Planting seeds for change in primary care practice
As primary care practices move toward a medical home model of care that provides comprehensive, patient-centered care, changes are needed to achieve the triple aim of better health care, better health, and reduced costs. "It's really hard for practices to do this on their own," says Michael Parchman, MD, director of the MacColl Center for Health Care Innovation at Group Health and a former Agency for Healthcare Research and Quality (AHRQ) staff member. "Change requires time for reflection and conversation to reach those 'aha' moments." Some practices are achieving change through those "aha moments" with the help of practice facilitators, trained individuals who support practices through quality improvement coaching.
"One of the most promising methods to support primary care transformation is a practice facilitation model that supports an ongoing, trusting relationship between an external facilitator and a primary care practice," says Parchman. "I make the analogy that it's like bringing the foreign exchange student home for dinner. It changes the whole tenor of the conversation when you have a stranger at the table, but in this case it's someone you know."
Many primary care practice facilitators help practices change the way they provide care, for example, moving to a team-based model of care. In addition, facilitators work with practices to improve care through specific activities, such as creating registries to identify and reach patients with specific illnesses or conditions, increasing the number of well child visits, selecting and maximizing the use of electronic health record (EHR) systems, and even health education activities.
AHRQ is helping to lay the groundwork for primary care practice facilitation. Through a Web site, a learning community, a newsletter, webinars, and a how-to guide, organizations and individuals interested in providing primary care practice facilitation services learn how to hire, train, and use practice facilitators (http://www.pcmh.ahrq.gov).
Facilitators often work with 10 or 20 practices at a time, notes Parchman, and tailor their work to a practice's needs. "Practice facilitators work with primary care practices to make changes. They don't do the work—they help the practice develop the skills and capabilities to do the work," explains Parchman. "In some ways, practice facilitation is like the old agricultural cooperatives that used extension agents to reach out to help farmers."
Parchman refers to an article published in the Annals of Family Medicine about a study that found that practices were 2.76 times more likely to adapt evidence-based guidelines if they had a practice facilitator. He says, "They empower the practice." But Parchman adds, "Practice facilitation is in its infancy. We still have not touched the vast universe of where primary care is delivered in the United States." He calls practices that take advantage of practice facilitation "early adapters." "The early adapters are willing to try something new and make sure they do it in a way that is transparent so others can observe," says Parchman. He likens early adapters to students who raise their hands in class and plead, "Choose me."
Spreading good ideas
"Because I run a PBRN (practice-based research network), I wanted something meaningful and useful for our practices that was different," said Lyndee Knox, PhD, founding director of LA Net, a primary care network in Los Angeles County, which has received research funding from AHRQ for work on primary care improvement through practice facilitation. Twenty-four organizations, mainly Federally Qualified Health Centers, participate in LA Net, representing 116 practice sites, which handle more than 1.2 million patient visits per year. "In the past, we had universities come in and say, 'We want to do research and study,' and our practices had enough of that. We never heard what happened," Knox told Research Activities. "We were looking for a way to be part of research and discovery, active quality improvement, and practice transformation."
She has had success through facilitation. "There's a difference between a consultant and a facilitator. A facilitator has intimate knowledge of the practice," says Knox. "The facilitator knows details about the practice's schedule, the receptionist, what EHR they're using so when a new treatment guideline or health services model shows promise, the facilitator already knows the landscape and can get to business very quickly and very efficiently. Basically, a facilitator has the key to the back door."
And that key turns on a regular basis. "Building on data-driven information, facilitators are improving how practices work with patients who have heart disease, asthma, and diabetes—on a large scale and efficiently," says Knox. "We like to think our facilitators are like honeybees. They're pollinators who spread good ideas."
They call them PEAs in Oklahoma
Cheryl Aspy, PhD, of the University of Oklahoma and the Oklahoma Physicians Resource/Research Network, hires facilitators who work at practices throughout the State, focusing on the needs of individual practices. Oklahoma is one of four States (the others are Pennsylvania, New Mexico, and North Carolina) that received a grant from AHRQ to support and evaluate facilitation in small and mid-sized practices to assist with primary care redesign and transformation. The grants to these four States support creating State-level collaborations with the other States to assist with their primary care transformation efforts. Each project has the potential to serve as a model for future Federal and State initiatives.
"We call our facilitators practice enhancement assistants or PEAs. We've had fun with the name," Aspy admits. "We've had split peas or part-time PEAs, peas in a pod or pregnant PEAs... It goes on and on." Four or five PEAs work with about 250 clinicians spread out in about 130 practices across the State.
"We look for PEAs with interpersonal skills, as well as computer skills to collect and manage data, and experience with quality improvement techniques, chart auditing, meeting facilitation, and practice redesign," says Aspy. "Most have at least a master's degree. Public health is a great background. They're more aware of problems."
To determine which practices would like a PEA, Aspy says, "We discovered the best way is to put a note up on the listserv asking 'Who is ready? Who is willing? Who is interested?'"
Aspy arranges for meetings between the PEAs and the practice. "We start with an academic detailing process. We go out and meet with practices," says Aspy. "We'll introduce the PEA if they haven't met. The PEA becomes part of the practice in a way. They approach solutions based on what's working down the street or in another town over. Sometimes it's local solutions that have credibility." Cara Vaught, MPH, a PEA in Oklahoma, has more than 10 years experience as a facilitator. "We don't have to make people change, we're just providing the avenues," she explains. "It's about repetition, lots of visits, and reminding them that I'm that 'project girl.'"
Katy Duncan Smith, MS, a PEA since 2005, says, "It can take at least 2 to 3 months to build a comfortable relationship with a practice before you can start doing real work." Taking time to develop relationships is one way facilitators can create an environment where change is possible.
"We're looking for a champion—it's usually not a physician, it's often an office manager—but it might be the nurse who has worked there for 20 years and everyone in the community knows her. She calls the shots and has the resources," says Smith. She has helped practices choose EHR systems. "We're self taught on so many systems, we can help practices utilize them."
Sometimes, facilitation involves the classic "other duties as assigned."
"Once we're out at a site, we can help with just about anything. We even help physicians maintain their certification for the American Board of Family Medicine," says Smith. "It's not difficult, but it's time-consuming for the physicians. It's a small part of what we do, but it's helpful. It's very important to me that when I walk into a clinic and they see my face, they go 'Oh great, Katy is here and I can ask for help and even if she doesn't have the answer, she's going to find it.'"
Finding out how to increase the number of well child visits in a practice she called "chaotic" took time for Crystal Turner, MPH After several visits, Turner admitted, "I felt overwhelmed. There was so much fussing. The office manager was taking on too many roles and the person who was pulling charts seemed to work well with patients. I suggested she would work better for referrals. Working with the office manager, we rearranged some staff members' positions." Turner also began monthly staff meetings. "The number of well child visits soared. It was a great, great success—even to this day, they're doing very well."
Editors note: You can find out more information about the patient-centered medical home at http://www.pcmh.ahrq.gov.