Physician Perspectives on the Influence of Medical Home Recognition on Practice Transformation and Care Quality for Children with Special Health Care Needs. Medical Home Recognition and Primary Care Practice Transformation

01/01/2014

Factors that Motivate and Support Practices in PCMH-Recognition and Functioning

Physicians described several, often overlapping, altruistic and financial motivations for their practices' obtaining NCQA PCMH-recognition (Table 2). Some perceived organizing as a PCMH as key to providing high-quality care and said that it was "the right thing to do." Others described recognition as acknowledgment for how they organized their practice. One physician said that NCQA was the "gold standard," while another said "having that status is about having a national badge. Now we can say, 'We do this and we do it well. We're a leader.'" Some physicians commented about the perceived future of health care, suggesting that their practices sought recognition because it was critical to remaining competitive in the health care market by attracting patients and higher payments. One physician said, "It was about making a darn good case for getting paid for what we are doing."

TABLE 2. Pediatricians' and Family Physicians' Perceptions of Factors That Motivate and Support Practices in Obtaining PCMH-Recognition and Functioning as PCMHs
Many physicians described common motivations and supports for becoming recognized PCMHs.
"It's [NCQA PCMH-recognition] one component of many that helps us improve quality in population-based care" (pediatrician in a large, integrated system).

"Everyone who knows about quality, knows about NCQA. It's good to have that effort be acknowledged" (family physician in an FQHC).

"We're really proud of it [NCQA PCMH-recognition]. We tell everyone we can. It helps us build our institution because we're a draw for insurance contracts" (family physician in an "other" practice).

"More important is that the system we have … is very set up to be a medical home. We have the resources, like the care coordinator, psychologist, dietician, and primary care physicians" (pediatrician in a large, integrated system).

"Every year, with funds generated through local giving, they [the hospital's foundation] pay the salaries of two care coordinators at our clinic. It's wonderful -- there's no way we'd be able to do that otherwise" (pediatrician in an independent, multisite practice).

"The biggest motivator was that [the practice] joined a pilot study in [our state]. We undertook this journey to become a medical home on varying levels [as part of the pilot]. That helped prompt recognition" (family physician in an independent, single-site practice).

"We had a coach in the practice from outside the practice who did a lot of team transformation … and quite frankly, the pilot offered money. There was financial incentive for us to become a medical home" (family physician in an independent, single-site practice).

"They had initially helped us with some practice improvement things like office flow and referral coordination and things like that. Having that [the coaches] for the practice really helped a lot. I don't think we could have done it [become a medical home] without the coaches" (family physician in an independent, single-site practice).

A key motivating factor and external support for practices was participation in PCMH demonstration projects and quality improvement (QI) initiatives. Many physicians reported that participation in such efforts provided important supports such as learning collaboratives, practice coaches, and in a few cases, enhanced reimbursement. Participation in these efforts also allowed some practices to obtain data from external sources, such as insurance companies and health information exchanges, which enhanced their QI strategies and ability to function as PCMHs.

Physicians described additional external factors as supporting their ability to obtain recognition and function as a PCMH (Table 2). Many described factors related to being well connected to other service providers in the "medical neighborhood," including access to patient notes through interoperable electronic health records (EHRs) and notifications of emergency department (ED) visits, hospitalizations, and discharges. Physicians within an integrated health system frequently discussed the value of resources shared across sites, such as nurse care coordinators. As one such physician said, "We have so much support outside of our office that I feel like we're in a unique position to provide better care." A few physicians discussed the importance of linkages to other systems that are critical to child well-being, such as social service agencies and school systems, in supporting their practice's ability to operate as a PCMH.

Characteristics of Practices Prior to the PCMH-Recognition Process

Most physicians reported that PCMH-recognition largely represented acknowledgment for the care that their practice was already providing (Table 3). This perception was consistent across physicians in all practice types in this study. Some physicians described NCQA-recognition as one step on an existing path to improving care that the practice was already headed down: "It's a continuum. It's the path we've been on for 10-15 years prior." Another physician in a large health system said, "We had a pretty good system to begin with. I think the only change was to utilize the services we already had in place more."

Most physicians described aspects of practice infrastructure and care processes that were in place prior to NCQA-recognition, including a focus on QI, formal care coordinators, and EHRs (Table 3). Other aspects of PCMHs that at least a few physicians described as being present in their practice prior to NCQA-recognition included use of nurses to provide advice during and after office hours; enhanced access through expanded office hours, electronic communication, and virtual visits; access to hospital records to help monitor and coordinate care; referral tracking; physical workspaces organized to facilitate team-based care; and access to non-physician providers, such as dieticians and psychologists. With respect to CSHCN, all physicians described at least one example of tailored care processes. At one end of the continuum, physicians used registries to identify and manage care for children with more common special needs like asthma and attention deficit hyperactivity disorder (ADHD). At the other end of the continuum, some physicians had access to special needs clinics, chronic care programs, and pediatric asthma programs staffed by nurse care coordinators.

TABLE 3. Pediatricians' and Family Physicians' Perceptions of Their Practices' Transformation Before and After NCQA PCMH-Recognition in 2009-2010
Most physicians perceived that their practices underwent little change in order to achieve NCQA PCMH-recognition.
"We figured we were just legitimizing or making official what we'd already been doing for special needs kids for a few years" (pediatrician in an independent, multisite practice).

"To be honest, I think that [health system] has this in their DNA. I don't see it as a thing where [health system] looked at NCQA and said, 'Oh, we should do this.' We've done it for a number of years" (pediatrician in a large, integrated health system).

"I started a quality improvement lunch discussion group several years ago. That was converted to an official quality improvement committee and that group was called on to address all the needed changes between the different clinical groups [for NCQA-recognition] …. I think we were already very oriented towards quality" (family physician in an independent, multisite practice).

"We [the practice] used to keep close tabs on them [CSHCN] even before. The care coordinator tracks all of our hospital admissions and ER visits and there hasn't been significant change" (pediatrician in an independent, single-site practice).
For practices that did make changes, most physicians reported changes as refinements and standardization of existing processes.
"We had to have a lot more structure and standardized approach in the clinics …. We standardized the way we do medication management. We have the same process in place when we're doing the well-child things that have to be done. We have a process for making sure we get x-ray reports back. We're doing preventative services and we're monitoring to make sure we are calling people back. We're standardizing those processes so that it doesn't matter which clinic someone goes to. They [will] get the same service" (pediatrician in an FQHC).

"We've always tracked referrals, but maybe we've tried harder since 2008 not to let things fall through the cracks" (pediatrician in an independent, multisite practice).
Some physicians described more substantial changes in their practice to achieve PCMH-recognition.
"We went from having no quality improvement (and we thought we were doing a decent job then) to collecting data and measuring our outcomes. We actually had numbers to see how we were doing and that was a wake-up call" (family physician in an independent, single-site practice).

"We really changed our workflows and redesigned our systems that allowed us to get out of that cottage-age century. We started using modern, industrialized processes. We adopted proved strategies like huddling in the morning, for example" (family physician in an independent, multisite practice).

"We started a couple of initiatives around tracking and monitoring kids, such as asthmatic monitoring. And we've been trying to do a better job of tracking ADHD kids …" (pediatrician in an independent, multisite practice).
Many physicians described ongoing practice transformation after achieving PCMH-recognition.
"That was part of a little brainstorm in the PCMH [pilot] … I think I just called up the [local mental health organization] and asked if they would be interested in putting someone in our office for a couple of days a week and they thought that would be a reasonable thing to try. That's been going well and has been going for a year and a half now" (family physician in an independent, single-site practice).

"We realized there was a gap there [in referral tracking], and we're actually now trying to figure out where the gap is between when we make the referral and what percent of people actually get to the specialist and what percent of time we actually get the report back. We realized those were two gaps in our process" (family physician in an "other" practice).

"As of the upgrade [to the practice EHR], for the patients that are on the patient portal, with two clicks, I can directly send the patients the lab results with a little note from me. That's a huge improvement in my ability to communicate with my patients …. We have a new, enhanced IT team too. We've had to grow to be able to organize and process the data that comes from the EHR to make it meaningful" (family physician in an FQHC).

Changes Made to Achieve PCMH-Recognition

For physicians who reported changes made in their practice to achieve PCMH-recognition, most described refinements and standardization of existing processes (Table 3). A few physicians reported that, although the practice did not make significant changes, the recognition process affected the QI activities the practice emphasized. A family physician in a multisite independent practice said, "We were already a high-quality organization. But I think it did help us focus on finishing the job and maintaining a technical exactness to quality improvement." One physician described the successful care coordination for a child newly diagnosed with Turner syndrome and when asked if the same level of coordination would have happened without PCMH-recognition, replied, "Yes, I'm sure this would have happened without recognition, but I think it's a lot more integrated. It's probably a little smoother now."

Some physicians reported making more substantial changes in their practices to achieve PCMH-recognition (Table 3). These physicians, commonly from smaller and independent practices, described changing practice culture to emphasize team-based care and QI, adjusting workflows, shifting staff responsibilities, and dedicating resources to patient registries, tracking strategies, and care coordination. A physician in a single independent practice said, "It's been transforming, and it has to be for it to work. If a group goes in to only get a plaque to put on their wall, it's not going to work. It has to transform your office. Maybe in large ones they have QI teams but mine is an average-sized family practice and those are the ones that really have to change and transform their practice."

Ongoing Practice Transformation after Initial PCMH-Recognition

For many practices, NCQA-recognition solidified a commitment to QI that they already embraced, and many physicians described ongoing transformation activities after their practice achieved recognition (Table 3). These included expanding the types of services offered, refining and broadening their use of patient registries, improving referral tracking processes, and upgrading health information technology (HIT). One physician described institutionalizing a QI mechanism: "We put in place a regular time and place to say 'This is not working. How do we make this more efficient?'" She also spoke of ongoing work to "enlist people around the improved quality mantra."

Some physicians emphasized how PCMH-recognition caused their practice to look more closely at processes they thought were high functioning and identify areas for improvement, including team building, integration of PCMH principles into practice culture, and clinical processes. A family physician in an independent practice that is also a residency training program said, "We hadn't fully implemented the philosophy of the PCMH as well as we thought. What we really had to do was get everyone together, break down into teams, do strategic planning, tactical planning, decision-making, to get everyone down to the rank and file people to feel what a PCMH was … I call it 'the tyranny of the pretty good.' … when you think you're pretty good there's not a lot of impetus to change." Similarly, a family physician at a single independent practice said "when we looked at the PCMH guidelines … we said, 'this is how we're pretty much already doing things, so it'll be a piece of cake …'. Of course it wasn't! We thought we were doing so well. When we started running the reports … we found out we weren't doing that well."

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