GPSC Literature Review

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  GPSC Literature Review What are the characteristics of an effective primary health care system for the future? Question 2: How do we best implement team-based care and the patient medical home?                               Prepared for the GPSC Workplan & Budget Working Group Prepared by Alana Rauscher, Health Care Management Consultant February 2, 2015

 

   

Table  of  Contents   Medical  Homes  ................................................................................................................................................  3     Medical  Home  Overview  ..............................................................................................................................  4   Definition  ......................................................................................................................................................................  4   Recognition  and  Accreditation  Programs  ..........................................................................................................  8   Examples  of  Medical  Homes  ...................................................................................................................................  9   Implementation  .......................................................................................................................................................  10   Transformation  and  Change  ................................................................................................................................................  12   Practice  Redesign  .....................................................................................................................................................................  16   Empanelment  .............................................................................................................................................................................  20   Team-­‐Based  Healing  Relationships  ..................................................................................................................................  21   Quality  Improvement  ..............................................................................................................................................................  23   Payment  Reform  .......................................................................................................................................................................  24   Health  Information  Technology  (HIT)  .............................................................................................................................  25  

  Team-­‐Based  Care  .........................................................................................................................................  26   Definition  ...................................................................................................................................................................  27   Team  Composition  ..................................................................................................................................................  27   Team  Characteristics  .............................................................................................................................................  30   Barriers  to  Team-­‐Based  Care  ..............................................................................................................................  31   Creating  Team-­‐Based  Care  ...................................................................................................................................  32  

  Physician  Extenders  ...................................................................................................................................  35   Nurses  and  Nurse  Practitioners  .........................................................................................................................  36   Physician  Assistants  ...............................................................................................................................................  37  

  Patient-­‐Centred  Care  ..................................................................................................................................  38   Patient  Engagement  /  Involvement  ..................................................................................................................  38   Patient  Perspective  .................................................................................................................................................  39   Patient  Experience  ..................................................................................................................................................  40  

  Reference  List  ...............................................................................................................................................  41    

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Medical  Homes     Main  Questions:     1. What  are  the  definitions/variations  of  medical  home?   2. How  do  we  implement  a  medical  home  (patient  medical  home/primary  care  home)?   3. What  is  team-­‐based  care  and  how  do  we  create  it?   4. What  is  the  role  of  the  GP  in  the  medical  home/primary  care  home?     Sub-­‐Questions   1. What  are  trends  or  models  of  multidisciplinary  care/team-­‐based  care?  For  example:  group   practice;  integrated  services;  practice  governance;  virtual  teams;  GP-­‐specialist  engagement;   allied  health  professionals;  physician  extenders;  community  health  service  providers   2. Physician  extenders:  What  type?  Which  jurisdictions  are  using  physician  extenders?  Have  they   changed  legislation  to  accommodate  physician  extenders?   3. What  does  a  team  look  like?  Team  composition  and  function  (fluid);  different  composition  for   different  populations  (collaboration  to  address  unique  challenges  of  specific  populations);   understanding  of  roles  and  responsibilities  in  scope  of  practice   4. Role  of  specialists  in  medical  home?  Are  they  members  of  a  team?  Is  the  specialist  the   “centre”  of  the  medical  home,  or  is  the  GP  the  centre?   5. Public  health  and  primary  health  care  roles  and  collaboration;  community  partnerships;  NGOs   6. Patient  engagement/involvement;  patient  experience;  patients  as  partners;  patient   perspectives  on  changes  needed  in  care   7. Public  education  about  primary  health  care;  self-­‐management;  peer  support   8. Patient  medical  continuity  of  care;  patient  coverage      

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Medical  Home  Overview     Definition     §

 

Patient  Centred  Medical  Homes  (PCMH)  were  first  introduced  by  the  American  Academy  of   Pediatrics  in  1967.  The  PCMH  model  was  an  extension  of  the  Chronic  Care  Model:  the  Chronic   Care  Model  was  developed  to  address  the  increasing  rate  of  patients  with  chronic  conditions   using  team-­‐based  care  (Green,  Wendland,  Carver,  Hughes  Rinker,  &  Mun,  2012).  Since  its   inception,  various  definitions  of  a  PCMH  have  been  developed:       The  Agency  for  Healthcare  Research  and  Quality  describes  a  PCMH  as  “a  model  structure  for   primary  health  care  that  is  patient-­‐centered,  comprehensive,  and  coordinated,  with  accessible   services  and  a  commitment  to  quality  and  safety;  the  goals  of  improved  care  quality,  patient   experience,  and  reduced  healthcare  costs”  (Fontaine  et  al.,  2014,  pg.1)   The  National  Committee  for  Quality  Assurance  describes  a  PCMH  as  “a  health  care  setting  that   facilitates  partnerships  between  individual  patients  and  their  personal  physicians,  and  when   appropriate,  the  patient’s  family.  Care  is  facilitated  by  registries,  information  technology,  health   information  exchange,  and  other  means  to  assure  that  patients  get  the  indicated  care  when  and   where  they  need  and  want  it  in  a  culturally  and  linguistically  appropriate  manner”  (Mitka,  2012,   pg.  770)     American  College  of  Physicians  describes  a  PCMH  as  “a  team-­‐based  model  of  care  led  by  a   personal  physician  who  provides  continuous  and  coordinated  care  throughout  a  patient’s  lifetime   to  maximize  health  outcomes.  The  PCMH  practice  is  responsible  for  providing  for  all  of  a  patient’s   health  care  needs  or  appropriately  arranging  care  with  other  qualified  professionals.  This  includes   the  provision  of  preventive  services,  treatment  of  acute  and  chronic  illness,  and  assistance  with   end-­‐of-­‐life  issues.  It  is  a  model  of  practice  in  which  a  team  of  health  professionals,  coordinated  by   a  personal  physician,  works  collaboratively  to  provide  high  levels  of  care,  access  and   communication,  care  coordination  and  integration,  and  care  quality  and  safety”  (Primary  Care   Progress,  2014).      

  The  College  of  Family  Physicians  of  Canada  defines  a  Canadian  medical  home  as:     “a  medical  office  or  clinic  where  each  patient  would  have:  her  or  his  own  family  doctor;  other  health   professionals  working  together  as  a  team  with  the  patient’s  own  family  doctor;  timely  appointments   for  all  visits  with  the  family  doctor  and  with  other  primary  care  team  members;  arrangement  and   coordination  of  all  other  medical  services,  including  referrals  to  consulting  specialists;  an  electronic   medical  record;  and  ongoing  evaluation  and  quality  improvement  programs”  (College  of  Family   Physicians  of  Canada,  [CFPC],  2009,  pg.7)  

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    The  College  of  Family  Physicians  of  Canada  further  outline  the  system  supports  that  are  required  for   the  medical  home,  including  (CFPC,  2009):     § Sufficient  health  human  resources;   § Adequate  funding  and  clearly  defined  liability  protection  for  all  team  members;   § System  support  for  electronic  health  record  systems;   § Agreements  from  each  health  care  profession  about  the  clinical,  and  organizational  roles  and   responsibilities  for  all  team  members,  and;     § Establishment  of  links/networks  with  other  health  professionals  and  hospitals  in  the   community.     The  patient  medical  home  aims  to  ensure  that:   1. Every  person  in  Canada  will  have  the  opportunity  to  be  part  of  a  family  practice  that  serves  as   a  patient  medical  home  for  themselves  and  their  families;   2. The  patient  medical  home  will  produce  the  best  possible  health  outcomes  for  the  patients,   the  practice  populations,  and  the  communities  they  serve;  and   3. The  patient  medical  home  will  reinforce  the  importance  of  the  Four  Principles  of  Family   Medicine  for  both  family  physicians  and  their  patients.     The  goals  of  the  medical  home  state  that  the  patient’s  medical  home  will  (CPFC,  2009):   1. Be  patient  centred;   2. Ensure  that  every  patient  has  a  personal  family  physician  who  will  be  the  most  responsible   provider  of  his  or  her  medical  care;   3. Offer  its  patients  a  broad  scope  of  services  carried  out  by  teams  or  networks  of  providers,   including  each  patient’s  personal  family  physician  working  together  with  peer  physicians,   nurses,  and  others;   4. Ensure  i)  timely  access  to  appointments  in  the  practice  and  ii)  advocacy  for  and  coordination   of  timely  appointments  with  other  health  and  medical  services  needed  outside  the  practice;   5. Provide  each  of  its  patients  with  a  comprehensive  scope  of  family  practice  services  that  also   meets  population  and  public  health  needs;   6. Provide  continuity  of  care,  relationships,  and  information  for  its  patients.   7. Maintain  electronic  medical  records  for  its  patients;   8. Serve  as  ideal  sites  for  training  medical  students,  family  medicine  residents,  and  those  in   other  health  professions,  as  well  as  for  carrying  out  family  practice  and  primary  care  research;   9. Carry  out  ongoing  evaluation  of  the  effectiveness  of  its  services  as  part  of  its  commitment  to   continuous  quality  improvement;  and   10. Be  strongly  supported  i)  internally,  through  governance  and  management  structures  defined   by  each  practice  and  ii)  externally  by  all  stakeholders,  including  governments,  the  public,  and   other  medical  and  health  professions  and  their  organizations  across  Canada.        

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In  2007,  the  Statement  of  Joint  Principles  were  established  by  the  Patient-­‐Centered  Primary  Care   Collaborative  to  describe  the  PCMH:   o The  Patient-­‐Centred  Primary  Care  Collaborative  is  a  group  of  large  organizations,  primary  care   societies,  national  health  plans,  patient  groups,  and  others  who  support  the  PCMH  concept,   including  by  the  American  Academy  of  Family  Physicians,  American  Academy  of  Pediatrics,   American  College  of  Physicians,  and  the  American  Osteopathic  Association  (Backer,  2009;   Janamian,  Jackson,  Glasson,  &  Nicholson,  2014)   o They  were  further  endorsed  by  various  other  organizations  and  associations  (e.g.  American   Medical  Association)  (Backer,  2009).  However,  many  others  found  the  principles  to  be   physician-­‐centric  (Manion,  2012).   o The  Joint  Principles  emphasize  patients’  ongoing  relationship  with  a  personal  physician;  team   approaches  to  care;  a  whole-­‐person  orientation;  mechanisms  to  support  care  integration,   quality,  safety  and  access;  and  payment  for  added  value.  

The  Joint  Principles  for  Patient-­‐Centred  Medical  Homes     (1)  Access  to  a  personal  physician:  each  patient  has  an  ongoing  relationship  with  a  personal   physician.  The  personal  physician  provides  first  contact,  continuous,  and  comprehensive  care.   (2)  Physician-­‐directed  medical  practice:  the  personal  physician  leads  a  team  of  individuals  who   collectively  take  responsibility  for  the  ongoing  care  of  patients.   (3)  Whole-­‐person  orientation:  the  personal  physician  is  responsible  for  providing  for  all  the  patient’s   healthcare  needs  and  for  appropriately  arranging  care  with  other  qualified  professionals.  The   personal  physician  is  responsible  for  providing  care  throughout  all  stages  of  life,  as  well  as  for  acute   care,  chronic  care,  preventive  services,  and  end  of  life  care.   (4)  Care  coordination  and/or  integration:  the  PCMH  will  provide  continuous  and  comprehensive  care   across  all  elements  of  the  complex  health  care  system  and  within  the  patient’s  community.  In  PCMH,   coordinated  care  is  supported  by  patient  registries,  information  technology,  health  information   exchange,  use  of  interpreters,  etc.   (5)  Quality  and  safety  benchmarking:  quality  and  safety  are  key  factors  in  the  PCMH.  Specific   activities  related  to  quality  and  safety  could  include  individualized  care  plans,  evidence-­‐based   decision  support  tools,  collection  and  reporting  of  quality  improvement  data,  use  of  information   technology.   (6)  Enhanced  care  availability:  enhanced  care  is  available  through  systems  such  as  open  access   scheduling,  expanded  hours,  and  new  options  for  communication.   (7)  Practice  payment  reform:  payment  is  derived  from  a  blended  funding  model  that  combines   capitation,  fees  for  services,  and  bonuses.  Reimbursement  strategy  provides  incentives  for  patient-­‐ centered  care  as  well  as  population-­‐oriented  preventive  care.     (Carney  et  al.,  2009;  Crabtree  et  al.,  2010;  Green  et  al.,  2012;  Janamian  et  al.,  2014;  Kirschner  &  Barr,  2010;  Meyer,  2010;   Rosser,  Colwill,  Kasperski,  &  Wilson,  2011)  

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The  Agency  for  Healthcare  Research  and  Quality  describes  five  functions  and  attributes  of  the   PCMH.  These  attributes  are  similar  to  the  Joint  Principles  described  by  the  Patient-­‐Centred   Primary  Care  Collaboration.  They  five  functions  and  attributes  include  (Agency  for  Healthcare   Research  and  Quality,  [AHRQ],  n.d.;  Nielsen,  Olayiwola,  Grundy,  Grumbach,  &  Shaljian,  2014;   Wexler,  Hefner,  Welker,  &  McAlearney,  2014):     1. Comprehensive  Care:  continuous  and  comprehensive  care  is  provided  by  teams  who  are   collectively  responsible  for  delivering  care.  PCMH  team  members  may  include  physicians,   advanced  practice  nurses,  physician  assistants,  nurses,  pharmacists,  nutritionists,  social   workers,  educators,  care  coordinators,  etc.   2. Patient-­‐Centered:  patient-­‐centred  care  is  when  providers  understand  and  respect  each   patient’s  unique  needs,  culture,  values,  and  preferences.  Practices  that  deliver  patient-­‐ centred  care  engage  patients  as  partners  in  their  care  (e.g.  in  establishing  care  plans).   3. Coordinated  Care:  a  team  of  care  providers  coordinates  care  across  all  elements  of  the   broader  health  care  system,  including  specialty  care,  hospitals,  home  health  care,  and   community  services  and  supports.  Particularly  critical  during  transitions  between  sites  of  care.   4. Accessible  Services:  delivers  accessible  services  with  shorter  waiting  times  for  urgent  needs,   enhanced  in-­‐person  hours,  around-­‐the-­‐clock  telephone  or  electronic  access  to  a  member  of   the  care  team,  and  alternative  methods  of  communication,  such  as  email  and  telephone  care.   5. Quality  and  Safety:  demonstrates  a  commitment  to  quality  and  quality  improvement  by:   o Using  evidence-­‐based  medicine  and  clinical  decision-­‐support  tools  to  guide  shared   decision  making  with  patients  and  families;     o Engaging  in  performance  measurement  and  improvement;   o Measuring  and  responding  to  patient  experiences  and  patient  satisfaction;  and   o Practicing  population  health  management.  

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  Additional  functions  and  attributes  include:  access  and  communication  processes;  patient   tracking  and  registry  functions;  care  management  guidelines;  patient  self-­‐management  support;   diagnostic  test  tracking;  referral  tracking;  performance  reporting  and  improvement;  advanced   electronic  communications;  payment  reform;  etc.  (Primary  Care  Progress,  2014)  

  Additional  Messages  About  The  Patient-­‐Centred  Medical  Home:     § The  PCMH  model  is  a  systematic  approach  to  coordinating  and  integrating  primary  health  care   services  that  ensures  optimal  value  and  health  outcomes  (Bidassie,  Davies,  Stark,  &  Boushon,   2014).   § The  PCMH  is  described  by  the  seven  Joint  Principles  identified  by  the  Patient-­‐Centred  Primary   Care  Collaborative;  all  of  the  seven  principles  are  highly  interdependent  (Nutting  et  al.,  2009).   § The  PCMH  is  made  up  of  four  “pillars”:  practice  organization;  health  information  technology;   quality  measures;  and  patient  experience  (Markova,  Mateo,  &  Roth,  2012).     § The  PCMH  emphasizes  care  that  is  (Grant  &  Greene,  2012;  Martin,  2014;  Tuepker  et  al.,  2014):  

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o Highly  accessible,  quality  and  safe;   o Continuous,  comprehensive,  coordinated,  compassionate;     o Patient  and  family  centered,  and  culturally  and  linguistically  appropriate;     o Team-­‐based;  and   o Data-­‐informed     The  PCMH  improves  access  to  care;  incorporates  electronic  health  records;  facilitates  access  to   specialty  care,  integration  of  specialty  care  services  (e.g.,  mental  health  and  oral  health  care  in   the  primary  care  setting),  transportation  and  case  management  to  enhance  care  coordination   (Grant  &  Greene,  2012).     PCMH  studies  continue  to  demonstrate  impressive  improvements  across  a  broad  range  of   categories,  including:  cost;  utilization;  population  health;  prevention;  access  to  care;  and  patient   satisfaction.  A  gap  still  exists  in  reporting  impact  on  clinician  satisfaction  (Nielsen  et  al.,  2014).     The  PCMH  model  holds  a  great  deal  of  potential  in  addressing  the  broken  healthcare  system,  but   at  the  same  time,  it  also  faces  many  obstacles  in  terms  of  payment  reform,  professional  support,   and  patient  participation  (Green  et  al.,  2012).   Main  concerns  about  the  PCMH  model  include:  possible  unrealistic  expectations;  the  potential   inability  of  small  practices  to  successfully  implement  the  model;  and  the  problem  of  obtaining   adequate  physician  reimbursement  (Kirschner  &  Barr,  2010).     Resources  for  PCMH  include  (Schram,  2012):   o Agency  for  Healthcare  Research  and  Quality  Patient  Centered  Medical  Home  Resource   Center   o National  Committee  for  Quality  Assurance  Patient-­‐  Centered  Medical  Home   o National  Committee  for  Quality  Assurance  Recognition  Training  PCMH   o American  Academy  of  Family  Physician  Medical  Home  Legislation  by  State   o The  Joint  Commission  Patient  Centered  Medical  Home  Self-­‐Assessment  Tool   o Utilization  Review  Accreditation  Commission  Patient  Centered  Health  Care  Home  Program  

   

Recognition  and  Accreditation  Programs   § §

  Recognition  and  accreditation  programs  provide  a  useful  roadmap  for  quality  improvement  and   practice  transformation  (Nielsen  et  al.,  2014).   There  are  various  US-­‐based  organizations  that  focus  on  PCMH  certification  and  accreditation:     The  National  Committee  for  Quality  Assurance     The  National  Committee  for  Quality  Assurance  has  a  three-­‐tiered  recognition  process  that  is  to  be   accomplished  over  a  3-­‐year  time  period.  To  achieve  recognition,  PCMH  must  meet  the  

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§

§   §

   

requirements  that  are  categorized  under  nine  standards  (Backer,  2009;  Fifield  et  al.,  2013;   Kirschner  &  Barr,  2010;  Nielsen  et  al.,  2014):     (1)  Access  and  communication   (2)  Patient  tracking  and  registry  functions   (3)  Care  management   (4)  Patient  self-­‐management  support   (5)  Electronic  prescribing   (6)  Test  tracking   (7)  Referral  tracking   (8)  Performance  reporting  and  improvement   (9)  Advanced  electronic  communications     Other  recognition  and  accreditation  bodies  include:  Accreditation  Association  for  Ambulatory   Health  Care,  The  Joint  Commission,  and  URAC  (formerly  the  Utilization  Review  Accreditation   Commission).     In  addition  to  these  national  programs,  states  (e.g.  Minnesota  Departments  of  Health  and  Human   Services,  and  several  commercial  health  plans  (e.g.  Blue  Cross  Blue  Shield  Michigan)  have   developed  their  own  standards  (Nielsen  et  al.,  2014).   The  specific  elements,  processes,  administrative  burden,  and  costs  for  undergoing  recognition   differ  significantly  across  programs  (Nielsen  et  al.,  2014).   These  recognition  and  accreditation  processes  do  not  offer  instructions  on  how  to  transition  to  a   patient-­‐centred  medical  home.  This  is  due  to  the  fact  that  each  practice  is  unique  and  therefore   requires  personalized  implementation  plans.  Consequently,  each  practice  must  create  their  own   implementation  plan  that  adheres  to  the  PCMH  principles  (Green  et  al.,  2012).  

Examples  of  Medical  Homes   §

 

  There  are  many  different  variations  of  the  PCMH  across  the  US  and  Canada.  Some  examples  of   the  different  models  are:     o The  National  Committee  for  Quality  Assurance  (NCQA)   o The  Commonwealth  Fund   o Veterans  Health  Administration  -­‐  Patient  Aligned  Care  Teams   o Geisinger  Health  System  –  ProvenHealth  Navigator  (PHN)    

 

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Implementation      

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“PCMH  demonstration  projects  suggest  organizational  and  individual  readiness  for  change  are   often  overestimated,  that  the  magnitude  and  time  frame  for  PCMH  changes  are  often   underestimated,  and  that  many  are  seriously  undercapitalized”  (Quinn  et  al.,  2013,  pg.  358)  

Specific  implementation  plans  and/or  guides  for  transforming  into  a  patient-­‐centred  medical   home  have  not  been  identified  due  to  the  need  to  consider  local  needs,  preferences,  culture,   infrastructure,  etc.  (Quinn  et  al.,  2013;  Wagner  et  al.,  2012).   Therefore,  the  practices  wishing  to  transform  to  a  PCMH  must  develop  a  coherent   implementation  strategy  that  includes  ways  to  ensure  practices  are  capable  of  making  and   sustaining  change  and  able  to  prioritize  the  order  in  which  components  are  adopted  (Crabtree  et   al.,  2010).     Stout  &  Weeg  (2014)  identified  various  approaches  for  successful  implementation  and   sustainment  of  the  patient-­‐centred  medical  home  (Stout  &  Weeg,  2014):       o Harness  the  power  of  meaning;     o Approach  PCMH  implementation  as  a  large-­‐scale  cultural  transformation;     o Engage  frontline  staff  and  patients  in  the  change  process;   o Encourage  staff  to  participate  in  creating  a  vision  for  the  transformation  effort;   o Develop  leadership’s  capacity  to  manage  and  support  the  change  process;  and   o Consider  sustainability  from  the  beginning.   The  Patient-­‐Centred  Primary  Care  Collaborative  identified  five  factors  that  contribute  towards  the   successfully  implementing  the  PCMH  (Patient-­‐Centred  Primary  Care  Collaborative,  [PCPCC],   2014):   1. An  effective  leadership  team  to  oversee  the  change  from  start  to  finish;  the  leadership   team  will  be  comprised  of  a  physician  champion,  a  practice  administrator,  as  well  as   both  clinical  and  clerical  leads.   2. Staff  engagement  and  empowerment  leads  to  active,  engaged  and  creative  members   of  the  change  management  team.   3. Integration  and  management  of  change  takes  constant  and  active  monitoring,  building   on  what  is  working  well,  changing  and  modifying  what  is  not  working  well.   4. Agree  on  and  establish  a  common  framework  of  measuring  the  impact  of  the   transformation.   5. Actively  solicit  honest  feedback  to  learn  about  how  things  are  progressing.  

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      1. 2. 3. 4. 5.

Core  Elements  for  Practice  Implementation  to  a     Patient-­‐Centred  Medical  Home  

Transformative  Change:  leadership  support;  engaged  leadership   Quality  Improvement:  quality  improvement  strategy   Empanelment:  linking  patients  to  specific  providers   Continuous  and  Team-­‐Based  Care:  interdisciplinary  teams   Practice  Redesign:  organized  evidence-­‐based  care,  enhanced  access,  care  coordination,   patient-­‐centred  care   6. Payment  Reform:  new  reimbursement  models   7. Health  Information  Technology:  electronic  health  records,  electronic  medical  records    

(Coleman  et  al.,  2014;  Fontaine  et  al.,  2014;  Grant  &  Greene,  2012;  Quinn  et  al.,  2013;  Rosser  et  al.,  2011;  Wagner,  Gupta,   &  Coleman,  2014)  

    §

Wagner  et  al.  (2012)  identified  eight  change  concepts  that  should  be  viewed  as  general  guidance   for  transforming  to  a  patient-­‐centred  medical  home.  Wagner  et  al.  (2012)  further  linked  to  the   Chronic  Care  Model  (CCM),  one  of  the  models  in  which  the  PCMH  model  was  derived  from.  The   eight  change  concepts  include:       Engaged  (and  active)  leadership  (CCM  element  =  health  care  organization):  visible  leadership   (clinical,  administrative,  and  clerical)  that  can  help  staff  envision  a  better  organization  and   improved  care,  establish  a  quality  improvement  apparatus  and  culture,  and  ensure  that  staff   have  the  time  and  training  to  work  on  system  change.   Quality  improvement  strategy  (CCM  element  =  health  care  organization  and  information   system):  an  effective  QI  strategy  relies  on  routine  performance  measurement  to  identify   opportunities  for  improvement  and  uses  rapid-­‐cycle  change  methods  to  test  ideas  for  change.   Empanelment  (CCM  element  –  information  system  and  proactive  care):  a  process  to  link   each  patient  or  family  with  a  specific  provider;  facilitates  continuity  of  relationship;  allows   practice  teams  to  monitor  their  panel  to  identify  and  reach  out  to  patients  needing  more   attention  and  services   Continuous  and  team-­‐based  healing  relationships  (CCM  element  =  practice  redesign  –  team   care):  physician-­‐led  interdisciplinary  teams  are  collectively  responsible  for  the  care  of  the   patient;  each  member  of  the  team  function  to  their  full  practice  scope.   Organized,  evidence-­‐based  care  (CCM  element  =  practice  redesign  –  planned  care,  decision   support,  and  information  systems):  using  information  system  tools  like  registries  enables   practices  to  identify  gaps  in  care  for  patients  before  they  visit,  so  practice  teams  can  plan  and   organize  care  to  ensure  all  patient  needs  are  met;  decision  support  systems  improve  care  by   alerting  providers  when  services  are  needed  and  helping  them  make  evidence-­‐based  choices.  

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  Patient-­‐centred  interactions  (CCM  element  =  activate  patients  and  self-­‐management   support):  patient-­‐centered  practices  endeavor  to  increase  their  patients’  involvement  in   decision-­‐  making,  care,  and  self-­‐management.   Enhances  access:  enhanced  access  is  a  key  component  of  the  PCMH;  this  can  be  achieved  by   providing  care  during  and  after  office  hours.   Care  coordination  (CCM  element  =  community  resources,  practice  redesign  –  care   management):  effective  care  coordination  involves  helping  patients  find  and  access  high-­‐ quality  service  providers,  ensuring  that  appropriate  information  flows  between  the  PCMH  and   the  outside  providers,  and  tracking  and  supporting  patients  through  the  process.   §

  §

§

  §  

  These  eight  change  concepts  were  subsequently  translated  into  three  steps  that  practices  can   apply  when  transforming  to  a  patient-­‐centred  medical  homes  (Wagner  et  al.,  2014):     (1) Lay  the  foundation:  engage  leadership,  develop  a  quality  improvement  strategy   (2) Build  Relationships:  establish  empanelment,  foster  continuous  and  team-­‐based   healing  relationships   (3) Change  Care  Delivery:  organize  evidence-­‐based  care,  create  patient-­‐centered   interactions   (4) Reduce  Barriers  to  Change:  enhance  access,  care  coordination   To  support  the  successful  implementation  of  the  PCMH,  practices  must  undergo  substantial   practice  restructuring  that  requires  additional  investment  /  resources  to  cover  the  initial  and   ongoing  costs  (Fontaine  et  al.,  2014;  Homer  &  Baron,  2010;  Kirschner  &  Barr  2010;  Tuepker  et  al.,   2014).     In  addition  to  additional  investment  /  resources,  practices  also  requires  substantial  amount  of   time  to  implement  the  PCMH.  To  date,  many  of  the  pilot  /  demonstration  projects  have  sought  to   establish  PCMH  within  a  2-­‐3  year  timeline;  evidence  now  shows  that  it  will  take  much  more  time   then  this  to  transform  into  a  PCMH  (Crabtree  et  al.,  2010).   One  challenge  is  paying  attention  to  implementing  components  while  also  ensuring  that  patients’   experiences  are  not  negatively  affected  (Crabtree  et  al.,  2010).  

Transformation  and  Change   §

The  transformation  to  a  patient-­‐centred  medical  home  requires  significant  paradigm  shifts  in   infrastructure,  culture,  and  practice  to  support  the  change  process  (Fontaine  et  al.,  2014;  Wagner   et  al.,  2014).  For  example,  for  practices  to  successfully  transform  into  a  PCMH,  they  must  consider   the  following  shifts  in  mental  models  (Crabtree  et  al.,  2010;  Nutting,  Crabtree  &  McDaniel,  2012):     1. Physician  centric  model  of  care  to  team-­‐based  care  that  respects  all  disciplines  as   equal  members  of  the  team.  

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  2. Authoritative  /  authoritarian  leadership  to  facilitative  leadership  that  mobilizes  and   empowers  all  staff.   3. Episodic  care  of  1  patient  to  proactive,  population-­‐based  care  that  considers  the  health   of  a  defined  population/community.   4. Physician-­‐centred  care  to  patient-­‐centred  care  where  the  patient  is  a  key  partner  in   their  care.   5. Fee  for  service  to  blended  payment  model  that  rewards  based  on  proactive  prevention   and  population-­‐based  care.        

Initial  Lessons  from  the  National  Demonstration  Project     The  National  Demonstration  Project  for  patient-­‐centred  medical  homes  was  launched  in  2006  by  the   American  Academy  of  Family  Physicians  (Nutting  et  al.,  2009).  Initial  lessons  learned  from  the   National  Demonstration  Project  are  as  follows:     1. Becoming  a  PCMH  requires  transformation   2. Technology  needed  for  the  PCMH  is  not  plug  and  play   3. Transformation  to  the  PCMH  requires  personal  transformation  of  physicians   4. Change  fatigue  Is  a  serious  concern  even  within  capable  and  highly  motivated  practices   5. Transformation  to  a  PCMH  Is  a  developmental  process   6. Transformation  is  a  local  process         § Transformation  implies  a  radical  change.  Therefore,  transformation  to  a  PCMH  requires  more   than  just  a  sequence  of  discrete,  incremental  structural  and  process  changes  that  could  be   checked  off  a  list  (CFPC,  2009;  Crabtree  et  al.,  2010).  It  requires  an  iterative,  developmental,  and   continuous  process  (Cronholm  et  al.,  2013;  Nutting  et  al.,  2009;  Nutting  et  al.,  2010).     § Successful  transformation  to  a  PCMH  requires  long  term  and  tangible  commitment  to   transformational  change  that  focuses  on  leadership,  teamwork,  high-­‐quality  communication,  staff   development,  and  ongoing  support  for  a  culture  of  change  (Janamian  et  al.,  2014).  More   specifically,  key  elements  that  are  critical  to  the  change  and  transformation  process  include   (Bleser  et  al.,  2014;  Crabtree  et  al.,  2010;  Cronholm  et  al.,  2013;  Fontaine  et  al.,  2014;  Green  et   al.,  2012;  Highsmith  &  Berenson,  2011;  Homer  &  Baron,  2010;  Janamian  et  al.,  2014;  Long,  Dann,   Wolff,  &  Brienza,  2014;  Nutting  et  al.,  2009;  Nutting  et  al.,  2010;  Tuepker  et  al.,  2014;  Wagner  et   al.,  2014):     o Organizational  commitment  and  approach  to  process  change  and  transformation;    

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  o Share  values,  vision,  and  goals  for  change  process;     o Culture  of  change,  including  external  and  internal  motivators  for  change:   § Internal  motivations:  derive  from  anticipated  enhancements  in  patient,  provider,   and  staff  satisfaction  with  care.     § External  motivations:  derive  from  efforts  that  can  make  a  practice’s   transformation  financially  viable.   o Strong  desire  to  change;   o Buy-­‐in  at  all  levels  of  the  organization,  including  physician  buy-­‐in;   o Committed,  engaged,  and  active  leadership  that  has  a  systems  perspective,  can  envision   change,  and  is  an  expert  in  (or  at  least  receptive  to)  change  management;   o A  supportive  organizational  culture;   o A  high  degree  of  support,  motivation,  communication  (e.g.  communication  plan);   o Considerable  time  and  resources  (financial  and  human);   o A  strong  core  (e.g.  material  and  human  resources,  organizational  structure,  clinical   process);   o Early  involvement  of  staff,  patients  and  families;   o Adaptive  reserve  (healthy  relationship  infrastructure,  aligned  management  model,  and   facilitative  leadership);   o Shifts  in  roles  and  mental  models  of  members  of  the  practice  team:     § Mental  models  are  the  internal  representations  that  result  from  one’s  perception  of   the  external  culture  and  individual  experience  (Cronholm  et  al.,  2013);   o Outside  expert  and  facilitative  assistance  to  support  the  transformation  process;   o Continuous  quality  improvement;   o Health  information  technology;  and,   o Attention  to  the  local  environment.    

Key  Barriers  to  the  Transformation  Process     Transformation  efforts  were  slowed  or  ceased  by  (Fontaine  et  al.,  2014;  Janamian  et  al.,  2014;  Quinn   et  al.,  2013;  Tuepker  et  al.,  2014;  Wagner  et  al.,  2014):     o Top-­‐down  approach  without  clinical  buy-­‐in     o Ineffective  change  management  processes   o Lack  of  leadership  needed  to  guide  the  practice  through  the  change   o Lack  of  an  infrastructure  and  culture  to  support  change     o Lack  of  readiness  for  change  or  change  fatigue   o Lack  of  communication  and  trust     o Unresponsive  management    

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  o Staff  skepticism  and/or  resistance  to  change  (e.g.  new  roles,  work  flow)         § Engaged  leadership  is  one  of  the  most  important  contributing  factor  towards  the  successful   transformation  to  a  patient-­‐centred  medical  home  (Fontaine  et  al.,  2014;  Wagner  et  al.,  2014).   The  “engaged”  descriptor  indicates  that  leaders  not  only  need  to  make  the  transformation  an   organizational  priority,  but  they  must  also  visibly  drive  change  themselves,  promote  a  supportive   culture,  secure  resources  (financial,  and  human),  build  internal  capacity,  and  help  staff  address   barriers  (Wagner  et  al.,  2012;  Wagner  et  al.,  2014).     § It  is  therefore  important  that  effective  leaders  have  knowledge  and  skills  in  three  important   domains  (Wagner  et  al.,  2014):     (1) Systems  thinking,  or  the  capacity  to  understand  the  practice  as  a  series  of  interrelated   processes  that  determine  performance;   (2) Envisioning  change,  or  recognizing  the  gap  between  current  and  optimal  practice  and   promising  changes  to  close  the  gap;  and   (3) Change  management,  or  implementing  proven  strategies  for  quality  improvement  and   engaging  staff  in  the  process.     § It  has  been  recommended  that  additional  support  and  resources  be  provided  to  drive  the   transformation  to  a  patient-­‐centred  medical  home.  For  example  addition  resources  are  required   to  help  practices  develop  their  adaptive  reserve,  hire  additional  staff,  and  implement  electronic   health  record  system  (Coleman  et  al.,  2014;  Crabtree  et  al.,  2010;  Cronholm  et  al.,  2013;  Nielsen   et  al.,  2014).     § External  experts,  such  as  practice  facilitator,  coaches,  medical  home  facilitators,  QI  experts,   change  management  consultants,  etc.  may  also  help  support  the  transformation  process     (Coleman  et  al.,  2014;  Homer  &  Baron,  2010).  Practice  facilitators  are  health  care  professionals   who  work  with  practice  staff  over  a  sustained  period  of  time  to  help  initiate,  implement,  and   sustain  redesign  activities.  Applying  their  expertise  in  change  management,  quality  improvement,   including  plan-­‐  do-­‐study-­‐act  cycles,  and  health  information  technology,  practice  facilitators  assess   a  practice’s  needs  and  its  capacity  to  reorganize  and  restructure  (Highsmith  &  Berenson,  2011).  In   particular  they  can  enhance  adaptive  reserve,  facilitate  implementation  of  new  primary  care   practice  models,  improve  quality  and  appropriateness  of  care,  and  reduce  costs.  They  also  can   help  with  advanced-­‐access  scheduling,  group  medical  visits,  self-­‐management  education,  and   team-­‐based  care.  Frequent  in-­‐person  contact  between  practice  facilitators  and  staff  helps  to  build   the  relationships  required  to  sustain  change  (Highsmith  &  Berenson,  2011).     § Involvement  of  staff,  patients  and  families  is  also  an  essential  factor  in  the  transformation  process   (Fontaine  et  al.,  2014;  Homer  &  Baron,  2010;  Kirschner  &  Barr,  2010).  For  example,  early   involvement  of  all  staff  in  the  planning  and  transformation  process  may  reduce  some  resistance   to  change  (Quinn  et  al.,  2013).  Patient  engagement  may  lead  to  an  enhanced  understanding  of  

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the  patient-­‐centred  medical  model,  which  may  result  in  increased  acceptance  of  this  model   (Backer,  2009).    

Adaptive  Reserve     Promoting  adaptive  reserve,  local  control  of  the  developmental  pathway,  and  ownership  of  the   process  is  critical  for  the  practice  transformation  process  (Crabtree  et  al.,  2010;  Homer  &  Baron,   2010;  Nutting  et  al.,  2010).       Adaptive  reserve  is  defined  as  the  practice’s  capacity  for  organizational  learning  and   development.  It  seems  to  be  a  function  of  unified  leadership  that  can  envision  a  future,   facilitate  staff  involvement  in  a  strategy  for  getting  there,  and  devote  time  to  plan,  make  and   evaluate  changes  (Wagner  et  al.,  2014).  Adaptive  reserve  includes  a  healthy  relationship   infrastructure,  an  aligned  management  model,  and  facilitative  leadership.     Adaptive  reserve  is  the  practice’s  most  precious  resources  during  the  transformation  process   and  therefore  the  practice’s  adaptive  reserve  should  be  assessed  and  steps  to  support  and   strengthen  it  should  be  identified  and  implemented  (Crabtree  et  al.,  2010;  Nutting  et  al.,   2010).     Janamian  et  al.  found  that  practices  without  adaptive  reserve,  that  is  the  capacity  for   organizational  learning  and  development,  were  more  likely  to  experience  “change  fatigue”   and  less  likely  to  successfully  implement  the  PCMH  model  (Janamian  et  al.,  2014).     Aligned  management  model  is  when  clinical  care,  practice  operations,  and  financial  functions   share  and  reflect  a  consistent  vision  (Nutting  et  al.,  2010).     Facilitative  leadership  entails  establishing  and  articulating  a  vision,  building  the  relationships   required  to  accomplish  it,  and  allocating  and  prioritizing  resources  to  enable  it  (Homer  &   Baron,  2010).     Adaptive  capacity  is  the  ability  of  a  practice  to  undertake  rapid  and  ongoing  change  (Homer  &   Baron,  2010).       § For  the  PCMH  model  to  be  integrated  into  the  larger  and  complex  health  care  system,  changes   cannot  be  made  just  in  the  primary  care  model,  but  must  also  be  made  in  specialty  care  models   and  hospitals  (Crabtree  et  al.,  2010)      

Practice  Redesign   §

Transforming  primary  care  practices  into  patient-­‐centred  medical  homes  will  require  substantial   changes  in  workflow  (Patel  et  al.,  2013).  

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    Organized,  Evidence-­‐Based  Care   § To  routinely  deliver  organized  evidence-­‐based  care,  PCMH  should  (Wagner  et  al.,  2012;  Wagner   et  al.,  2014):     o Use  planned  care  according  to  patient  need   o Identify  high-­‐risk  patients  and  ensure  they  are  receiving  appropriate  care  and  case   management  services   o Use  point-­‐of-­‐care  reminders  based  on  clinical  guidelines   o Enable  planned  interactions  with  patients  by  making  up-­‐to-­‐date  information  available  to   providers  and  the  care  team  before  the  visit     Enhanced  Access   § Accessibility  is  defined  as  the  ability  to  receive  medical  care  whenever  one  needs  it.  It  is  a  defining   element  of  primary  care  (Wagner  et  al.,  2012).     § To  support  enhanced  access,  a  PCMH  should  (CFPC,  2011;  Wagner  et  al.,  2014):   o Promote  and  expand  access  by  ensuring  that  patients  have  24/7/365  continuous  access  to   their  care  teams  via  phone,  e-­‐mail,  or  in-­‐person  visits;   o Provide  scheduling  options  that  are  patient  and  family-­‐centered  and  accessible  to  all   patients;   o Make  an  appointment  with  another  physician,  nurse,  or  other  qualified  health   professional  member  of  the  PCMH  when  the  patient’s  personal  family  physician  is   unavailable.    

Strategies  to  Enhance  Access     1. Advanced  access  or  “open”  scheduling  that  permits  same  day  appointments.   2. Expanded  hours,  including  before  and  after  the  normal  workday,  through  evening  and  weekend   walk-­‐in  clinics,  after  hours  on-­‐call  system,  etc.   3. Innovative  communication  methods  that  support  enhanced  access,  such  as  e-­‐health,  telehealth,   secure  e-­‐mail,  and  interactive  websites.     (CFPC,  2011;  Janamian  et  al.,  2014;  Martin,  2014;  Meyer,  2010;  Rosser  et  al.,  2011)  

  §

 

Evidence  suggest  that  increasing  panel  size  may  then  in  turn  impact  the  accessibility  of  services;   therefore,  patient-­‐centred  medical  homes  are  cautioned  to  assess  multiple  factors  to  determine   the  appropriate  panel  size,  including  the  number  of  physicians  and  other  team  members  in  the   practice,  the  practice’s  obligations  and  commitment  to  teaching  and  research,  and  the   demographics  of  the  patient  population  being  served  (e.g.  the  age  of  the  patients  and  the   complexity  of  their  medical  problems)  (CFPC,  2011).  

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  Coordination  and/or  Integration  of  Care   § A  main  principle  for  the  PCMH  is  to  provide  care  coordination  and/or  integration  across  the   health  care  system  and  the  patient’s  community.  To  support  these  activities,  the  PCMH  operates   as  the  central  hub  for  all  patient  information  and  care  coordination  (Kirschner  &  Barr,  2010).     The  Commonwealth  Fund  describes  care  coordination  as:     “…  a  patient  and  family-­‐centered,  assessment  driven,  team-­‐based  activity  designed  to  meet  the   needs  of  patients  ...  Care  coordination  addresses  interrelated  medical,  social,  developmental,   behavioral,  educational  and  financial  needs  in  order  to  achieve  optimal  health  and  wellness   outcomes”  (McAllister  et  al.,  2009,  pg.  495)     § To  better  coordinate  and/or  integrate  care,  the  patient-­‐centred  medical  should  (Green  et  al.,   2012;  Kirschner  &  Barr,  2010;  Meyers,  2010;  Wagner  et  al.,  2012;  Wagner  et  al.,  2014):     o Appropriately  train  clinicians  and  staff  for  team-­‐based  models  of  care  coordination   § It  is  critical  to  understand  the  appropriate  health  professional  skill  required  for  this   activity,  and  the  training  and  requisite  support  (Homer  &  Baron,  2010)   o Integrate  health  information  systems  that  support  care  coordination  (e.g.  patient   registries,  health  information  exchange  options)     o Establish  care  managers  or  care  coordinator  positions  within  the  PCMH   o Integrate  behavioral  health  and  specialty  care  into  care  delivery  through  co-­‐location  or   referral  agreements   o Incorporate  payment  models  that  compensate  for  the  effort  devoted  to  care  coordination   o Track  and  support  patients  when  they  obtain  services  outside  the  practice   o Follow  up  with  patients  within  a  few  days  of  an  emergency  room  visit  or  hospital  discharge   o Link  patients  with  community  resources  to  facilitate  referrals  and  respond  to  social  service   needs     § For  the  success  of  the  PCMH,  it  is  important  to  maintain  productive  relationships  with  the   community  and  its  resources,  and  with  the  medical  neighborhood  of  specialists,  hospitals,  plans   and  agencies  (Homer  &  Baron,  2010).     § Additional  resources  there  are  required  to  support  care  coordination  and/or  integration  within   the  patient-­‐centred  medical  home  (Meyers,  2010).       Patient-­‐Centred  Care   § Patient-­‐centred  care  is  a  key  principle  of  the  patient-­‐centred  medical  home.  The  PCMH  places  a   high  priority  on  patient  involvement  and  recognition  of  patient  needs  and  preferences,  and   includes  patients  in  their  own  care  (Kirschner  &  Barr,  2010;  McAllister  et  al.,  2009).     § There  are  various  definitions  of  patient-­‐centred  care.     Medical  Homes  Literature  Review  February  2015  

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  §

Patient-­‐centred  care  is  “the  experience  (to  the  extent  the  informed,  individual  patient  desires   it)  of  transparency,  individualization,  recognition,  respect,  dignity,  and  choice  in  all  matters,   without  exception,  related  to  one’s  person,  circumstances,  and  relationships  in  health  care”   (Berwick,  2009,  pg.  560).       The  Institute  of  Medicine  defines  patient-­‐centred  care  as  care  that  is  respectful  of  and   responsive  to  the  preferences,  needs,  and  values  of  an  individual  patient.  It  ensures  that   patient  values  guide  all  clinical  decisions  (CFPC,  2014).  

Three  useful  maxims  for  patient-­‐centred  care  (Berwick,  2009):       (1) “The  needs  of  the  patient  come  first”   (2) “Nothing  about  me  without  me”   (3) “Every  patient  is  the  only  patient”  

 

Five  Key  Changes  to  Facilitate  Patient-­‐Centered  Interactions       1. Respect  patient  and  family  values  and  expressed  needs   2. Encourage  patients  to  expand  their  role  in  decision-­‐making,  health-­‐related  behaviours,  and  self-­‐ management   3. Communicate  with  patients  in  a  culturally  appropriate  manner,  in  a  language  and  at  a  level  that   the  patient  understands   4. Provide  self-­‐management  support  at  every  visit  through  goal  setting  and  action  planning   5. Obtain  feedback  from  patients/families  about  their  health  care  experience  and  use  this   information  for  quality  improvement     (Wagner  et  al.,  2012;  Wagner  et  al.,  2014)  

  §

§

§ §

Patient-­‐centred  care  builds  relationships  between  providers  and  patients  that  meet  all  of  a   patient’s  needs  and  treat  the  patient  with  dignity  and  respect  by  including  them  in  the  decision   making  process  (Primary  Care  Progress,  2014).   Patient-­‐centered  care  involves  patients  in  decisions  about  their  care  and  in  the  process  of  care  to   ensure  that  it  is  consistent  with  the  patient’s  preferences,  values,  and  culture  (Wagner  et  al.,   2014).     In  accordance  with  patient-­‐centred  care  principles,  it  is  important  to  ensure  that  patients   understand  the  purpose  and  vision  for  the  PCMH  (Backer,  2009;  Green  et  al.,  2012).   A  key  strategy  to  support  the  delivery  of  patient-­‐centred  care  is  to  involve  patients  and  families  in   the  beginning  of  the  transformation  process  (Fontaine  et  al.,  2014;  Homer  &  Baron,  2010;   Kirschner  &  Barr,  2010).  This  can  be  achieved  through  surveys,  focus  groups,  patient  advisory  

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§

  §  

groups,  or  by  including  a  patient  representative  on  other  practice  committees  (McAllister  et  al.,   2009).   Patient-­‐centred  care  is  also  associated  with  other  key  elements  of  the  PCMH.  For  example,   effective  interdisciplinary  primary  care  team  approaches  are  a  critical  component  of  advancing   patient-­‐centered  care  (Rodriguez  et  al.,  2014).  Patient-­‐centered  care  is  a  quality  dimension   (Berwick,  2009).     Note:  Scholle  et  al.  (2010)  provides  a  further  description  on  how  the  patient-­‐centred  medical   homes  can  become  more  patient-­‐centred  from  the  “consumer”  perspective  (Scholle  et  al.,  2010).  

Empanelment   §

§

§

§

§  

Empanelment  (patient  rostering  or  paneling)  is  the  act  of  assigning  individual  patients  to   individual  primary  care  providers  and  care  teams  with  sensitivity  to  patient  and  family  preference   (California  Association  of  Public  Hospitals  and  Health  Systems,  [CAPH],  2014).  It  is  formalized   linkage  and  long-­‐term,  ongoing  relationship  between  a  patient  and  his/her  primary  care  provider   based  on  a  mutual  commitment.  Empanelment  is  a  foundational  building  block  of  the  PCMH   (Health  Quality  Council  of  Alberta,  [HQCA],  2014).   Empanelment  must  be  an  early  change  on  the  journey  to  becoming  a  patient-­‐centred  medical   home  as  other  key  features,  such  as  continuous,  team-­‐based  healing  relationships,  enhanced   access,  population-­‐based  care,  and  continuity  of  care,  depend  on  its  existence  (CAPH,  2014;   Wagner  et  al.,  2012).  In  fact,  practices  that  created  patient  panels  found  that  it  paved  the  way  for   other  PCMH  changes  (Wagner  et  al.,  2014).     Rostering  can  enable  the  practice  to  more  readily  define  its  panel  size  (CFPC,  2011;  CFPC,  2012a;   CFPC,  2012b).  Panel  size  is  the  number  of  individual  patients  under  the  care  of  a  specific  provider   or  the  number  of  patients  that  can  be  accepted  and  registered  with  each  practice.  PCMH  are   cautioned  to  assess  multiple  factors  to  determine  the  appropriate  panel  size,  including  the   number  of  physicians  and  other  team  members  in  the  practice,  the  practice’s  obligations  and   commitment  to  teaching  and  research,  and  the  demographics  of  the  patient  population  being   served  (e.g.  the  age  of  the  patients  and  the  complexity  of  their  medical  problems)  (CFPC,  2011).   As  such,  the  actual  panel  size  for  each  practice  will  vary  depending  (CFPC,  2011).       A  key  benefit  to  the  team-­‐based  approach  to  care  within  the  PCMH,  is  that  some  of  the  activities   that  were  once  completed  by  the  physician  can  be  assigned  to  other  members  of  the  team,   including  the  nurse  practitioner  and/or  physician  assistant;  this  may  enable  many  PCMH  to   consider  increasing  their  panel  sizes  (CFPC,  2011).     To  achieve  successful  patient  panels,  patient-­‐centred  medical  homes  should  (Wagner  et  al.,  2012;   Wagner  et  al.,  2014):   o Assess  practice  supply  and  demand,  and  balance  patient  load  accordingly   o Assign  all  patients  to  a  provider  panel  and  confirm  assignments  with  providers  and   patients  

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  o Review  and  update  panel  assignments  on  a  regular  basis   o Use  panel  data  and  registries  to  proactively  contact  and  track  patients  according  to   disease  status,  risk  status,  self-­‐management  status,  and  community  and  family  needs   § §

§  

  The  decision  to  form  a  patient–provider  relationship  should  have  input  from  both  the  patient  and   the  practice  (Wagner  et  al.,  2012).   Patient  panels  and  information  systems  with  registry  functionality  enable  staff  to  identify  and   reach  out  to  patients  with  unmet  needs  (Wagner  et  al.,  2014).     One  of  the  concerns  regarding  patient-­‐to-­‐physician  rostering  is  that  if/when  a  physician  decide  to   leave  the  PCMH,  the  patient  may  lose  access  to  the  team  in  which  they  were  receiving   comprehensive  care  from  (The  Conference  of  Canada,  2013).  

Team-­‐Based  Healing  Relationships   §

§  

A  main  facet  of  the  PCMH  is  the  transformation  from  physician-­‐centric  to  team-­‐based  care,  where   the  team  collectively  takes  responsibility  for  the  ongoing  care  of  patients  (Markova  et  al.,  2012;   Rosser  et  al.,  2011).  In  fact,  many  studies  concluded  that  well-­‐functioning  teams  were  perceived   as  key  to  successful  implementation  of  the  PCMH  (Bleser  et  al.,  2014;  Tuepker  et  al.,  2014;   Rodriguez  et  al.,  2014;  Wagner  et  al.,  2014).   Team-­‐based  care  is  essential  for  establishing  continuous,  team-­‐based  healing  relationships.  To   provide  continuous  team-­‐based  healing  relationships,  effective  PCMH  should  (Wagner  et  al.,   2012;  Wagner  et  al.,  2014):   o Establish  and  provide  organizational  support  for  care  delivery  teams  that  are  accountable   for  the  patient  population/panel   o Link  patients  to  a  provider  and  care  team  so  both  patients  and  provider/care  teams   recognize  each  other  as  partners  in  care   o Assure  that  patients  are  able  to  see  their  provider  or  care  team  whenever  possible   o Define  roles  and  distribute  tasks  among  care  team  members  to  reflect  the  skills,  abilities,   and  credentials  of  team  members  

§

  Evidence  suggest  that  to  support  the  development  of  effective,  high  functioning  teams,  that  roles   and  identities  need  to  change  if  a  practice  is  to  get  beyond  incremental  change  and  actually   transform  (Crabtree  et  al.,  2010).  However,  there  are  significant  challenges  related  to  role   expansion  that  may  hinder  team  development,  including  the  cultural  trappings  of  traditional,   clinician-­‐centric  power  and  reimbursement  structures,  issues  related  to  gender  and  class,   frustration  with  increased  responsibilities,  resentment  of  other  team  members’  roles,  and  fear  of   losing  control  (Cronholm  et  al.,  2013).  To  accomplish  and  sustain  organizational  culture  change,   all  team  members  need  to  be  empowered  to  speak  freely  and  initiate  a  process  of  improvement   (Markova  et  al.,  2012).  Therefore,  it  is  important  to  consider  existing  power  structures  and  how   they  can  support  or  impede  the  development  of  effective,  healthy  teams  (Cronholm  et  al.,  2013).    

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  To  establish  a  well-­‐functioning  team,  it  is  essential  there  be  adequate  staffing.  Therefore,  it  is   critical  that  additional  staffing  be  hired  to  implement  the  patient-­‐centred  medical  home  (Patel,   2003;  Tuepker  et  al.,  2014).  There  are  various  formulas  used  to  identify  the  amount  of  additional   staff  required  per  physician  FTE  however,  the  exact  mix  of  new  personnel  will  vary  by  each   individual  practice  (Patel  et  al.,  2013).   § There  isn’t  specific  evidence  on  the  optimal  team  ratio,  the  efficiencies  of  the  allied  health   professionals,  the  team  composition’s  effect  on  panel  size,  and  what  the  team’s  skill  mix  should   look  like,  as  much  depends  on  the  panel  and  its  needs  (CFPC,  2011).     § Research  shows  that  if  the  PCMH  does  account  for  a  larger  portion  of  primary  care  in  the  future,   its  average  panel  sizes  will  become  a  key  issue  in  assessing  future  workforce  adequacy  (Auerbach   et  al.,  2013).       Inadequate  staffing  posed  an  insurmountable  barrier  to  solid  team  function  (Tuepker  et  al.,  2014)     § The  goal  of  team-­‐based  care  is  to  have  every  member  of  a  practice  team  working  “at  the  top  of   their  license”  by  providing  all  the  care  their  license  or  certification  allows  (Wagner  et  al.,  2014).   Therefore,  team-­‐based  care  begins  with  defining  the  critical  roles  and  tasks  involved  in  the  PCMH,   assigning  them  to  the  most  appropriate  members  of  the  team,  and  ensuring  the  team  members   are  appropriately  trained  to  perform  them  well  (Wagner  et  al.,  2012).     § In  a  traditional  PCMH,  the  primary  care  provider  is  responsible  for  leading  the  team.  In  the   Statement  of  Joint  Principles  for  Patient-­‐Centred  Medical  Homes  developed  by  the  Patient   Centred  Primary  Care  Collaborative  identifies  the  physician  at  the  leader  of  the  healthcare  team   (Glazier  &  Redelmeier,  2013;  Janamian  et  al.,  2014,  Meyer,  2010;  Rosser  et  al.,  2011).   § However,  others  would  argue  that  in  order  to  truly  be  patient-­‐centred,  the  care  team  would  not   necessarily  be  “physician-­‐led”;  rather,  the  choice  of  leadership  by  a  physician,  nurse  practitioner,   or  other  clinician  should  belong  to  the  patient  and  family  (Scholle,  Torda,  Peikes,  Han,  &  Genevro,   2010).     The  College  of  Family  Physicians  of  Canada  includes  the  personal  family  physician  and  nurse  at  the   core  of  the  teams  in  the  patient’s  medical  home.  Other  roles,  such  as  physician  assistants,   pharmacists,  psychologists,  social  workers,  physiotherapists,  occupational  therapists,  and  dietitians   are  to  be  encouraged  and  supported  as  needed  (CFPC,  2011).     § Furthermore,  additional  training  is  required  to  establish  a  well-­‐functioning  and  effective  team.   Suggested  modules  include:  team  development,  skill  development,  communication,  issues  of   power,  autonomy  and  control,  etc.  (Cronholm  et  al.,  2013;  Tuepker  et  al.,  2014).  It  is  also   recommended  that  teams  learn  through  group  learning  activities,  as  it  allows  teams  to  practice   and  use  the  skills  they  learned  together  (Bidassie  et  al.,  2014;  Fontaine  et  al.,  2014).     For  more  on  information,  see  Team-­‐Based  Care   §

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  Quality  Improvement     § §

§  

The  quality  improvement  process  could  be  introduced  as  a  practice  self-­‐monitoring  improvement   program  or  as  an  assessment  carried  out  by  an  external  group  (CFPC,  2011).     Within  the  transformation  process  to  becoming  a  patient-­‐centred  medical  home,  it  is  imperative   that  a  formal  quality  improvement  strategy  be  developed  to  facilitate  and  guide  the   transformation  process.  An  effective  quality  improvement  strategy  (Fontaine  et  al.,  2014;   Spenceley  et  al.,  2013;  Wagner  et  al.,  2012;  Wagner  et  al.,  2014):     o Has  strong  and  engaged  leadership  and  expertise  in  change  management;     o Uses  rapid-­‐cycle  change  methods  to  test  ideas  for  change;   o Relies  on  routine  performance  measurement  to  identify  opportunities  for  improvement;   o Routinely  obtains  and  uses  patient  experience  data  to  inform  improvement  efforts;   o Involves  staff  in  the  development  and  implementation  process:   § The  involvement  of  staff  in  improvement  activities  provides  a  grounded  perspective  on   current  processes  and  ideas  for  change,  and  may  make  changes  more  acceptable   (Wagner  et  al.,  2014);  and,   o Engages  patients  and  families  in  efforts  to  make  the  practice  more  responsive  to  the   needs  and  preferences  of  their  clientele:     § Strategies  to  engage  patients  and  families  in  ongoing  quality  improvement  efforts   include:  soliciting  regular  feedback  through  surveys,  gathering  additional  information   on  patient  perspectives  through  the  formation  of  patient/family  advisory  councils,  and   inviting  individual  patients  and  consumer  and  patient  organizations  to  contribute  to   quality  improvement  activities  (Peikes,  Genevro,  Scholle,  &  Torda,  2011).     To  establish  an  effective  QI  Strategy,  a  practice  should  (Homer  &  Baron,  2010;  McAllister,  Presler,   Turchi,  &  Antonelli,  2009;  Wagner  et  al.,  2012;  Wagner  et  al.,  2014):   o Establish  a  quality  improvement  team  (including  patients  and  families)  to  support  the   implementation  of  the  quality  improvement  strategy   o Choose  and  use  a  formal  model  for  quality  improvement  that  relies  on  rapid  cycles  of   change,  planned  and  tested  small  changes,  process  mapping,  and  continuous   measurement  (e.g.  model  for  improvement,  lean,  six  sigma,  or  a  more  home  grown   approach)     § Little  rigorous  evaluative  or  comparative  research  is  available  to  help  practices  choose   among  these  approaches  (Wagner  et  al.,  2014)   o Establish  and  monitor  metrics  to  evaluate  routine  improvement  efforts  and  outcomes;   ensure  all  staff  members  understand  the  metrics  for  success   o Ensure  that  patients,  families,  providers,  care  team  members,  and  local  champions  are   involved  in  quality  improvement  activities  

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§

o Optimize  use  of  health  information  technology  that  support  critical  functions,  such  as   performance  measurement,  provider  alerts  and  reminders,  computerized  order  entry,  and   population  management       For  the  quality  improvement  strategy  to  be  effective,  it  is  important  that  clinically  meaningful  and   actionable  metrics  that  are  appropriate  to  each  practice  and  community  setting  be  selected   (CFPC,  2011;  Coleman  et  al.,  2014;  Martin,  2014).  Example  indicators  include  clinical  quality,   patient  experience,  provider/staff  satisfaction,  utilization,  patient  outcomes  (CFPC,  2011;   Coleman  et  al.,  2014).  Using  clinical  data  for  quality  improvement  however,  continues  to  be  a   challenge  for  many  practices  (Coleman  et  al.,  2014).  

  Payment  Reform   §

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§

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Under  current  payment  structures,  there  is  a  misalignment  between  traditional  volume-­‐based   payment  models  and  the  PCMH  goals,  including  population-­‐based  care  and  proactive  prevention   (Fontaine  et  al.,  2014;  Grant  &  Greene,  2012;  Janamian  et  al.,  2014;  Tuepker  et  al.,  2014).  For   example,  traditional  fee-­‐for-­‐service  reimbursement  schemes  that  pay  only  for  face-­‐to-­‐face  visits   undermine  the  provision  of  care  coordination  services,  especially  for  complex  patients  (Meyers,   2010).  In  fact,  payment  structures  were  identified  as  one  of  the  most  significant  barriers  to   implementing  the  PCMH  (The  Conference  Board  of  Canada,  2013;  Wagner  et  al.,  2012b).     Evidence  demonstrates  that  successful  PCMHs  include  payment  structures  that  reward  based  on   improving  population  health  rather  than  paying  a  fee  for  each  discrete  service  for  each  individual   patient  (Meyer,  2010).  Therefore,  it  is  recommended  that  the  payment  structures  be  reformed  to   reflect  (Fontaine  et  al.,  2014;  Grant  &  Greene,  2012;  Meyer,  2010;  Patel  et  al.,  2013):   o Comprehensive  management  of  large  numbers  of  patients  (patient  panels)   o Value-­‐based  care   o Patient-­‐centred  care   o Population-­‐based  care   o Team-­‐based  care     Capitation  and  bundling  reimbursement  schemes  and  some  forms  of  direct  care  models  create  a   healthier  policy  landscape  for  primary  care  practice  development  (Crabtree  et  al.,  2010).   Therefore,  It  is  recommended  that  payment  structures  be  reformed  to  include  a  blended  funding   model  that  combines  capitation,  fee  for  services,  and  bonuses  (Crabtree  et  al.,  2010;  Janamian  et   al.,  2014,  Meyer,  2010;  Rosser  et  al.,  2011).     Blended  funding  is  also  the  key  recommendation  of  the  College  of  Family  Physicians  of  Canada   (CFPC,  2011).  The  Canadian  Health  Services  Research  Foundation  recommends  sessional   payments  for  physicians,  or  a  blended  model  of  capitation,  sessional  payment,  and/or  fee-­‐for-­‐ service  (CFPC,  2011).   There  is  concern  that  adverse  risk  selection  and  “cherry  picking”  may  be  accentuated  with   payment  structures  that  only  have  capitation;  therefore,  it  is  important  that  blended  payment  

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§

§ §

§

 

models  be  utilized,  including  additional  fee  for  service,  bonuses,  and  incentives  (Glazier  &   Redelmeier,  2013).     Physicians  in  alternative  payment  models  (salary,  capitation,  blended)  may  be  more  incentivised   to  participate  in  team  meetings  than  physicians  in  fee-­‐for-­‐service  models  (The  Conference  Board   of  Canada,  2012b).   Non-­‐physician  team  members  are  most  often  paid  on  salary  (The  Conference  Board  of  Canada,   2012b).   Appropriate  remuneration  must  also  be  in  place  not  only  for  family  physicians  but  for  all   members  of  the  team  (CFPC,  2011)  however,  there  is  little  research  on  the  impact  of  funding  and   remuneration  schemes  for  non-­‐physician  IPC  team  members  (The  Conference  Board  of  Canada,   2012b).     Majority  of  PCMH  have  integrated  blended  payment  models;  for  example:     Ontario’s  Family  Health  Teams:  physicians  receive  payment  based  on  capitation  (by  age  and   sex),  additional  fees  for  service,  and  graded  bonuses  for  achieving  prevention  targets  and   special  payments  to  expand  the  scope  of  care  to  incorporate  prenatal  and  intrapartum  care,   inpatient  care,  home  visits,  and  palliative  care  for  their  patient  panel.  Fee  income  provides   incentives  for  physicians  to  increase  desired  services;  progressive  population-­‐based  bonuses   provide  incentives  for  preventive  services  (Rosser,  Colwill,  Kasperski,  &  Wilson,  2010).    

Health  Information  Technology  (HIT)     Four  Critical  Roles  Health  Information  Technology  Plays     in  Enabling  Transformation    

1. 2. 3. 4.  

  Registry  functionality  and  population  management:  identifying  and  managing  the  population  of   patients  within  a  practice  as  a  population.   Care  planning:  populating  and  sharing  the  content  of  care  plans  efficiently.   Communication:  effective  HIT  can  facilitate  primary  care-­‐specialty  communication,  patient-­‐ doctor  communication,  and  in-­‐office  team  communication.     Monitoring  and  tracking  change  and  improvement  

(CAPH,  2013;  Green  et  al.,  2012;  Homer  &  Baron,  2010)  

    §

The  PCMH  model  includes  the  use  of  an  electronic  medical/health  record  (EMR/EHR)  system.   These  systems  facilitate  (CFPC,  2011):     o Day-­‐to-­‐day  patient  care   o Communication  between  team  members   o The  sharing  of  information  needed  in  the  referral-­‐consultation  process   o Teaching  

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  o Carrying  out  practice-­‐based  research   o The  evaluation  of  the  effectiveness  of  the  practice    

§

 

  While  many  patient-­‐medical  homes  in  the  US  already  had  an  EMR/HER  system,  health   information  technology  was  cited  as  a  main  barrier  to  PCMH  transformation  Reasons  for  this   included  (CFPC,  2011;  Crabtree  et  al.,  2010;  Fontaine  et  al.,  2014;  Grant  &  Greene,  2012;  Green  et   al.,  2012;  Janamian  et  al.,  2014;  Nutting  et  al.,  2009;  Quinn  et  al.,  2013):     o o o o o o o o o

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Insufficient  funds  to  purchase  and  integrate  EMR/EHR  systems   Difficult  and  time  consuming  implementation  of  new  technology   Lack  of  available  and  knowledgeable  IT  staff   The  EMR/EHR  systems  were  unsuitable  in  meeting  PCMH  goals  (e.g.  population-­‐based   care)     The  EMR/EHR  systems  were  not  formatted  to  document  care  plans  or  care  coordination   notes,     The  EMR/EHR  systems  did  not  provide  registry  capabilities   The  EMR/EHR  systems  did  not  provide  population  health  metrics   There  was  a  lack  of  interoperability  between  EMR/EHR  systems   Issues  of  privacy  and  confidentiality  

  For  successful  integration  of  EMR/EHR  systems,  practices  will  require  a  significant  investment  of   time,  effort,  and  resources  (Fontaine  et  al.,  2014;  Rosser  et  al.,  2011).  Furthermore,  the  systems   must  be  adequately  funded,  have  standardized  language  to  ensure  common  data  management,   and  be  interoperable  with  other  EMR/EHR  systems.  There  must  also  be  ample  training  and   ongoing  technical  support  for  all  team  members  in  the  practice  (CFPC,  2011).     The  College  of  Family  Physicians  of  Canada  state  that  system  supports,  including  funding  to   support  the  transition  from  paper  records,  must  be  in  place  to  enable  every  patient’s  medical   home  to  introduce  and  maintain  EMR/EHR  (CFPC,  2011).  They  further  state  that  each  practice   should  be  allowed  to  select  its  EMR/EHR  product  and  service  providers  from  a  list  of  provincially,   territorially,  or  regionally  approved  vendors;  these  EMR  and  electronic  health  record  systems   must  be  interconnected,  user-­‐friendly,  and  interoperable  (CFPC,  2011).     Practices  continue  to  need  support  to  effectively  use  EMR/EHR  systems  for  measurement  and  to   redesign  workflows  (Coleman  et  al.,  2014).  

Team-­‐Based  Care      

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Definition     §

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Teamwork  in  healthcare  is  a  group  of  providers  and  staff  with  complimentary  skills  and   competencies  who  cooperate,  collaborate,  communicate,  and  integrate  services  so  that   healthcare  is  reliable  and  available  for  all  those  who  wish  to  access  services  (Martin,  2014).   Multiple  terms  are  used  to  describe  teams  in  health  care,  including  multidisciplinary  and   interprofessional  (also  known  as  interdisciplinary).  A  multidisciplinary  team  is  generally   understood  to  mean  various  health  professionals  working  parallel  to  each  other,  but  not   necessarily  collaborating  in  the  care  of  a  patient.  For  health  care  teams  to  be  most  effective,  an   interprofessional  model  is  most  successful.  In  interprofessional  teams,  each  health  professional   works  to  his/her  full  scope  of  practice,  collaborates  in  the  planning  and  comprehensive  care  of   the  patient,  and  communicates  effectively  with  the  team  (Alberta  Medical  Association,  [AMA},   2013).   The  current  evidence  suggests  that  an  interprofessional  integrated  and  collaborative  model   performs  the  best  (Sajdak,  2013).  An  interprofessional  collaborative  team  are  teams  with  2  or   more  health  care  disciplines  working  interdependently  and  communicating  regularly  to  meet  the   needs  of  a  patient  population  in  a  primary  care  setting  (Sajdak,  2013;  The  Conference  Board  of   Canada,  2012a;  Virani,  2012).  Team  members  contribute  their  disciplinary  perspective  and  work   to  their  full  scope  of  practice  (Wagner  et  al.,  2012).  They  also  share  information  and  coordinate   processes  and  interventions  to  provide  patient-­‐centred  care.  Generally,  there  is  an  explicit  or   underlying  value  for  non-­‐hierarchical  decision-­‐making  in  interprofessional  collaborative  teams   (Virani,  2012).   Health  Canada  states  that  the  interprofessional  collaborative  team  model  is  designed  to  promote   the  active  participation  of  each  discipline  in  patient  care.  It  enhances  patient-­‐  and  family-­‐centred   goals  and  values,  provides  mechanisms  for  continuous  communication  among  caregivers,   enhances  staff  participation  in  clinical  decision-­‐making  within  and  across  disciplines  and  fosters   respect  for  disciplinary  contributions  of  all  professionals  (The  Conference  Board  of  Canada,  2013).  

  Team  Composition     §

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  The  composition  of  a  health  care  team  should  meet  community  and  patient  needs,  be  designed   to  improve  access  while  also  support  continuity  of  care,  and  enhance  cost  effectiveness  in  the   delivery  of  care  (CFPC,  2011).     There  are  many  different  variations  of  team  compositions.  Team  members  may  include:     o Extended  group  members  are  pharmacists,  psychologists,  psychiatrists,  social  workers,   counselors,  physiotherapists,  occupational  therapists,  dieticians,  midwives,  licensed   practical  nurse,  (CFPC,  2009;  Rodriguez  et  al.,  2014;  Rosser  et  al.,  2011;  The  Conference   Board  of  Canada,  2012a).  

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  o Other  essential  members  of  a  team  include  administrative  and  clerical  /  support   personnel,  such  as  case  managers,  data  analysts,  and  clerk  or  medical  support  assistants   (Patel  et  al.,  2013;  Rosser  et  al.,  2011;  The  Conference  Board  of  Canada,  2013).   §

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  According  to  the  Conference  Board  of  Canada  (2012a),  current  models  of  interprofessional   primary  care  teams  in  Canada  are  physician-­‐led  practices,  nurse  practitioner-­‐led  practices,   community-­‐led  practices,  and  integrated  primary  care  networks  (The  Conference  Board  of   Canada,  2012a).     (1) Physician-­‐led  practices  (PLP):     Physician-­‐led  practices  are  managed  or  led  by  a  physician  or  group  of  physicians.   Within  this  model,  the  family  physician  or  general  practitioner  is  responsible  for   providing  care  to  the  patient.  They  physicians  working  within  a  Physician-­‐led  practices   are  predominately  remunerated  under  a  blended  payment  model,  while  other  team   members  are  often  paid  on  a  contract  or  salary  basis  (The  Conference  Board  of   Canada,  2012a).     Examples  of  physician-­‐led  practices  in  Canada:  Ontario  Family  Health  Teams,  Quebec   Integrated  Network  Clinics,  BC  Integrated  Health  Networks,  and  Alberta  Primary  Care   Networks.     (2) Nurse  practitioner  (NP)-­‐led  practices  (NPLP):     NP-­‐led  practices  are  led  by  a  nurse  practitioner.  Within  this  model,  the  NP  is   responsible  for  providing  care  to  the  patient.  Evidence  has  shown  that  nurse-­‐led   models  of  care  provide  equal  or  better  care  when  compared  to  physician-­‐led  models  of   care  (Virani,  2012).  Given  this,  NP-­‐led  practices  can  serve  as  an  alternative  model  of   primary  care  delivery,  especially  for  patient  populations  that  have  difficulties  accessing   a  family  physician  (The  Conference  Board  of  Canada,  2012a).       It  is  important  to  note  that  there  are  some  differences  in  the  NP’s  scope  of  practice   compared  with  that  of  a  physician,  which  can  vary  by  jurisdiction.     Examples  of  nurse  practitioner-­‐led  practices:  Ontario  Nurse  Practitioner-­‐Led  Clinics,   Manitoba  Quick  Care  Clinics,  and  Saskatchewan  Health  Bus.     More  often  than  not,  however,  physicians  play  the  leadership,  particularly  when  the  funding  for   primary  care  is  tied  to  fee-­‐for-­‐service  or  capitation  models,  in  contrast  to  models  that  are  more   supportive  of  team-­‐based  care  (e.g.  models  where  all  team  members  are  salaried)  (Virani,  2012)   Under  the  PCMH  model,  the  primary  care  physician,  in  close  collaboration  with  the  patient,  would   lead  the  interdisciplinary  healthcare  team  (Janamian  et  al.,  2014,  Meyer,  2010;  Rosser  et  al.,   2011).  However,  others  argue  that  to  truly  be  patient-­‐centred,  the  care  team  would  not   necessarily  be  “physician-­‐led”;  rather,  the  choice  of  leadership  by  a  physician,  nurse  practitioner,   or  other  clinician  should  belong  to  the  patient  and  family  (Scholle  et  al.,  2010).  

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  It  is  imperative  that  the  core  primary  care  team  is  made  up  of  clinical  providers  whose  scopes  of   practice  are  fully  extended  around  participating  in  population  management,  the  delivery  of  whole   person-­‐oriented  care  for  a  defined  population  of  patients  over  time  (Spenceley  et  al.,  2013).   Optimal  team  size,  composition,  skill  mix,  and  roles  and  responsibilities  must  be  adjusting   according  to  the  population  needs  of  the  patient  panel  (CFPC,  2011;  The  Conference  Board  of   Canada,  2014).  Knowledge  and  understanding  of  providers’  scopes  of  practice  and  competencies,   and  evidence  of  effectiveness  and  cost-­‐effectiveness,  are  important  in  determining  the   appropriate  provider  mix,  roles,  and  responsibilities  for  the  team  (The  Conference  Board  of   Canada,  2014).  As  such,  there  is  no  one  team  complement  that  will  serve  every  population   (Spenceley  et  al.,  2013).       A  team  based  approach  involves  maximizing  the  skills  of  each  professional  on  the  primary  care  /   family  practice  team  in  a  complementary  manner;  no  healthcare  professional  should  be  a   substitute  for  the  role  of  another  (CFPCC,  2011).  Supplementation  refers  to  the  principle  of   starting  with  a  core  primary  care  provider  (i.e.,  the  provider  with  the  broadest  skill  set  in  terms  of   providing  comprehensive  whole  person-­‐oriented  care  for  a  defined  population  of  patients  over   time),  most  often  a  family  physician,  and  then  adding  complementary  team  members  with  the   goal  of  leveraging  their  full  scope  of  clinical  skills  to  provide  whole-­‐person  care  to  a  patient   population.  Supplementation  emphasizes  everyone  working  to  his/her  full  scope  of  practice.   Substitution  refers  to  the  process  of  substituting  one  provider  for  another.  This  process  may  lead   to  increased  fragmentation  and  reduced  continuity  of  primary  care.  Substitution  thinking  is  also   fed  by  the  a  priori  basket-­‐of-­‐service  approach  taken  in  primary  care  reform  initiatives  (Spenceley   et  al.,  2013).     Effective  teams  also  include  an  office  manager  and  reception  staff,  as  a  group  practice  will  require   some  level  of  administrative  support  to  reduce  the  workload  of  the  team.  The  office  manager   needs  to  have  responsibility  for  the  day-­‐to-­‐day  management  of  the  practice,  staffing  levels,   budget  control,  staff  development  and  oversight  of  premises  (e.g.,  facilities  and  equipment   management,  overall  operations).  The  office  manager  would  also  be  responsible  for  performance   reports  and  support  the  improvement  in  quality  of  clinical  practice  (Sajdak,  2013).  For  a  group   practice  there  would  also  need  to  be  a  team  of  receptionists  that  would  provide  additional   administration  support  to  the  practice,  such  as  scheduling  and  coordinating  appointments,  filing,   photocopying  and  completing  patient  registration  (Sajdak,  2013).     Example  of  PCMH  teams  include:   Ontario’s  Family  Health  Team  (Rosser  et  al.,  2011):   o The  Family  Health  Team  model  includes  an  interprofessional  team  of  professional  who   work  together  to  provide  patient  care.  The  team  includes  family  physicians,  nurse   practitioners,  registered  nurses,  social  workers,  dietitians,  and  other  professionals  as   determined  by  their  patient  population.  Each  of  the  Family  Health  Teams  are  set-­‐up  based   on  local  health  and  community  needs.    

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Veterans  Health  Administration  –  Patient  Aligned  Care  Team  (Tuepker  et  al.,  2014):   o Veterans  Health  Administration  is  the  largest  integrated  US  health  system  to  implement   patient-­‐centred  medical  homes.  The  PCMH  were  called  Patient-­‐Aligned  Care  Teams.  The   Patient-­‐Aligned  Care  Teams  includes  a  primary  care  provider,  nurse  care  manager  (NCM),   clinical  associate,  a  clerical  associate,  and  is  further  supported  by  social  workers,   pharmacists,  nutritionists,  and  psychologists  

  Team  Characteristics   §

§

  Teams  share  a  number  of  different  characteristic,  including  (American  Hospital  Association,  2013;   CFPC,  2011;  Markova  et  al.,  2012;  Rodriguez  et  al.,  2014;  The  Conference  of  Canada,  2014;   Tuepker  et  al.,  2014;  Wagner  et  al.,  2014;  Virani,  2012):     o An  interprofessional  team  where  all  members  practice  to  the  legislated  full  scope  of   his/her  practice,  respectfully  share  differing  views  and  collaborating  in  order  to  deliver  the   highest  quality  care  to  the  patient;   o A  common  commitment,  vision,  and  goal;   o A  formal  and/or  informal  team  leader  who  facilitates  long-­‐term  team  processes  and   fosters  relationships  to  achieve  team  goals;   o A  shared  identity  with  clearly  defined  and  transparent  roles  and  responsibilities  and  well-­‐ defined  cross-­‐coverage  policies  that  are  well  understood  by  all  team  members;   o Regularly  and  frequently  communicate  openly  and  honestly  with  each  other;   o Mutual  trust  and  respect  for  all  team  members;   o Willingness  to  cooperate  and  collaborate;  and,     o A  set  of  performance  goals  for  which  they  hold  themselves  mutually  accountable.     The  characteristic  most  commonly  cited  as  critical  for  healthy  team  functioning  is  having  well-­‐ defined  and  clear  teamwork  processes  and  supportive  policies  (Rodriguez  et  al.,  2014).  Well-­‐ functioning  teams  also  require  adequate  staffing,  training,  and  dedicated  time  for  team   development  (Tuepker  et  al.,  2014).  

 

List  of  Traits  for  Effective,  High  Functioning  Interprofessional     Primary  Health  Care  Teams   o o o o o

  Strong  governance  and  leadership  at  the  administrative  and  service  provision  levels;   Appropriate  funding,  remuneration,  and  financial  incentives;   Provision  of  and  equitable  access  to  appropriate  health  and  social  services;   Recruitment  and  retention  of  highly  skilled  personnel  who  work  to  their  full  scopes  of  practice;   Existence  of  and  adherence  to  practice  policies  and  agreements  that  pertain  to  scopes  of  

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o o o o

practice,  team  member  roles  and  responsibilities,  shared  care  and  decision-­‐making,  and   communication  within  the  team  and  across  health  sectors,  including  coordination  and  continuity   of  care;   Clear  separation  between  administrative  and  patient  service  provisions;   Interprofessional  education  and  training  for  service  providers  where  the  team  learn  about,  from,   and  with  each  other  to  enable  effective  collaboration  (formative  and  continuous);   Supportive  infrastructure,  including  co-­‐location,  open  design  of  physical  space,  opportunities  for   team  communication,  and  appropriate  use  of  information  technology;  and,   Appropriate,  standardized,  and  consistent  monitoring  and  evaluation  of  individual  and  team   performance  and  of  patient  outcomes,  including  SMART  accountability  measures  that  are  linked   to  performance.  

 

(AMA,  2013;  The  Conference  Board  of  Canada,  2014)    

     

Barriers  to  Team-­‐Based  Care   §

§  

  Creating  a  healthy,  functioning  health  care  team  can  take  anywhere  from  one  to  three  years  to   become  fully  functional,  depending  on  the  readiness  of  the  team  and  the  level  of  governance,   leadership,  and  infrastructural  support  (The  Conference  Board  of  Canada,  2012b).  In  fact,  the   process  of  effectively  developing  and  integrating  teams  into  primary  care  is  a  challenge  that  is  all   too  often  underestimated  in  its  complexity,  and  under-­‐supported  from  a  change  management   perspective.       The  Conference  Board  of  Canada  (2012b)  identified  three  levels  of  interprofessional  collaborative   team  barriers:   Individual-­‐level  barriers:     o Lack  of  role  clarity  and  trust:  attributable  to  limited  knowledge  and  understanding  of   other  team  members’  knowledge,  skills,  and  scopes  of  practice.  Overlapping  skills  can   create  difficulties  in  formally  establishing  defined  roles.   o Hierarchical  roles  and  relationships:  team  effectiveness  and  collaboration  can  be   compromised  when  team  members  perceive  and/or  project  a  professional  hierarchical   order  of  importance  or  power.     Practice-­‐level  barriers:     o Lack  of  strong  governance  and  leadership:  lack  of  strong  organizational  leadership  is  an   underestimated  barrier  to  the  implementation  of  effective  interprofessional  collaborative   teams.   o Difficulties  in  establishing  appropriate  skill  mix  and  team  size:  there  is  no  one-­‐size-­‐fits-­‐all   model  in  terms  of  appropriate  skill  mix  and  team  size;  it  is  highly  reliant  on  the  

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professional  competencies  or  skills  and  experience  required  to  address  the  health  needs   of  the  patient  population.   o Insufficient  space  and  time  for  communication  and  collaboration:  quantity  and  quality  of   interprofessional  collaboration  is  related  to  the  design  of  the  physical  space,  whether   there  is  co-­‐location  of  team  members,  and  the  amount  of  time  available  for  team   members  to  formally  communicate.   o Inadequate  tools  for  communication:  inadequate  time  for  mechanisms  of  communication   between  IPC  team  members  remain  a  significant  barrier  to  interprofessional  collaboration   and  team  effectiveness.     System-­‐level  barriers:     o Inadequate  interprofessional  education  and  training:  lack  of  competency  in   interprofessional  collaboration  due  to  lack  of  or  inadequate  interprofessional  education   and  training.   o Sub-­‐optimal  funding  models:  challenge  is  to  determine  the  appropriate  remuneration   model  and  financial  incentives  to  promote  increased  and  improved  interprofessional   collaboration,  optimize  individual  scopes  of  practice,  and  improve  recruitment  and   retention  of  health  human  resources/   o Lack  of  appropriate  monitoring  and  evaluation:  one  of  the  greatest  and  most  important   challenges  in  the  optimization  of  interprofessional  collaborative  teams  is  the  lack  of   consistently  collected,  reported,  and  meaningful  performance  data.     There  are  significant  challenges  that  may  hinder  team  development,  including  the  cultural   trappings  of  traditional,  clinician-­‐centric  power  and  reimbursement  structures,  issues  related  to   gender  and  class,  resentment  of  other  team  members’  roles,  and  fear  of  losing  control  (Cronholm   et  al.,  2013).  Therefore,  factors  that  perpetuate  hierarchy,  such  as  language  and  decision-­‐making   processes,  could  be  modified  in  order  to  reduce  their  potential  negative  impact  on   interprofessional  collaboration  (The  Conference  Board  of  Canada,  2012b).   Another  factor  impeding  the  development  of  effective  team  in  health  care  is  the  use  of  clinical   decision-­‐support  tools  and  guidelines  that  are  constructed  around  a  single  disease  or  a  single   provider.  A  key  priority  must  be  for  evidence-­‐informed  and  integrated  decision-­‐support  tools  to   support  continuous  and  comprehensive  team-­‐based  care  for  individuals  living  with  multiple   chronic  conditions  and  risk  factors  (Spenceley  et  al.,  2013).     Although  there  is  abundant  literature  on  the  barriers  to  interprofessional  collaborative  team   optimization,  it  remains  unclear  as  to  how  may  of  these  barriers  can  be  overcome  (The   Conference  Board  of  Canada,  2012b).  

    Creating  Team-­‐Based  Care    

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Team-­‐based  care  is  facilitated  when  extensive  effort  is  made  early  in  the  team  formation  process   to  develop  positive  interpersonal  and  interprofessional  relationships  (Solimeo  et  al.,  2013).  For   teams  to  flourish  into  effective,  high-­‐functioning  teams  that  deliver  team-­‐based  care,  it  is   important  that  they  have  protected  time  to  participate  in  team  meetings  and  other  collaborative   activities,  opportunities  to  attend  learning  session,  and  access  to  team-­‐level  performance  data   (Markova  et  al.,  2012;  Solimeo  et  al.,  2013).     Preliminary  stages  for  building  a  team  may  focus  on  building  teams  and  trust;  understanding   scopes  of  practice,  roles,  and  responsibilities;  fostering  communication;  and  learning  how  to  work   together,  a  process  that  includes  developing  shared  care  protocols  (The  Conference  Board  of   Canada,  2014).  

Five  steps  to  building  a  health  team  include:     Step  1:  Develop  a  shared  vision,  mission,  and  values  for  the  team   Step  2:  Establish  roles  and  responsibilities   Step  3:  Develop  operating  guidelines  and  policies   Step  4:  Create  organizational  structures,  including  team  meetings   Step  5:  Establish  a  method  to  evaluate  and  celebrate  progress  and  outcomes    

(The  Conference  Board  of  Canada,  2014)  

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Elements  required  for  building  effective  and  sustainable  teams  include  developing  team   leadership,  revising  job  descriptions,  cross-­‐training  staff,  communicating  clear  goals,  setting   measurable  objectives,  and  publically  praising  teams  and  individuals  for  accomplished  task   (Markova  et  al.,  2012;  Wagner  et  al.,  2014).       It  is  important  that  teams  regular  communicate  with  one  another.  This  can  be  done  via  formal  or   information  mechanisms,  such  as:  weekly  or  monthly  staff  meetings,  clinical  operations  meetings,   practice  improvement  teams,  regular  scheduled  team  meetings,  interprofessional  conferences,   team  huddles,  education  rounds,  and  engagement  in  learning  collaboratives  (Markova  et  al.,   2012;  The  Conference  Board  of  Canada,  2014).   EMR/EHR  systems  can  facilitate  communication  among  team  members;  however,  this  type  of   communication  does  not  necessarily  support  or  optimize  collaboration  (The  Conference  Board  of   Canada,  2014).     A  study  conducted  by  Solimeo  et  al.  found  that  teams  with  stable  membership,  particularly   members  with  experience  working  together,  were  able  to  develop  and  advance  more  quickly  than   those  teams  with  new  employees  (Solimeo  et  al.,  2013).  

Key  Recommendations  for  Developing  and  Optimizing     Interprofessional  Care  teams  in  Canada:  

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    o Establish  a  strong  and  stable  governance  and  leadership  structure  that  includes  a  management   team  with  appropriate  knowledge  and  skills     o Adopt  a  funding  and  remuneration  structure  that  supports  interprofessional  collaboration  and   delivery  of  accessible,  high-­‐quality,  cost-­‐effective,  patient-­‐centred  care   o Provide  population  needs-­‐based  services  delivered  by  the  right  providers,  at  the  right  time,  in  the   most  cost-­‐effective  way   o Establish  and  implement  standardized  patient  hand-­‐offs,  referrals,  and  care  coordination  among   providers  on  the  team,  and  across  organizations  and  sectors,  to  ensure  quality  and  continuity  of   care   o Mandate  high-­‐quality  interprofessional  education  and  training  for  all  health  professionals  to   support  the  development  and  mastering  of  the  core  competencies  of  interprofessional   collaboration   o Optimize  the  use  of  communications  technology,  physical  space,  and  other  infrastructural   supports  to  facilitate  and  improve  collaboration   o Engage  in  regular  and  consistent  monitoring  and  evaluation  of  cost-­‐effectiveness,  provider  and   organizational  provider  performance,  and  use  of  data  linkage  and  knowledge  sharing  within  and   across  teams   o Adopt  clear  and  enforceable  accountability  processes  for  the  organization,  administration,  and   providers,  which  are  linked  to  performance     (The  Conference  of  Canada,  2013)  

  Additional  Education  and  Training   § Additional  interprofessional  education  and  training  is  a  critical  component  to  the  development  of   effective,  high-­‐functioning  teams  (Tuepker  et  al.,  2014).  In  fact,  it  was  identified  as  one  of  the   main  solutions  to  address  individual,  practice,  and  system  level  barriers  to  IPC  (The  Conference  of   Canada,  2013).       § Additional  education  and  training  should  focus  on  six  core  competencies  for  interprofessional   collaboration  (The  Conference  of  Canada,  2014):     (1) Interprofessional  communication:  the  ability  to  communicate  with  other  professions  in  a   collaborative,  responsive,  and  respectful  manner.   (2) Client-­‐centred  care:  the  ability  to  search  for,  integrate,  and  value  clients’  input  and   engagement  in  care/services  decision-­‐making  and  implementation.   (3) Role  clarification:  the  ability  to  understand  one’s  own  role  and  the  roles  of  others,  and  to   use  this  knowledge  to  establish  and  achieve  client  populations’  goals.   (4) Team  functioning:  the  ability  to  understand  the  principles  of  teamwork  and  group   dynamics  in  order  to  be  effective  in  the  practice  of  interprofessional  collaboration.   (5) Collaborative  leadership:  the  ability  to  understand  and  apply  principles  of  leadership  to   be  effective  in  the  practice  of  interprofessional  collaboration.  

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  (6) Interprofessional  conflict  resolution:  the  ability  to  actively  engage  with  others  (such  as   team  members  and  clients)  to  positively  and  constructively  address  conflicts   §

  Other  suggested  topics  include  leadership  development,  interprofessional  collaborative  practice   competency  and  skill  development,  stages  of  team  development,  team  dynamics,  effective   communication,  shared  decision-­‐making  (Long  et  al.,  2014;  Martin,  2014).  

  Collaborative  learning  series  /  group  learning   § Collaborative  learning  series  /  group  learning  allows  teams  to  practice  and  use  the  skills  they   learned  together  (Bidassie  et  al.,  2014).  Collaborative  learning  series  increase  participant’s   knowledge  and  skills,  improves  collaborative  team  practices  (e.g.  team-­‐led  huddles,  regular  team   meetings),  and  contributed  towards  a  clear  understanding  of  team  member  roles  and   responsibilities  (Bidassie  et  al.,  2014,  Coleman  et  al.,  2014,  Fontaine  et  al.,  2014).     § Collaborative  learning  series  are  common  strategies  used  by  patient-­‐centred  medical  homes  to   support  continuous  team-­‐based  healing  relationships.       Veterans  Health  Administration  -­‐  Patient  Aligned  Care  Teams  Collaborative  Modeled   after  the  Institute  for  Healthcare  Improvement’s  Breakthrough  Series  Collaborative   Model.  It  includes  training  seminars,  virtual  communities  of  practice,  and  virtual  lectures   (Bidassie  et  al.,  2014;  Solimeo  et  al.,  2013).     § Implementing  collaborative  learning  series  /  group  learning  activities  requires  additional   resources  (e.g.  facilitators,  coaching  assistance)  (Bidassie  et  al.,  2014).      

   

Physician  Extenders   §

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  The  impending  shortage  of  primary  care  physicians  combined  with  convincing  evidence  that   minor  illnesses  consuming  much  of  a  physician’s  time  can  be  treated  effectively  and  less   expensively  by  nurse  practitioners  and  physician  will  likely  fuel  the  continued  expansion  of  the   use  of  physician  extenders  (Auerbach  et  al.,  2013;  McKinlay  &  Marceau,  2012).   Physician  extenders  free  up  the  time  of  physicians  by  re-­‐allocating  the  routine  and  less  complex   aspects  of  medical  practice  to  other  primary  care  providers,  which  allows  physicians  to  use  their   time  and  expertise  in  a  more  effective  way  (Stanik-­‐Hutt  et  al.,  2014;  Vanstone,  Boesveld,  &   Burrows,  2014).   Physician  extenders  are  becoming  more  common  due  to  the  shortage  of  family  physicians  and  the   increasing  demand  on  the  primary  care  system  (Vanstone  et  al.,  2014).  Current  forecasts  of   supply  and  demand  suggest  large  shortages  of  physicians  and  surpluses  of  nurse  practitioners  and   family  physicians  in  the  near  future  (Auerbach  et  al.,  2013).    

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For  physician  extenders  to  be  truly  effective,  scope-­‐of-­‐practice  laws  may  need  to  be  revised  to   allow  nurse  practitioners  and  physician  assistants  to  perform  expanding  roles  (Auerbach  et  al.,   2013)     Barriers  to  integrating  physician  extenders  (Auerbach  et  al.,  2013;  Kellermann,  Saultz,  Mehrotra,   Jones,  &  Dalal,  2013;  Spenceley  et  al.,  2013):   o Restrictive  scope-­‐of-­‐practice  laws  that  require  physicians’  involvement  in  certain  care   processes  and  patients’  perceptions  of  nurse  practitioners  and  preferences  for  providers.   o Remuneration  issues  for  both  the  physician  extender  and  the  supervising  physician.   o Although  PAs  and  NPs  require  less  training  than  medical  doctors,  they  still  require  a   significant  amount  of  schooling  and  additional  training.     Some  patient-­‐centred  medical  homes  are  already  using  physician  extenders.  For  example,  the   VHA-­‐PACT  model  includes  a  primary  care  provider,  which  can  be  either  a  physician,  physician’s   assistant,  or  a  nurse  practitioner,  as  well  as  a  registered  nurse  (RN)  care  manager,  a  licensed   practical  nurse  (LPN),  and  a  clerk  or  medical  support  assistant  (Rodriguez  et  al.,  2014).   Many  small  primary  care  practices  include  one  or  more  midlevel  clinicians,  such  as  nurse   practitioners  or  physician  assistants  (Nutting  et  al.,  2012).  

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Nurse  managed  health  centres  could  greatly  reduce  the  need  for  primary  care  physicians   (Auerbach  et  al.,  2013).     Nurse  practitioners  (NP)  are  considered  advanced  practice  nurses,  an  umbrella  term  defined   internationally  as  registered  nurses  (RNs)  who  have  acquired  the  expert  knowledge  base,  complex   decision-­‐making  skills,  and  clinical  competencies  for  expanded  practice  (Koren,  Mian,  &  Rukholm,   2010).   A  nurse  practitioner’s  practice  activities,  roles,  and  responsibilities  are  often  similar  to  those  of   medical  doctors  (MD),  and  NPs  and  MDs  often  work  in  the  same  practices  or  settings  (Kellermann   et  al.,  2013;  Stanik-­‐Hutt  et  al.,  2014).     A  NP  delivers  high  quality,  safe,  and  effective  care  to  a  large  number  of  patient  populations  in  a   variety  of  settings  (Stanik-­‐Hutt  et  al.,  2014).  They  can  practice  autonomously  and/or  in   partnership  with  MDs  have  a  very  significant  role  in  promoting  health  and  providing  care  to   diverse  populations  (Stanik-­‐Hutt  et  al.,  2014).  Accumulating  evidence  over  50  years  shows  nurses   can  provide  primary  care  that  is  as  effective  and  has  similar  outcomes  as  that  provided  by   physicians  (McKinlay  &  Marceau,  2012).  For  example,  research  confirms  the  capabilities  of  nurses   and  nurse  practitioners  to  provide  chronic  care  management  and  preventive  services  at  levels  at   least  comparable  to  that  provided  by  physicians  (Homer  &  Baron,  2010).  Evidence  indicates  that  if   needs  can  be  met  by  NPs,  then  systems  should  incorporate  NPs  to  the  fullest  extent  possible.  This   structure  would  free  up  MDs  to  attend  to  patient  needs  that  demand  their  scope  of  capabilities   (Stanik-­‐Hutt  et  al.,  2014).      

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There  have  long  been  challenges  to  integrating  enhanced  roles  for  nurse  practitioners  in  primary   care  practices  in  part  due  to  real  and  perceived  resistance  from  physicians  and  physician   organizations  (Auerbach  et  al.,  2013;  Crabtree  et  al.,  2010).   The  role  of  the  NP  in  a  patient-­‐medical  medical  home  is  often  limited  by  the  definition  of  a  PCMH,   which  states  that  patients  will  have  access  to  a  personal  physician.  The  role  of  the  NP  is  not   utilized  to  the  fullest  if  they  are  unable  to  be  leaders  of  medical  homes  for  their  patients  (Manion,   2012).  If  the  PCMH  definition  insists  on  using  physician-­‐only  language  in  the  medical  home   definition,  the  ultimate  goal  of  the  medical  home  is  lost  (Manion,  2012).  The  National  Association   of  Pediatric  Nurse  Practitioner’s  defines  the  “pediatric”  health  care/medical  home  as  a  model  of   care  that  promotes  holistic  care  of  children  and  their  families  where  each  patient  and  their  family   has  continuous  relationship  with  a  health  care  professional  (Manion,  2012).     It  is  essential  that  future  models  of  care  take  full  advantage  of  the  growing  number  of  NPs  to  their   full  potential  and  capabilities  (Stanik-­‐Hutt  et  al.,  2014).  

Physician  Assistants   §

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  Physician  assistants  (PA)  are  a  new  health  profession  (Vanstone  et  al.,  2014).  They  were  proposed   as  a  potential  solution  to  help  improve  access  to  health  care  and  reduce  wait  times  (Vanstone  et   al.,  2014).     PAs  are  skilled  health  professionals  trained  in  basic  medical  sciences  who  provide  care  under  the   direction  and  supervision  of  a  physician  (CFPC,  2011).  PAs  are  trained  to  take  patient  histories,   conduct  physical  examinations,  order  and  interpret  tests,  diagnose  and  treat  illnesses,  counsel  on   preventive  health  care,  and  may  develop  additional  specialized  skills  while  working  with  a   supervising  physician.  They  are  not  autonomous  health  professionals;  their  scope  of  practice  is   directly  defined  by  their  supervising  physician,  who  retains  responsibility  and  liability  for  acts   delegated  to  the  PA  (Vanstone  et  al.,  2014).       The  College  of  Family  Physicians  of  Canada  recognizes  that  physician  assistants,  under  the   direction  and  supervision  of  a  family  physician,  are  among  those  professionals  with  the  potential   to  augment  access  to  family  practice  services  and  primary  care  (CFPC,  2011).  The  College  of   Family  Physicians  of  Canada  supports  the  role  of  physician  assistants  as  a  resource  within  family   practice  and  other  environments  involving  family  physicians,  working  collaboratively  with  family   physicians  and  other  health  care  professionals  (CFPC,  2011).   Both  the  Canadian  Association  of  Physician  Assistants  and  the  Canadian  Medical  Association   recommend  that  physician  assistants  within  Canada  be  regulated  and  registered  with  their   provincial  or  territorial  medical  regulatory  authority  (CFPC,  2011).   A  number  of  provinces  have  incorporated  physician  assistants  into  primary  health  care,  including   Manitoba,  where  they  have  been  regulated  since  1999,  as  well  as  Alberta  and  British  Columbia.   Regulation  and  certification  requirements  are  still  under  consideration  (Vanstone  et  al.,  2014).  

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Patient-­‐Centred  Care    

Patient  Engagement  /  Involvement     §

 

  One  of  the  key  principles  of  patient-­‐centred  medical  homes  is  patient-­‐centred  care.  To  support   the  delivery  of  patient-­‐centred  care,  it  is  important  to  engage  patients  and  families  into  the   design  and  functioning  of  the  PCMH  (Scholle  et  al.,  2010;  Wexler  et  al.,  2014).  To  do  so,  it  is   suggested  that  a  pool  of  informed  and  activated  patients  who  can  serve  as  effective  participants   in  practice  design  be  developed  (Scholle  et  al.,  2010).  The  existing  evidence  based  for  patient   engagement  in  PCMH  design  and  implementation,  and  the  effectiveness  and  feasibility  of  specific   approaches  however  is  limited  and  variable.  Efforts  to  engage  patients  in  their  own  care,  practice   improvement,  or  policy  related  to  the  PCMH  are  not  common  (Scholle  et  al.,  2010).  

Three  Levels  for  Patient  Engagement  in  the     Design  and  Functioning  of  a  Patient-­‐Centred  Medical  Home      

1. Engagement  in  their  own  care,  including  communication  and  information  sharing,  self-­‐ care,  decision-­‐making,  safety):   § Learn  about  how  the  practice  works   § Discuss  roles  with  team   § Work  with  provider(s)  to  identify  and  monitor  treatment  and  self-­‐care  goals   § Participate  in  peer  support  groups  or  group  visits,   § Review  evidence-­‐based  decision  aids   § Review  medical  information  and  treatment  results   § Report  on  adverse  events  and  potential  safety  problems     2. Quality  improvement  in  the  primary  care  practice:     § Participate  in  quality  improvement  teams   § Participate  in  patient/  family  advisory   § Councils  or  other  regular  committee  meetings   § Provide  feedback  through  surveys   § Help  in  development  of  patient  materials   § Participate  in  focus  groups   § Do  “walk-­‐through”  to  give  staff  a  patient  perspective  of  practice  workflow   § Conduct  peer-­‐to-­‐  peer  patient  surveys     3. Development  and  implementation  of  policy  and  research:     § Serve  on  policy  and  quality  improvement  committees  at  various  levels  of  private   and  public  sectors  

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  § § §  

Gather  input  from  other  consumers   Participate  in  design  of  medical  home  demonstration  programs   Participate  in  training  for  clinicians  or  practice  teams  

(Peikes  et  al.,  2011;  Scholle  et  al.,  2010)    

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§

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  Key  lessons  about  successful  engaging  patients  and  families  (Scholle  et  al.,  2010):   o Asking  patients  and  families  what  matters  most  to  them  is  a  critical  step  in  engaging  them   in  care;   o Both  providers  and  patients  and  families  need  to  develop  new  skills  to  facilitate  patient   and  family  engagement;  this  can  be  achieved  through  additional  training  for  providers,   patients,  and  families;   o There  is  no  one-­‐size-­‐fits-­‐all  solution;  patient  engagement  will  look  very  different  for   different  practices,  patient  populations,  and  individual  patient-­‐provider  interactions;   o Need  multiple  and  flexible  approaches  to  gain  patient  input;  and   o Health  information  technology  has  the  potential  to  support  patient  engagement  in  the   context  of  thoughtfully  designed  care  systems.     Decision-­‐makers  can  promote  greater  patient  engagement  by  (Peikes  et  al.,  2011):   o Requiring  primary  care  practices  to  demonstrate  active  engagement  of  patients  and   families  in  patient  care  and  quality  improvement  activities;     o Using  payment  strategies  to  support  the  active  engagement  of  patients  as  partners  in   their  own  care  and  in  practice-­‐level  quality  improvement;     o Supporting  practices  with  technical  assistance,  tools,  and  shared  resources  to  engage   patients;     o Requiring  health  information  technology  standards  to  recognize  and  promote  patient   engagement;     o Requiring  meaningful  patient  input  in  the  design,  implementation,  and  evaluation  of   PCMH;  and,     o Supporting  additional  research  on  the  feasibility  and  impact  of  patient-­‐engagement   strategies.     Engaging  and  involving  patients  and  families  in  PCMH  design  and  function  is  limited  by  financial   and  logistical  constraints  (Scholle  et  al.,  2010).  For  example,  traditional  fee-­‐for-­‐service   reimbursement  does  not  reward  practices  for  engaging  patients.  Therefore,  payment  reform  is   critical  to  support  patient  and  family  engagement.  

Patient  Perspective    

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  §

According  to  the  “consumer”  perspective,  a  PCMH  can  become  more  patient-­‐centred  by   integrating  the  following  strategies  (Scholle  et  al.,  2010):     o Care  team:  the  care  team  is  led  by  a  qualified  provider  of  the  patient’s  choice,  and   different  types  of  health  professionals  can  serve  as  team  leader.   o Whole-­‐person  orientation:  the  PCMH  “knows”  its  patients  and  provides  care  that  is   whole-­‐person  oriented  and  consistent  with  patients’  unique  needs  and  preferences.   o Care  coordination:  the  PCMH  takes  responsibility  for  coordinating  its  patients’  health  care   across  care  settings  and  services  over  time,  in  consultation  and  collaboration  with  the   patient  and  family.   o Self-­‐management  support:  patients  and  their  caregivers  are  supported  in  managing  the   patient’s  health.   o Shared  decision-­‐making:  patients  and  clinicians  are  partners  in  making  treatment   decisions.   o Quality  improvement:  the  PCMH  seeks  out  and  encourages  patient  feedback  on   experience  of  care,  and  uses  that  information  to  improve  the  quality  of  care  provided;  the   PCMH  collaborates  with  patient  and  family  advisors  in  quality  improvement  and  practice   redesign.   o Access:  the  patient  has  ready  access  to  care;  open  communication  between  patients  and   the  care  team  is  encouraged  and  supported.   o Communication  and  trust:  the  PCMH  fosters  an  environment  of  trust  and  respect.  

   

Patient  Experience     §

§

  According  to  the  Patient  Centred  Primary  Care  Collaborative,  patient  experience  seeks  to  explore   what  patients  did  or  did  not  experience  in  their  interactions  with  providers  and  the  health  care   system  (PCPCC,  2010).  It  is  a  key  measure  of  patient-­‐centeredness  (PCPCC,  2010).     Patient  experience  may  be  captured  by  assessing  (PCPCC,  2010):     o Ease  of  scheduling  appointments;   o Availability  of  information;   o Communication  with  clinicians;   o Responsiveness  of  clinic  staff;   o Coordination  between  care  providers;     o How  the  provider  engages  a  patient  as  a  whole  person  and  in  decision  making;   o Disease  management;  and,   o Health  promotion.  

 

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  §      

There  are  a  number  of  activities  that  can  enhance  the  patient  experience.  For  example,  in   addition  to  improving  decision-­‐making  and  care  for  patient,  pre-­‐visit  team  huddles  have  been   shown  to  result  in  improved  patient  satisfaction  (Green  et  al.,  2012).  

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