Becoming a medical home is a radical change, requiring both a new mental model for primary care and the skills and resources to accomplish it,” say the authors of the article, How to Scale Up Primary Care Transformation: What We know and What We Need to Know?

There are plenty of examples of successful transitions to Patient-Centered Medical Home (PCMH) models – but they are still examples, developed by innovative leaders who were able to find adequate technical and financial support. To make the PCMH transformation mainstream, note the authors, requires the recognition and application of 10 critical success factors:

  1. Leadership.  No matter the size of the practice, at least one physician or practice manager must possess the vision to transform to a PCMH, the ability to sell the concept to other members of the team, and the skills to implement the vision.
  2. Resources. A PCMH is a new business model, requiring some upfront investment in time and money, and an ongoing revenue stream. It calls for innovation in working with local health insurers for new models of payment, as well as examining how to relate the new model to existing fee-for-service practices.
  3. Relationships. This is where the physician-staff-patient partnership becomes important, as well as integration with community resources and families for both prevention and care of chronic diseases. Who in your practice can be responsible for identifying these relationships and making sure they are developed and maintained?
  4. Patient and Family Engagement. New capacities created by health care technology can help build partnerships with patients with chronic diseases and their families. The PennCME/BestPractice website is one tool that can assist you by referring your patients to its Patient Resource Center, or via e-mail. From there, patients can learn about partnering, learn about their chronic disease, and get information on building a healthy lifestyle. In addition, you may wish to share content of a patient’s medical record with him/her, and offer an e-mail service to answer specific questions not requiring a visit.
  5. Competent Management and Finances. Take a look at the TransforMEDsite, affiliated with the American Academy of Family Physicians (AAFP), to learn more about “adaptive capacity” that enables a practice to take on a transformative program that examines the organizational structure as well as the financial structure.
  6. Improvement Technique. There are a number of techniques from which to choose to bring about change. Every practice and its leadership need to select a model that fits. Consult the Institute for Healthcare Improvement (IHI)) or Improving Performance in Practice (IPIP) for a range of possibilities.
  7. Expert and Facilitated Assistance. Many organizations – both in health care and in business – use outside consultants to assist in a transformation process. Consultants can often help identify blocks to practice change as well as pathways to improvement. You may be able to identify such a resource in the management of a nearby practice that has successfully migrated to a PCMH, or turn to a professional society such as the AAFP, its affiliate TransforMED, or the American College of Physicians (ACP). Local practice management consultants may also possess the knowledge and skills to assist.
  8. Health IT. There are four attributes to a well-designed electronic health record systems that can substantially improve transition to a PCMH:
    1. Registry functionality, to track your patient population in terms of markers of chronic disease and of prevention. This function enables prompt recall of, for example, patients with diabetes whose glycosylated hemoglobin (HbA1c) is not in good control and who have not returned in more than 3 months (go to Step 3); or patients who need flu shots or pneumococcal vaccine, and are at high risk.
    2. Care planning, which allows development of collaborative plans with staff and patients, updating of the plans on a regular basis, and sharing with all involved – including community health resources when appropriate.
    3. Communication among staff, patients, specialists, and community resources, via e-mail and/or data.
    4. Monitoring and tracking change and improvement, the result of good registries, care plans, and updates.
  9. Capacity to Deliver Coordination. The size of your practice and its relationship to other health care resources in the community will help you decide whether to coordinate from your own practice or find a larger care coordination network to work within – such as an Accountable Care Organization (ACO), a statewide network such as exists in Vermont, or a hospital-based network.
  10. Professional and Staff Roles and Training. Perhaps the simplest way to describe this is TEAMWORK. Building a successful team means redefining responsibilities and encouraging each staff member to work to the capacity of his or her knowledge and skills, especially in the management of patients with chronic disease and those in need of prevention and risk reduction.
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