Trust and Reflection in Primary Care Practice Redesign (original) (raw)
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Primary Care Practice Development: A Relationship-Centered Approach
The Annals of Family Medicine, 2010
PURPOSE Numerous primary care practice development efforts, many related to the patient-centered medical home (PCMH), are emerging across the United States with few guides available to inform them. This article presents a relationship-centered practice development approach to understand practice and to aid in fostering practice development to advance key attributes of primary care that include access to fi rst-contact care, comprehensive care, coordination of care, and a personal relationship over time. METHODS Informed by complexity theory and relational theories of organizational learning, we built on discoveries from the American Academy of Family Physicians' National Demonstration Project (NDP) and 15 years of research to understand and improve primary care practice. RESULTS Primary care practices can fruitfully be understood as complex adaptive systems consisting of a core (a practice's key resources, organizational structure, and functional processes), adaptive reserve (practice features that enhance resilience, such as relationships), and attentiveness to the local environment. The effectiveness of these attributes represents the practice's internal capability. With adequate motivation, healthy, thriving practices advance along a pathway of slow, continuous developmental change with occasional rapid periods of transformation as they evolve better fi ts with their environment. Practice development is enhanced through systematically using strategies that involve setting direction and boundaries, implementing sensing systems, focusing on creative tensions, and fostering learning conversations. CONCLUSIONS Successful practice development begins with changes that strengthen practices' core, build adaptive reserve, and expand attentiveness to the local environment. Development progresses toward transformation through enhancing primary care attributes.
BACKGROUND: The Patient-Centered Medical Home (PCMH) has become a dominant model of primary care re-design. The PCMH model is a departure from more traditional models of healthcare delivery and requires significant transformation to be realized. OBJECTIVE: To describe factors shaping mental models and practice culture driving the PCMH transformation process in a large multi-payer PCMH demonstration project. DESIGN: Individual interviews were conducted at 17 primary care practices in South Eastern Pennsylvania. PARTICIPANTS: A total of 118 individual interviews were conducted with clinicians (N=47), patient educators (N=4), office administrators (N=12), medical assistants (N=26), front office staff (N=7), nurses (N=4), care managers (N=11), social workers (N =4), and other stakeholders (N = 3). A multi-disciplinary research team used a grounded theory approach to develop the key constructs describing factors shaping successful practice transformation. KEY RESULTS: Three central themes emerged from the data related to changes in practice culture and mental models necessary for PCMH practice transformation: 1) shifting practice perspectives towards proactive, population-oriented care based in practice-patient partnerships; 2) creating a culture of self-examination; and 3) challenges to developing new roles within the practice through distribution of responsibilities and team-based care. The most tension in shifting the required mental models was displayed between clinician and medical assistant participants, revealing significant barriers towards moving away from clinician-centric care. CONCLUSIONS: Key factors driving the PCMH transformation process require shifting mental models at the individual level and culture change at the practice level. Transformation is based upon structural and process changes that support orientation of practice mental models towards perceptions of population health, selfassessment, and the development of shared decisionmaking. Staff buy-in to the new roles and responsibilities driving PCMH transformation was described as central to making sustainable change at the practice level; however, key barriers related to clinician autonomy appeared to interfere with the formation of teambased care.
Population health management, 2017
The objective was to quantify the activities required for patient-centered medical home (PCMH) transformation in a sample of small to medium-sized National Committee for Quality Assurance (NCQA) recognized practices, and explore barriers and facilitators to transformation. Eleven small to medium-sized PCMH practices in Southeastern Pennsylvania completed a survey, which was adapted from the 2011 NCQA standards. Semistructured follow-up interviews were conducted, descriptive statistics were computed for the quantitative analysis, and a process of thematic coding was deployed for the qualitative analysis. Practices had considerable quantitative variation in their workforce composition and the PCMH-related activities they implemented. Most practices improved access and continuity through staff training and team-based care as well as expanded data collection for population management. The barriers to PCMH recognition were least burdensome for the largest practices. The heterogeneity of ...
Evaluation of Patient Centered Medical Home Practice Transformation Initiatives
Medical Care, 2011
Background-The patient-centered medical home (PCMH) has become a widely cited solution to the deficiencies in primary care delivery in the United States. To achieve the magnitude of change being called for in primary care, quality improvement interventions must focus on wholesystem redesign, and not just isolated parts of medical practices. Methods-Investigators participating in 9 different evaluations of Patient Centered Medical Home implementation shared experiences, methodological strategies, and evaluation challenges for evaluating primary care practice redesign. Results-A year-long iterative process of sharing and reflecting on experiences produced consensus on 7 recommendations for future PCMH evaluations: (1) look critically at models being implemented and identify aspects requiring modification; (2) include embedded qualitative and quantitative data collection to detail the implementation process; (3) capture details concerning how different PCMH components interact with one another over time; (4) understand and describe how and why physician and staff roles do, or do not evolve; (5) identify the effectiveness of individual PCMH components and how they are used; (6) capture how primary care practices interface with other entities such as specialists, hospitals, and referral services; and (7) measure resources required for initiating and sustaining innovations. Conclusions-Broad-based longitudinal, mixed-methods designs that provide for shared learning among practice participants, program implementers, and evaluators are necessary to evaluate the novelty and promise of the PCMH model. All PCMH evaluations should as comprehensive as possible, and at a minimum should include a combination of brief observations and targeted qualitative interviews along with quantitative measures.
Journal of General Internal Medicine, 2020
BACKGROUND: Despite widespread adoption of patientcentered medical home (PCMH), little is known about why practices pursue PCMH and what is needed to undergo transformation. OBJECTIVE: Examine reasons practices obtained and maintained PCMH recognition and what resources were needed. DESIGN: Qualitative study of practice leader perspectives on PCMH transformation, based on a random sample of primary care practices engaged in PCMH transformation, stratified by US region, practice size, PCMH recognition history, and practice use of Consumer Assessment of Healthcare Providers and Systems (CAHPS®) PCMH survey. PARTICIPANTS: 105 practice leaders from 294 sampled practices (36% response rate). APPROACH: Content analysis of interviews with practice leaders to identify themes. RESULTS: Most practice leaders had local control of PCMH transformation decisions, even if practices adopted quality initiatives under the direction of an organization or network. Financial incentives, being in a statewide effort, and the intrinsic desire to improve care or experiences were the most common reasons practice leaders decided to obtain PCMH recognition and pursue associated care delivery changes. Leadership support and direction were highlighted as essential throughout PCMH transformation. Practice leaders reported needing specialized staff knowledge and significant resources to meet PCMH requirements, including staff knowledgeable about how to implement PCMH changes, track and monitor improvements, and navigate implementation of simultaneous changes, and staff with specific quality improvement (QI) expertise related to evaluating changes and scaling-up programs. CONCLUSION: PCMH efforts necessitated support and assistance to frontline, on-site practice leaders leading care delivery changes. Such change efforts should include financial incentives (e.g., direct payment or additional reimbursement), leadership direction and support, and internal or external staff with experience with the PCMH application process, implementation changes, and QI expertise in monitoring process and outcome data. Policies that recognize and meet the needs of on-site practice leaders will better promote primary care practice transformation and move practices further toward their PCMH transformation goals.
Patient Trust: Is It Related to Patient-Centered Behavior of Primary Care Physicians
Medical Care, 2004
Background: Patients' trust in their health care providers may affect their satisfaction and health outcomes. Despite the potential importance of trust, there are few studies of its correlates using objective measures of physician behavior during encounters with patients. Methods: We assessed physician behavior and length of visit using audio tapes of encounters of 2 unannounced standardized patients (SPs) with 100 community-based primary care physicians participating in a large managed care organization. Physician behavior was assessed via 3 components of the Measure of Patient-Centered Communication (MPCC) scale. The Primary Care Assessment Survey (PCAS) trust subscale was administered to 50 patients from each physician's practice and to SPs. We used multilevel modeling to examine the associations between physicians' Patient-Centered Communication during the SP visits and ratings of trust by both patients and SPs. Results: Component 1 of the MPCC, which explored the patient's experience of the disease and illness, was independently associated with patient's rating of trust in their physician. A 1 SD increase in this score was associated with 0.08 SD increase in trust (95% confidence interval 0.02-0.14). Each additional minute spent in SP visits was also independently associated with 0.01 SD increase in patient trust. (95% confidence interval 0.0001-0.02). Component 1 and visit length were also positively associated with SP trust ratings. Conclusions: Physician verbal behavior during an SP encounter is associated with trust reported by SPs and patients. Research is needed to determine whether interventions designed to enhance physicians' exploration patients' experiences of disease and illness improves trust.
Physician Organization-Practice Team Integration for the Advancement of Patient-Centered Care
The Journal of ambulatory care management, 2012
The patient-centered medical home is being promoted as a cornerstone for transforming primary care. Physician organizations (POs) are playing a more prominent role by facilitating practices' transformation to the patient-centered medical home. Using a framework of organizational integration, we investigated the changing relationship between POs and practices through qualitative interviews. Through increased integration, POs can support both the big picture and day-today activities of practice transformation. Most PO-practice unit connections we identified reflected new areas of engagement-competencies that POs were not developing in the past-that are proving integral to the broad-scale practice change of patient-centered medical home implementation.
Care Managers and Knowledge Shift in Primary Care Patient-Centered Medical Home Transformation
Primary care practices across the United States are implementing a new model of care, the patient-centered medical home (PCMH), in an effort to improve care to patients and, consequently, control health care costs. The addition of care managers is a key aspect of PCMH implementation with important implications for the production and reproduction of authoritative knowledge in primary care. Redistribution of patient interaction from the primary care provider to a range of other health care providers in this model of care is a significant means by which primary care approaches to the prevention and management of chronic diseases such as diabetes are being transformed. Based on a study of a health insurance company-sponsored primary care transformation project in Michigan, we explore the perceptions of care management from the perspective of providers and practice staff to examine these shifts in knowledge and their broader implications for primary care. This research demonstrates how the diffusion of clinical power and knowledge production redefine primary care relationships to patients, as traditional hierarchies shift to team-based care. The addition of care managers reshapes power and agency within clinical practice and understandings of the social dimensions of chronic illness. Care management emphasizes the affective qualities of provider care-giving, euphemized in terms of teamwork, partnerships, and relationships; however, these are also measured through the perceptions of patient transformation into self-managed owners of their illness.
Measuring Organizational Attributes of Primary Care Practices: Development of a New Instrument
Health Services Research, 2007
Objective. To develop an instrument to measure organizational attributes relevant for family practices using the perspectives of clinicians, nurses, and staff. Data Sources/Study Setting. Clinicians, nurses, and office staff (n 5 640) from 51 community family medicine practices. Design. A survey, designed to measure a practices' internal resources for change, for use in family medicine practices was created by a multidisciplinary panel of experts in primary care research and health care organizational performance. This survey was administered in a cross-sectional study to a sample of diverse practices participating in an intervention trial. A factor analysis identified groups of questions relating to latent constructs of practices' internal resources for capacity to change. ANOVA methods were used to confirm that the factors differentiated practices.