Facilitating Transformational Change in Primary Care

By Bob McNellis, M.P.H., P.A., AHRQ‘s Senior Advisor for Primary Care
Twitter: @AHRQNews

I was recently recalling a trip to a national conference in Boston where I crossed paths with a fellow physician assistant who was working in a primary care practice. “Becoming a medical home was the hardest thing we ever did,” she said. “Everyone hated it, and we would never do it again.”

Her assessment surprised me because I knew that, over time, her practice had become a top performer in her State. I wanted to understand: How did the practice solve its problems? How did the team eventually succeed despite a difficult-to-use electronic health record (EHR) system, an outdated scheduling and billing system, and a medical assistant who initially refused all new responsibilities?

The turning point came when one of the State’s practice transformation organizations offered to send a practice facilitator who met with team members to understand their goals, identify their most pressing problems, and assess their strengths.

The assistance provided by the practice facilitator helped the team conquer some of its most difficult challenges. She helped streamline workflows. She arranged for an EHR expert to help ease input of patient data and generate quality reports. She squared away their billing system so much that they could afford an additional medical assistant.

Transformational change is hard, especially in healthcare. But it is essential if we are to get the healthcare we need at a cost we can afford. Innovations that have occurred in recent years — growth of the patient-centered medical home model, widespread adoption of EHRs, the development and use of performance measurement and reporting — have put primary care at the epicenter of transformational change.

Amidst these sweeping changes, AHRQ embarked on a series of research investments to understand not only how transformation occurs in primary care, but how to support practices that seek to adapt and improve care. Through that research, AHRQ tried to understand not only why change can be so difficult, but also more importantly, how to overcome the difficulties.

AHRQ’s EvidenceNOW, one of our largest primary care research projects, helped practices implement evidence to improve healthcare with a focus on heart health. The initiative not only helped practices expand their capacity to receive and incorporate evidence, it developed a model to support primary care transformation using practice facilitators, expert consultation, EHR support, and other transformational tools and resources.

New lessons learned from EvidenceNOW and other practice transformation initiatives in the U.S. and Canada are described in a recent supplement to the Annals of Family Medicine. Several papers in the special issue are the products of nearly $800 million invested by Federal health agencies, including AHRQ, to test transformation facilitation in thousands of practices across the United States.

Important findings from EvidenceNOW are included in the supplement:

  • Michael L. Parchman, M.D, M.P.H., and colleagues found that practices that receive practice facilitation plus educational outreach visits and shared learning were more than twice as likely as those who received practice facilitation alone to reach a blood pressure performance goal of 70 percent.
  • Erin S. Rogers, Dr.P.H., and colleagues found practice facilitators create an important connection between small practices and the external healthcare environment. Practice facilitators can also create awareness of quality gaps; connect practices to information, resources, and strategies to support change; and optimize the EHR for quality improvement goals.
  • Arthur Kaufman, M.D, and coauthors describe approaches to primary care extension programs in five States. They show that health extension is a viable model to support practices, integrate social determinants of health into primary care, and expand linkages between primary care and community resources.

The supplement also includes rich findings from the Center for Medicare & Medicaid’s (CMS’s) $700 million Transforming Clinical Practice Initiative. The lessons here are consistent with what AHRQ has learned from its research investments: the full potential of primary care transformation will not be reached without paying attention to three foundational supports: well-implemented, functional health information technology; a prepared primary care and quality improvement workforce; and new payment models like those being advanced by CMS.

Findings in this supplement and elsewhere will help inform future research and primary care transformation efforts. For example, lessons learned from EvidenceNOW are being used to inform a new AHRQ initiative to screen and manage unhealthy alcohol use in primary care. AHRQ developed its Tools for Change – a curated library of more than 100 tools to help implement evidence into primary care – based on successful approaches to practice transformation in EvidenceNOW.

Meanwhile, AHRQ recently released a Notice of Intent to launch a new program to fund development of State-level capacity to disseminate and implement patient-centered outcomes research evidence into primary care.

When I think back to the day in Boston when my conference colleague recalled the difficulty of bringing transformation change to her primary care practice, I recall she rephrased her earlier comment, “We would never try practice transformation without support again.”

The road ahead will not be easy, but I am ultimately inspired – not just by the proven success by her and many others, but by the many emerging transformation efforts supporting primary care practices and clinicians to improve the care and health of all Americans.

This article was originally published on AHRQ Views Blog and is republished here with permission.