Medical Home Features Small Panels, Long Visits, Outreach, and Caregiver Collaboration, Leading to Less Staff Burnout, Better Access and Quality, and Lower Utilization

Service Delivery Innovation Profile

Medical Home Features Small Panels, Long Visits, Outreach, and Caregiver Collaboration, Leading to Less Staff Burnout, Better Access and Quality, and Lower Utilization

Snapshot

Summary

Group Health Cooperative piloted a patient-centered medical home model in one clinic. Based on five common design principles, key elements of the model include significant reductions in panel sizes and increases in average visit time (achieved by hiring more physicians and other staff); pre- and postvisit outreach and care management by nonphysician staff; close communication and collaboration between physicians and other caregivers; upgrades to and better use of existing technology; and the elimination of productivity-based bonuses. The program reduced staff burnout, ambulatory care sensitive admissions, and emergency department visits and increased physician satisfaction and patient perceptions of access to and quality of care, without increasing overall health care costs.

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation comparisons of a variety of metrics related to staff burnout and patient experiences derived from surveys of patients and staff at the pilot clinic and at two Group Health control clinics. Comparisons of patient care costs, including ED visits and inpatient admissions, were made between adult enrollees at the pilot clinic (8,100 patients) and 230,000 patients enrolled in 19 other Group Health clinics in western Washington.

Use By Other Organizations

Many organizations have toured Group Health to examine the medical home, including provider groups, commercial insurers, safety-net clinics, and others. They have also been visited by primary care visitors from at least five other countries.

Date First Implemented

2006

Problem Addressed

Primary care clinics face increased demands for greater efficiency and productivity, which frequently leads to the adoption of large patient panels and productivity-based compensation. At the same time, patients are demanding greater access to care, including same-day appointments and e-mail and telephone access to providers. These demands often leave primary care physicians (PCPs) feeling stressed and overburdened, without adequate time to get to know patients, help enhance their self-care, or develop comprehensive care plans. Not having enough time with patients can, in turn, lead to increases in specialist and emergency department (ED) visits and inpatient admissions.

  • Demands for greater efficiency, productivity: The prevalence of chronic conditions—most of which are handled in primary care settings—among a rapidly aging patient population has placed great demands on primary care practices. Between 1997 and 2005, U.S. adult primary care visits to physicians increased from 273 million to 338 million annually, or 10 percent on a per capita basis.1 Despite that increased demand, PCPs earn half as much as specialists, even when they work the same number of hours, due to lower reimbursement rates by health plans. As a result, PCPs are pressured to see more patients to generate more income.2
  • Overburdened PCPs leaving medicine: Currently, 35 percent of the nation's physicians are over age 55, and most will retire within the next 5 to 10 years, leaving an inadequate number of PCPs to care for an aging population with growing incidences of chronic diseases, unless their practices can be restructured to provide more rewarding, less stressful practices.3 After increasing patients loads to 2,300, which is near the national average, Group Health risked losing experienced providers who were approaching retirement age.
  • Demands for better, faster access: Patients increasingly want better access to primary care, including the ability to schedule same-day appointments and to communicate with their doctor via e-mail and telephone. Patients also want quicker access to test results, preferably in writing and delivered quickly through an online system.4
  • Difficulties adjusting to electronic health records (EHRs): Many primary care clinics, including those at Group Health, have put in place EHRs to help facilitate efficiency and access improvements. However, adjusting to these new systems can be difficult for busy physicians, particularly when first implemented, when they have little time or training to adapt to them.
  • Leading to physician burnout, lower quality, higher downstream costs: The growing demands being placed on PCPs frequently lead to their feeling overburdened and stressed, which in turn can result in diminished quality of care and higher downstream costs. At Group Health, for example, the demands on PCPs resulted in a significant increase in physician workload, fatigue, and stress levels due to the large panel sizes, short amount of time for face-to-face visits, and large volumes of e-mail correspondence with patients.5 Despite earlier efforts to boost access to care, patient needs were clearly not being met, as quality of care indicators suffered and referrals to specialists, ED visits, and inpatient admissions increased, leading to higher overall health care costs. 5 , 6

Patient Population

More than half of patients treated by the pilot clinic were college-educated, with 85 percent being white, 82 percent being in good or excellent health, and 69 percent being age 45 or older.

Description of the Innovative Activity

After earlier efforts to improve efficiency and access to already overburdened providers, Group Health Cooperative piloted a patient-centered medical home model in one clinic. Based on five design principles (see Planning and Development section for details), key elements include significant reductions in panel sizes and increases in average visit time (achieved by hiring more physicians and other staff); pre- and postvisit outreach and care management by nonphysician staff; enhanced communication and collaboration between physicians and other caregivers; upgrades to and better use of existing technology; and the elimination of productivity based bonuses. Additional details on each of these key elements are described below:

  • Smaller panel sizes, longer visits (achieved through staff increases): Each physician in the pilot clinic cares for an average of 1,800 patients, well below the 2,327 average panel size before the redesign, which was close to the national average. In addition, the clinic allocates 30 minutes for each primary care visit (up from 20 minutes before adoption of the model). To accomplish these changes, Group Health increased staffing in the clinic significantly, including physicians (by 15 percent), physician assistants (44 percent), nurses (17 percent), licensed practical nurses (18 percent), and onsite clinical pharmacists (72 percent). One-fourth of patients were reassigned to the newly hired physicians (see the Planning and Development section for information on the transition process for these patients). In addition, increased emphasis on e-mail and telephone visits as an important component of patient care helped decrease demand for inperson visits.
  • Pre- and postvisit outreach, care management: Existing and newly-hired staff, including physicians when appropriate, dedicate considerable time to patient outreach and care management, both before and after visits, as outlined below:
    • Previsit planning and postvisit followup: Each physician has one medical assistant (the licensed practical nurse) who conducts outreach to new patients, previsit planning (e.g., patients, chart review, visit planning), and postvisit telephone followup (e.g., to those with abnormal test results).
    • Disease management: Two nurses provide intensive short-term disease management for patients with uncontrolled chronic illnesses and transitional care to these patients after a hospitalization. The nurses also use motivational interviewing techniques to engage patients in self-managing their condition.
    • Post-ED visit and hospitalization followup: Two licensed practical nurses follow up with patients after unplanned ED visits and hospitalizations.
    • Medication consultations: The onsite clinical pharmacist regularly meets with and supports other caregivers, providing guidance on appropriate medication therapy for managing patient's conditions. The pharmacist may also directly contact patients with advice and medication adjustment recommendations.
  • Enhanced e-mail and telephone access: Additional nursing and medical assistant staff provide better and more timely responses to patient e-mails and calls, which take the place of office visits when appropriate. The clinic encourages patients to use e-mail communications and to complete an electronic health risk assessment by promoting its secure Web portal.
  • Enhanced communication between physicians, other caregivers: Paired physicians and medical assistants share office space to allow for closer collaboration and coordination of care. Care teams also meet regularly to discuss and implement needed changes to care processes (using a rapid-cycle improvement process) and also hold mandatory “team huddles” each day to discuss particular cases or issues. The team has access to data from a visual reporting system that tracks the impact of implemented changes, with results being posted in prominent locations within the clinic.
  • Better use of automated systems to support clinic-based and followup care: Providers became more effective at incorporating EHR functions into their daily work. Clinicians fully utilized the real-time alerts related to best practices and health maintenance, including care deficiency reports that highlight the need for a particular test, medication, or service. The EHR system also supports staff in providing followup care to patients after ED visits and inpatient admissions, and in identifying patients with chronic illnesses who could benefit from Group Health's self-management workshops. In addition, an automated routing system ensures that calls are answered quickly by the appropriate person.
  • Flat salary (replacing productivity bonuses): Clinic physicians receive a flat salary after the elimination of relative value unit–based productivity incentives.

Context of the Innovation

Group Health Cooperative provides health care insurance and comprehensive care to 580,000 members in Washington and Idaho; members receive services through an owned network of primary care and specialty clinics and through hospitals and EDs under contract with the plan. Group Health serves employees of major companies such as Microsoft and Boeing, along with individuals, Medicare and Medicaid beneficiaries, and children enrolled in the State Children's Health Insurance Program. Between 2002 and 2006, Group Health implemented a series of reforms to improve efficiency and access at 20 primary care clinics in western Washington. These reforms increased physician workload, fatigue, and turnover and led to negative trends in quality of care and utilization. Recognizing these problems, leaders at the Group Health Research Institute began working with health plan senior management to research, develop, implement, and evaluate use of a patient-centered medical home model in one of the clinics.

Results

The program reduced staff burnout, ambulatory care–sensitive admissions, and ED visits, and increased physician satisfaction and patient perceptions of access to and quality of care; these benefits were achieved without increasing overall health care costs.

  • Less staff, physician “burnout”: Before implementation, 33 percent of clinic staff and physicians at the pilot clinic reported high rates of emotional exhaustion as measured by the Maslach Burnout Inventory. Twelve months after implementation, their reported high exhaustion rate fell to 9.7 percent. At two control clinics, high exhaustion rates reported by providers over the same time period remained relatively level, declining slightly over the 12-month period from 34.5 percent to 30 percent.
  • Higher physician satisfaction, turnover averted: Physicians in the pilot clinic gave the medical home model very positive reviews, noting they no longer had to make personal sacrifices to deliver quality care. The two experienced physicians who had been planning to retire both chose to continue working, as they viewed the new environment created by the medical home model as being highly supportive, and hence their jobs as much more manageable.
  • Enhanced access to providers, driven by phone and e-mail contact: Even though face-to-face visits were 6 percent lower in the pilot clinic than in the comparison clinics, patients perceived that they had better access to care, with the mean score on the Ambulatory Care Experiences Survey (ACES) Short Form composite measure of access rising from 87.3 to 88.4, compared to a more modest rise (from 82.1 to 82.5) in the control clinics. Perceptions of enhanced access were driven by increases in telephone and e-mail communication between patients and clinic staff, which increased substantially over the 12-month period in the pilot clinic. E-mail threads nearly tripled (from 0.83 to 2.25 per patient per year) in the pilot clinic, well above the roughly 50-percent increase (from 0.7 to 1.16) in the two control clinics. Similarly, telephone encounters increased by 33 percent (from 2.07 to 2.76 contacts per patient per year) in the pilot clinic, modestly more than the 28-percent increase (from 1.93 to 2.47) in the control clinics.5
  • Improved perceptions of care quality: Mean scores on ACES composite measures of the quality of doctor-patient interactions, level of shared decisionmaking, coordination of care, and helpfulness of the office staff all increased in the pilot clinic more than in the control clinics. Similar results were found in the perceptions of patients with chronic illnesses, with greater improvements in mean scores in the pilot clinic on composite measures of patient activation/involvement in care and goal-setting/tailoring of care (as measured by the Patient Assessment of Chronic Illness Care Survey).5
  • Better followup care: Pilot clinic patients were 9.8 times more likely to have had an e-mail exchange with their provider within 14 days of a well-care visit than were control clinic patients, and 1.89 times more likely to get a telephone call or have an e-mail exchange with providers within 3 days of an ED visit.
  • Fewer ED visits and ambulatory care sensitive admissions: Pilot clinic patients experienced 11 percent fewer ambulatory care sensitive inpatient admissions (i.e., admissions for conditions that could have been effectively treated by primary care providers) and 29 percent fewer ED visits than did patients in the two control clinics. (No difference was found, however, in overall hospital admissions.5 )
  • Cost neutral: No significant difference existed between total health care costs for patients seen in the pilot clinic and those seen in the two control clinics. Additional staffing added $16 per patient per year, and additional specialist visits added $37 per patient per year to pilot clinic costs, but these additional expenses were matched by reductions in the costs of ED visits ($54 per patient per year).5

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation comparisons of a variety of metrics related to staff burnout and patient experiences derived from surveys of patients and staff at the pilot clinic and at two Group Health control clinics. Comparisons of patient care costs, including ED visits and inpatient admissions, were made between adult enrollees at the pilot clinic (8,100 patients) and 230,000 patients enrolled in 19 other Group Health clinics in western Washington.

Planning and Development Process

Key steps in the planning and development process included the following:

  • Developing “guiding principles”: Health plan leaders and researchers established five principles to guide development of the patient-centered medical home, declaring that the model should:
    • Enhance and strengthen the relationship between the physician and patient.
    • Enable the PCP to lead the clinical team and be responsible for collaborating with patients.
    • Keep patients actively informed and encourage them to participate in their health care.
    • Provide 24-hours-a-day, 7-days-a-week access based on patients' needs, making maximum use of technology to facilitate such access.
    • Align clinical and business systems to achieve the most efficient, effective patient experience.
  • Selecting pilot clinic: Group Health leaders selected the Factoria Medical Clinic in Bellevue, WA as the pilot clinic due to its modest size, history of successfully engineering various practice changes, and high rates of staff attrition, including the impending retirement of two experienced physicians.
  • Designing model: Organizational leaders, researchers, outside experts, all clinic staff, specialists, PCPs, and several patients crafted the redesign, using the aforementioned principles to guide their efforts. As many as 40 individuals attended planning meetings over a period of several months. Patient participation helped to defuse professional rivalries and keep the focus on the patient experience.
  • Determining and articulating need for new staff: From the beginning, physicians at the clinic made clear the need for additional staff. They determined ideal physician-patient ratios and the number of additional staff needed to offer the longer 30-minute visits.
  • Transitioning to new model: To ease the transition process, patients who needed to change physicians received an invitation to tour the clinic and meet the new physician during an open house. In addition, patients had the option to change providers if desired.
  • Hiring and training staff: Group Health hired and trained a number of new staff to support the physicians, as outlined previously.
  • Expanding program: In 2007, Group Health made the decision to spread the medical home prototype redesign to all 26 clinics in 2010 and 2011. Group Health opted to use Lean tools and techniques to standardize the processes across the clinics and as a mechanism to spread the innovation. The prototype redesign was examined and packaged in a series of modules for systemwide implementation modules.

Resources Used and Skills Needed

  • Staffing: In addition to the previously described hiring of additional physicians and staff, a physician researcher and staff from the Group Health Research Institute oversaw, documented, and evaluated the pilot to gauge the model's appropriateness for use in other clinics. In addition, medical home and chronic disease management experts participated in the development of the model. Finally, all clinic staff participated in the planning process as well.
  • Costs: Implementation of the model cost approximately $600,000. As noted, incremental staffing costs ran roughly $16 per patient, although savings in other areas offset these additional expenses, making the program cost neutral on an operating basis.

Funding Sources

Funding for the evaluation of the medical home was provided by Group Health Research Institute. The medical home redesign itself was funded by Group Health Cooperative.

The evaluation for the patient-centered medical home spread across all clinics at Group Health is underway, funded in part by an Agency for Healthcare Research and Quality grant.

Tools and Resources

National Committee for Quality Assurance (NCQA) Standards and Guidelines for Physician Practice Connections ® —Patient-Centered Medical Home (PPC-PCMH ™). Available at: http://www.ncqa.org/portals/0/programs/recognition/pcmh_overview_apr01.pdf.

Patient-Centered Primary Care Collaborative. The collaborative is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians and others working to develop the patient-centered medical home. Information available at: http://www.pcpcc.net

American College of Physicians, Internal Medicine. Understanding and Running a Patient-Centered Medical Home. Available at: http://www.acponline.org/running_practice/pcmh/

Getting Started with This Innovation

  • Secure senior leadership commitment: Senior leadership should commit the time, resources, and additional staff and training required to implement a patient-centered medical home model.
  • Establish guiding principles, leverage existing resources: These principles should guide the implementation of the model. Other medical home models can serve as a reference for these principles and be a source of best practices for serving patients in a patient-centered manner.
  • Involve physicians, clinic staff, and patients in design: Involving all physicians and staff in the redesign helps to secure their support, whereas participation by a few patients keeps the effort focused on the patient experience and helps to reduce the potential for interprofessional tension and conflict. To avoid loading more work on already overtaxed providers, set aside adequate time for physicians and staff to participate in these discussions without falling further behind in their work.

Sustaining This Innovation

  • Continually monitor, share results: The model's impact on staff and patient satisfaction, ED usage, hospitalizations, quality, costs, and other key metrics should be continuously monitored, with results shared with key stakeholders, including clinic staff and physicians. Seeing the positive benefits of the model helps to maintain support for it.

Use By Other Organizations

Many organizations have toured Group Health to examine the medical home, including provider groups, commercial insurers, safety-net clinics, and others. They have also been visited by primary care visitors from at least five other countries.

Lessons Learned

Group Health is generally paid a flat rate to provide all necessary health services to enrolled members. Thus, it is able to realize savings from reductions in ED visits and hospitalizations and use those savings to pay for the enhanced primary care services in this program. Organizations that operate in different reimbursement environments might face different considerations in building the business case for such a program.


Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Robert J. Reid, MD, PhD
Associate Investigator
Group Health Research Institute, Group Health Cooperative
1730 Minor Ave, Ste 1600
Seattle, WA 98101
Phone: (206) 287-2886
E-mail: reid.rj@ghc.org



Innovator Disclosures

Dr. Reid has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Reid R, Fishman P, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009 Sep 1;15(9):e71-87. Available at: http://www.ajmc.com/media/pdf/AJMC_09sep_ReidWEbX_e71toe87.pdf

McCarthy C, Mueller K, Tillmann I. Group health cooperative: reinventing primary care by connecting patients with a medical home. The Commonwealth Fund, July 2009. Available at: http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2009/Jul/1283_McCarthy_Group%20Health_case_study_72_rev.pdf

Footnotes

  1. Chen L, Farwell W, Jha A. Primary care visit duration and quality: does good care take longer? Arch Intern Med. 2009;169(20):1866-72. [PubMed] Available at: http://archinte.ama-assn.org/cgi/content/abstract/11866-69-20

  2. Bodenheimer T, Berenson R, Rudolf P. The primary care–specialty income gap: why it matters. Ann Intern Med. 2007;146:301-6. [PubMed] Available at: http://www.annals.org/content/146/4/301.full.pdf

  3. Johnson A, Easterling D, Williams L, et al. Insight from patients for radiologists: improving our reporting systems. J Am Coll Radiol. 2009 Nov;6(11):786-94. [PubMed] Available at: http://www.jacr.org/article/S1546-1440(09)00360-3/abstract

  4. McCarthy C, Mueller K, Tillmann I. Group Health Cooperative: reinventing primary care by connecting patients with a medical home. The Commonwealth Fund, July 2009. Available at: http://www.commonwealthfund.org/Publications/Case-Studies/2009/Jul/Group-Health-Cooperative-Reinventing-Primary-Care-by-Connecting-Patients-with-a-Medical-Home.aspx

  5. Conrad D, Fishman P, Grembowski D, et al. Access intervention in an integrated, prepaid group practice: effects on primary care physician productivity. Health services research. 2008 Oct 1;43(5p2):1888-905. [PubMed]

  6. Robert Wood Johnson Foundation. Improving Access to Improve Quality: Evaluation of an Organizational Innovation. Washington, DC: AcademyHealth; 2008. Available at: http://www.hcfo.org/pdf/findings0808.pdf

Innovations in Medical Homes Improve Patient Care Quality

By Robert L. Phillips, Jr., MD, MSPH
Vice President for Research & Policy, American Board of Family Medicine
Former Director, Robert Graham Center: Policy Studies in Family Medicine and Primary Care

Patient-centered medical homes have gained the attention of policymakers as an innovative model that can transform health care delivery. The recently passed health care reform legislation will expand practice- and community-based medical home demonstration projects through Medicare.

While medical homes have been around for decades, their design varies considerably. Primary care societies including the American Academy of Family Physicians have joined with payers and Fortune 100 companies to form the Patient Centered Primary Care Collaborative around a set of joint principles for recognizing physician practices as medical homes. They are also working with the National Committee on Quality Assurance (NCQA) to establish valid measures of patient-centered medical homes.

A patient-centered medical home is a primary care–based scheme that delivers care that patients need, when they need it, and that is linguistically and culturally appropriate. The patient-centered medical home also manages population health through the use of data and effective financing. Data can come from a variety of sources, including patient registries, electronic health records, prescriptions, and patient visits, with a goal of monitoring patient care to know whether someone is falling through the cracks.

The Group Health Cooperative of Puget Sound program demonstrates the outcomes of early medical home demonstrations that focused on improved models of primary care. Its initial assumptions that the medical ho me would improve efficiency led to experiments with expanding panel sizes. Instead, large panels, which grew to 2,300 patients for every primary care physician, failed miserably and led to increased physician burnout and reduced patient satisfaction.

With little time to interact with patients, physicians couldn't develop comprehensive care and/or self-care plans, which increased patient visits to specialists and emergency departments, as well as inpatient admissions. In addition, physician bonuses were dependent on the number of patients they saw.

Group Health Cooperative made several changes when they established a pilot patient-centered medical home including smaller panel sizes, longer patient visits, and more primary care staff, including physician assistants who could manage care. Two nurses were also hired to provide intensive, short-term disease management for patients with uncontrolled chronic illnesses and transitional care posthospitalization. Group Health Cooperative no longer paid physicians bonuses for seeing more patients and instead paid them a flat salary. As a result of these changes, physicians reported less burnout and stress and greater satisfaction with the care they provided, and patients reported greater access to physicians and satisfaction.

It is noteworthy that the Group Health Cooperative medical home pilot achieved budget neutrality. Although hiring additional staffing cost $16 per patient per year, the costs were offset by the reduced emergency department visits of $54 per patient per year.

Limitations of the Group Health Cooperative medical home program are that it excluded behavioral health care and can only be generalized to other integrated health care systems like Geisinger that embed medical homes within accountable care organizations and have lots of resources.

The Community Care of North Carolina program is a unique State-based, public-private partnership that supports medical homes in managing the health of Medicaid enrollees. Local, self-governing community health networks provide case/disease management services and participate in State and local quality improvement initiatives. Various studies found that the program improved the quality of care for patients with asthma and diabetes and significantly reduced hospital and emergency department use and health care costs, resulting in an annual savings of nearly $150 million in 2007.

North Carolina is one of the first States to implement a medical home model for Medicaid enrollees and achieve a significant savings in 1 year, although the model was limited mainly to disease/case management. In addition, the State gave local community level partners considerable autonomy in deciding how to deliver care to Medicaid enrollees and organize quality improvement initiatives. The program also monitored population health data and reported the data to the community health networks, which is critical for vulnerable Medicaid populations. The program could be strengthened by having a description of the implementation costs as well as cost savings.

The North Carolina model can be generalized to other States that want to establish public-private partnerships to manage Medicaid patients living in both rural and urban settings. In fact, Vermont is building on this model, using funding from Medicaid and private payers to fund the transformation of physician practices and establish community care teams that can support multiple, small practices.

Disclosure Statement: Dr. Phillips has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this commentary.

Original Publication: 03/31/10

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 07/02/14

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 06/23/14

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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