1. M ODULE 1: Getting Started Coach Medical Home Strategies & tools to support patient-centered medical home transformation

2. Learning objectives for this module After completing this module, you will know how to: Articulate why PCMH transformation is not business as usual and ways to support it. Establish a relationship with practices. Take a step-by-step approach to establish a plan of action that supports long-term improvement. Coach Medical Home: Module 1 2

3. Overview of contents in this module The challenge of transformation and keys to success Kick-start your work with a practice Assessing and strengthening practice readiness Establishing a practice transformation facilitation plan 3 Coach Medical Home Module 1

4. The challenge of transformation and keys to success S ECTION 1 Coach Medical Home: Module 1

5. We live in interesting times Coach Medical Home: Module 1 5 Federal health care reform is counting on: Primary care that improves quality, reduces costs, and improves patient experience Greater capacity and higher quality among the nation’s federally qualified health centers (FQHCs) CMS and the Bureau of Primary Health Care use the PCMH as the model of robust primary care.

6. PCMH transformation is not business as usual “Change is hard enough; transformation to a PCMH requires epic whole-practice reimagination and redesign.” (Nutting, et al.) Coach Medical Home: Module 1 6 Asking physicians & staff to change their roles Investing time & money Changing how care is provided For most practices, transformation means:

7. Comparing old and new care Coach Medical Home: Module 1 7 Typical care “My patients are those who make appointments to see me.” Patients are responsible for coordinating their own care. “It’s up to the patient to tell us what happened to them.” Care is determined by today’s problem & time available. Care varies by provider. “I know I deliver high-quality care because I’m well trained.” Clinic operations focus on meeting doctors’ needs. PCMH care “Our patients are those on our team’s panel, whether they make appointments or not.” A prepared team of professionals coordinates all patient care. “We track tests & consultations and follow up after ED & hospital visits.” Care is determined by a proactive plan to meet health needs, with or without visits. Care is standardized by evidence-based guidelines. “We measure our quality and make rapid changes to improve it.” An inter-disciplinary team focuses on meeting patients’ needs. Typical care PCMH care

8. What helps practice transformation? 8 Coach Medical Home: Module 1 Practice will, ideas, and execution Practice facilitation Payment and recognition Change concepts Trusted measurement system Learning communities

9. Keys and obstacles to success Practice willingness & organizational readiness Practice facilitation Learning communities A trusted measurement system The primary motivation is increased revenue Leaders are unenthusiastic or against change Cash flow or EHR problems, high staff turnover Lack of capacity to track performance What worksPossible red flags 9 Coach Medical Home: Module 1

10. Kick-start your work with a practice S ECTION 2 Coach Medical Home: Module 1

11. Successful practice facilitation A helpful resource from the Agency for Healthcare Research & Quality (AHRQ): A how-to guide for primary care facilitation programs www.pcmh.ahrq.gov/portal/server.pt/commu nity/pcmh__home/1483/pcmh_implementin g_the_pcmh___practice_facilitation_v2 www.pcmh.ahrq.gov/portal/server.pt/commu nity/pcmh__home/1483/pcmh_implementin g_the_pcmh___practice_facilitation_v2 Coach Medical Home: Module 1 11

12. Getting ready for the kick-off meeting Coach Medical Home: Module 1 Take time to plan your first meeting Develop your understanding of the practice Meet with leadership and other team members Explain next steps and your role as a coach 12

13. Answering common questions about becoming a PCMH Yes, or performance metrics won’t change. Do we really have to change how we deal with patients? See above. Can’t we just complete the forms? The PCMH model covers all the elements of effective primary care. Why so many different changes? No! That would be overwhelming. Plus, some changes will build on others. Do we have to change everything at once? Difficult, but not impossible. It requires trying small changes over time. How difficult is practice transformation? Coach Medical Home: Module 1 13

14. Good relationships are essential Most practices will need help figuring out how best to work their facilitator. The success of practice facilitation appears to be related to the quality and intensity of the relationship between the coach and the practice. Coach Medical Home: Module 1 14 Solid, trusting relationships Get to know the practice Show them how to work with a coach Visit the practice early Meet with leaders often Encourage leaders to meet with staff

15. Assessing and strengthening practice readiness SECTION 3 Coach Medical Home: Module 1

16. Lessons from quality improvement (QI) collaboratives Half or more of practices show no evidence of improvement. Readiness to change distinguishes practices that improve from those that do not. Coach Medical Home: Module 1 16 Half Empty Half Full

17. Two perspectives on readiness Practices that don’t look anything like a PCMH can be ready to change—and many are. Organizational readiness to change: Is the practice motivated to change and does it have the will & capacity to make changes? Progress toward PCMH: How far along is the practice on the journey to becoming a fully implemented PCMH? Coach Medical Home: Module 1 17

18. What is readiness for change? ”A shared psychological state in which organizational members feel committed to implementing an organizational change and confident in their collective abilities to do so.” 1 But readiness is more than a psychological state of the staff. It also includes practice characteristics that enable change. Coach Medical Home: Module 1 18 1. Motivation Leadership 2. Capability 1. Nutting PA, et al., 2011

19. Readiness element #1: Motivation Motivation is the collective willingness and commitment of organizational members—in this case, a primary care practice team—to implement the designed organizational change. 1 Coach Medical Home: Module 1 19 Comes from within—from beliefs, fears, aspirations, etc. Example: Trying to stop smoking because of concerns about your health. Intrinsic motivation Comes from outside Example: Trying to stop smoking because your company offers employees $50 to quit. Extrinsic motivation More closely linked with quitting smoking & other behavior change 1. Wise CG, et al., 2011

20. Readiness element #2: Capability Adaptive reserve Facilitative leadership Effective relationships A learning culture Group time Core capacity Sound financial systems Stable leadership and staff Stable information technology (IT) Can the practice function well in times of stability? Can the practice change to adjust to shifting policy or to improve? Coach Medical Home: Module 1 20

21. Measuring organizational readiness for change (ORC) vs. PCMH progress The PCMH-A is primarily a measure of progress toward transformation, but it also includes some items that assess readiness. Few tools have been widely used or tested in healthcare settings. ORC is generally not assessed by PCMH progress measures. Examples: NCQA Readiness Assessment, the PCMH-A PCMH progress measures gauge the extent to which a practice resembles a medical home. Coach Medical Home: Module 1 21

22. Establishing a practice transformation facilitation plan S ECTION 4 Coach Medical Home: Module 1

23. Launching the transformation process Coach Medical Home: Module 1 23 Relationship building Readiness assessment Developing and implementing a plan Monitoring and maintenance planning

24. Establishing a plan of action Coach Medical Home: Module 1 24 Consider readiness assessment results Is NCQA recognition important? Set goals Consider a Memorandum of Understanding Clarify expectations Use patients as advisors to the extent possible Involve patients

25. Setting goals for practice transformation Coach Medical Home: Module 1 25 Quality improvement Designate an explicit QI team, if possible. Take advantage of existing approaches to QI. Peer-to-peer learning Consider being part of a formal learning community. Look for opportunities to interact.

26. It is not always a good idea to move ahead with PCMH transformation Coach Medical Home: Module 1 26 ProblemPotential actions Financial instability A practice management consultant may help Unstable IT Link practices with regional IT resources (e.g., REC, LEC) Problematic leadershipLeadership training Staff turnoverAssess staff satisfaction/burnout Lack of teamworkTeam-building activities

27. Change needs to be both top down & bottom up Coach Medical Home: Module 1 27 Effective leadership creates & sustains the practice’s vision for PCMH transformation Facilitate staff involvement Encourage & empower staff Provide time to plan & implement changes

28. Emphasize intrinsic motivation Financial incentives may increase the likelihood that a practice will participate in PCMH initiatives, but many aren’t ready to change. Early efforts should appeal to intrinsic motivators. Use stories from providers and staff at transformed practices who report higher career satisfaction. Coach Medical Home: Module 1 28 Extrinsic motivators Financial incentives Management edict Public reporting Intrinsic motivators Putting patients first Job satisfaction