Effective team-based primary care: observations from innovative practices.

BACKGROUND: Team-based care is now recognized as an essential feature of high quality primary care, but there is limited empiric evidence to guide practice transformation. The purpose of this paper is to describe advances in the configuration and deployment of practice teams based on in-depth study of 30 primary care practices viewed as innovators in team-based care. METHODS: As part of LEAP, a national program of the Robert Wood Johnson Foundation, primary care experts nominated 227 innovative primary care practices. We selected 30 practices for intensive study through review of practice descriptive and performance data. Each practice hosted a 3-day site visit between August, 2012 and September, 2013, where specific advances in team configuration and roles were noted. Advances were identified by site visitors and confirmed at a meeting involving representatives from each of the 30 practices. RESULTS: LEAP practices have expanded the roles of existing staff and added new personnel to provide the person power and skills needed to perform the tasks and functions expected of a patient-centered medical home (PCMH). LEAP practice teams generally include a rich array of staff, especially registered nurses (RNs), behavioral health specialists, and lay health workers. Most LEAP practices organize their staff into core teams, which are built around partnerships between providers and specific Medical Assistants (MAs), and often include registered nurses (RNs) and others such as health coaches or receptionists. MAs, RNs, and other staff are heavily involved in the planning and delivery of preventive and chronic illness care. The care of more complex patients is supported by behavioral health specialists, RN care managers, and pharmacists. Standing orders and protocols enable staff to act independently. CONCLUSIONS: The 30 LEAP practices engage health professional and lay staff in patient care to the maximum extent, which enables the practices to meet the expectations of a PCMH and helps free up providers to focus on tasks that only they can perform.

Development of a facilitation curriculum to support primary care transformation: the "coach medical home" curriculum.

BACKGROUND: In an effort to improve patient care, retain high-quality primary care providers, and control costs, primary care practices across the United States are transforming to patient-centered medical homes. This is no small task. Practice facilitation, also called "coaching," is increasingly being used to support system change; however, there is limited guidance for these programs. OBJECTIVE: To develop an evidence-based curriculum to help practice coaches guide broad-scale transformation efforts in primary care. METHODS: We gathered evidence about effective practice transformation coaching from 25 published programs and 8 expert interviews. Given limited published information, we drew extensively on our experience as leaders and coaches in the Safety Net Medical Home Initiative. Using these data, and with input from a User Group, we identified 6 curricular topics and created learning objectives and curricular content related to these topics. RESULTS: The Coach Medical Home curriculum guides coaches in the following areas: getting started with a practice; recognition and payment; sequencing changes; measurement; learning communities; and sustainability and spread. CONCLUSIONS: Coach Medical Home is a publically available web-based curriculum that provides tools, resources, and guidance for practice transformation support programs, including practice facilitators and learning community organizers.

Assessing progress toward becoming a patient-centered medical home: an assessment tool for practice transformation.

OBJECTIVE: To describe the properties of the Patient-Centered Medical Home Assessment (PCMH-A) as a tool to stimulate and monitor progress among primary care practices interested in transforming to patient-centered medical homes (PCMHs). STUDY SETTING: Sixty-five safety net practices from five states participating in a national demonstration program for PCMH transformation. STUDY DESIGN: Longitudinal analyses of PCMH-A scores were performed. Scores were reviewed for agreement and sites were categorized over time into one of five categories by external facilitators. Comparisons to key activity completion rates and NCQA PCMH recognition status were completed. DATA COLLECTION/EXTRACTION METHODS: Multidisciplinary teams at each practice completed the 33-item self-assessment tool every 6 months between March 2010 and September 2012. PRINCIPAL FINDINGS: Mean overall PCMH-A scores increased (7.2, March 2010, to 9.1, September 2012; [p < .01]). Increases were statistically significant for each of the change concepts (p < .05). Facilitators agreed with scores 82% of the time. NCQA-recognized sites had higher PCMH-A scores than sites that were not yet recognized. Sites that completed more transformation activities and progressed over defined tiers reported higher PCMH-A scores. Scores improved most in areas where technical assistance was provided. CONCLUSIONS: The PCMH-A was sensitive to change over time and provided an accurate reflection of practice transformation.

Evidence on the Chronic Care Model in the new millennium.

Developed more than a decade ago, the Chronic Care Model (CCM) is a widely adopted approach to improving ambulatory care that has guided clinical quality initiatives in the United States and around the world. We examine the evidence of the CCM's effectiveness by reviewing articles published since 2000 that used one of five key CCM papers as a reference. Accumulated evidence appears to support the CCM as an integrated framework to guide practice redesign. Although work remains to be done in areas such as cost-effectiveness, these studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes.

Finding common ground: patient-centeredness and evidence-based chronic illness care.

Health outcomes for patients with major chronic illnesses depend on the appropriate use of proven pharmaceuticals and other therapeutic technologies, and effective self-management by patients. Effective chronic illness care then bases clinical decisions on the best, rigorous scientific evidence, or evidence-based medicine. Effective support for patient self-management includes efforts to increase patient participation in care and collaborative goal-setting and planning of treatment. These interventions appear somewhat consistent with recent conceptualizations of patient-centered care. The consistent delivery of proven therapies and information and support for self-management requires practice systems organized for that purpose. The Chronic Care Model is a compilation of those practice system changes shown to improve chronic care. This paper explores the concept of patient-centeredness and its relationship to the Chronic Care Model. We conclude that the Model is both evidence-based and patient-centered and that these can be properties of health systems, and not just of individual practitioners.