Collaborative Medical Home Building 101 Harry Potter Learns

Collaborative Medical Home. Building 101: Harry Potter Learns Practice Jazz William L. Miller, MD, MA Lehigh Valley Health Network Allentown, PA February 29, 2008 STFM CONFERENCE ON FAMILIES AND HEALTH

Situation in FM Rising Demand Growing Competition • • Urgent Care Retail Clinics EDs CAM NPs/PAs Internet Specialists Shrinking Capacity • • • Less Hospital Care Less ED Care Less Procedures Less Point of Care Services Less Children Less Income Less Students/Graduates Less Investment More Demand More Paperwork More Documentation More Referrals More Patient Needs Unmet

The Miracle! PRIMARY CARE • Better Health Outcomes • Lower Costs • Greater Equity Patient-Centered Medical Home

www. transformed. com

National Demonstration Project Evaluation Team Center for Research in Family Medicine and Primary Care Carlos R. Jaén, MD, Ph. D (PI) Benjamin F. Crabtree, Ph. D Paul A. Nutting, MD, MSPH William L. Miller, MD, MA Kurt C. Stange, MD, Ph. D & Elizabeth Stewart, Ph. D (analyst) Reuben R. Mc. Daniel, Ed. D (consultant)

National Demonstration Project: Background The Future of Family Medicine report (2004) gave recommendations on “developing a strategy to transform and renew the specialty of family medicine. ” 1 The American Academy of Family Physicians allocated funding for a demonstration project to “test” the implementation of the new model(s) of family medicine as proposed by FFM. 1 The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004; 2: S 3 -S 32.

National Demonstration Project: Background Proof of concept of a new model(s) of care for family medicine: • Quality of care • Practice finances Determining the best process for transformation: • Facilitated • Self-directed

Domains of NDP Evaluation Discovering what the transformed model looks like in the real world Effect of the transformed model on the practice Effect of the transformed model on patients Understanding the process of practice change Understanding transformation

NDP Design Volunteer practices (36) selected by technical advisory committee from over 300 applicants Randomly assigned to two change approaches: Facilitated (18) Self-directed (18) July 2006 to June 2008 (2 yrs) Mixed method assessment: RCT with pre/post and inter-group comparisons Comparative case study

www. transformed. com

Practice Description Number of Sites Facilitated Self-directed Solo and Solo +1 3 3 Small (3 or less clinicians) 4 4 New 2 2 Medium (4 -6 clinicians) 5 5 Large (7 or more clinicians) 4 4 Total 18 18

Facilitated Practices Three Transfor. MED facilitators – each one assigned 6 practices. Intervention includes: • Site visits • Learning sessions/collaboratives • Facilitated conference calls and webinars • Connecting to nationally known consultants • Constant contact w/facilitators (phone, email) • Discounted goods and services (e. g. , website, disease registry)

Self-Directed Practices Very minimal intervention that will still allow this group to be a valid comparison group • Access to resources and information from Transfor. MED website • Practices self-organized and created their own retreat • Site visits by qualitative analyst

Data Sources: Quantitative • Patient surveys • Clinician/staff surveys • Medical chart reviews • Practice finances

Data Sources: Qualitative • Field notes/observations from facilitators (site visits, phone call logs, etc) • Field notes/observations from Qual. Analyst (facilitator huddles, meetings, etc) • Key informant & informal interviews • Email strings between practices and facilitators • Online discussions between practices • Conference calls, learning sessions

NDP Early Results • Proof of concept of a new model(s) of care for family medicine: – Quality of care • No difference between FPs & SDPs on patient outcomes • No relationship between # components & patient outcomes – Practice finances • Practices are less facile than initially assumed – Other • Practice relationship-centeredness ~ Patientcentered care

NDP Early Results • Determining the best process for transformation: • No difference between FPs & SDPs relative to # of components implemented • Tailoring appears helpful – Facilitation when relationships need work – Individual coaching for leadership, finances, etc. – With high motivation & high resources, consultative/instrumental approach helpful • The “New Model” Patient-Centered Care

Emergent Hope • Patient-centered medical homes may still be achievable • Multiple pathways • Full engagement of practice needed • Requires particular attention to: – The clinical process – Relationships among all members of practice – Relationships between practice & larger health care system & community – Motivation and capacity of key stakeholders • Confirmed earlier/current other studies

Personal Family Wisdom • Tree House Rule = “Whatever is said in the tree house, stays in the tree house. ” • Earth is the tree house • Adoption Rule = “Nurture & discover the unknown child. ” • “There is no perfection. ” • “Mistakes are for learning. ”

Background • Collaborative team has conducted a series of descriptive and intervention projects over a 15 year period. • Funded by NCI, NHLBI, NIDDK, NIMH and American Academy of Family Physicians (AAFP) • Results from these projects have informed an evaluation of the AAFP’s National Demonstration Project (Transfor. MED)

Observation DOPC Direct Observation of Primary Care (1994 -97) P&CD Prevention & Competing Demands in Primary Care (1996 -99) IMPACT Insights from Multimethod Practice Assessment of Change over Time (2001 -2004) Intervention STEP-UP Study To Enhance Prevention by Understanding Practice (1996 -2000) ULTRA Using Learning Teams for Reflective Adaptation (2002 -07)

First insights into role of complexity in understanding practices Practices could not be described in mechanistic terms – too many non-linear relationships among events – All the parts and people of a practice are interconnected and interdependent in terms of both relationships and functions. – Any change in one part of the practice will have ripple effects through the other parts of a practice. Those ripple effects will create tension and problems that can be barriers to change. – Changes don’t occur in a linear fashion. Small changes can have dramatic effects at times, large changes can produce small results at others. – What works in one practice may not work in another--many different ways of achieving good outcomes

Properties of Complex Adaptive Systems (CAS) • CAS consist of ‘agents’ with capacity to learn and freedom to act in unpredictable ways. • Agents are often individuals, they may be teams, organizational processes, technical components. • Agents are connected in non-linear ways--one agent’s actions changes the context for other agents. • The quality of the interactions among agents is more important than the quality of the agents.

Properties of Complex Adaptive Systems Self-organization: systems generate new structures and patterns over time as a result of their own internal dynamics. Order emerges from patterns of relationships among agents. Emergence: process by which non-linear interactions among agents results in new patterns of behavior. The system that evolves over time is more than the sum of its parts. Co-evolution: process of mutual transformation of the agent and the environment in which it exists.

Implications for Practice Change • Patterns of relationships among staff (‘agents’) are critical determinants of practice change. (The quality of the interactions is more important than the quality of the staff. ) • From high quality interactions, process will emerge to create high quality change • Emerging processes will not be the same in every practice.

According to CAS principles, successful practices will: • Move from an ‘organization as machine’ paradigm and begin to understand their practices as complex adaptive systems. • Pay more attention to the quality of the interactions among staff than on the quality of the staff. • Focus on staff learning rather than on what they know today. • Encourage cognitive diversity among staff (and teams) and leverage diversity to foster learning and emergence • Recognize that the practice is a social entity, and foster sense-making, learning, and improvisation • Expect and celebrate surprise as opportunities to learn and grow • Begin to understand the interdependence between the formal and informal organizations rather than making everyone conform to the formal organization

According to Complexity Science … • There are ghosts in the system because of Sensitivity to Initial Conditions. – Persistence of self-organization when there is much loose coupling and multiple feedback loops. • Power laws are operating because of Nonlinearity (think 80/20) – No normal distributions so averages are meaningless – Examples: • Length of stay – can’t use averages since the distribution isn’t a “normal” one – 80% of LOS # is based on 20% of the outlier patients • Referred admissions from family docs – 80% of admissions come from 20% of the docs • 80% of a practice’s attention is devoted to 20% of their patients • 80% of employee challenges in a practice are related to only 20% of the employees

IMPACT CHANGE MODEL

Relationship-Centered Practice Capacity Model Learning CULTURE s ill Kn le Action Sk ow dg e Mindful Heedful Diversity Improvisation Sensemaking Trust Social/ Task Rich/Lean Respect Fin an Dynamic Local Ecology Teamwork Build Memory ce s Reflection STORIES Facilitative LEADERSHIP s r pe O a n io t

NDP Early Lessons Implementation of new model components, especially technology, is a monumental undertaking… requiring a level of effort and intensity well beyond what most practices have done in the past. Practices are unfamiliar with changes at the systems level, and many do not function as a coordinated system and therefore lack insight into the complexity of their practice.

NDP Early Lessons: Motivation & Capacity 1. Leadership & key stakeholders need to be motivated and engaged in the change process. 2. A practice's resources & capacity for change at baseline is a huge determinant for that practice's progress, and equally important is the ability to increase that capacity.

NDP Early Lessons: Leadership & Reflection 3. The most successful practices seem to have shared leadership systems rather than an individual physician leader. • • So little leadership So much power 4. A critically important role of leadership is to assure adequate time for personal and practice-level reflection.

NDP Early Lessons: Relationships & Conversations 5. Despite being highly motivated some practices had serious dysfunctional problems within the relationship infrastructure that required significant time and energy on the part of the facilitator. 6. A critical factor in improving relationships is for leadership to assure adequate and appropriate conversations.

Early Lessons: Technology & Fatigue 7. The technology in the New Model, while shining with possibilities, is not by any means an easy "plug and play" interface for the practices. 8. Due in part to the ongoing challenges of technology, even the most successful practices are experiencing change fatigue.

NDP Early Lessons: Help & Support Depending on initial practice capacity assessment, may need one or more: a. Targeted consultation – e. g. Advanced Access, EMR, finances, specific operations, etc. b. Coaching – e. g. leadership, finances, etc. c. Facilitation – e. g. relationships, reflection, leadership, etc (different intensity of joining practice and/or system, ranging from just being there to active facilitation). d. Group Learning & Knowledge Access

More Lessons from NDP • • Essential New Skills/Curriculum Identity Issues Paradigm Problems Dual Organization Importance of IMPACT Model Breathe & Celebrate No Transformation Yet

NDP Early Lessons: It’s Personal For some physicians, the new model requires transformation at the personal level, as practices must move from a physician-centric approach to one that is more patient & relationship (team) centered. Each practice not only has a different way of implementing the new model, but each physician has a different vision of what transformation really is.

Harry Potter Wisdom • Make choices • Seek good friends • Do what matters

Change Thinking • Unfreeze & Initiate • Set initial conditions & start conversations • Requires HEAT • Everyone must be unfrozen • Transition & Trouble • Prepare for & deal with difficult emotions & conversations • Requires good & flexible project management • COMMUNICATE • Chill & Accelerate • Continue culture change & seek disruptions • Expect “change fatigue”

Being “Tempered Radicals” • Resisting quietly & staying true to one’s self • Turning personal threats into opportunities • Broadening the impact through negotiation • Leveraging small wins • Organizing collective action - Debra E. Meyerson (2001)

Jazz Secrets • Turn-taking • Soloing • Supporting • Passing-off • • Building Empathetic listening Continual negotiation Facilitative leadership Hanging out Here & Now In the Groove

Leadership Types • Leadership as Leader – Engineer • Strategic Engineer (design for fit with environ. ) • Economic Engineer (design for perfor. outcomes) • Social Engineer (design for behav. outcomes) • Leadership for Emergence • Administrative Leadership • Enabling Leadership • Adaptive Leadership - See Complexity Systems Leadership Theory by Hazy, et al (2007)

Emergent Leadership Properties • Distributing Intelligence • Fostering Conversations & Enriching Connections • Sustaining Tensions • Looking for Patterns - See Complexity Systems Leadership Theory by Hazy, et al (2007)

The Magnificent 7 • • Mindfulness Respectful interaction Heedful inter-relating Mix of rich and lean communication Diversity Mix of social and task relatedness Trust

Types of Teams CONTROL (Think Football) AUTONOMY (Think Baseball) COLLABORATION (Think Basketball) From R. Keidel, Corporate Players

Characteristics of Good Team • Relational Coordination • • • Frequent, timely communication Shared goals Shared knowledge Mutual respect Problem-solving • Team Culture (supportive) • Other Key Features • Clinical & administrative systems • Training & cross-training

Roles of Future FP • Manager of Care Staff • Manger of Informational System • Doer of the Tough Clinical • “It’s OUR patient” and not “It’s MY patient. ”

3 Conversational Intents • Doing the Project • Stakeholder/Structure/Matrix Development Work • Adaptive Capacity Building

Some New Models • The BIG Home • • Transfor. MED Ambulatory Practice of the Future Optimal Healing Environments Cooperative Clinics • The LITTLE Home • Micropractices • Concierge practices • Access Healthcare • Real Estate Agents with Perks • “Retail” clinics • Urgent care/ED express care

References Organizational Change & Complexity Science 1. Cohen D, Mc. Daniel RR Jr, Crabtree BF, et. al. A practice change model for quality improvement in primary care practice. J Healthc Manag. 2004 May -Jun; 49(3): 155 -68. 2. Miller, W. L. , Crabtree, B. F. , Mc. Daniel, R. A. , and Stange, K. C. Understanding Primary Care Practice: A Complexity Model of Change. J Fam Pract, 1998 46(5): 369 -376. 3. Miller WL, Mc. Daniel RR, Jr. , Crabtree BF, Stange, K. Practice Jazz: Understanding variation in family practice using complexity science. J Fam Pract 2001; 50(10): 872 -878.

References 4. Stroebel CK, Mc. Daniel RR, Crabtree BF, Miller WL, Nutting PA, Stange KC. How complexity science can inform a reflective practice improvement process. Joint Comm J Qual and Patient Safety. 2005; 31(8): 438 -446. 5. Safran DG, Miller W, Beckman H. Organizational dimensions of relationship-centered care. J Gen Intern Med 2006; 21: S 9 -15.

References 6. Crabtree BF, Miller WL, Tallia AF, Cohen DJ, Di. Cicco-Bloom B, Mc. Ilvain HE, Aita VA, Scott JG, Gregory PB, Stange KC, Mc. Daniel RR. Delivery of Clinical Preventive Services in Family Medicine Offices. Ann Fam Med. 2005; 3(5): 430 -435. 7. Miller WL, Crabtree BF. Healing landscapes: Patients, relationships and optimal healing places. J Complementary and Alternative Med. 2005, 11 Suppl 1: S 41 -9. 8. Crabtree B. Primary Care Practices are Full of Surprises! Health Care Manage Rev, 2003, 28(3): 279 -283.

References 9. Tallia AF, Lanham H, Mc. Daniel R, Crabtree BF. Seven Characteristics of Successful Work Relationships Family Practice Management 2006 Jan; 13(1): 47 -50. 10. Solberg LI, Hroscikoski MC, Sperl-Hillen JM, Harper PG, Crabtree BF. Transforming medical care: Case study of an exemplar small medical group. Ann Fam Med. 2006 Mar-Apr; 4(2): 109 -16.