The practice perspective on transformation: experience and learning from the frontlines.

BACKGROUND: The transition of a primary care practice to a patient-centered medical home can be arduous. It requires time and resources from staff and leaders. Evidence to date suggests that not all medical homes are equally successful and that there is a substantial difference between the achievement of medical home recognition and meaningful transformation. However, little information is available to help a practice understand which approaches or strategies it might employ to prepare itself for successful transformation. OBJECTIVES: Leaders in 2 very different primary care practices that participated in the Safety Net Medical Home Initiative (SNMHI) offer their impressions, contextualizing the experience of practice transformation from the perspective of the medical practice and providing insight on approaches that may support success. DESIGN: The authors self-identified a set of shared approaches they believe allowed their organizations to successfully implement and sustain changes consistent with the PCMH Model of Care. RESULTS: The approaches are: (1) harness the power of meaning; (2) approach PCMH implementation as a large-scale cultural transformation; (3) engage frontline staff and patients in the change process; (4) develop leadership's capacity to manage and support the change process; (5) consider sustainability from the beginning.

Early experience of a safety net provider reorganizing into an accountable care organization.

Although safety net providers will benefit from health insurance expansions under the Affordable Care Act, they also face significant challenges in the postreform environment. Some have embraced the concept of the accountable care organization to help improve quality and efficiency while addressing financial shortfalls. The experience of Cambridge Health Alliance (CHA) in Massachusetts, where health care reform began six years ago, provides insight into the opportunities and challenges of this approach in the safety net. CHA's strategies include care redesign, financial realignment, workforce transformation, and development of external partnerships. Early results show some improvement in access, patient experience, quality, and utilization; however, the potential efficiencies will not eliminate CHA's current operating deficit. The patient population, payer mix, service mix, cost structure, and political requirements reduce the likelihood of financial sustainability without significant changes in these factors, increased public funding, or both. Thus the future of safety net institutions, regardless of payment and care redesign success, remains at risk.

Developing High-Functioning Teams: Factors Associated With Operating as a "Real Team" and Implications for Patient-Centered Medical Home Development.

Team-based care is a foundation of health care redesign models like the patient-centered medical home (PCMH). Yet few practices rigorously examine how the implementation of PCMH relates to teamwork. We identified factors associated with the perception of a practice operating as a real team. An online workforce survey was conducted with all staff of 12 primary care sites of Cambridge Health Alliance at different stages of PCMH transformation. Bivariate and multivariate analyses of factors associated with teamwork perceptions were conducted. In multivariate models, having effective leadership was the main factor associated with practice teamwork perceptions (odds ratio [OR], 10.49; 95% confidence interval [CI], 5.39-20.43); in addition, practicing at a site in an intermediate stage of PCMH transformation was also associated with enhanced team perceptions (OR, 2.44; 95% CI, 1.28-4.64). In a model excluding effective leadership, respondents at sites in an intermediate stage of PCMH transformation (OR, 1.95; 95% CI, 1.1-3.4) and who had higher care team behaviors (such as huddles and weekly meetings; OR, 3.41; 95% CI, 1.30-8.92), higher care team perceptions (OR, 2.65; 95% CI, 1.15-6.11), and higher job satisfaction (OR, 2.00; 95% CI, 1.02-3.92) had higher practice teamwork perceptions. This study highlights the strong association between effective leadership, care team behaviors and perceptions, and job satisfaction with perceptions that practices operate as real teams. Although we cannot infer causality with these cross-sectional data, this study raises the possibility that providing attention to these factors may be important in augmenting practice teamwork perceptions.

From healthcare to health: A proposed pathway to population health.

Innovations in payment are encouraging clinical-community partnerships that address health determinants. However, little is known about how healthcare systems transform and partner to improve population health. We synthesized views of population health experts from nine organizations and illustrated the resulting model using examples from four health systems. The transformation requires a foundation of primary care, connectors and integrators that span the boundaries, sharing of goals among participants, aligned funding and incentives, and a supporting infrastructure, all leading to a virtuous cycle of collaboration. Policies are needed that will provide funding and incentives to encourage spread beyond early adopter organizations.

Health Systems Innovation at Academic Health Centers: Leading in a New Era of Health Care Delivery.

Challenged by demands to reduce costs and improve service delivery, the U.S. health care system requires transformational change. Health systems innovation is defined broadly as novel ideas, products, services, and processes-including new ways to promote healthy behaviors and better integrate health services with public health and other social services-which achieve better health outcomes and/or patient experience at equal or lower cost. Academic health centers (AHCs) have an opportunity to focus their considerable influence and expertise on health systems innovation to create new approaches to service delivery and to nurture leaders of transformation. AHCs have traditionally used their promotions criteria to signal their values; creating a health systems innovator promotion track could be a critical step towards creating opportunities for innovators in academic medicine. In this Perspective, the authors review publicly available promotions materials at top-ranked medical schools and find that while criteria for advancement increasingly recognize systems innovation, there is a lack of specificity on metrics beyond the traditional yardstick of peer-reviewed publications. In addition to new promotions pathways and alternative evidence for the impact of scholarship, other approaches to fostering health systems innovation at AHCs include more robust funding for career development in health systems innovation, new curricula to enable trainees to develop skills in health systems innovation, and new ways for innovators to disseminate their work. AHCs that foster health systems innovation could meet a critical need to contribute both to the sustainability of our health care system and to AHCs' continued leadership role within it.

The Harvard Medical School Academic Innovations Collaborative: transforming primary care practice and education.

PROBLEM: Academic medical centers (AMCs) need new approaches to delivering higher-quality care at lower costs, and engaging trainees in the work of high-functioning primary care practices. APPROACH: In 2012, the Harvard Medical School Center for Primary Care, in partnership with with local AMCs, established an Academic Innovations Collaborative (AIC) with the goal of transforming primary care education and practice. This novel two-year learning collaborative consisted of hospital- and community-based primary care teaching practices, committed to building highly functional teams, managing populations, and engaging patients. The AIC built on models developed by Qualis Health and the Institute for Healthcare Improvement, optimized for the local AMC context. Foundational elements included leadership engagement and development, application of rapid-cycle process improvement, and the creation of teams to care for defined patient populations. Nineteen practices across six AMCs participated, with nearly 260,000 patients and 450 resident learners. The collaborative offered three 1.5-day learning sessions each year featuring shared learning, practice coaches, and improvement measures, along with monthly data reporting, webinars, and site visits. OUTCOMES: Validated self-reports by transformation teams showed that practices made substantial improvement across all areas of change. Important factors for success included leadership development, practice-level resources, and engaging patients and trainees. NEXT STEPS: The AIC model shows promise as a path for AMCs to catalyze health system transformation through primary care improvement. In addition to further evaluating the impact of practice transformation, expansion will require support from AMCs and payers, and the application of similar approaches on a broader scale.

Healing a community by innovating at a community health center.

Somava Stout led care transformation at a Boston-area clinic and now spearheads implementation of the patient-centered medical home model at the Cambridge Health Alliance.