Appendix 1: Clinica Campesina and Group Visits

1.1 Clinica Campesina and the Group Visit Model

Clinica Campesina is a community health center that is committed to providing affordable, high-quality medical care to low-income, unemployed, and uninsured people in the surrounding community. As part of their organizational mission to increase access to care in the community, Clinica Campesina core group members chose to adopt a group visit model in 2000. Group visits increase patient capacity without the need to hire additional staff, improve continuity of care, and provide an opportunity for mutual support among patients. In these group visits, 15 to 20 individuals with the same condition or health need see a physician as a group. One physician moves from patient to patient discussing individual concerns and conducting a brief examination, while the rest of the group receives a patient education segment, participates in a question-and-answer session, and has routine wellness measures taken (e.g., blood pressure, blood sugar). Patients who have similar medical conditions and problems make a long-term commitment to meet regularly. Over time, they form a primary support group. Clinica Campesina currently holds group visits for prenatal, newborn, well-child, diabetes, AIDS/HIV, depression, and weight-loss care.

1.2 Decision to Implement Group Visits

The Clinica Campesina core group learned about the group care model during a search for an innovative care approach to meet the needs of their patients. In the early 1990s, Clinica Campesina was recruited to take part in an Institute for Healthcare Improvement (IHI) diabetes collaborative assessing diabetes care models. As part of this collaborative, Clinica staff were required to collect several key measures to assess the efficacy of their diabetes programs. Analysis at Clinica and other facilities participating in the collaborative showed suboptimal outcomes for the key measures. Following that initial collaboration with IHI, Clinica decisionmakers realized that the care model they were using was not effective in producing the outcomes they desired.

Clinica Campesina decisionmakers began actively searching for a conceptual model of change to improve outcomes and increase access to services at their clinic. Clinica core group members began to research idealized office design concepts, and in September 2000 a core group from Clinica attended a large IHI conference. The group consisted of key leaders within the organization, including medical directors, site managers (RNs and operations), and an operations director. The core group participated in all office redesign clinics offered at the IHI conference, including a strategy and design clinic for implementing the group visit model.

The decision to implement the group care model was made almost immediately after Clinica core group members participated in the clinics at the IHI conference. The decision to seek an alternative model was prompted by the immediate need to increase access to and quality of care at Clinica Campesina. Low-income patients at Clinica did not have access to care and were not receiving scheduled medical treatment because of the high demand for services. An innovation was needed that would improve access to care and allow Clinica to expand its patient population significantly.

Another major consideration in the decisionmaking process was the cost of the model. Group members considered the cost of the initial physical restructuring, additional staff commitments, and work hours. Clinica decisionmakers were faced with a limited budget and had to determine which innovation would bring the most added benefit in return for the cost.

In reviewing possible innovations to adopt, the core group also reviewed the expected benefit to patients that each candidate innovation would create. They wanted to provide medical services in a way that would enable patients to establish a long-term relationship with Clinica by engaging them and allowing them to build relationships both with their medical providers and health communities and with other patients.

The expected observability of benefits was also a factor. Staff wanted to be able to measure the benefit not only to the clinic but also to the patient. Measures included patient and provider satisfaction, increased access to health services, increased attendance at appointments, and improved lab results for key medical areas. Along with observability, decisionmakers at Clinica focused on the trialability of the innovation—the ability to implement it on a small scale or for a short period.

One of the most vital aspects that the core group considered in the decision process was compatibility. They were eager to find an innovation that would be compatible with the mission and culture of Clinica Campesina. The core group looked at various aspects of compatibility, including organizational culture, staff abilities, staff attitudes, patient attitudes, and staff readiness for change. These factors were discussed prior to the decision to implement by core group members and were later assessed as part of the implementation process. Core group members discussed these factors in light of their experience working with Clinica staff and patients.

The primary factors considered before adopting the group visit model were access to care, cost, expected benefit, observability, trialability, and compatibility. Participants also discussed some factors that they did not take into account in decisionmaking. In retrospect, members of the core group realized that physical space needs should have been factored into the original decision about innovations. The shifting roles and responsibilities of employees at Clinica Campesina was another factor that was not considered in the initial decisionmaking process. The group visit model of care dramatically changed the roles of medical providers and support staff. Medical providers shifted from one-on-one patient care to group care, and other clinical staff (physician assistants, RNs) became responsible for group education and group care management. Administrative staff roles also changed to reflect the emphasis on continuity of care. Administration was restructured into different administrative and medical “pods,” which functioned independently and served the same patients continuously.

1.3 Decisionmaking Process

At Clinica Campesina, decisionmaking is a group process involving individuals who represent various management and operational roles within the organization. As part of the group decisionmaking process, core team participants discussed all the candidate innovations and eliminated various innovations on the basis of the key factors discussed above. After the initial core group decision to implement an innovation, buy-in and approval from senior management and the chief executive officer were safeguarded.

The decisionmaking culture at Clinica is one of trying. This aspect of the organizational culture played a key role in the decision to go ahead with an innovation. They did not choose to adopt the group visit model irreversibly, but rather chose to try it. This model of trying may limit the ability to generalize the findings on the decisionmaking process and may not apply to innovations that are not well suited to a trial or pilot test. Clinica Campesina follows this model in day-to-day decision processes and large-scale innovation decisions. The model builds employee/management buy-in during the trial, minimizes perceived risk, and allows Clinica staff to try more innovations than similar organizations can.

We frequently find ourselves ‘trying’ if something [at Clinica] doesn’t work. People don’t feel like they are making a change if it is gradual. A complete consensus doesn’t have to be made to try something; people understand it is a process and they provide input and they understand that the endpoint is going to be different. People are more able to tolerate the problems that occur.

Clinica decisionmakers use several tools to monitor the innovations they try; the most important tool is PDSA (Plan, Do, Study, Act), a rapid-cycle improvement tool. This tool allows Clinica to monitor the success/benefits of an innovation and helps guide the final decision on whether to adopt the innovation permanently. Along with outcome tracking, Clinica uses patient and provider surveys to assess the compatibility of its programs within the organization and to solicit feedback from staff and patients on current innovations and readiness for change.

1.4 Decisions Not to Adopt

Because of the organizational culture of trying, respondents could think of very few instances in which they decided to forgo adopting an innovation completely. In most cases, they decided to try a part of an innovation and then made a final decision after considering the feedback they received from employees, management, and patients. For example, the medical practitioners at Clinica once tried adopting an e-mail care program after receiving positive feedback from patients. The program was unable to deliver the results that practitioners at Clinica expected because of their patients’ lack of access to computers. After receiving the results of surveys analyzing computer access, Clinica management decided to discontinue the program.

1.5 Lessons Learned

Clinica Campesina staff provided an invaluable perspective on the adoption decision process and the degree to which the core elements of adoption decisionmaking (i.e., access to care, costs, observability, trialability, and compatibility) factored into their organization’s adoption decision experiences.

When asked about things they wished they had considered ahead of time, respondents said that they wished they had conducted a better assessment of physical space needs and the changing roles of employees that emerged during implementation of the group visit model.

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