'Lean' Teams Build Patient-Centered Medical Homes

Thanks to health care reform, the idea of patient centered medical homes (PCMHs) is a topic du jour in policy circles. But 22 physician practices are making the concept a reality as part of the South Central Pennsylvania Alliance’s (SCPA) Patient-Centered Medical Home Collaborative. SCPA is a community in Aligning Forces for Quality (AF4Q), the Robert Wood Johnson’s signature effort to lift the overall quality of health care in targeted communities, reduce racial and ethnic disparities, and provide models for national reform.

Now in its third year, the collaborative has steadily grown more sophisticated. It aims to improve care quality, transform practices into patient-centered medical homes, and give patients a seat at the table.

The program starts with an intensive year-long practice improvement effort. In the initial phase, coaches teach the practices of the Toyota Lean method. This step helps practices “see waste in what they’re doing in their processes every day,” said Karen Jones, MD, the Alliance’s physician champion. “If they can eliminate some of the waste in their practices, then they can have time and energy to work on quality improvement and becoming a patient-centered medical home.”

The entire staff, not just care providers, are trained in the Lean method and are part of developing solutions, said Rush Gross, the collaborative’s coordinator. They realize Lean is not a way to cut jobs but rather to fix frustrating work practices, remove barriers to care, and reduce redundancies.

Each practice creates a quality leadership team that includes a physician champion, coach, practice manager, clinical coordinator, and quality improvement apprentice, who gets extra training and hands-on experience in quality improvement. In the first year, the teams meet once a week, have five dinner meetings, and participate in regular phone meetings.

The practices work toward becoming a “functional” PCMH, Jones said. “The reason we call it a functional patient-centered medical home is because being recognized by an external agency doesn’t mean that you really are a medical home,” she said. The collaborative focuses on the importance of demonstrated practice leadership and the commitment to reducing unnecessary waste in health care spending. Those two items don’t appear to be included in external agency PCMH recognition or certification, Jones added.

Health care has been very provider interest driven, said Christine Amy, project director of the South Central Pennsylvania Alliance. “What works best for the hospital? What works best for the practice? The doctor wants to work from 8 to 4, so that’s our hours. Well, patients work during that time,” she said. “Does a primary care doctor feel responsible if someone is admitted to the hospital? If a patient is obese, is the practice really invested in that person being able to actually lose weight?” Both Lean and the PCHM model switch the focus to the consumer/patient, Amy said.

The collaborative took its PCMH definition, developed by the Alliance’s Payment Reform Involving Corporate Engagement Work Group, melded it with National Committee for Quality Assurance (NCQA) criteria, and developed steps to transform the practices. The practices are working toward qualifying for NCQA patient centered medical home recognition under its 2011 standards by June 2013. The 2011 NCQA standards are more stringent than the 2008 criteria.

Quality improvement also is part of the program. The collaborative, initially focused on diabetes, now has a broader reach. It tracks and shares with the practices their results on diabetes performance measures, ED visits, and potentially avoidable hospitalizations.

“The end outcome is a patient-centered medical home, and Lean is a tool,” explained Jones. “Then diabetes, ED visits, and preventable hospitalizations are a way to focus people and to rally them around meaningful data so that they can say, ‘That patient had that amputation, and these patients have an A1C greater than nine, so how is it that we make our medical home better to prevent those things?’”

Initially the collaborative’s leadership team thought one year of intensive learning would be enough for the practices, Amy said. But in the second year, the performance results from the practices that participated in the first year started to drop. As a result, the collaborative created the Enduring Learning Forum so practices can sustain their quality improvements and take on new challenges.

Practices in the forum agree to continue to measure quality, their quality leadership teams continue to meet regularly, and the practices gather as a larger group three times a year. Nine practices are in the 2011 intensive learning phase, and 13 are in the enduring learning forum. The practices in the intensive phase participate in enduring learning meetings so they can learn from the more-experienced practices.

Another major change came to the program in its second year. That’s when the collaborative created the Patient Partner Program. Each practice invites two patients to join its quality leadership team. The patients take part in leadership team meetings at least once a month. The collaborative got the idea at an AF4Q national meeting from two Alliances that had started involving patients in their PCMH efforts, Jones said.

“The patients keep us honest because we can think we’re developing the best processes in the world but develop it around ourselves inadvertently, and our patients say, ‘Why do you do it that way? What about this?’” Jones said.

The patients have brought practical ideas forward. One diabetic patient partner inspired his practice to replace the old, large, painful glucometer that had to be retrieved by a nurse at every visit with the newer, less-painful device he used for self-monitoring. The new glucometers are now in each of the practice’s exam rooms, and the change has spread to other practices.

Michael Chilcoat, patient partner at Partners in Family Health since July 2010, created a walking group for himself and other patients that is managed through the practice’s patient portal.

The physicians respect and value his opinion, he said. Being a patient partner has taught him to be more engaged in his own health. “One of the things that I push now is that the patient is totally responsible for his own recovery or to get himself straightened out,” Chilcoat said. “The doctor can tell you to take these meds, to exercise and to watch your diet, but it’s up to you to do it.”

The practice is now part of the Enduring Learning Forum. Chilcoat introduces himself to patient partners at practices in the intensive learning phase. “The big thing the first meeting or two is to make them feel comfortable,” he said. At the joint meetings, he tells the new patient partners: “Just tell yourself before you go in that the doctors put their pants on the same way you do.”

The dinner meeting discussions educated Chilcoat about the challenges practices face. “When they explain all the things they’re trying to do to cut health care costs, it will open your eyes to the fact that they’re as concerned about it as the patients are,” he said.

One of the latest additions to the collaborative is the team maturity assessment tool. “It came from an industrial background, and we coaxed it into an examination of the culture of the practice,” Gross said. The tool helps practices assess their cultures through a rating system that looks at leadership, collaboration, continuous process improvement, and learning.

So far, the tool has been used twice to measure leadership team culture. “By January we’re expecting to roll it out to an assessment of the entire practice,” Gross said.

Lessons Learned

• Start with a committed leadership team that can shepherd the PCMH collaborative forward because it is labor intensive. PCMH collaboratives also need to have a project coordinator dedicated solely to the project, as does the Patient Partner Program.

• Use performance data to drive change. The collaborative establishes performance goals for process and outcomes measures and shares the results monthly so practices can compare their performance to others and learn from each other.

• Involving patients in PCMH leadership teams helps practices become truly patient centered. They identify inefficiencies that providers might overlook, bring a unique perspective to the team, and come up with fresh ideas for change.