems—may require additional training, education, and communication campaigns.

3. Provide Information About PCMH-Like Care Practices: Major changes require breaking established habits and adopting new approaches. PCMH transformations may also require reorganization of staff composition and roles. If so, it may be necessary to provide information about how to implement more PCMH-aligned practice. Relevant information may include new tactics introduced in other practices, evidence-based practices, methods for using new technologies, and techniques such as teaching self-care and motivational interviewing as a way of gathering information from clients.

4. Campaign for Skeptical Staff: Even with the very best efforts, not all stakeholders can be convinced to support the transformation process, particularly in large organizations. Change proponents must therefore continue communicating the benefits the new model offers compared to the one currently in use. Reports and data from practices where PCMH has succeeded can be published to demonstrate the model's efficacy. Meetings should also be organized with individuals who are skeptical about the transformation. However, when most of these methods fail, it may be necessary to let such employees go (Bleser et al., 2014).

Create a Work Environment Supportive of PCMH Transformation

When implementing large-scale changes such as patient-centered medical home transformation, it is important to create an environment in which all staff feel they are part of the process. This can be achieved through the following strategies.

Create a workflow of well-defined and flexible duties and responsibilities: A transformational plan must clearly define the duties of every team member. Furthermore, the plan should be built around small, incremental measures rather than a single large step. Plan development should therefore involve extensive consultation with all relevant stakeholders.

Encourage an atmosphere of openness: An open organizational culture will help make everyone feel comfortable. With that comfort, employees will feel free to offer criticism, ideas, thoughts, and suggestions on the PCMH transformation process. Additional incentives such as suggestion boxes, regular meetings, and rewards for interesting ideas can also encourage staff to contribute actively.

Establish a culture of creativity: A culture of creativity not only allows but actively facilitates innovativeness and the generation of new ideas among employees. Many employees have advocated for organizations to incentivize creativity through rewards, benefits, or special recognition for individuals who develop new approaches.

Use PCMH champions to achieve higher buy-in: Individuals who are passionate about PCMH transformation naturally emerge during many change processes in different practices, and in some settings such individuals are formally appointed. Giving these champions special recognition and supporting their advocacy among colleagues can help dissociate the PCMH transformation from executive management. When staff see that a peer has successfully mastered the new model's practices, they are more likely to believe they can do the same (Bleser et al., 2014).

Sustaining Employee Energy and Motivation

Constantly provide feedback on PCMH implementation progress: When employees learn how the process has helped the organization earn higher revenues or has improved patient satisfaction, they are more motivated to continue contributing effort. Evaluating teams and offering constructive feedback helps teams correct mistakes and generate better ideas for carrying out their assigned tasks. Giving praise where it is due also increases problem-solving and productivity.

Utilize internal and external data to highlight success and benchmark: Good use of data can increase commitment to the change process and foster a sense of ownership, pride, and accomplishment among those responsible for successes. External data is valuable for demonstrating the benefits of the new model compared to the old one in other practices. Internal data is important for identifying best practices within the organization and sharing them with all employees. Although regular assessment is beneficial, it should not be conducted too frequently; allowing a period of approximately eight weeks before the next evaluation gives employees adequate time to make necessary changes and helps reduce anxiety (Bleser et al., 2014).

Conclusion

Leaders need to carry out management rounds to directly learn what each clinic care team is involved in and the kinds of challenges they face. They must also create systems-level measures for establishing whether the adjustments made are actually transforming care, and ensure that the organization has data reporting capabilities. Leaders must involve the entire senior management team in quality improvement and emphasize specific success metrics in board meetings and reports. They should also focus on increasing productivity by instilling passion and confidence in the workplace. They must overcome obstacles to success, even if this means making difficult decisions or changing established ways of doing things. Finally, they should establish regular development or sponsor team meetings with their subordinates.

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