Creating and Sustaining Care Teams in Primary Care: Perspectives From Innovative Patient-Centered Medical Homes.

Objective: To learn from the experiences of innovative primary care practices that have successfully developed care teams.

Research Design: A 2½-day working conference was convened with representatives from 10 innovative primary care practices, content experts, and researchers to discuss experiences of developing care teams. Qualitative data included observation notes, transcripts of conference sessions and interviews, and narrative summaries of innovations.

Trust and Reflection in Primary Care Practice Redesign.

Objective: To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH).

Data Sources/study Setting: Primary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH.

Study Design: We conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States.

Practice context affects efforts to improve diabetes care for primary care patients: a pragmatic cluster randomized trial.

Background: Efforts to improve primary care diabetes management have assessed strategies across heterogeneous groups of patients and practices. However, there is substantial variability in how well practices implement interventions and achieve desired outcomes.

Objective: To examine practice contextual features that moderate intervention effectiveness.

Manifestations and implications of uncertainty for improving healthcare systems: an analysis of observational and interventional studies grounded in complexity science.

Background: The application of complexity science to understanding healthcare system improvement highlights the need to consider interdependencies within the system. One important aspect of the interdependencies in healthcare delivery systems is how individuals relate to each other. However, results from our observational and interventional studies focusing on relationships to understand and improve outcomes in a variety of healthcare settings have been inconsistent.

Coaching strategies for enhancing practice transformation.

Background: Current research on primary care practice redesign suggests that outside facilitation can be an important source of support for achieving substantial change.

Objectives: To analyse the specific sequence of strategies used by a successful practice facilitator during the American Academy of Family Physicians' (AAFP) National Demonstration Project (NDP).

Methods: This secondary analysis describes a sequence of strategies used to produce change in family medicine practices attempting to adopt a new model of care.

Metrics for assessing improvements in primary health care.

Metrics focus attention on what is important. Balanced metrics of primary health care inform purpose and aspiration as well as performance. Purpose in primary health care is about improving the health of people and populations in their community contexts.

Practice facilitation to improve diabetes care in primary care: a report from the EPIC randomized clinical trial.

Purpose: We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation.

Methods: We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys.

A qualitative comparison of primary care clinicians' and their patients' perspectives on achieving depression care: implications for improving outcomes.

Background: Improving the patient experience of primary care is a stated focus of efforts to transform primary care practices into "Patient-centered Medical Homes" (PCMH) in the United States, yet understanding and promoting what defines a positive experience from the patient's perspective has been de-emphasized relative to the development of technological and communication infrastructure at the PCMH. The objective of this qualitative study was to compare primary care clinicians' and their patients' perceptions of the patients' experiences, expectations and preferences as they try to achieve care for depression.

Methods: We interviewed 6 primary care clinicians along with 30 of their patients with a history of depressive disorder attending 4 small to medium-sized primary care practices from rural and urban settings.

A typology of primary care workforce innovations in the United States since 2000.

Purpose: Innovative workforce models are being developed and implemented to meet the changing demands of primary care. A literature review was conducted to construct a typology of workforce models used by primary care practices.

Methods: Ovid Medline, CINAHL, and PsycInfo were used to identify published descriptions of the primary care workforce that deviated from what would be expected in the typical practice in the year 2000.

Effects of facilitated team meetings and learning collaboratives on colorectal cancer screening rates in primary care practices: a cluster randomized trial.

Purpose: The purpose of this study was to evaluate a primary care practice-based quality improvement (QI) intervention aimed at improving colorectal cancer screening rates.

Methods: The Supporting Colorectal Cancer Outcomes through Participatory Enhancements (SCOPE) study was a cluster randomized trial of New Jersey primary care practices. On-site facilitation and learning collaboratives were used to engage multiple stakeholders throughout the change process to identify and implement strategies to enhance colorectal cancer screening.

Evaluating Depression Care Management in a Community Setting: Main Outcomes for a Medicaid HMO Population with Multiple Medical and Psychiatric Comorbidities.

The authors describe the implementation of a depression care management (DCM) program at Colorado Access, a public sector health plan, and describe the program's clinical and system outcomes for members with chronic medical conditions. High medical risk, high cost Medicaid health plan members were identified and systematically screened for depression. A total of 370 members enrolled in the DCM program.

Small primary care practices face four hurdles--including a physician-centric mind-set--in becoming medical homes.

Transforming small independent practices to patient-centered medical homes is widely believed to be a critical step in reforming the US health care system. Our team has conducted research on improving primary care practices for more than fifteen years. We have found four characteristics of small primary care practices that seriously inhibit their ability to make the transformation to this new care model.

The role of the champion in primary care change efforts: from the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP).

Background: Change champions are important for moving new innovations through the phases of initiation, development, and implementation. Although research attributes positive health care changes to the help of champions, little work provides details about the champion role.

Methods: Using a combination of immersion/crystallization and matrix techniques, we analyzed qualitative data, which included field notes of team meetings, interviews, and transcripts of facilitator meetings, from a sample of 8 practices.

More black box to explore: how quality improvement collaboratives shape practice change.

Background: Quality improvement collaboratives (QICs) are used extensively to promote quality improvement in health care. Evidence of their effectiveness is limited, prompting calls to "open up the black box" to better understand how and why such collaboratives work.

Methods: We selected a cohort of 5 primary care practices that participated in a 6-month intervention study aimed at improving colorectal cancer screening rates.

Transforming physician practices to patient-centered medical homes: lessons from the national demonstration project.

Many commentators view the conversion of small, independent primary care practices into patient-centered medical homes as a vital step in creating a better-performing health care system. The country's first national medical home demonstration, which ran from June 1, 2006, to May 31, 2008, and involved thirty-six practices, showed that this transformation can be lengthy and complex. Among other features, the transformation process requires an internal capability for organizational learning and development; changes in the way primary care clinicians think about themselves and their relationships with patients as well as other clinicians on the care team; and awareness on the part of primary care clinicians that they will need to make long-term commitments to change that may require three to five years of external assistance.

Evaluation of patient centered medical home practice transformation initiatives.

Background: The patient-centered medical home (PCMH) has become a widely cited solution to the deficiencies in primary care delivery in the United States. To achieve the magnitude of change being called for in primary care, quality improvement interventions must focus on whole-system redesign, and not just isolated parts of medical practices.

Methods: Investigators participating in 9 different evaluations of Patient Centered Medical Home implementation shared experiences, methodological strategies, and evaluation challenges for evaluating primary care practice redesign.

Primary care practice transformation is hard work: insights from a 15-year developmental program of research.

Background: Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches.

Methods: Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective.

Using Learning Teams for Reflective Adaptation (ULTRA): insights from a team-based change management strategy in primary care.

Purpose: The Using Learning Teams for Reflective Adaptation (ULTRA) study used facilitated reflective adaptive process (RAP) teams to enhance communication and decision making in hopes of improving adherence to multiple clinical guidelines; however, the study failed to show significant clinical improvements. The purpose of this study was to examine qualitative data from 25 intervention practices to understand how they engaged in a team-based collaborative change management strategy and the types of issues they addressed.

Methods: We analyzed field notes and interviews from a multimethod practice assessment, as well as field notes and audio-taped recordings from RAP meetings, using an iterative group process and an immersion-crystallization approach.

It takes two: using coleaders to champion improvements in small primary care practices.

Background: Making the kind of improvement changes necessary to move toward a patient-centered medical home will continue to challenge small, independent primary care practices. Here we describe further analysis of a successful program to understand the roles of coleaders of a change management process.

Methods: Through an improvement collaborative we trained 2 coleaders (a physician and a non-physician) from 16 small primary care practices to institute depression care improvements.

Sustainability of depression care improvements: success of a practice change improvement collaborative.

Background: Long-term sustainment of improvements in care continues to challenge primary care practices. During the 2 years after of our Improving Depression Care collaborative, we examined how well practices were sustaining their depression care improvements.

Methods: Our study design used a qualitative interview follow-up of a modified learning collaborative intervention.

Methods for evaluating practice change toward a patient-centered medical home.

Purpose: Understanding the transformation of primary care practices to patient-centered medical homes (PCMHs) requires making sense of the change process, multilevel outcomes, and context. We describe the methods used to evaluate the country's first national demonstration project of the PCMH concept, with an emphasis on the quantitative measures and lessons for multimethod evaluation approaches.

Methods: The National Demonstration Project (NDP) was a group-randomized clinical trial of facilitated and self-directed implementation strategies for the PCMH.

Summary of the National Demonstration Project and recommendations for the patient-centered medical home.

This article summarizes findings from the National Demonstration Project (NDP) and makes recommendations for policy makers and those implementing patient-centered medical homes (PCMHs) based on these findings and an understanding of diverse efforts to transform primary care. The NDP was launched in June 2006 as the first national test of a particular PCMH model in a diverse sample of 36 family practices, randomized to facilitated or self-directed groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical record audits, and patient and clinical staff surveys.

Primary care practice development: a relationship-centered approach.

Purpose: Numerous primary care practice development efforts, many related to the patient-centered medical home (PCMH), are emerging across the United States with few guides available to inform them. This article presents a relationship-centered practice development approach to understand practice and to aid in fostering practice development to advance key attributes of primary care that include access to first-contact care, comprehensive care, coordination of care, and a personal relationship over time.

Methods: Informed by complexity theory and relational theories of organizational learning, we built on discoveries from the American Academy of Family Physicians' National Demonstration Project (NDP) and 15 years of research to understand and improve primary care practice.

Patient outcomes at 26 months in the patient-centered medical home National Demonstration Project.

Purpose: The purpose of this study was to evaluate patient outcomes in the National Demonstration Project (NDP) of practices' transition to patient-centered medical homes (PCMHs).

Methods: In 2006, a total of 36 family practices were randomized to facilitated or self-directed intervention groups. Progress toward the PCMH was measured by independent assessments of how many of 39 predominantly technological NDP model components the practices adopted.

Journey to the patient-centered medical home: a qualitative analysis of the experiences of practices in the National Demonstration Project.

Purpose: We describe the experience of practices in transitioning toward patient-centered medical homes (PCMHs) in the National Demonstration Project (NDP).

Methods: The NDP was launched in June 2006 as the first national test of a model of the PCMH in a diverse sample of 36 family practices, randomized to facilitated and self-directed intervention groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical records, and patient and practice surveys.