Looking Back on my Practice –
A Thirty Year Evolution
I started my primary care practice nearly thirty years ago with a group that grew to seven of us. Ten years in, we joined Premier Medical, which became what is now a group of 106 physicians and providers, and a staff of 350, providing care at seven locations. We are one of the largest multi-specialty groups in our region.
Early in the group’s existence, we talked a lot about being a “team,” but we provided care the same way that most physicians had, for decades.
We gave little thought to efficiency, cost-containment, measurable outcomes, or even the overall patient experience. We focused on our time with the patient. The doctor-patient relationship was the core of our ethos – of why patients liked us. It was, indeed, a simpler time.
I’m proud to say that as we grew, we were always forward thinking and early adopters of new ways of doing the work - as long as it was focused on improving patient care. In fact, we started down the path of moving to team-based care long-before it became a focus of the entire healthcare system.
Today, we consistently exceed the quality goals we set for ourselves, and have created a culture where our providers, and staff understand our expectations, and want to meet them – because we care deeply about the work we do.
(See, AHRQ's website dedicated to Team-Based Care:
https://www.ahrq.gov/ncepcr/tools/transform-qi/create-teams.html)
Why We First Started Looking at a New Model – and A Focus on Chronic Disease
About twelve years ago, we recognized that if we wanted to continue to improve patient outcomes, and to drive high quality care for our entire panel of patients, we’d need to transform the way we deliver that care.
I’m proud that we took on the challenge, and our ability to meet the needs of our patients, and to create an amazing team-based culture, supports the argument in favor of doing this work.
In our case, this discussion grew out of the realization that independent urgent care providers were disrupting our care model, and our revenue stream. Essentially, we were facing the loss of our acute care revenue stream. This forced a realization, earlier than most, that our value was not in the traditional primary care delivery model, but in effectively managing chronic disease states.
We had to rethink every aspect of how we provide care to our most vulnerable patient populations. Organizations, and people, especially physicians, do not naturally embrace change - so this was going to be a challenge.
The complexity of care required for these patients meant that no physician could effectively “own” their care. We needed to move an already large, complex, organization to a new, interdisciplinary team-based model of care. The goal was to move away from a traditional top-down delivery system, toward an interdisciplinary care model.
We were fortunate. Because we started this process early, we had more than a decade to refine and perfect the model. It did NOT always go smoothly, but over the past five years, our practice has shown dramatic improvements in quality, efficiency, and cost-reduction. It’s amazing to look back and see the transition, and what’s it meant for our patients, and our people.
(Your might also like a recent blog on building effective teams:
Key Steps
Investing in New Roles, and Dedicated Responsibilities
We took funds that traditionally went to providers, and invested them in new team members, creating positions that did not exist prior to the transformation.
We implemented an integrated, twenty-four-seven hospitalist program focusing on intensifying hospital-based care. This allowed the outpatient providers to give one-hundred percent attention to outpatient chronic disease-based care.
Outpatient primary care physicians focused on treating the top eleven chronic disease states. These conditions drive the highest per member per month cost: stroke, cancer, COPD and allied conditions, diabetes, osteoporosis, arthritis, depression, heart disease, Alzheimer’s disease and other dementias, hypertension, and dyslipidemia.
In addition to focusing on these disease states, we developed workflows to decrease the total cost of care.
Building an Outpatient Team
After developing the hospitalist program, we transformed the outpatient teams. We hired clinical pharmacists, social workers, clinical nurse coordinators, dieticians, diabetic educators, and behavioral health specialists to focus on the 10% of the patient population that generated 70% of the total cost of care.
Focusing on Readmissions
We started using our team huddles every morning to identify patients who were at risk for hospitalization, or who were flagged for possible decline in care. We utilized our nurse coordinators to follow lists of vulnerable patients, and they made outreach calls to identify care needs before those needs escalated into problems.
Paying close attention to the discharge plan, we developed a sophisticated transition of care program, including seeing patients early after discharge for follow-up, in-office appointments. This helped to prevent readmissions because we had a point person on our team addressing care needs.
Our goal was to prevent hospitalizations and readmissions and this group’s dramatic success was an early win for our value-based care journey.
Preventive Care Strategies
We then deployed a practice-wide effort to work on preventative care strategies, designed to improve care and reduce costs. These efforts were multifactorial and comprehensive.
We worked on:
Medication adherence;
Increasing preventative cancer screening;
Expanding adult and pediatric immunization strategies; and
Delivering evidence-based care for patients with hypertension, diabetes mellitus, coronary artery disease, and/or congestive heart failure.
These efforts were supported by the early, and continued, investment in sophisticated practice analytics programs. These allowed us to identify gaps in care – so we could quickly close those gaps.
We had over a decade to make this transition. You, likely, do not.
Culture Change and Leadership
Creating a New Vision. Ultimately, we created a shared culture that values providing comprehensive preventative care to improve quality outcomes and reduce hospital admissions and readmissions, especially for our most vulnerable patients. It took time, though, for people to understand the vision, and to fully buy-in to the changes – because change is difficult for everyone.
Value Everyone. Moving to this new model would not work without staff buy-in and support. One way we addressed this need, was to ensure that team members felt valued. We gave people roles and responsibilities that allowed them to work at the top of their license.
These strategies gave the medical assistants, APPs, pharmacists, and support staff, greater job satisfaction and removed tedious tasks from our top-level providers, in turn reducing physician burn out.
Quality Transparency. One of the ways that we drove improvement was via transparency in the reporting of our quality goals, to our providers. This was a cultural shift. Initially, it created angst among some of the lower performers. Eventually, everyone accepted that we are striving for excellence as a group, and that we can only do that by openly discussing our performance metrics.
Change Management Skills. Early in the process, I recognized that we needed a consistent approach to change management. I became a master teacher of the AHRQ Team STEPPS Change Management Program closely following John Kotter’s 8 Steps of Change Management. This was a key to developing a shared culture and helping our providers become more comfortable being a part of the interprofessional team.
Physicians’ Sense of Autonomy. We also had to acknowledge, and deal with, the perceived loss of autonomy and control of physicians, themselves. Many of us (I struggled at first, too.) felt valued because all of the patient’s care came through us. We were solely responsible for the patient’s well-being and the work that needed to be done. The rest of the “team” existed to support OUR work.
We did this by asking for patience, through a focus on group, and individual coaching, by engaging physicians in creating the vision, and the new model, and by constantly showing them how much better this was for our patients – which is what they really cared about. We also challenged physicians to stop thinking of themselves as “individual contributors”, as THE expert, and as more of the Leader of the care team. Developing leadership skills had to become a new focus for us.
Lessons Learned
There is no template for what team-based care will look like for you.
We had over a decade to make this transition. You, likely, do not. As other groups have started asking for our advice, I’ve put together a list of a few key lessons that may be of value:
1. Every organization is unique. Your goals, market realities, organizational challenges, data capabilities, performance metrics, care and communication processes, and EHR systems, hospital relationships, team-member make-up, etc, will dictate what your transition will look like. There is no template for what team-based care will look like for you.
2. Develop Early Champions. Engage key stakeholders and establish the case for the transition, BEFORE you start to make any changes or even show anyone a plan. Ensure that you develop champions, early, at every level: Physicians, providers, managers, and staff.
3. Seek Help. Create a detailed, flexible, and realistic plan. Most organizations do not have change management, strategic planning, or project management expertise. Seek expert help where you need it and avoid detours, false starts and avoidable mistakes.
4. Set Expectations. Be transparent about the amount of work involved, and that it will NOT all go smoothly. Establish reasonable expectations, including that you’ll be asking for help in addressing the challenges that will, most assuredly, arise.
5. Support Leaders. Pre-emptively coach leaders on how to approach this initiative. Make NO assumptions about their skills or abilities. I had to learn, myself, that this work was going to require new, different, leadership skills on my part.
6. Engaging People. It’s good to remind yourself, that people (including physicians, who are people, too!) need three things to be fully bought in, and engaged. Always keep these in mind:
Competence – They need to understand their role, what’s expected of them and be given the opportunity to master new skills, so they feel confident.
Autonomy – It’s OK to mandate that the change is happening, but wherever possible give people a role in creating the new world they’ll work in.
Connection – Create a sense that the entire organization is doing this together. This is NOT a leadership initiative. Make the extra efforts required to help people to feel connected to their immediate colleagues, and the larger organization – create a sense of pride in your willingness to do this work!
The Future
Twelve years ago, Premiere Medical Associates embarked on a journey to transform our practice. We weren’t quite sure of where we were going but we knew the journey was an absolute necessity.
Little did we know that we would come this far. Our inter-professional team-based approach has exceeded expectations and will continue to grow for years to come. We remain committed to providing high-quality, value-based care to our patients, which means we never stop working on patient care initiatives, workflow innovations, and adding new team roles.
This work has been incredibly rewarding for all of us – especially me as I can recall, clearly, how different my own practice was, thirty years ago. Change, and innovation, is hard in healthcare. I’m proud that we took on the challenge, and our ability to meet the needs of our patients, and to create an amazing team-based culture, supports the argument in favor of doing this work.
I’ll be joining my outstanding colleagues, Francis R. Colangelo, M.D., M.S.-HQS, FACP, and Jennifer Obenrader, Pharm.D., CDCES to present “Leveraging an Interdisciplinary Team in Innovative Ways to Provide High Value Care” at the AMGA conference in Las Vegas in March of this year.
If you'd like to learn more about Trailhead Strategic Solution's approach to supporting physician leaders, as they take on this transition, feel free to reach out!
You can download our paper on Creating a Culture of Physician Leadership at the Trailhead landing page:
Comments