Juliana O. Tillema

Medical Home Transformation: A Gradual Process and a Continuum of Attainment

PURPOSE The patient-centered medical home is often discussed as though there exist either traditional practices or medical homes, with marked differences between them. We analyzed data from an evaluation of certified medical homes in Minnesota to study this topic. METHODS We obtained publicly reported composite measures for quality of care outcomes pertaining to diabetes and vascular disease for all clinics in Minnesota from 2008 to 2010. The extent of and change in practice systems over that same time period for the first 120 clinics serving adults certified as health care homes (HCHs) was measured by the Physician Practice Connections Research Survey (PPC-RS), a self-report tool similar to the National Committee for Quality Assurance standards for patient-centered medical homes. Measures were compared between these clinics and 518 non-HCH clinics in the state. RESULTS Among the 102 clinics for which we had precertification and postcertification scores for both the PPC-RS and either diabetes or vascular disease measures, the mean increase in systems score over 3 years was an absolute 29.1% (SD = 16.7%) from a baseline score of 38.8% (SD = 16.5%, P ≤.001). The proportion of clinics in which all patients had optimal diabetes measures improved by an absolute 2.1% (SD = 5.5%, P ≤.001) and the proportion in which all had optimal cardiovascular disease measures by 4.4% (SD = 7.5%, P ≤.001), but all measures varied widely among clinics. Mean performance rates of HCH clinics were higher than those of non-HCH clinics, but there was extensive overlap, and neither group changed much over this time period. CONCLUSIONS The extensive variation among HCH clinics, their overlap with non-HCH clinics, and the small change in performance over time suggest that medical homes are not similar, that change in outcomes is slow, and that there is a continuum of transformation.

Minnesota's Early Experience with Medical Home Implementation: Viewpoints from the Front Lines.

ABSTRACTBACKGROUNDEvidence is evolving about the impact of patient-centered medical homes (PCMHs) on important outcomes in primary care. Minnesota has developed its own PCMH certification process, envisioned as an all-payer initiative with an emphasis on patient-centeredness, which may add unique experiences and outcomes to the national discussion.OBJECTIVEWe aimed to identify the facilitators and barriers encountered by nine diverse primary care practices selected from the first 80 to achieve PCMH certification in Minnesota.DESIGNThis was a qualitative analysis of semi-structured, in-person interviews.PARTICIPANTSThirty-one administrative and clinical leaders, including clinic managers, physician champions, medical directors, nursing supervisors, and care coordinators participated in the study.KEY RESULTSSix factors emerged as most important to the efforts to become PMCHs: leadership support, organizational culture, finances, quality improvement (QI) experience, information technology (IT) resources, and patient involvement. Facilitators included committed leadership at local and higher levels, prior experience and ongoing support for QI initiatives, and adequate financial and IT resources. Reimbursement was a significant barrier due to perceived inadequacy and inconsistent participation by health plans. The unsuitability of electronic medical records (EMRs) to PCMH documentation requirements likewise presented ongoing challenges. Many interviewees described patient input as helpful to their clinics’ PCMH-related changes and were enthusiastic about their “patient partners.” The majority of interviewees felt that becoming a PCMH was right for patients and was personally worthwhile, even while acknowledging the tremendous effort involved and voicing skepticism about reimbursement over the short term.CONCLUSIONSThe experience of participants in Minnesota’s state-wide initiative to legislate PCMH transformation provides a broad view of facilitators and barriers. Unique facilitators included a requirement for patient involvement, which pushed practices to create patient-centered innovations, and new reimbursement models based on quality indicators for a population. Among barriers were the costs to practices and patients, and EMRs that failed to accommodate PCMH requirements.

Challenges of Medical Home Transformation Reported by 118 Patient-Centered Medical Home (PCMH) Leaders

Background: Little is known about the most important organizational factors and strategies for transforming primary care clinics into patient-centered medical homes (PCMHs), so we studied this in newly certified medical homes in Minnesota. Methods: We collected the following information from the first 120 clinics serving adults to be certified: (1) a 105-item survey about the presence and function of practice systems now and 3 years ago; (2) standardized composite clinic performance measures for diabetes and cardiovascular disease; and (3) a 44-item survey about PCMH transformation derived from 31 qualitative interviews about barriers, facilitators, and change strategies with participants from 9 diverse clinics. Results: The response rates for the systems survey was 92.5% and was 98.3% for the survey about transformation. Nearly all the items from the qualitative interviews identified as potentially important for transformation were strongly endorsed. Eighteen items in this survey also correlated significantly (P = <.01) with change in practice systems at the level of r ≥ 0.20. However, there was little relationship between these items and either absolute levels of systems or performance on composite measures of diabetes or vascular disease quality outcomes. Conclusions: Many items in the survey about transformation seem to have face validity for leaders of certified PCMHs and to be associated with the extent to which their clinics have made systems changes. While clinics may need to find their own unique path to transformation, the items identified here should be considered in those decisions.

The Effect of Achieving Patient-Reported Outcome Measures on Satisfaction

Objective: To determine how frequently patients with advanced imaging for back or abdominal pain achieve outcomes that are identified by patients as important and whether those achieving those outcomes are more satisfied. Methods: Cross-sectional analysis of survey responses from patients of an 800-physician multi-specialty group in Minnesota in 2013. A total of 201 patients with abdominal pain and 167 patients with back pain 1 year earlier that was serious enough for a computed tomography or magnetic resonance imaging scan (67% of those contacted). The main outcomes were the frequency of occurrence of 19 outcomes previously identified by patients as important, plus satisfaction with the results of care. Results: The majority of patients surveyed had achieved most of the desired outcomes. For abdominal pain, 17 of 19 of the desired outcomes were achieved by >50% of patients, while 11 of 19 desired outcomes were achieved by >50% of patients with back pain. Seven of the desired outcomes were significantly associated with satisfaction. Conclusion: Achieving outcomes important to patients is associated with greater patient satisfaction. Such measures are potentially valuable measures of quality.

Organizational Factors and Change Strategies Associated With Medical Home Transformation

There is limited information about how to transform primary care practices into medical homes. The research team surveyed leaders of the first 132 primary care practices in Minnesota to achieve medical home certification. These surveys measured priority for transformation, the presence of medical home practice systems, and the presence of various organizational factors and change strategies. Survey response rates were 98% for the Change Process Capability Questionnaire survey and 92% for the Physician Practice Connections survey. They showed that 80% to 100% of these certified clinics had 15 of the 18 organizational factors important for improving care processes and that 60% to 90% had successfully used 16 improvement strategies. Higher priority for this change (P = .001) and use of more strategies (P = .05) were predictive of greater change in systems. Clinics contemplating medical home transformation should consider the factors and strategies identified here and should be sure that such a change is indeed a high priority for them.

Using Principles of Complex Adaptive Systems to Implement Secondary Prevention of Coronary Heart Disease in Primary Care

CONTEXT Primary care practice. OBJECTIVE To test whether the principles of complex adaptive systems are applicable to implementation of team-based primary care. DESIGN We used complex adaptive system principles to implement team-based care in a private, five-clinic primary care practice. We compared randomly selected samples of patients with coronary heart disease (CHD) and diabetes before system implementation (March 1, 2009, to February 28, 2010) and after system implementation (December 1, 2011, to March 31, 2013). MAIN OUTCOME MEASURES Rates of patients meeting the composite goals for CHD (blood pressure < 140/90 mmHg, low-density lipoprotein cholesterol level < 100 mg/dL, tobacco-free, and using aspirin unless contraindicated) and diabetes (CHD goal plus hemoglobin A1c concentration < 8%) before and after the intervention. We also measured provider and patient satisfaction with preventive services. RESULTS The proportion of patients with CHD who met the composite goal increased from 40.3% to 59.9% (p < 0.0001) because documented aspirin use increased (65.2%-97.5%, p < 0.0001) and attainment of the cholesterol goal increased (77.0%-83.9%, p = 0.0041). The proportion of diabetic patients meeting the composite goal rose from 24.5% to 45.4% (p < 0.0001) because aspirin use increased (58.6%-97.6%, p < 0.0001). Increased percentages of patients meeting the CHD and diabetes composite goals were not significantly different (p = 0.2319). Provider satisfaction with preventive services delivery increased significantly (p = 0.0017). Patient satisfaction improved but not significantly. CONCLUSION Principles of complex adaptive systems can be used to implement team-based care systems for patients with CHD and possibly diabetic patients.

New summary measures of population health and well-being for implementation by health plans and accountable care organizations

Health plans and accountable care organizations measure many indicators of patient health, with standard metrics that track factors such as patient experience and cost. They lack, however, a summary measure of the third leg of the Triple Aim, population health. In response, HealthPartners has developed summary measures that align with the recommendations of the For the Public’s Health series of reports from the Institute of Medicine. (The series comprises the following 3 reports: For the Public’s Health: Investing in a Healthier Future, For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges, and For the Public’s Health: The Role of Measurement in Action and Accountability.) The summary measures comprise 3 components: current health, sustainability of health, and well-being. The measure of current health is disability-adjusted life years (DALYs) calculated from health care claims and death records. The sustainability of health measure comprises member reporting of 6 behaviors associated with health plus a clinical preventive services index that indicates adherence to evidence-based preventive care guidelines. Life satisfaction represents the summary measure of subjective well-being. HealthPartners will use the summary measures to identify and address conditions and factors that have the greatest impact on the health and well-being of its patients, members, and community. The method could easily be implemented by other institutions and organizations in the United States, helping to address a persistent need in population health measurement for improvement.

A qualitative study of processes used to implement evidence-based care in a primary care practice

BACKGROUND Evidence-based guidelines for care of coronary heart disease patients are not fully implemented. Primary care practices provide most of the care for these patients. OBJECTIVE To learn how providers and staff in a busy primary care practice implement interventions to provide evidence-based care of coronary heart disease patients. METHODS We conducted a qualitative analysis of the responses to open-ended questions in nine electronically administered bimonthly surveys of key physicians, clinic staff and managers in the practice. RESULTS Ten to 16 (mean=12.3) personnel responded to each survey. Nearly 30% were physicians and 40.5% were clinic staff. Four major themes emerged from the qualitative analysis: (i) giving data about not-at-goal patients to providers for care plan development; (ii) developing team roles and defining tasks; (iii) providing patient care and implementing care plans and (iv) providing technology support to generate useful, accurate data. The frequency that the subthemes were mentioned varied from survey to survey, but their mention persisted over the entire time of all nine surveys. CONCLUSIONS Developing a system for implementing evidence-based care involves considerations of roles and teamwork, technology use to develop a patient registry and obtain needed clinical data, care processes for pre-visit planning, and between-visit care management. A registered nurse care manager is a central figure in implementing and sustaining the process. Implementing evidence-based guidelines is an ongoing process of revision, retraining and reinforcement.

The effect of price reduction on salad bar purchases at a corporate cafeteria.

The objective of this study was to determine the effect of a price reduction on salad bar purchases in a corporate cafeteria. We reduced the price of salad bar purchases by 50% during March 2012 and analyzed sales data by month for February through June 2012. We also conducted an anonymous survey. Salad bar sales by weight more than tripled during the price reduction and returned to baseline afterward. Survey respondents reported that the high price of salad relative to other choices is a barrier to purchases. Policies that make the price of salads equal to other choices in cafeterias may significantly increase healthful food consumption.

Concordance Between Life Satisfaction and Six Elements of Well-Being Among Respondents to a Health Assessment Survey, HealthPartners Employees, Minnesota, 2011

Introduction We assessed and tracked perceptions of well-being among employees of member companies of HealthPartners, a nonprofit health care provider and health insurance company in Bloomington, Minnesota. The objective of our study was to determine the concordance between self-reported life satisfaction and a construct of subjective well-being that comprised 6 elements of well-being: emotional and mental health, social and interpersonal status, financial status, career status, physical health, and community support. Methods We analyzed responses of 23,268 employees (of 37,982 invitees) from 6 HealthPartners companies who completed a health assessment in 2011. We compared respondents’ answers to the question, “How satisfied are you with your life?” with their indicators of well-being where “high life satisfaction” was defined as a rating of 9 or 10 on a scale of 0 (lowest) to 10 (highest) and “high level of well-being” was defined as a rating of 9 or 10 for 5 or 6 of the 6 indicators of well-being. Result We found a correlation between self-reported life satisfaction and the number of well-being elements scored as high (9 or 10) (r = 0.62, P < .001); 73.6% of the respondents were concordant (high on both or high on neither). Although 82.9% of respondents with high overall well-being indicated high life satisfaction, only 34.7% of those indicating high life satisfaction reported high overall well-being. Conclusion The correlation between self-reported life satisfaction and our well-being measure was strong, and members who met our criterion of high overall well-being were likely to report high life satisfaction. However, many respondents who reported high life satisfaction did not meet our criterion for high overall well-being, which suggests that either they adapted to negative life circumstances or that our well-being measure did not identify their sources of life satisfaction.