Transformation is Hard Work Lessons from Transfor MED s

Transformation is Hard Work: Lessons from Transfor. MED’s National Demonstration Project Presented by Elizabeth E. Stewart, Ph. D October 21, 2007

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

Components of Transfor. MED Model of Care Access to care Access to information Team approach Point of care services Information services Redesigned offices Practice management Quality and safety Whole-person orientation Personal medical home Patient-centered care Continuous relationship

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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 At present, site visits by qualitative analyst Their data are not the basis in this report – however, ongoing learning provides confirmatory data

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

1 st year 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 Lessons 15

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. 16

NDP Early Lessons The most successful practices seem to have shared leadership systems rather than an individual physician leader. Leadership systems have complementary pieces for practice vision, practice operations, and practice finances. When the leadership system is in place, a practice’s ability to adopt changes accelerates significantly. 17

NDP Early Lessons Despite high levels of motivation, some practices had serious dysfunctional problems at baseline. These required significant time and energy on the part of the facilitator. Before the facilitators could begin making changes… they had to shore up and fortify the practice relationship infrastructure. 18

NDP Early Lessons A practice's capacity for change at baseline is a huge determinant for that practice's progress. Equally important is the facilitator's ability to increase that capacity. Such capacity is dependent upon some of the key elements facilitators worked to foster in the beginning. 19

NDP Early Lessons Proposed new model technology is not by any means an easy "plug and play" interface for the practices. The technology landscape for medical practices resembles a pile of different jigsaw puzzles thrown together. Sorting through and making it work requires tremendous energy. Implementation forces rigorous examination to guard against “automated inefficiencies. ” 20

NDP Early Lessons Due in part to the ongoing challenges of technology, even the most successful facilitated practices are experiencing change fatigue. Learning sessions have been critical for renewal and regeneration. Preliminary data from SD practices also indicate a strong desire for an outside force to “ride herd” and sustain energy. 21

NDP Early Lessons 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 team-centered. Each practice not only has a different way of implementing the new model, but each change leader physician has a different vision of what transformation really is. 22

NDP Early Lessons Focusing the Role of Facilitator: Depending on initial practice capacity assessment, a practice may need one or more: 1. Targeted consultation • Practice finances (reduce overhead, etc) • EHR implementation/work flow • Specific operations (same day scheduling, group visits, etc) 23

NDP Early Lessons Focusing the Role of Facilitator: 2. Coaching • Leadership • Finances (understanding/managing) • Specific roles (office manager) 24

NDP Early Lessons Focusing the Role of Facilitator: 3. Facilitation * Relationships * Reflection * Leadership Facilitation seems to vary in its intensity, ranging from “joining” a practice or system to being a supportive background presence. 25

Family Medicine Practice Trying to Change… The upgrade needs to be done while the plane is still flying! 26

Transformation Complete? 27