Unit 1 Assignment 2 Case Study Key Assessment LO#6 Health Information Management Systems
jmjewett
PCMH_Case_Studies.pdf
Innovation in Physician Practices: 13 Case Studies to Guide
Michigan Physicians January 2011
Prepared for Medical Advantage Group
Michigan Academy of Family Physicians
Michigan Chapter of the American Academy of Pediatrics
Michigan Chapter of the American College of Physicians
Michigan Osteopathic Association
Michigan State Medical Society
Prepared by Public Sector Consultants
Lansing, Michigan
www.pscinc.com
Contents Introduction ..................................................................................................................... 1
BlueSky Health ................................................................................................................ 5
ProMed Physicians – Borgess Pediatrics ...................................................................... 10
Edward C. Bush Family Medicine .................................................................................. 15
Cadillac Family Physicians ............................................................................................ 19
Children’s Healthcare Access Program ......................................................................... 26
Children’s Medical Group of Saginaw Bay ..................................................................... 29
Family Tree Medical Associates .................................................................................... 36
Gratiot Family Practice .................................................................................................. 41
Henry Ford Health System – General Internal Medicine ................................................ 47
Infinity Primary Care ...................................................................................................... 51
Michigan Medicine Specialists ....................................................................................... 56
Pine Medical Group ....................................................................................................... 63
St. Johns Professional Associates ................................................................................. 66
Innovation in Physician Practices 1
Introduction
This series of case studies profiles diverse primary care physician practices to capture the
actual experience of Michigan physicians as they made the decision to implement patient
care innovations in their offices, most often resulting in designation as a patient-centered
medical home (PCMH). We hope that these case studies are rich and varied enough for a
physician to say of at least one, ―Yes, that‘s like my practice and that‘s where I am right
now in my thinking about innovation and PCMH.‖
These case studies vary by practice size and practice location. They also vary by the level
of supportive infrastructure the practices had in place as they moved toward PCMH
designation. Many have had an electronic medical record (EMR) in place for years;
others implemented an EMR as a tool to achieve designation; others still do not have an
EMR, but have implemented an electronic patient registry. In some cases, the current set-
up of the office lends itself well to PCMH innovations; in others, major rearranging of the
office—or a new office—has been deemed necessary. And, not surprisingly, the practices
have experienced varying degrees of provider and staff support for the implementation of
PCMH innovations.
While frustration with some aspect of PCMH designation is common, all of the providers
interviewed declare that patient care in their offices has improved since putting the
required innovations in place. This is true even for the several physicians and office staff
who claim that a primary driver behind their decision to seek designation was that they
were already providing care consistent with PCMH requirements.
Each case study describes:
The practice size and location
The practice‘s decision to innovate in the delivery of patient care
The transition from current practice to PCMH
The response of providers, staff, and patients to the innovations
The financial and other resource implications of PCMH
How the providers and staff envision their practice‘s future with PCMH
Public Sector Consultants (PSC), a Lansing-based public policy research firm that has
worked with the Michigan State Medical Society (MSMS) on numerous projects,
including a series of case studies on the implementation of EMR in physician practices,
was commissioned to prepare these case studies. Several staff from PSC visited practices
and spoke with physicians and non-physicians to hear their perspectives on practice
innovation and PCMH.
The innovations described in each case study do not necessarily represent all of those
implemented by the practice. The questions in the case study interview guide were fairly
open-ended and, thus, interviewees were able to talk about those innovations they
deemed most important for their practice. For some practices, the focus is on group visits;
for others it is on the underlying processes they have put in place to support innovation or
Innovation in Physician Practices 2
the electronic infrastructure that they have had to put into place; and for still others the
focus is on the host of changes they have made to support chronic disease care.
MAJOR THEMES
Although the purpose of this report is to convey the valuable details of physicians‘
experiences with PCMH, this introduction highlights themes that came up frequently
during the site visits or seem particularly useful for physicians considering seeking
PCMH designation. It is important to note, however, that this is not a statistically
significant research study. While we have attempted to present varied practices that
reflect the primary care physician practice environment in Michigan, these 13 case
studies are not a representative sample of physician practices in our state.
Proactive Care Management
The providers and non-clinicians interviewed have found that rigorous application of
patient care processes and documentation of evidence-based care leads to more proactive
care. Practices that have received PCMH designation have engaged in several activities
that make the care they provide more proactive. They call patients to let them know they
are due for preventive care; they follow up with patients to ensure they receive any lab
work the physician has requested or even ask that patients have lab work done before
office visits; they identify patients with chronic diseases and get them in for regular
check-ups; and they carefully review patient charts prior to the office visit to ensure that a
plan for the care that needs to be provided is clearly laid out.
A few of the practices noted that more preparation right before patient visits leads to far
fewer interruptions during the patient visit. Before these innovations were put in place,
physicians would often leave the exam room in search of lab results and other patient
information. With staff in charge of locating this information in advance, physicians have
what they need at their fingertips.
Team-Based Care and Empowered Staff
This proactive care, most practices have found, cannot be delivered by the primary
providers (i.e., physicians, physician assistants, and nurse practitioners) alone. These
practices have found it necessary and gratifying to empower other caregivers and staff to
assume increased roles in patient care. To provide the most efficient care possible, some
activities that were previously handled by physicians are now done by nurses, and tasks
previously conducted by registered nurses are now handled by medical assistants, and so
on. To support providers and staff in their efforts, written protocols and standing orders
have been put in place so everyone in the office knows what to expect and what is
expected of them. Several offices have implemented the practice of regular ―huddles‖ to
prepare for each day‘s patients.
The team approach to care does not necessarily mean that physicians spend more time
with patients under PCMH, but most people interviewed say that patients are getting
better, more valuable care when they are in the office.
Innovation in Physician Practices 3
Tools of the Trade: Flow Sheets, Electronic Alerts, and Action Plans
Along with written protocols, other tools were developed and used at many of the
practices PSC visited to support the efficiency and effectiveness of each office visit,
especially for patients with chronic care needs. These tools went by a variety of names—
flow sheets, task lists, and action plans—but the purpose is consistent: to ensure that
patients receive appropriate care seamlessly. The flow sheets contain lists of questions
and information the providers should discuss and address with patients during the visit.
For practices with EMR, electronic alerts in the patient records were often used to serve
the same purpose. These alerts ensure that anyone who comes into contact with the
patient during the office visit is aware of the care that should be provided. All of these
tools ensure that evidence-based care is provided and that important care items are not
skipped during a visit.
Bringing Everyone Along
It is not a slam dunk that everyone in a medical practice is going to be ready and willing
to take on changes to the way care is provided. In most cases, a physician champion was
behind the decision to seek PCMH designation, but quite often a practice manager or
administrator was put in charge of making it happen. These individuals offer sage advice
for working with everyone in the practice to make PCMH a reality. Most often they
suggest involving as much of the staff as possible in discussions. This ensures that
everyone understands why changes are being made, and can also invite buy-in when
shared-decision making is employed. For a few practices, the availability of data through
a patient registry or EMR has proved useful in convincing providers that either a change
needed to be made, or that improvements are, in fact, occurring through PCMH
implementation.
Financial Implications
The overall financial and other resource implications vary across practices. Several noted
that many hours were required for training and educating everyone in the office. Some
practices added staff, usually a diabetes educator; others were able to decrease their staff
once they saw where inefficiencies existed.
While most everyone said the opportunity to improve patient care drives their interest in
innovation, they also described increased insurance reimbursement from Blue Cross Blue
Shield of Michigan, among others, as a helpful nudge in their decision to seek PCMH
designation. The increased reimbursement is more helpful to some practices than others,
based on the proportion of patients with the appropriate insurance. A few practices also
received financial incentives from the physician organizations to which they belong.
Challenges and Frustrations
The practices that participated in the case studies, not surprisingly, have been challenged
as they have implemented PCMH innovations. New processes and change invariably lead
to frustration for somebody. These issues, however, have come and gone and, for the
most part, the practices are working relatively smoothly as PCMHs.
Two issues continue to plague most of the practices, however. One is the lack of
interconnectivity between their EMRs and those of local hospitals and specialists. While
Innovation in Physician Practices 4
the practices generally believe they have good relationships with the hospitals and
specialists, and they obtain the information they need from them, they are frustrated that
they cannot receive this information more easily electronically. The other large issue is
lack of enhanced reimbursement from more payers for PCMH-type care. Some practices
say that this limits the extent to which they can continue to implement new innovations.
Higher Quality of Care and Better Patient Outcomes
Regardless of the financial implications and frustrations they have experienced, none of
those interviewed expressed any interest in returning to the way they used to provide
care. All said they have seen clear improvements in the quality of care provided and some
have seen evidence of better patient outcomes. Several also noted that patients are
increasingly becoming partners in their own care.
Innovation in Physician Practices 5
BlueSky Health
PRACTICE PROFILE
BlueSky Health is a primary care practice founded by Dr. Jeffrey Huotari in 2006. It is
located in Houghton, Michigan, in the remote and rural western Upper Peninsula. When
establishing BlueSky Health, Dr. Huotari‘s goal was to apply engineering principles to
health care systems and standardized care to optimize the doctor/patient relationship.
BlueSky strives to serve as a patient-centered medical home (PCMH) that provides direct
access to health providers, eliminating barriers to quality care. BlueSky Health was first
designated as a PCMH through the Blue Cross Blue Shield of Michigan (BCBSM)
Physician Group Incentive Program (PGIP) in 2009.
Approximately 30 percent of the BlueSky patient population is pediatric, 30 percent is 18
to 39 years of age, and 30 percent is 40 to 64 years old. Only 10 percent of BlueSky
patients are 65 years old or older and receiving Medicare benefits. The clinic is most
frequently visited by patients between 40 and 64 years of age with chronic disease.
The practice has gained 30 to 35 new patients each month since it opened; this is
impressive given that it is located in what is considered a non-growing patient population
area.
The practice employs two physicians, Dr. Huotari and Dr. Kimberly Dovin; one nurse
practitioner, PeriAnn Wasie; and one administrative staff person, Leanne Nordstrom.
PSC interviewed all four members of the BlueSky team via Skype. Dr. Huotari also gave
the interviewers a cyber-tour of the practice.
THE DECISION TO INNOVATE
Dr. Huotari‘s medical school and residency experiences were the impetus for redesigning
his primary care practice. He felt that the traditional hospital-based, subspecialty-driven
health system was not adequately equipped to meet primary care patient or provider
needs, and that primary care medicine can be more convenient for patients as well as
providers, and less expensive for payers. Knowing he could be in practice in primary care
for another 25 to 30 years, Dr. Huotari felt he needed to choose to either tolerate the
current system or find a better way to make it work. He picked the latter.
Dr. Huotari chose to implement his model in the western Upper Peninsula because he
wanted a model that was proven to be successful in a rural area.
Part of my purpose with BlueSky is to introduce disruptive market forces that
drive change throughout the larger primary care provider community, in order to
extend my reach to non-BlueSky patients as well. For BlueSky to accomplish its
goals, it needs to be scalable and profitable in communities dependent on primary
care, such as rural areas.
For this initial clinic, he also wanted an area with a manageable number of third-party
payers, easily identified competitors, and a geographically well-defined service area.
Innovation in Physician Practices 6
INNOVATIONS IN PRACTICE
Systematic Approach to Meeting Patients’ Needs
In order to deliver care that meets the needs of his patients, Dr. Huotari‘s goal is to build
an innovative practice from the ground up that focuses on eliminating barriers between
patient and provider. The care provider is often the only person patients come in contact
with when they visit the clinic. As part of the relationship-building strategy, the provider
collects all patient information, demographics, insurance, and vitals, in addition to
performing traditional diagnosis functions. By design, there is no receptionist and the
patient rarely, if ever, interacts with administrative staff other than to support the provider
in billing or scheduling if needed.
The experience at BlueSky—scheduling appointments, the clinical visit, and the office
location and environment—is engineered for patient comfort and aesthetics and focused
on opening the lines of communication between patient and provider. The clinic is
located in a strip mall, near a large retail store. Huotari chose the location specifically
because he believes primary care services, for convenience, should be decentralized to
locations where people actually spend their time, and ―in this area, that‘s where people
are, so that‘s where we need to be.‖
All appointments are made through either the BlueSky website (at any time) or by calling
the provider directly. To eliminate messaging errors and delay (one of the most common
sources of frustration for both patients and providers in traditional systems), all calls go
directly to voicemail where they are automatically transcribed to text and preserved in a
.wav file and e-mailed to the appropriate provider. The request is addressed and the
patient is contacted within 90 minutes. There is a physician directly available by cell
phone 24 hours daily.
The waiting area at BlueSky is designed to be comfortable and pleasing to all senses.
Since there is no receptionist, there is no traditional reception desk or traditional checking
in process. A computer with Internet access is available in the waiting room so that
patients can schedule appointments. Signage replaces other receptionist functions.
Appointments start at the scheduled time, eliminating patient waiting.
After arriving at the clinic, patients are greeted by their provider and welcomed into the
consultation room. The consultation room is arranged like a comfortable office conducive
to conversation and is used for most of the 30- to 45-minute appointment. The providers
at BlueSky do not interview patients while they are unclothed on the examination table;
therefore, the examination room, accessed through the consultation room, is used only
briefly, as needed. The clinic also provides a conference room for educational seminars
and group visits, a feature of chronic disease management and preventive care that Dr.
Huotari is now implementing.
Dr. Huotari designed BlueSky so that physicians act as case managers for their patients.
Each patient‘s case is managed holistically by the provider, from intake to follow-up. If
specialty referrals are necessary, the BlueSky provider makes all contact with the
specialist‘s office and completes any necessary paperwork. The practice has good
relationships with specialty providers, ensuring good communication and better patient
Innovation in Physician Practices 7
care. Time is built into each BlueSky provider‘s day to interact with specialty practices
on behalf of his or her patients.
Since BlueSky was designed with patient needs in mind, spending adequate time with
each of the 8 to 12 patients seen daily is a priority for the entire staff. Occasionally, the
system is abused, according to nurse practitioner PeriAnn Wasie, especially time spent
with the physicians. However, Wasie reports that it happens infrequently and can be
expected when working with people.
Technology and Administration
Dr. Huotari operates BlueSky with as little overhead expense as possible. To do so, the
practice is streamlined. Lab tests and immunizations are not offered at the clinic. Staffing
is limited to two full-time equivalent providers, including physicians and nurse
practitioner, and one part-time support person.
Leanne Nordstrom was hired in 2008 as ―back room‖ administrative support.
Nordstrom‘s responsibilities include billing and payroll support, print media and website
support, IT support, and chronic disease and prevention program development. Her
contact with patients is limited to returning phone calls to new patients, orienting them to
the practice and providing basic information. She also spends a substantial amount of
time working on insurance issues with patients, typically via e-mail.
Nordstrom is also responsible for maintaining the practice‘s website. She states that the
site was developed with simplicity in mind. Patients can access the site to research prices,
services, and appointment availability. The site is tailored specifically to patients‘ needs.
The use of technology enables the practice to run efficiently with fewer support staff and
lower overhead. The entire office team participates in any experiments with new
technologies. If a new system is not effective or efficient, it is discarded.
Not all patients care to use technology, such as voicemail, e-mail, or Web scheduling.
From Wasie‘s perspective, this makes communication more challenging. However, she
indicates that patients are adapting, especially to the voicemail system. The practice is
also responding to the technological needs of its patients. Originally, the practice tried a
phone menu system, which was not well received. Switching to a more familiar
voicemail system provided a friendlier atmosphere for patients. Dr. Dovin remarked that
while the older population is somewhat more resistant to technology in the clinic, many
patients like the convenience, stating that, ―patients love e-mail.‖
BlueSky relies almost completely on electronic medical records. In keeping with Dr.
Huotari‘s desire to keep overhead low, the EMR software is an inexpensive, off-the-shelf
product. Although the software cost only $1,000 and is easy to use in the practice, staff
are finding that, like many software solutions, it does not interact well with outside
systems. Wasie, however, finds the EMR system very efficient and mentioned that
having technology right at her fingertips helps her provide better care to her patients.
Innovation in Physician Practices 8
TRANSITION TIME
BlueSky is in the second phase of Dr. Huotari‘s two-phase building plan. The first phase,
intended to last one to three years, saw the practice move from a low-overhead, direct
patient interaction pilot project, through the addition of staff—first another physician,
then a nurse practitioner and support staff. In years four through six, phase two will see
the establishment of relationships and integration with existing systems, such as larger
hospitals and accountable care organizations.
PROVIDER AND PATIENT RESPONSE
All three members of Dr. Huotari‘s staff stated that the reason they wanted to work at
BlueSky was its innovative practice model. Nurse practitioner Wasie appreciates the
autonomous role she has in the practice and the contact time she has with patients,
allowing her to meet their needs. She also appreciates that one of the physicians is always
immediately available to provide care management. Compared to traditional practices,
providers at BlueSky can provide more comprehensive care because of the direct
interaction with patients. The result is that patients get more quality time with their
provider. Everything is settled when they leave, including prescriptions, referrals, follow-
up appointments, and payment. The entire process takes place between the provider and
the patient.
Dr. Dovin thinks that the extensive use of technology sets BlueSky apart from the
traditional practices in which she has had experience. Her opinion is that some of those
technologies are not as efficient as traditional systems; Web-based fax receipts, for
example, are slow. However, she enjoys the direct connection with her patients. She says,
―Patients don‘t expect anything different when they come in, but are pleasantly surprised
when they are greeted by their provider. I always had the mindset that I wanted more
time with patients; I wanted a better connection.‖ Dovin said that joining BlueSky has
provided her with the right fit to achieve this professional objective.
Leanne Nordstrom had never worked in a medical practice before taking the job at
BlueSky. She immediately believed in Dr. Huotari‘s model. Nordstrom thinks the
patients at BlueSky are better educated about their health care because of the time they
spend with their providers. Patients come away with a better understanding of the
rationale for their treatment decisions. Overall, she feels that the practice provides better
customer service.
Patient satisfaction at BlueSky Health was recently measured with a survey in which
more than 800 questionnaires were distributed to patients at sequential office visits. The
survey had an approximately 80 percent response rate. According to Dr. Huotari, of those
who responded, over 99 percent stated that they were satisfied with their experience of
the practice (just two unsatisfied responses were received).
Patients do occasionally see drawbacks in the practice model. From time to time, patients
are concerned that there is no receptionist. Patients also express concern with the online
system or not speaking to a ―live person‖ when they deliver their message to their
provider via voicemail. Also, patients are sometimes intimidated by the direct interaction
with their providers.
Innovation in Physician Practices 9
Overall, however, ―patients are engaged,‖ says Wasie. ―They like the ease of getting in
for an appointment. They are gaining understanding of the role of a nurse practitioner, a
new concept for many.‖
FINANCIAL (RESOURCE) IMPLICATIONS
BlueSky operated on a cash-only basis for its first six months. Dr. Huotari had hoped to
do so for a longer period, but started accepting Blue Cross Blue Shield of Michigan,
Medicare, and Medicaid in order to meet the needs of more patients and remain
financially viable. Because of the region‘s sparse population, there is not a wide variety
of private payers. Huotari made the decision to add support staff primarily because of
insurance billing, which accounts for 60 percent of his overhead. He says that insurance
billing has expenses to the practice, but has also improved revenue.
Dr. Huotari says that he has not received any significant outside financial support for his
innovative approach. His practice is entirely self-financed with home equity lines of
credit; he has assumed a very large personal risk. Although national and regional support
of the medical home model has led to some payment changes, he finds the overall lack of
third-party payer support for new primary care payment models one of the biggest
obstacles he faces:
The existing fee-for-service payment model, with its face-to-face visit emphasis
and ICD-9 and CPT billing requirements, is obsolete in the face of what current
and future hardware and software trends allow us to do, as well as the growing
influence of social media in shaping patients‘ and providers‘ expectations of how
care is delivered.
Additionally, he has found that despite a new flow of dollars into initiatives to fund
primary care transformation, these dollars tend to flow to or through larger traditional
organizations, capping the potential to benefit small independent practices, and blunting
significant transformation efforts within that core community of primary care providers.
THE FUTURE
Dr. Huotari is implementing a chronic disease management and prevention system, in
which all chronic disease and preventive care is individually pre-planned on a yearly
basis. Unplanned acute care diagnostic services are currently available 40 hours per week
face-to-face, with a long-term goal of 84 hours weekly. Twenty-four-hour phone
availability is and will remain in place. He is working to achieve a goal of decreasing
emergency department visits and hospitalizations for his patients by 90 percent.
He continues to seek direct-payer relationships that aren‘t dependent on ICD-9 and CPT-
based reimbursement structures, as he feels this is where true system transformation will
ultimately occur. Currently, his focus is on the employer and patient market, but he is
hopeful that it will ultimately include insurance companies as well.
Innovation in Physician Practices 10
ProMed Physicians – Borgess Pediatrics
PRACTICE PROFILE
ProMed Physicians is a pediatric care practice located in southwest Michigan. It is an
affiliate of Borgess Health System and comprises three offices located in Kalamazoo,
Portage, and Richland. Patients have access to providers in all three locations. ProMed
Physicians has been designated as a patient-centered medical home (PCMH) through the
Blue Cross Blue Shield of Michigan (BCBSM) Physician Group Incentive Program
(PGIP).
ProMed Physicians employs 12 physicians, 2 physician assistants, and 6 nurse
practitioners, all of whom see patients part-time. ProMed has approximately 28,000
active patients in its three office locations; approximately 21 percent of patients are
Medicaid beneficiaries.
PSC spoke with the following individuals from the Kalamazoo location: Becky Cross,
director; Kelly Burk, PCMH model coordinator for the Borgess system; physician
assistant Melissa Mickelson; and nurse practitioner Sherry Hanly.
THE DECISION TO INNOVATE
The decision to implement a PCMH in the Kalamazoo practice was made based on
financial incentives from Borgess Health System. In 2002, the health system‘s
administration was beginning to learn about the medical home model and made a
decision to pilot that model in one family practice. In June 2009, the option to implement
medical home models system-wide was given to practices. While implementing new and
innovative practices was not mandatory, a full-time staff person joined Borgess Health
System to assist those practices that chose to explore the options.
Borgess chose to encourage innovative practice to achieve two goals. First, Borgess is
continually looking to improve patient satisfaction; increasing ease of access to care is
important to Borgess. Second, from a financial aspect, the Borgess system wanted to find
ways to allow doctors to spend more time with patients without increasing costs. The
shared medical appointment model seeks to achieve both of those goals. Becky Cross, the
director of ProMed Kalamazoo, worked with providers in her office to begin offering
shared patient visits for well-baby check-ups. Patients would have the option to attend
shared medical appointments for their infants‘ well-baby exams, from the age of two
weeks to six months. This case study focuses solely on that aspect of the practice‘s
PCMH implementation.
PREPARING FOR IMPLEMENTATION
Once the decision to implement shared medical appointments was made, administrators
met with staff to discuss the model, along with the changes that would be necessary for
its success. This included transitioning to a larger appointment room to accommodate a
group, changing forms, and developing a model for group appointments that would work
for the practice. Additionally, one staff member was identified as the ―clinical
coordinator‖ to take on the specific duties to facilitate the transition and ensure the
Innovation in Physician Practices 11
model‘s continued success. A conference room and small exam rooms in the basement
were renovated to accommodate the larger groups.
Multiple staff meetings provided ample opportunity to explain the model to staff, and
mock appointments were conducted to familiarize them with how the new appointments
would work. Technical adjustments needed to be made as well, most importantly to the
scheduling software used by the practice. Training for receptionists was needed to
accurately schedule shared appointments. One nurse practitioner and one physician
assistant were responsible for the shared group appointments.
All families with children between the ages of two weeks and six months were contacted
to explain the changes and given the option to participate. Other issues that were
addressed for patients included incorporating all of the elements of a well-child exam into
the group setting, while still making families comfortable; devising methods to handle
contentious or personal concerns within the group; and, most important, patient privacy.
With a blueprint for implementing the model, and updated space for the larger groups, the
practice began scheduling appointments.
INNOVATIONS IN PRACTICE
The shared medical appointment provides a setting for patients to come together, not only
for basic, ongoing medical care, but also to provide support and learn from others who
are going through similar experiences. This model became popular in the early 2000s.
While it was generally applied to adults with chronic conditions, such as diabetes, staff
members from ProMed believed that the model could be easily modified for pediatric
patients.
ProMed‘s model allows for 8–10 patients to share a 90-minute visit. Melissa Mickelson,
the physician assistant, or Sherry Hanly, the nurse practitioner, makes sure to review each
patient‘s chart extensively before each visit, in order to address any common problems
among patients or to address individual problems without targeting that individual. Upon
arrival, each patient is quickly screened for illness before going to the group exam room.
Additionally, all families must sign a HIPAA form, in addition to a general
confidentiality form, to protect each patient‘s privacy.
The session begins with parents suggesting topics that they would like discussed during
the appointment. Parents are then led through the basic information that would be
included in an individual appointment and are encouraged to share ideas and concerns
with each other, through a ―support group‖ model. Not all topics that are initially
suggested are discussed; the flow of the appointment really follows the interest and
discussion of the parents as opposed to being dictated by providers. Each child is then
taken into an exam room to be physically examined, as well as to receive any
immunizations that may be required. Parents are also encouraged at that time to raise any
issues that they are uncomfortable sharing in a group setting.
One barrier that the providers initially anticipated was parents‘ reluctance to share
difficulties they may be having and how to engage parents in discussions of those issues.
The providers have found, however, that generally all parents are comfortable discussing
Innovation in Physician Practices 12
issues in the group setting. Even those who may not be comfortable do not usually have
to worry; since all of the children participating in the appointments are so close in age,
providers say that at least two parents are struggling with the same issues and that if one
doesn‘t bring it up, the other will.
Challenges
The first challenge facing the practice was convincing staff to adopt this model. Some
staff had a difficult time understanding what the new appointment model would look like.
Initially, some staff members reacted negatively to offering such an appointment to
patients, fearing that the quality of patient care would be diminished as a result of less
individual attention. In order to make the transition as comfortable as possible, several
staff meetings were held to clarify what the changes would mean for them, for the day-to-
day flow of the office, and for patient interaction with providers. After conducting just a
few appointments, the staff began to understand the model and enjoy offering new,
innovative options to patients.
Convincing providers to change was difficult as well. The shared group appointment is
completely different from how most providers are traditionally trained to deliver care. In
individual settings, the provider sets the tone, pace, and agenda for appointments. In a
shared model, the patients really dictate those elements of the appointment. Ceding
control of the appointment to the parents required a fundamental shift from providers,
who feared that the care they were providing would be of lower quality due to the loss of
one-on-one time with each patient.
Identifying the essential elements of the individual exam and managing time to ensure
that those elements are addressed was vital to the success of shared appointments.
Additionally, the shared appointment model requires a greater time commitment, not only
for the appointment itself, which lasts 90 minutes, but also in preparing for it. Charts
must be reviewed extensively before the appointment because of the short amount of
individual time with each patient.
Logistically, one challenge to the shared appointment was accurately recording changes
and other vital information in each patient chart. In order to address this, one person is
assigned sole responsibility to record information during the group visit.
One final challenge for providers is ensuring that each child is seen and examined
individually. The parents get so involved in the conversation that providers sometimes
find it difficult to end the group session. One provider commented that parents sometimes
view the group appointment as a social setting, or parenting group, as opposed to a
doctor‘s appointment.
PROVIDER AND PATIENT RESPONSE
Overall, both providers and patients at ProMed Physicians have responded positively to
this innovation. Although one provider described the new appointment model as
―exhausting,‖ she also admitted that taking this on was a ―group decision, group
investment, and group reward.‖ After each appointment, staff meet to debrief and
improve techniques used in the appointment. Providers have learned from negative
Innovation in Physician Practices 13
aspects of previous appointments and a continued commitment to change prevails in the
staff culture. Additionally, the expanded time with parents allows the appointments to
take on a more educational focus, which would not be possible in traditional 20- to 30-
minute patient visits.
Many parents view the appointments as a support group, learning from and leaning on
other parents with similar experiences. Patient surveys have shown overwhelmingly
positive responses. The model has been so successful for this practice that it was featured
in a local news channel broadcast.
FINANCIAL (RESOURCE) IMPLICATIONS
When implementing the new appointment model, the practice found few challenges to
targeting resources to support the change. Because of the support and encouragement of
the larger health system to which ProMed belongs, acquiring additional supplies and
materials, as well as reorganizing space to hold the appointment, was not difficult. The
practice‘s major investment was the time spent in training and making staff comfortable
with the changes.
Institution of the group appointment seems to result in a win-win situation for both
providers and patients. Although 8–10 patients are seen in a group setting, the
appointments are still billed as individual well-child exams, because each child is
examined individually. This has a direct impact on the financial bottom line of the
practice. Under the traditional well-child model, three children would be seen in any 90-
minute time frame. Now, three times that many can complete a well-child exam at the
same cost. At the same time, the quality of care is unchanged and parents receive more
information and support than they would in a traditional setting, all while developing
relationships with other parents in their community.
THE FUTURE
The providers and staff at ProMed have been increasingly satisfied with the decision to
implement the shared group appointments for infant well-child exams. The response from
both staff and patients has been so positive, in fact, that the practice hopes to be able to
expand the infant well-child exams to children up to 18 months old and also use the
model for asthmatic children as well as kindergarten readiness physicals. The other two
ProMed offices will begin to offer patient appointments in this fashion.
The practice is considering creating cohorts of patients, meaning that the same 8–10
patients will be seen in the same group throughout the duration of their participation in
the shared appointment model. ProMed providers hope that this will further encourage
and facilitate a supportive setting for parents to become comfortable in sharing concerns
and learning from others.
At this time, the shared appointment model is not used as a marketing tool for the larger
Borgess system, but the practice administrator hopes this will change in the future. She
believes that at this time it has not been used to its full advantage due to a lack of
understanding, both among the public and providers. Her hope is that Borgess will soon
Innovation in Physician Practices 14
promote the benefits of shared medical appointments and that this will draw new patients
to the system.
Innovation in Physician Practices 15
Edward C. Bush Family Medicine
PRACTICE PROFILE
Edward C. Bush Family Medicine is in Riverview, a Downriver bedroom community for
people working in and retired from the automobile and steel industries. The community
has been hit hard in recent years by the deep recession and the downsizing of
manufacturing. Dr. Chris Bush is the sole physician in the practice, which also includes a
half-time nurse practitioner. The practice has 6,000–7,000 patient visits a year and has
achieved patient-centered medical home (PCMH) certification through the Blue Cross
Blue Shield of Michigan (BCBSM) Physician Group Incentive Program (PGIP).
PSC spoke with five people during its visit: Dr. Bush, nurse practitioner (NP) Janet Sohn-
Bush, biller Frances Cayton, receptionist Marie Emery, and medical assistant (MA) Bea
Smith.
THE DECISION TO INNOVATE
For Dr. Bush, moving toward the patient-centered medical home was born of necessity:
―Family doctors have to adapt and re-engineer their practices to survive. We have to have
a better product, adding value in the management and supervision of care.‖ Incentives,
especially from BCBSM, helped drive the re-engineering: ―The Blues used to give 2–3
percent quality updates, but now you have to be in PGIP to get that incentive payment. If
you don‘t play, you get behind every year. There is no new money in health care.‖ Nurse
practitioner Sohn-Bush adds, ―We‘ve always had a high standard of quality. Now it‘s
documented and validated [through PGIP]. We need to innovate to be at the forefront of
what‘s best for patients. We must constantly change to stay alive.‖
Change required a ―fairly dramatic‖ shift in the culture of the practice, according to Bush.
―We had computers for scheduling and billing, but there was nothing clinical on them. It
was difficult to devote the time to making the change,‖ he explained. All staff are now
involved in patient care. Biller Frances Cayton appreciates that clinical information that
was previously available only in the chart is accessible to her: ―Everyone in the office—
even if you‘re not a clinician—is more involved with patients. You‘re more aware of
what‘s going on with them so you can help them.‖ Marie Emery, the receptionist,
concurs: ―We‘re all involved with our diabetic patients. I know what they need—labs,
making sure of follow-up appointments.‖
Dr. Bush has not made the jump to electronic medical record (EMR), though he relies
increasingly on the computer to provide patients information in a timely fashion: ―I print
updates for my patients, especially for the diabetics, and make sure they have the
requisite tests before I see them in the office.‖ As for the EMR, Bush says, ―I‘m trying to
decide. The stimulus package offers incentives—and, then, in 2012, the disincentives
kick in. It‘s hard to change when you‘re used to paper.‖ Bush notes that Medical
Advantage Group (MAG), a consulting and management services company, has sent staff
to his practice as part of an ongoing education process that is helping him make decisions
to improve patient care. He anticipates that he will soon begin searching for an EMR
vendor.
Innovation in Physician Practices 16
PREPARING FOR IMPLEMENTATION
The implementation of the PCMH has come gradually for the practice. It began with e-
prescribing—―Doctors are notorious for poor penmanship,‖ Bush notes—and his
involvement with MSMS and its Medical Advantage Group alerted him early on to the
opportunity. His staff converted easily to e-prescribing and patient safety has improved as
a result. The practice also uses Ariphron, a Web-based, point-of-care patient registry that
helps manage preventive care and chronic disease. ―Ariphron allows us to see trending
over time with patients—HbA1c, LDL, and HDL,‖ nurse practitioner Sohn-Bush said.
The PCMH, Dr. Bush explains, was an opportunity to get his patients on disease-specific
registries. The practice began with patients with diabetes and is now moving on to those
with congestive heart failure.
Bush‘s practice is in the process of being recertified for PGIP and the process is labor-
intensive: ―Blue Cross is getting more prescriptive [to be recertified],‖ he explained. ―We
had two medical assistants working on this, but one of them left. We‘re trying to find
someone who can work the computer and take patients‘ vitals.‖ Nurse practitioner Sohn-
Bush echoed Dr. Bush‘s sentiments: ―It‘s a huge investment of time for a small practice
to meet PGIP requirements. Once you‘ve set it up, it‘s OK. We have this huge binder in
which we collect information on what we do every day with patients. It‘s time
consuming.‖
The transition to e-prescribing and the patient registries took time, but, according to
Emery, ―it wasn‘t as overwhelming as I thought it would be. Once you get used to it, it‘s
much easier.‖
INNOVATIONS IN PRACTICE
Patient visits, states Sohn-Bush, are now more focused on the patients: ―We don‘t have to
flip through charts and have more quality face-to-face time. Medical assistant Smith likes
the reminders for preventive screenings from Ariphron, which ―makes sure I don‘t forget
any questions to ask the patient.‖ Dr. Bush notes that the practice is ―just scratching the
surface with Ariphron. We don‘t yet have an interface between the lab tests and the
registry, so we must input labs manually.‖
Bush thinks that, on average, he spends less time with patients, but the time is better
spent than before. ―We can get down to the most important things, like getting them to
quit smoking or exercise more.‖
E-prescribing has made the practice more efficient and made patients happier. ―We get
many fewer calls from the pharmacies, asking for clarification on handwriting,‖ Emery
says. She adds that e-prescribing is ―much easier for the patients. We don‘t have to print
the prescription—we send it electronically to their pharmacy.‖
The practice has made great strides managing diabetes care. As Dr. Bush explains,
―We‘re getting good buy-in on quarterly chronic care visits. We‘re trying to re-educate
patients to come in when they‘re not sick. Of course, they have a copay, which I think
should be removed to encourage preventive visits. But most patients can now grasp the
importance of keeping their HbA1c under control.‖ Smith likes that she can easily pull up
Innovation in Physician Practices 17
the diabetes patients‘ goals for Dr. Bush to review with the patient: ―And the information
helps me understand more about the illness so I can help address the patient‘s concerns,‖
she adds.
Perhaps Smith sums it up best: ―There is so much information in one place on a patient
that we have time to talk with patients—and they will tell you things they wouldn‘t
normally tell you that you need to know to care for them.‖
Challenges
Beyond the customary adjustment to new computer programs, the practice does not seem
to have had too much trouble with implementation. Dr. Bush and Sohn-Bush have
broader concerns: the difficulty of communicating patient information readily with other
practices, and the fact that health systems and plans do not share patient information or
financial incentives. As Sohn-Bush says, ―Smaller practices really have a hard time
changing software and entering and re-entering data.‖
PATIENT RESPONSE
Overall, patients have responded positively to the innovations put in place at Bush Family
Medicine. As Sohn-Bush states, ―The patients like e-prescribing and the registries.
Instead of running to urgent care, they call the office first now. We‘re convincing them,
one by one, through repetition, that we can help them quickly because we know them.‖
Biller Cayton adds that most patients like that the system helps the practice follow up
with patients to make sure they get necessary tests: ―A lot of them like to be reminded,‖
she says.
An ongoing challenge is a subset of patients who, according to Dr. Bush, ―have been
raised that you go to the doctor only when you‘re sick. Give me my pills and let me
smoke. There are no easy answers for these folks.‖
FINANCIAL (RESOURCE) IMPLICATIONS
Dr. Bush and his colleagues spoke more of the cost of not becoming a PCMH than the
cost of becoming one. With payment pressures from Medicare and private insurers
combining with patients losing their jobs and their employer-sponsored health insurance,
the practice sees PCMH as essential to its financial viability. ―Without pay for
performance [for PCMH elements], our practice income would have plummeted. It‘s
good to see HAP [Health Alliance Plan] and Priority Health extending their incentives, to
go along with the Blues,‖ Bush states. And the practice aims to soon be part of
Medicare‘s Physician Quality Reporting Initiative (PQRI), which is an incentive
program.
THE FUTURE
Dr. Bush and his team look forward to extending their PCMH practice and earning the
incentive payments that enhanced patient care offer. As Sohn-Bush states, ―We want to
do more of everything, especially educating patients about healthy lifestyles. It sounds
simple, but it is very hard and we want to spend more time with patients.‖ The promise of
connectivity with other practices and health systems will also improve their ability to care
Innovation in Physician Practices 18
for patients. This small practice is cautious, but committed to making a more comfortable
medical home for its patients.
Innovation in Physician Practices 19
Cadillac Family Physicians
PRACTICE PROFILE
Cadillac Family Physicians is a primary care practice located in the northern Lower
Peninsula of Michigan. Patients in this rural community come from an approximately 50-
mile radius to visit the practice. Cadillac Family Physicians‘ primary providers are the six
full-time physicians and one part-time nurse practitioner. Other caregivers in the practice
include seven registered nurses (RNs), three limited practice nurses, and five medical
assistants (MAs). The practice administrator holds a master‘s degree in social work. The
practice is a member of the Wexford Mercy Physician Hospital Organization, of which
Dr. James Whelan, one of the practice‘s physicians, is the medical director.
Cadillac Family Physicians has achieved patient-centered medical home (PCMH)
certification through the Blue Cross Blue Shield of Michigan (BCBSM) Physician Group
Incentive Program (PGIP), and is in the process of applying for the PCMH designation
from the National Committee for Quality Assurance (NCQA).
PSC spoke with five people during its visit to Cadillac Family Physicians: practice
administrator Cheryl Bader; Dr. Whelan; clinical quality supervisor and registered nurse
Sandy Stehouwer; nurse practitioner Dianne Conrad; and Dr. Alan Conrad.
THE DECISION TO INNOVATE
Cheryl Bader credits the practice‘s physicians for the impetus to change: ―We have
doctors who are visionary. They were visionary 11 years ago when they hired me to
move the practice onto an EMR, and they always watch for financial incentives.‖ Thus, it
was a clear next step for Cadillac Family Physicians to implement the innovations that
have now earned them the PCMH certification from BCBSM. Bader states, ―We were
doing a lot of these things, like open access scheduling, long before the incentives came
along because that‘s what best practice said to do.‖ Dr. Conrad says PCMH is a
validation of the type of care he has always worked to provide:
I‘ve been trying to do these things for so long—appropriate care delivered,
patients informed of test results, getting patients in for preventive visits. I‘ve
always tried to get patients to get labs done prior to appointments. And I try to
write goals on their results, so they know what they need to do.
Dianne Conrad, the practice‘s nurse practitioner, concurs:
When the [PCMH] concept came out, we realized we were doing a lot of it
already. It was a validation of what we do. We recognized we had a lot of
elements, but we had to formalize them.
Dr. Whelan calls PCMH certification the ―final step of many steps.‖ He says, ―Blue
Cross payments made [what we were already doing] financially worthwhile.‖
PREPARING FOR IMPLEMENTATION
While Cadillac Family Physicians was already using electronic medical record (EMR)
and had implemented many of the elements of PCMH informally, the task of becoming a
Innovation in Physician Practices 20
certified PCMH involved preparation and planning, and continues to involve unwavering
dedication on the part of the staff and providers.
As the practice administrator, Bader has led the practice through the process of becoming
PCMH certified and formalizing the required elements of PCMH. This has required her
to work closely with both the staff and the physicians to move the process along. ―We
bring staff in as soon as possible in planning,‖ she says. ―They‘re part of the team. If it
doesn‘t make sense to them, the process won‘t work. It‘s a continual process of talking to
the staff and checking in with them.‖ Of the physicians, Bader states, ―Doctors have to be
on board right from the beginning.‖ And, even when they are, she asserts, ―that still
means going back and forth with them to move things forward.‖
Dianne Conrad describes ongoing preparation and planning to implement changes to
workflow as a process of identifying challenges and solutions:
First you have to identify the problems. That came from Cheryl finding the
perspectives from doctors, nurses, staff, and patients. Then you find the solution.
It can be as easy as changing reminder systems to reworking the whole nursing
process and how we provide nursing care.
Patients have had to be prepared for the shift as well. Clinical quality supervisor and RN
Sandy Stehouwer notes: ―In addition to meetings and training for staff, we tried to put
some information out to patients, too. We had handouts so they could understand what
PCMH entails, and we have signs in the waiting room to alert them to our status as a
PCMH.‖
INNOVATIONS IN PRACTICE
Becoming certified as a PCMH has led to some major changes in the work flow as well
as shifts in responsibility among providers at Cadillac Family Physicians. These changes
have combined to result in more robust patient care management, but have also created
some challenges.
One of the more significant—and recent—innovations implemented at Cadillac Family
Physicians is the institution of nurse schedules. Bader says the practice ―used to have
each nurse assigned to a doctor. Now, people are assigned functionally to what patients
need each day. Some people don‘t need to see a doctor.‖ RNs are now supervising teams
of MAs, who are rooming patients and doing prior authorizations.
The practice is laid out with two halls that are a mirror-image of each other. Bader
describes the division of labor by hall: ―We have two providers on each hall and an RN
supervisor on each hall.‖ She notes that patient care is carefully coordinated each
morning, when
[the RN supervisor] meets with her team and they huddle to talk about the day‘s
patients. They look for potential bottle-necks in the schedule and they identify
the team members who will be responsible for each aspect of care. They also
ensure that practice standards will be met for each patient.
Innovation in Physician Practices 21
Stehouwer, who has been with the practice for 16 years, coordinates nursing care as the
clinical quality supervisor. She and Bader meet regularly with the RN supervisors to
identify and address any issues.
Stehouwer is also responsible for ensuring that all patients receive the preventive and
chronic disease care that is prescribed in evidence-based guidelines. To this end, she
directs front office staff to contact patients to let them know when they need to come in
for visits and when they need to complete lab work. According to Stehouwer, ―we track
what tests have been completed and need to be completed, and we contact patients to
have them get the work done. We also contact other providers to get reports of patient
visits.‖
Stehouwer also reviews patient charts ahead of their scheduled visits to identify what
they will need when they are in the office and places alerts in the patients‘ records so
everyone in the office knows what chronic and preventive care tasks should be
accomplished during the visit. Dr. Conrad says, ―The majority of the time when I walk in,
nurses have already done the work I need to help the patient. Just this morning,‖ he adds,
―a nurse had done the work I needed for a patient whose asthma was slightly not in
control. The staff is empowered to make me a better practitioner.‖
MAs and RNs are supported in taking the initiative to respond to patient alerts because
they are considered part of a team, each member of which has clear roles and
responsibilities. Bader notes, ―Everyone from schedulers to providers knows how to
handle patient alerts. RNs don‘t have to wait for providers to ask them to do something.
They have standing orders to handle chronic and preventive care measures.‖
This sort of wraparound care helps ensure that chronic illness is managed for all of
Cadillac Family Physicians‘ patients. As Stehouwer puts it, ―My role and that of the MA
and scheduler is to make sure that patients with chronic disease get appointments.
Reminders on charts help to ensure that patients get the care they need when they are
here.‖
These shifts in responsibility and improvements to work flow have led to improvements
in patient care. Dr. Whelan says, ―The efficiency and effectiveness have certainly
improved.‖ He adds that the innovations have ―transformed how we approach each visit.
We provide less simple acute care, and now we are addressing chronic care at each visit
as well.‖
Dianne Conrad also notes the improvements to work flow and patient care that have
come through implementation of PCMH:
Before we implemented this concept, I would come in and have an assigned MA.
Now I have a team of support staff helping me get the best results possible—
advocating for patients and looking ahead so we can accomplish our goals, and
making sure we document everything to get the pay for performance incentives.
We were doing it before, but not as efficiently as we are now. We‘re working
smarter.
Bader says the innovations have not necessarily allowed physicians to spend more time
with patients, but she believes the care has improved all the same: ―I don‘t think [PCMH]
Innovation in Physician Practices 22
would allow doctors to see patients longer, but we give patients more for their money in
one visit. A multidisciplinary team is so important.‖ Dr. Conrad agrees that he does not
spend more time with patients, but of the time he does spend he says, ―It‘s more
productive.‖ Dr. Whelan adds, ―We use the time more efficiently to address chronic
care.‖
The changes to office flow are supported through monthly clinical meetings and monthly
meetings of front office staff. Bader says the practice ―[doesn‘t] meet as a full staff very
often because we have an electronic health record and a better system for
communicating.‖ Physicians also are given quarterly reports on their performance so they
can identify any gaps in care. Dr. Whelan admits:
I was most likely to have gaps in care because I over-individualized care and
allowed patients to set the agenda. [PCMH] has allowed me to eliminate that
without being pushy to patients. It‘s a win-win having someone double-check
those gaps; now I have fewer.
Bader adds, ―We weren‘t as vigilant about looking at [performance improvement
measures] before the morning huddles, which started in February. Now we work to catch
patients on all of the care standards.‖
Challenges
Implementation of innovations at Cadillac Family Physicians has included some
challenges. For example, providers may not fully embrace the use of guidelines to direct
patient care. Dr. Whelan says, ―Sometimes it can feel like you‘re doing things to meet
guidelines, rather than because it is in the best interest of the patients.‖ He adds, ―One of
our doctors feels that to do urine micro albumin screening annually is unnecessary when
the patient is on medication. But we have to do this for BCBSM.‖ Bader notes:
We have seven providers, and they span the continuum of thought processes.
Standardizing care is uncomfortable for people who don‘t think that way
naturally. The doctors and I meet monthly to talk about innovations. Decisions to
move forward are always unanimous, but in practice there can still be some
resistance.
Another frustration for the practice is limited ability to interface electronically with other
providers. According to Bader, ―What we‘re hindered by is other offices that aren‘t
electronic and HIEs [health insurance exchanges] are just not there.‖ Whelan is also
frustrated by the limitations caused by lack of interconnectivity: ―There are technical
limitations to good data flow. Other offices in the area aren‘t electronic, and some
electronic media can‘t communicate with others.‖ Bader points out, however, ―We have a
good collaborative community. I can call other office staff and our doctors know other
doctors, but we can‘t really share information electronically yet.‖
Ensuring that the practice receives all of the enhanced reimbursement it deserves can also
pose a challenge. Dr. Conrad says:
Keeping abreast of reimbursement is a challenge. You have to have a process in
place to document that you‘re meeting pay for performance guidelines. We have
to make sure we can meet meaningful use guidelines, which means we have to
Innovation in Physician Practices 23
send 80 percent of prescriptions electronically. This is a challenge when older
adults use mail-order, or when pharmacies don‘t accept e-prescriptions.
An overarching challenge to working as a PCMH, according to Stehouwer, is simply this:
―It takes time. It makes you a lot busier as a practice. You don‘t wait for phone calls. You
don‘t wait for people to just come in with problems.‖
TRANSITION TIME
Looking back, Dr. Whelan recalls that ―implementing EMR took a year, and there are
times that updates make us feel like we go backward.‖ He and Bader agree that most
other innovations have been implemented fairly quickly. Bader says, ―Depending on the
innovation, most people felt like we were doing it forever. It takes a little while to get it
100 percent, but I‘d say we‘re 80 percent wonderful at it right from the get go.‖ For
example, Whelan says, ―The change in workflow seemed to just happen over a couple of
days.‖
Stehouwer and Dr. Conrad describe the innovations as a work in progress. Stehouwer
notes, ―It‘s sort of an ongoing process still. It‘s been about a year now since we first
started PCMH officially. We‘re sort of getting comfortable with our roles and the checks
and balances.‖ Dr. Conrad adds, ―It‘s a process of continuous quality improvement, and
while we‘re making strides, there are things we can do better. We haven‘t arrived yet. It‘s
the art of becoming.‖
PROVIDER AND PATIENT RESPONSE
Overall, both providers and patients have responded positively to the innovations put in
place at Cadillac Family Physicians. When the practice was first considering PCMH
certification and subsequently introduced the concept to patients, most people wondered
how it was different from current practice. Bader says, ―When we first brought up the
concept of PCMH to the staff, I heard over and over again, ‗This is what we do.‘‖ She
adds, ―As we talked to patients, they even recognized that we were already doing these
things.‖
Dianne Conrad agrees:
Patients who saw the PCMH brochure said, ―This is already what you were
doing.‖ But we told them, ―We‘re just trying to formalize the relationship and
make it a two-way street.‖
And now that the innovations have been implemented, Stehouwer says:
Patients have responded pretty positively. They feel that they‘re being looked at
comprehensively and we‘re trying to get the most out of their visits. When you
call to remind them they‘re overdue for something, they feel like you care about
them.
Among providers, the response has also been fairly positive. Physicians and the nurse
practitioner have appreciated how more work is done by nurses and MAs before they see
the patients, and the nurses and MAs also seem to appreciate their new roles. Dianne
Conrad notes, ―My sense is that the nurses feel that they‘re more empowered and part of
Innovation in Physician Practices 24
the team.‖ Dr. Conrad adds, ―Nurses working as a team seems beneficial. The huddles
empower nurses and get them on the same page.‖
Even with the primarily positive response, Bader notes that ―some people would like it to
slow down a skosh.‖ But, she adds, ―Staff know if it‘s initially uncomfortable, we‘ll
answer their questions and try to give them what they need.‖
Among physicians, Dr. Whelan says:
Engagement varies. There‘s always a cynicism that it‘s all just an exercise
without practical benefits. It‘s not prevalent here, but there‘s still a little residual
of that. Data will show if it is beneficial to be this patient care intensive.
Bader and Whelan believe the innovations can attract both new clinicians and new
patients. Bader says, ―We don‘t hesitate to talk about the innovations and be proud of
them. Anybody who‘s looking, we mention it to them.‖ She adds that ―patients are
impressed that their doctors are keeping up with things in a modern way.‖
Dr. Whelan notes that ―as the world becomes more tech savvy, patients appreciate it [in
their doctor‘s office].‖ He adds that ―If we were recruiting, the fact that we‘re a PCMH
and are electronic will attract young people coming out of residencies.‖
FINANCIAL (RESOURCE) IMPLICATIONS
When considering the financial implications of the innovations Cadillac Family
Physicians has made, the cost of the EMR system comes to mind for providers and staff.
The system has, however, been integral to the practice‘s ability to manage patient care
effectively. Dr. Conrad notes,
The EMR is a huge investment. We had a five-year investment plan for how
much it would cost, but it cost a lot more. We didn‘t anticipate the ongoing
nature of the costs and time for staff and training. Even so, it‘s still beneficial in
the sense that we‘re so much better organized with our information. I can find
things so much more easily.
The more recent innovations implemented by Cadillac Family Physicians have not
appeared to have a significant effect on their bottom line, either positively or negatively.
According to Dr. Whelan, ―We see the same number of patients and make the same
amount of money.‖
The way the practice is organized is resource intensive and requires having more RNs on
staff than other similar practices might generally have. Bader says that she is often asked,
―How do you afford that many RNs?‖ She acknowledges, ―It‘s a large part of our budget.
It‘s very expensive to do this. But the doctors have made a commitment to quality.‖ And,
she adds, ―We‘ve also been able to capture incentives.‖
Dr. Whelan agrees that ―added reimbursement makes it more cost-effective.‖ He
concludes:
My gut feeling is that in the long run it will be better for patients. It may not be
cost-effective as a business proposition, but in terms of improving our quality of
care and improving patient health, it‘s worth it.
Innovation in Physician Practices 25
THE FUTURE
While the providers and staff at Cadillac Family Physicians have been happy with the
improvements they have made in the way they care for patients, they note the need to
involve patients more directly in their own care. Bader says, ―We need to try to make a
contract with patients and set goals for them to work on over a period of months.‖ Dr.
Conrad states, ―We‘re trying to help patients understand that they have some
responsibility in their own care.‖ To this end, Bader says that she and Stehouwer are
―going to get some training on patient goal setting and then train the rest of the staff.‖
The training, according to Stehouwer, is on motivational interviewing techniques, which
she believes will help the practice ―work better with patients to help themselves.‖
The practice is also going to begin holding group visits, which both BCBSM and Priority
Health are encouraging, and will make further use of a patient portal, which was
implemented just a few weeks prior to PSC‘s visit to Cadillac. Stehouwer believes the
portal will ―help us get information to patients more efficiently.‖
Dr. Whelan is excited by the possibilities for improved patient outcomes due to the
implementation of PCMH innovations:
I look most forward to saying that as a community we are providing superior
health care to patients in this community. I want to see that gaps in care have
declined, that diabetes care has improved, and to have data to show that it all
matters. I have confidence that it will.
Innovation in Physician Practices 26
Children’s Healthcare Access Program
PROGRAM PROFILE
The Children‘s Healthcare Access Program (CHAP) is a unique multi-site patient-
centered medical home (PCMH) demonstration project in Kent County. According to
Thomas Peterson, MD, the program‘s medical director, CHAP is ―a virtual patient-
centered medical home at the community level,‖ in which 40 pediatricians and 10–12
family practitioners, physician assistants, and nurse practitioners collaborate to care for
more than 15,000 eligible children on Medicaid. Four private practices; a teaching clinic
in Helen DeVos Children‘s Hospital; Cherry Street Health Services, a federally qualified
health center; and the Grand Valley State University nurse-managed clinic participate.
CHAP‘s mission is bold, as its leaders believe that their model can work for children
across Michigan:
Improve the quality of health care for all publicly insured children in Michigan
Enhance the efficiencies and effectiveness of the delivery of Medicaid services in Michigan
Lower overall costs of Medicaid for children in Michigan
To fulfill this mission, CHAP has identified these desired outcomes:
Decrease inappropriate use of emergency departments (EDs) and hospitalizations
Improve child health through well-child visits, immunizations, lead testing, and asthma management
Increase the appropriate use of a medical home
Increase access to a medical home Improve medical home quality Provide supportive services and parent education
Advocate for system-level improvements in the delivery of health care to children
To date, more than 5,000 children have been referred to CHAP services, approximately
one-third of those eligible. CHAP is in the second phase of the demonstration, which
began August 1, 2008. As will be shown below, the program is evolving and expanding
to better meet the health care needs of children in Kent County and beyond.
THE DECISION TO INNOVATE
From the beginning, Dr. Peterson emphasizes, CHAP has been a collaborative initiative
driven by the commitment of broad, high-level community leadership. First Steps, Kent
County‘s Great Start Collaborative focused on children from birth to age five, saw the
promise of a Denver program and brought it to west Michigan. First Steps championed
CHAP and forged a partnership among Priority Health, Helen DeVos Children‘s
Hospital, Cherry Street Health Services, private pediatric practices, numerous human
service agencies, schools, and private foundations. Dr. Peterson cannot say enough about
this partnership: ―The extent of the commitment is extraordinary. The local foundations
Innovation in Physician Practices 27
have funded the program. Everyone comes to the table and they are thinking only about
what is best for the children.‖
Priority Health has been essential to this success. All of the children eligible for CHAP
are covered by Priority Health Medicaid. ―Priority has contributed not just funding and
incentives,‖ explains Peterson. ―Its top management met with us every two weeks for two
years to get the program running. They have been very supportive on strategy for the
community‘s benefit.‖ Priority‘s incentives take the form of higher rates to private
physicians and the residents‘ clinic at Helen DeVos Children‘s Hospital. The health plan
also rewards Cherry Street Health Services for reducing hospitalizations and unnecessary
ED use.
Dr. Peterson also praises CHAP‘s program manager, Maureen Kirkwood. ―The program
is about managing significant change in the way services and supports are delivered to
families. It is essential to have a good manager—and Maureen is it.‖ Peterson says that
the role of the CHAP office is to stimulate collaboration of the practices and clinics.
Kirkwood brings the CHAP practice managers together monthly and providers together
quarterly to trouble-shoot and share best practices. ―One of the private practices sent
nurses to help with Grand Valley State‘s immunization clinic,‖ Peterson explains. ―They
go to great lengths to help each other out.‖
INNOVATIONS IN PRACTICE
Kirkwood‘s role, of course, is not only to work with providers. In Dr. Peterson‘s eyes, her
office is the glue that unites the partners and families and makes CHAP unique. The
office offers technical assistance to improve the ―medical homeness‖ of participating
primary care practices, coordinates non-health resources (such as transportation) for
families, facilitates parent and child education, and convenes community stakeholders to
address systems issues. For example, transportation is a key matter: ―The law requires
that children on Medicaid get transportation help, if they need it, within three days. For
kids with certain conditions, that‘s just too long. CHAP helps get them to the doctor‘s
office much sooner,‖ Peterson says.
He adds that parent education must include explanation of the importance of using the
medical home. For example, medical students and residents sometimes visit patients‘
homes to talk with them about medication noncompliance. They learned that, in some
instances, parents didn‘t know what ―refill‖ meant.
To sum up the CHAP office‘s importance, Dr. Peterson says that ―it fills the level of
coordination that Medicaid managed care lacks. It gets immediate transportation for
children and culturally appropriate education for parents. It links with Early On and Head
Start. CHAP is in the middle, working with everyone.‖
Consistent with Blue Cross Blue Shield of Michigan and National Committee for Quality
Assurance (NCQA) standards for patient-centered medical homes, CHAP practices and
clinics feature patient registries, extended access, performance reporting, care
management, links to community services, support for self-management (or, in this case,
parent management), and coordination of care.
Innovation in Physician Practices 28
The extent to which CHAP expands the medical home beyond the walls of the practice or
clinic is perhaps best seen in its pediatric asthma initiative. In a concerted effort to
address the most prevalent chronic disease in children, the program ―connects the dots‖
among six domains—home, school, medical home, hospital, health plan, and
community/neighborhood. CHAP coordinates these domains, as all must be involved if
children with asthma are to manage their condition successfully and stay out of the
emergency room. This was not easy work—Peterson notes that it took two years for all
practices and clinics to use the same asthma action plan.
CHAP is quality- and outcomes-driven, states Dr. Peterson. ―There is a dashboard with
12 metrics for asthma,‖ he explains. ―We profile offices and compare them. Peer-to-peer
comparisons can drive positive change. Practices range from meeting 4 of 12 to 11 of 12
metrics. And we offer the practices support services—how to use a spirometer, for
example—so that everyone is improving.‖ So far, the results are very good, with a 30
percent decline in emergency room visits and 63 percent decline in admissions for
children‘s asthma.
Results
CHAP is now seeing more children on Medicaid, and Priority has given $500,000 in
provider incentives. Dr. Peterson says that Priority Health has broken even on the project,
as the savings from reduced ED use and hospital admissions have gone into enhanced
reimbursement for physicians, the federally qualified health center, and the clinics.
Overall, CHAP has seen a decrease of 10.8 percent in ED use and a 9.2-percent decline in
inpatient hospital admissions.
THE FUTURE
CHAP plans to expand in the future within Kent County and, Dr. Peterson hopes, to other
communities across Michigan. In Kent County, new initiatives are under way to address
childhood obesity (Fit Kids 360), the leading concern of parents; otitis media
management, the number one cause of ED visits in the county; and behavioral health, the
biggest concern of providers in the county.
Wayne, Kalamazoo, and several other counties are considering CHAP, and Peterson
believes it is a model for caring for children on Medicaid statewide. He emphasizes that it
succeeds only when it is localized: ―It must be led by pediatricians in a community.‖ A
neutral convener with influence—such as First Steps in Kent County—must be present as
well. And the program‘s unique features must be adapted to each individual site, because
patient-centered navigation of systems depends on the relationships among practices,
agencies, schools, health plans, and community leaders.
Ultimately, Dr. Peterson would like to see CHAP go statewide. He cites North Carolina
as a state that sees the value of the program and funds it. The Tar Heel State has 15 hubs
of 4–6 practices each. The state supports the medical director in each hub with a $0.50
per member per month payment and the practices are each paid $1.50 per member per
month to coordinate children‘s care. From North Carolina‘s perspective, this is money
very well spent.
Innovation in Physician Practices 29
Children’s Medical Group of Saginaw Bay
PRACTICE PROFILE
Children‘s Medical Group of Saginaw Bay is a pediatric primary care practice with
offices in Bay City and Saginaw. The practice‘s 5,700 patients, who range in age from
birth to 18 years, come primarily from the Thumb area of the state, Bay City, Clio,
Midland, Saginaw, and Standish. Providers in the practice include two board-certified
pediatricians, a pediatric nurse practitioner, and a physician assistant. Children‘s Medical
Group received patient-centered medical home (PCMH) designation from the Blue Cross
Blue Shield of Michigan (BCBSM) Physician Group Incentive Program (PGIP) in July of
2010.
PSC spoke with five people during its visit to Children‘s Medical Group: Jeff Van
Gelderen, MD; registered nurse (RN) Pam Lesniak; front desk manager Amy Kostal;
biller Kelli Roth; and quality improvement coach Mike Ruhland. As a participant in the
Improving Performance in Practice (IPIP) program, Children‘s Medical Group received
assistance with the implementation of continuous quality improvement practices from
coaches provided by the Michigan IPIP program. IPIP is a state-based quality
improvement initiative funded largely by the Robert Wood Johnson Foundation and
sponsored by the American Board of Medical Specialties. The program was developed to
help physicians improve chronic disease and preventive care in the office-practice setting.
In Michigan, the program is coordinated by the Michigan Primary Care Consortium and
the Automotive Industry Action Group (AIAG).
THE DECISION TO INNOVATE
Dr. Van Gelderen says the decision to implement PCMH and other innovations has been
―driven by the physicians.‖ He asserts, ―Dr. Thill and I wanted to implement EMR
[electronic medical record] and wanted to provide best care to our patients. We saw the
opportunity to get into quality improvement programs and looked at financial incentives
from BCBSM.‖
Amy Kostal, front desk manager, describes Van Gelderen as forward thinking. She says,
―I guess you could say that Jeff is very up on the latest of everything, so there was no
way to go but to charge forward.‖ She adds that the initial direction for implementing
EMR and PCMH came from the physicians, Dr. Van Gelderen in particular: ―He
basically told us this is where we‘re going and this is what we‘re going to do, and we
agreed.‖
PREPARING TO INNOVATE
According to Van Gelderen, he and partner Thill knew back in 2008 that they wanted
their practice to participate in IPIP, but they first had to implement EMR—a requirement
for participation. The practice went live with the billing portion of its EMR in September
2008 and with the medical records portion in May 2009. At that point, IPIP assigned the
practice two coaches, including Mike Ruhland. Van Gelderen recalls, ―The coaches came
out to our practice and asked us what were our biggest problems and hurdles. We wanted
to get PCMH designation and we wanted to get efficiencies back that we had lost because
Innovation in Physician Practices 30
of just implementing EMR. They met with us every two weeks at first, and then once a
month.‖ Preparation for implementation of EMR and PCMH has involved ―lots of
education of the staff,‖ according to Van Gelderen.
Ruhland describes the work he has engaged in with Children‘s Medical Group as a series
of conversations. He says initially, ―We talked with staff about how the structure of
innovation is prioritized. Many of the people involved in IPIP would do time studies and
Six Sigma kind of stuff. This is just a conversation. We used the PDSA [plan, do, study,
act] model, but it wasn‘t a lot of statistical analysis.‖
INNOVATIONS IN PRACTICE
To move forward with quality improvement innovations, the practice created a team of
two people from each department—front desk, billing, nursing, and providers—to
become ―superusers‖ for EMR, to disseminate information to all staff on PCMH, and to
serve as a core team for the practice‘s quality improvement program.
Two new tools for identifying and prioritizing quality improvement issues have been
developed with the help of the quality improvement coaches. The ―white board‖ is a
Microsoft Word document that is accessed through the practice‘s internal network.
Anyone in the practice can make note of an issue or concern on the white board at any
time. The other document is a responsibility matrix that lists practice objectives and who
is responsible for accomplishing various tasks. Together, these two documents provide a
way to ensure that all issues are addressed and that top priorities are identified and
handled in rank order.
The team comprising two members of each department meets once a month with the
quality improvement coaches. Dr. Van Gelderen says these meetings are
used to determine priorities for the office. During these meetings, we look at the
white board and our practice objectives, we update where we‘re at, and we assign
responsibilities—based on employee responsibilities and desires—and they are
added to responsibility matrix.
Ruhland notes, ―Every idea gets filtered and prioritized. Everything is ranked based on
the objectives of the organization, so the most important things are addressed first.‖
Prior to working with the coaches, the practice had staff meetings ―every three or six
months, maybe not even that often,‖ says RN Pam Lesniak. Now the staff meets weekly
to review progress and address any barriers on projects listed on the responsibility matrix
that are under way. And each department has bi-weekly meetings to address any
department-specific issues. The new meeting structure has led to some changes in office
communication patterns. Dr. Van Gelderen notes that ―Everything used to flow up to me,
the practice manger, and then it would flow back down to department managers, but it
was centralized.‖ Lesniak adds,
Communication was very fragmented and difficult. Providers might tell
something to one person and think it was getting communicated, but it wasn‘t.
Because of communication improvements, we can talk to each other more easily
now.
Innovation in Physician Practices 31
A tool has also been developed to help moderate staff behavior by providing a structure
for assessing one‘s own efforts and those of co-workers. Ruhland described a teamwork
grid that defines good and bad behavior. He says, ―Items you would expect in a
performance review are embodied in that grid. So everyone here could conduct an on-the-
spot review of their colleagues. It enables a structural relationship between employees.‖
The grid, which was developed with staff input, provides descriptions of employee
behavior on a scale of 1 (poor) to 5 (excellent).
Lesniak says the staff members appreciate the grid:
If it‘s on paper, you can see where you‘re performing. It offers a concise way to
communicate with each other about how we are conducting our work. What I
find is that there are a lot of people who started as threes. Now people are
working together to be fours and fives.
The practice has begun to focus on high-level functions rather than specific job roles.
Each employee has a role in accomplishing the high-level functions. Lesniak notes,
―Having a focus on functions has improved how we work together.‖ Ruhland says,
―Function is a pretty important word. We spent a lot of time focusing on how to define
function, and identifying high-level functions. It‘s all about understanding how the
overall function needs to be achieved, and how everyone can contribute.‖
Kostal says, ―You used to never think to interfere with another department because it
wasn‘t yours. Now all departments interact. It used to be this was your job and only your
job. Now we‘re all expected to work with each other.‖ This mindset was cultivated at the
management level, according to biller Kelli Roth: ―Dr. Jeff really expected us to each do
our own job, but now we are all expected to do different jobs and do as much as we can.‖
Lesniak says that,
One of the biggest changes has been the relationships among the front desk staff,
billers, and nurses. We used to all have our own jobs and didn‘t really involve
ourselves in what each other was doing. Now, pretty much everything we do
affects one of the other groups. Having an understanding of each other‘s jobs
makes us do our jobs better.
These process-oriented activities, along with the new focus on functions, have supported
the implementation of several changes to the way work is done and care is provided at
Children‘s Medical Group. Lesniak says that the front desk staff has several new
responsibilities that support the work of the care providers.
The front desk [staff] is now more involved in assisting with chronic disease
management and handing out follow-up questionnaires. They‘re also involved in
patient reminders for follow-up and preventive visits. And they have
responsibility for running reports to find out which patients need visits for well
care or chronic disease care.
Van Gelderen notes, ―Nurses now do most of our patient education as opposed to
providers. They are freed up to do this because of the work [they used to do] that has
been handed over.‖ For example, nurses used to provide patient demographic information
to labs. Now the front desk staff have been assigned this responsibility. Roth adds, ―We
Innovation in Physician Practices 32
took referrals over from nurses. [Nurses] are definitely more involved in patient care
now. It used to hold up nurses when they would be calling specialists, but now they do
other things.‖ Ruhland describes the changes this way: ―Everything is structured so the
highest value providers are providing the highest value of care that they can.‖
Another change has required patients to think differently about their appointment times.
When an appointment is scheduled for 8:00, this is the time that the patient can expect to
see the primary provider. For this reason, patients are asked to arrive 15 minutes prior to
their scheduled appointment. When patients arrive, Roth notes that they are ―given a half
sheet with questions regarding why they are there to prompt them to be prepared for the
discussion with the provider.‖
The changes do not necessarily allow physicians or other caregivers to spend more time
with patients, but providers and staff agree that patient visits are more efficient and
effective. They believe the patients are receiving greater value during the time they spend
in the office. Ruhland says, ―All of the time [patients] spend in the office is meaningful,
not just the time with the provider. The time the patient is here is all value-added.‖ Van
Gelderen adds, ―I would say the patients are taken care of by a team instead of a provider.
We try to make the most of it and have the visits be as efficient as possible.‖
Children‘s Medical Group measures the quality of the care it provides as well as the
quality of its administrative activities. Ruhland notes, ―There is a specific metric to
measure billing errors.‖ Roth says, ―The reports we run keep us on track.‖
The chronic disease on which the practice focuses for the PCMH designation is asthma.
Thus, monthly quality reports include patient measures of asthma control. Quarterly
quality reports include ―what would be considered HEDIS [Healthcare Effectiveness
Data and Information Set] guidelines,‖ according to Van Gelderen. ―These are things like
well-visit rates, vaccination rates, and lead testing. We can track our own progress and
make changes to improve our own numbers internally.‖ Ruhland says the reports provide
a ―better indication earlier of what needs to be addressed.‖
One activity that the entire practice appears excited about is moving into a new building
that has been designed to match the new work flow. Lesniak says in the new building,
several improvements will be made over the current office.
We‘ve improved our signage and geared everything toward getting patients in to
see the provider and getting them the education they need after they see the
providers. We‘ve also added an additional window at the front desk to help with
flow and billers are now behind the front desk instead of being in a separate area.
The checkout area is much larger for better flow and efficiencies.
Challenges
Implementation of EMR and PCMH has not been easy for Children‘s Medical Group of
Saginaw Bay. In fact, at the beginning, some of the staff really struggled to maintain their
support for the efforts. Lesniak reports, ―Nine months ago it was really bad here. We
were ready to walk out the door.‖
Innovation in Physician Practices 33
Dr. Van Gelderen says,
We found out several months into implementation that some employees didn‘t
really understand what PCMH was all about. It took a lot of education to
understand why we were doing what we‘re doing. Some thought it was just
financial. Now, all staff have had education on PCMH and the chronic care
model. Once they could see more of the overall benefits, they came on board.
Roth notes, ―A lot of people handle change differently, and it was hard at first. But once
you could see how it was going, everybody pulled together.‖ Lesniak adds, ―Going
through that difficulty makes us appreciate all the more where we are now.‖
A few external challenges remain to improving patient care to the fullest extent possible.
Dr. Van Gelderen noted specifically that a lack of insurance reimbursement for PCMH
services beyond what they receive from BCBSM limits the practice financially. He also
stated that the ―lack of a community interface from an EMR standpoint‖ continues to
limit coordination of care with specialists and hospitals. ―There is software to allow
EMRs to communicate,‖ he notes. ―But it is not available in our area.‖
TRANSITION TIME
When asked how long it took for the practice to feel like its innovations were fully
integrated into the way the office works, Dr. Van Gelderen glanced at a quarterly report
of practice data on quality of care, and said, ―Six to nine months. That was how long it
took us to get back to the same throughputs, but many other innovations were put in place
during that time frame.‖
Lesniak says, ―Six months after ‗go-live‘ with EMR we were more comfortable with the
flow. The front end started before [nursing staff].‖ But the practice did not have the
luxury of time to get comfortable. She adds, ―Two months after we went live with EMR,
we started with PCMH and IPIP.‖ Kostal notes, ―It was a really busy time when we
implemented the EMR, so that was particularly challenging.‖
As described above, once the EMR was in place, the coaches helped the practice make
structural changes to the way the staff work together and ultimately to the way care is
provided. These modifications have enabled the practice to absorb changes more easily
than before. Because it has put processes in place for prioritizing and implementing
changes to workflow and patient care, the practice is hardly daunted by the challenges of
implementation anymore. Van Gelderen says, ―Now with some structural changes, we
can handle challenges in stride. In the language of our coaches, we just ‗turn the crank.‘‖
Ruhland adds, ―Every new thing that comes along, we can put in place almost
immediately because of the structures we‘ve put in place.‖
PROVIDER AND PATIENT RESPONSE
Biller Kelli Roth says, ―For the most part everybody [in the office] thinks [the
innovations] are great.‖ Ruhland notes that employee satisfaction surveys have been
conducted every six months. These ―internal questionnaires show how much it‘s
improved,‖ he says.
Innovation in Physician Practices 34
Lesniak says, ―We would never want to go back to the way we used to do things. But,
early on we would question the wisdom of doing things the new way.‖ Kostal adds,
―There was initially some doubt, especially among nurses, during the EMR transition.
The technology was a little more difficult for some of the less computer literate among
us.‖ She notes, ―Dr. Jeff is willing to pay to send us to classes if we think they will be
helpful to doing our job.‖ Roth adds, ―Learning new things has been exciting for most
staff, and it pretty much happens on a daily basis.‖
The patients have also responded very positively to the innovations, according to
providers and staff. Kostal says that ―surveys have shown that patients are satisfied
overall.‖ She says that while the practice requests information from patients more often
than it used to, patients find it less burdensome:
[Patients] have to fill out a form at every single visit, but they are just confirming
the information we print out from their records. They like this better than the
revised information form they used to have to complete at the beginning of each
year.
Lesniak adds that due to some of the changes, ―there‘s a better flow of communication
between patients and staff.‖ Speaking of the EMR implementation, she says, ―At first it
felt like we were too into the computer and weren‘t as personal with the patients. But for
the most part [patients] see the technology and seem very excited about it.‖ The practice
has also implemented a Web portal through which patients can e-mail medical questions
to providers or request appointments or medication refills. The practice can use the portal
to notify patients of needed care or to e-mail documents to patients. Lesniak says, ―The
patients that use the Web portal love it.‖ Kostal asserts, ―We check our e-mail system
every time we check out a patient. So people get responses fairly quickly.‖
FINANCIAL (RESOURCE) IMPLICATIONS
In terms of the financial and resource implications of both EMR and PCMH, Dr. Van
Gelderen says, ―We‘ve added 1.5 FTEs, but PCMH dollars have offset the cost of
additional staff, and hopefully meaningful use of stimulus dollars will offset the cost of
the EMR.‖ Van Gelderen bemoans the fact that ―BCBSM is the only insurance company
recognizing our efforts.‖ But he states, ―At this point, we‘re pretty much neutral
financially.‖ Ruhland points out that ―It takes effort to make it neutral,‖ making it clear
that added reimbursement alone does not ensure financial success with PCMH
implementation.
THE FUTURE
As Children‘s Medical Group of Saginaw Bay looks to the future, Dr. Van Gelderen says
he anticipates ―more electronic interfaces with specialists and hospitals, better patient
self-management, and more health coaching for patients.‖
Van Gelderen‘s colleagues are excited to continue to learn new things and maintain the
forward momentum. Kostal says the innovations have ―made it so much easier to keep
track of things. We used to have to look through a paper chart to see who was due for a
visit. Now we can keep track of when patients are due for well visits and re-checks better.
This results in improved patient care; we‘re not missing nearly as many.‖ The group has
Innovation in Physician Practices 35
received some recognition for its innovations as well. Roth says, ―My friends at other
practices tell me they hear we‘re top dogs. It‘s nice to be recognized as one of the best.‖
Kostal says that ―When [Van Gelderen] tells us something new is coming down the line,
it‘s like, ‗Bring it!‘‖ Roth adds, ―We have a crisp functioning group office and now we‘ll
be in a better facility. It can‘t get any better than this.‖
Innovation in Physician Practices 36
Family Tree Medical Associates
PRACTICE PROFILE
Family Tree Medical Associates (FTMA) is a primary care practice in Hastings that
provides care to patients throughout Barry County. Patients also come from Battle Creek,
Grand Rapids, Kalamazoo, Lansing, and as far as Saginaw. The practice‘s primary
providers include two full-time physicians and two part-time nurse practitioners. A case
manager and registered nurses also participate in patient care at FTMA.
FTMA achieved a patient-centered medical home (PCMH) designation from Blue Cross
Blue Shield of Michigan (BCBSM) through its Physician Group Incentive Program
(PGIP) in 2009, and was recognized as a PCMH by the National Committee for Quality
Assurance (NCQA) in January 2010. FTMA is one of only 12 physician practices in
Michigan to have achieved Level 3 PCMH recognition from NCQA; that is, it received
75 or more points on the 100-point scale NCQA uses to score practices and met 10 out of
10 of the ―must-pass elements‖ identified by NCQA.
PSC spoke with four people during its visit to Family Tree Medical Associates: Troy
Carlson, MD; nurse practitioner Kathleen Carlson; nurse practitioner Brenda Nyenhuis;
and case manager Debbie Mays.
THE DECISION TO INNOVATE
Deciding to implement the innovations necessary to become a patient-centered medical
home hardly required a second thought at FTMA. The only decisions were ―what to do
first and how to make it work,‖ according to case manager Debbie Mays, who adds, ―We
haven‘t been afraid to change and that‘s what makes us successful.‖
FTMA has a history of focusing on patients and a bent toward innovation. The providers
in the practice are constantly seeking ways to improve patient care while also increasing
efficiency. Discussing PCMH-related activities, nurse practitioner Brenda Nyenhuis says,
―We‘ve been doing this for years, but this just documents it.‖
With the implementation of the electronic medical record (EMR) system in 2007, the
providers were excited at the possibilities for improving the care they provided patients.
They recognized opportunities for systematically addressing patient care needs while
providing individualized care. They also saw the potential for managing health at a
population level with the ability to monitor indicators of health among their entire patient
load.
This enthusiasm led them to develop many of the patient care practices that helped the
practice achieve PCMH designation from both BCBSM and NCQA. Dr. Troy Carlson
professes to be ―disenchanted with the current medical care system [and] frustrated with
the way care is typically delivered. [Medical care] is not about us,‖ he adds, implying that
FTMA believes it is about the patients. Carlson views EMR and other PCMH innovations
as ―tools that can systemize the delivery of health care.‖ Of PCMH, he says, ―It allows us
to be proactive rather than reactive.‖
Innovation in Physician Practices 37
PREPARING FOR IMPLEMENTATION
Much of the preparation for recent innovations at FTMA occurred when the practice
implemented its EMR system in 2007. In fact, much of what the EMR allowed the
practice to do (e.g., e-prescribing, electronic-based charting, patient registries) is included
in the criteria for designation as a patient-centered medical home. Continued refinement
of these activities, as well as formal documentation of their efforts for PCMH
designation, involves regular in-house training and constant communication among
providers and staff.
Dr. Carlson asserts, ―We have a culture in this office for training on a weekly basis.‖
Nurse practitioner Kathleen Carlson and case manager Debbie Mays lead the training,
which can include discussions of paradigm shifts, updates to the EMR, and new policies.
Occasionally, community resources are brought in to assist with providing information
and education.
A critical aspect to preparing providers and staff for the implementation of any
innovations is including everyone in the discussions. Dr. Carlson notes, ―We validate and
value others‘ feelings. We involve everyone in the changes.‖ Kathleen Carlson adds, ―We
include everybody. Nothing is hidden.‖
INNOVATIONS IN PRACTICE
Increased efficiency became imperative in early 2009 when the practice went from three
physicians to two. The remaining providers faced the challenge of continuing to care for
the 1,100 patients who had typically been seen by the departing physician. This led to the
implementation of one of the practice‘s key innovations—two physician-directed patient
care teams. Now, all patients are seen either by the Carlson Team (Dr. Troy Carlson) or
the Garber Team (Dr. Matthew Garber). In addition to a physician, each team consists of
a nurse practitioner, a registered nurse who serves as a case manager, a medical assistant
who acts as a flow manager, a phone manager, and a pre-planner. To ensure that team
members are prepared to meet the needs of patients, Mays reports, ―Each team has a
weekly huddle to talk about the upcoming week.‖
A critical aspect to the way care is delivered at FTMA is that all staff members
understand their role and know that they have a role in caring for the patients. Kathleen
Carlson describes it this way: ―We took it to a level of ‗You [the staff] own this.‘ We
empowered staff to be problem solvers. We said, ‗You have ownership in the care of
patients.‘‖ This approach within the context of a team model has allowed the practice to
maintain the 1,100 patients of their former colleague and effectively place the patient at
the center of the team.
The front office pre-planner ensures that patient lab work and any other work that should
be completed between visits is done prior to a patient coming into the office. According
to Dr. Carlson, ―the EMR lets us see which labs aren‘t done, and we are constantly
calling patients between visits. The Clinical Decision Support Service on our EMR
identifies things patients need beyond the primary issue they are presenting with.‖ The
pre-planner also ensures that any necessary paperwork and educational handouts are
ready for the patient when he or she arrives. Dr. Carlson notes that having lab results and
Innovation in Physician Practices 38
other information readily available during the patient visit means that physicians and
nurse practitioners have the information they need at their fingertips, which ―lets the
provider be the decision maker.‖
The case manager is primarily responsible for assisting providers and patients with
chronic disease management. The case manager role is fairly unique, according to Dr.
Carlson: ―Very few small primary care practices have case managers. She partners with
physicians and nurse practitioners in coordination of care for patients with hypertension,
diabetes, and attention deficit disorder.‖
Mays describes how she works with patients who have received a diabetes diagnosis:
I go into the room before the physician and sit down to talk with the patient. I
review their lab work and explain what a diabetes diagnosis means. Sometimes I
also help order medication and set up appointments with a diabetes educator and
a dietician. After the doctor has visited with the patient, I go back in to reiterate
the key points. They often need to hear the information more than once. Then I
schedule a follow-up appointment in four to six weeks, when we‘ll establish
goals with the patient for diet and exercise.
During these visits, Mays says it is critical to ―meet them [patients] where they‘re at. We
don‘t just spew information. We really try to understand the patient‘s perspective.‖
The idea of meeting patients where they are and involving them in their own care is
clearly a principle of care at FTMA. Kathleen Carlson says, ―We care by partnering. It
does me no good to walk into a room and just decide what needs to be done. We get the
best outcomes when the patient is empowered and feels part of the decision.‖ As Mays
says, ―We empower our staff and our patients.‖
To support patient self-management, FTMA has begun the implementation of a patient
portal that allows patients to access much of the information in their medical records and
also provides an additional avenue for communicating with providers in the practice.
Currently, about 20 percent of FTMA‘s patients are connected through the portal.
Patients are required to come into the office to receive a password and training for using
the portal. As Kathleen Carlson states, ―We see ‗patient-centered medical home‘ as
caring for patients not just when they are in our space, but all the time.‖
A critical aspect to care improvement at FTMA is frequent review of patient health data.
Dr. Carlson carries around a three-ring binder containing a variety of charts and graphs
demonstrating progress in Hba1c levels and other indicators of patient health. He says,
―We‘re trying to aggregate patient data across the practice so we can identify outliers—
what percent have HbA1c‘s of less than seven—and identify ways to improve the care we
provide as an organization and teams.‖ Carlson‘s philosophy with regard to the data is,
―If we can‘t measure it, we can‘t manage it.‖ Mays says FTMA uses the data to identify
practice improvements, by asking, ―What do we need to do to fix what we have going
on?‖
In tandem with paying close attention to patient health indicators, the practice ensures
that patients with chronic diseases receive recommended care. Dr. Carlson says, ―Every
month, we look at patients with chronic conditions and ensure they are not lost to follow-
Innovation in Physician Practices 39
up.‖ Mays and Kathleen Carlson note that a combination of clear guidelines and staff
who understand their roles makes this possible. ―We‘ve identified parameters for when
follow-up is needed,‖ says Mays. Carlson is quick to add, ―Other staff makes this happen;
this is not all on the physicians and nurse practitioners.‖
Challenges
Despite what appears to be great success with the implementation of an EMR and the
PCMH model, Family Tree Medical Associates has encountered some challenges. One
challenge noted by Dr. Carlson is the lack of a health information exchange that would
enable FTMA to share patient data with other practices, like specialists. He also notes
with frustration the ―attitudes outside these walls.‖ He adds, ―We need to get more people
to see we‘re in this together,‖ referring to the notion that a relatively small number of
practices seem to be embracing the nature of care provided at FTMA.
On a practical level, the practice site is not set up to offer care the way FTMA envisions
it will in the future. Mays notes that ―the space is not conducive to group visits,‖ which
the practice would like to start implementing soon.
TRANSITION TIME
Looking back, Dr. Carlson notes with pride that FTMA lost very little time and
productivity when it implemented EMR in 2007: ―When we converted to EMR, we were
back to full our patient-load in four weeks.‖ As for other innovations, he notes, ―There
has been no loss in productivity and, hopefully, we have increased patient satisfaction.‖
Kathleen Carlson points out, ―We created a culture a long time ago that this is how things
would be.‖
PROVIDER AND PATIENT RESPONSE
While varying levels of involvement in identifying and implementing changes necessarily
exist, the practice has generally not experienced issues related to staff or provider
reluctance to adopt the innovations. In fact, when an outside trainer came to the office to
help FTMA launch its EMR, the trainer noted with surprise that every employee was
attending the training and commented that he had not visited a practice where it was this
clear that everyone was a willing participant in EMR implementation.
While some people have struggled more than others, the providers at FTMA believe these
are internal issues that are easily addressed during weekly staff meetings when training
and dissemination of new information are handled. Mays says, ―Change was harder for
people who had been here longer. There are only one or two of them left.‖ Among those
who remain, Kathleen Carlson says it is her impression that there are ―not different levels
of enthusiasm, just different levels of involvement. We have created a culture where
change is okay.‖
As for patients, Mays notes, ―We have experienced apprehension, but I don‘t think
patients notice this. We have a structure in place so patients are okay with change
because they know how things work.‖ Survey results show that patients are largely
unaware of any issues among staff. Patient survey findings indicate high levels of
Innovation in Physician Practices 40
satisfaction with the way the practice works and the care provided. In a recent survey,
about half of the 200 patients who responded provided written comments. Kathleen
Carlson believes this is because ―they know we listen.‖
What the practice heard was that ―there are struggles with our phones and the wait time in
waiting rooms can be long. Our goal is to that 85 to 90 percent of patients are in the
office no longer than one hour.‖
FTMA has also made it clear to its patients that they have a responsibility for their own
health and health care. Dr. Carlson says, ―We have laid out for people what our
expectations are. We tell them our philosophy so they can decide if it will work for them.
We say, ‗This may not be the place for you. You can‘t just show up when you‘re sick.‘‖
Kathleen Carlson adds, ―Patients know that ultimately it‘s for them. It‘s not us trying to
get more money. They know our standards are high. They also know we listen.‖ Mays
says most patients have chosen to stick with the practice: ―When [patients] leave our
practice, it‘s usually because they‘re moving. If it‘s due to a disagreement, it‘s usually
clearly understood on both sides.‖
FINANCIAL (RESOURCE) IMPLICATIONS
Dr. Carlson reports that the investment in terms of both money and time is not
insignificant, but FTMA has already begun to see a return on its investment and expects it
to grow. He notes that the practice saw a return on investment from its EMR in 16
months. With the implementation of some of the PCMH innovations, Carlson said that
―overhead went up a bit with the addition of a pre-planner and case manager,‖ adding that
―the practice spent $25,000 to $30,000 in personnel time to put PCMH in place.‖
However, Carlson also says that efficiency has increased—he can see 30 patients in a day
and still be done by 5:15 or 5:30.
Kathleen Carlson also says it is ―hard to identify the value added from the care we
provide. There is no way to monetize the value patients receive from just feeling better.‖
THE FUTURE
FTMA‘s providers will continue to seek ways to use technology and implement
innovative practices they believe will improve patient care. As noted above, the practice
would like to implement group visits, especially for patients with diabetes. Staff members
also look forward to the possibility of EMR interconnectivity and being able to exchange
information with other practices, which would contribute to their participating in ―true
population management,‖ as Dr. Carlson puts it.
Ideally, Dr. Carlson says, ―I look forward to not having to worry about how many
patients we see—we all know how many we need to break even.‖ In the meantime,
Kathleen Carlson and Debbie Mays say, the practice‘s providers will continue to
carefully examine and improve the care they provide. Carlson says, ―We‘re always
looking at what‘s wrong to see what we can do better.‖ Mays adds, ―We‘re not afraid to
take a look.‖
Innovation in Physician Practices 41
Gratiot Family Practice
PRACTICE PROFILE
Gratiot Family Practice is a primary care practice located in Alma, Michigan. The town is
home to 9,000 residents; an additional 50,000 residents live in surrounding areas. This
rural community‘s largest employers are the local hospital and Alma College. There are
also a number of family farms in the area. Gratiot Family Practice employs a total of 25
staff, including three full-time physicians who own the practice, one full-time nurse
practitioner, one full-time physician assistant, and one part-time physician assistant.
Other caregivers and staff in the practice include a practice manager, one registered
nurse, six limited practice nurses, and two medical assistants. Gratiot Family Practice is a
member of the Gratiot County Medical, PC, and became a patient-centered medical home
(PCMH) certified by Blue Cross Blue Shield of Michigan in June 2009.
PSC spoke with seven people during its visit to Gratiot Family Practice: Dr. Gregg
Stefanek; practice manager Sandy Young; nurse practitioner Lisa Bigelow; nurse
educator Laura Fletcher; public health intern Elizabeth Payne; patient representative Judy
Hersey; and biller Dawn Cooper.
THE DECISION TO INNOVATE
Gratiot Family Practice started using electronic medical record (EMR) in 2006 after
recognizing the inefficiencies created by using paper. The physicians also had a general
understanding of how technology could influence the future of practicing medicine, by
creating efficiencies and the ability to better manage their entire patient population. Dr.
Stefanek says that once the practice transitioned to using EMR, ―It changed everything.‖
The staff saw how EMR allowed them to do things they had not been able to do with
paper files. This encouraged the physicians and mid-level staff to seek other innovative
models to better serve their patients. The patient-centered medical home appeared to
bring all of the providers‘ values and patient care ideas into one model. Lisa Bigelow
says:
Now we have a solid foundation as to how we practice. It‘s our philosophy. It is
how we have all wanted to practice and take care of our patients. We are drivers
to patients taking care of themselves. We‘re there to counsel and give them
information. We‘re the experts of their health, but they are the experts of their
body.
Dr. Stefanek notes that he also saw some financial advantages to implementing PCMH,
and he believed they needed to pursue it to stay up with or even ahead of current practice
standards. Stefanek says that the transition to the PCMH requires a lot of work; he notes
the importance of having support from the practice manager to drive the process and help
gain buy-in from all of the physicians in the practice. He comments that the practice
manager had a ―willingness to learn and step out of the traditional practice manager role.‖
Innovation in Physician Practices 42
PREPARING FOR IMPLEMENTATION
Both the EMR and PCMH processes were defined and agreed upon from the beginning
with the doctors of the practice. Dr. Stefanek says, ―We didn‘t prepare ourselves enough
when we started the EMR. We needed to work on the culture and environment to make
sure our staff was prepared for the changes with the PCMH.‖ To reduce costs when
implementing the EMR, the practice had only two employees trained on the use of the
EMR. These employees then served as a ―go-to‖ team who did most of the work of
implementation and training the rest of the staff. When the practice implemented the
PCMH model, everyone was involved in the process.
The practice manager and doctors held an in-service with all of the staff to describe the
PCMH model, what they were trying to accomplish with PCMH, and what it would look
like from the perspective of both the practice and the patients. They also worked with the
staff to create a vision and set goals for the practice. A team was then assigned to create a
―Responsibility Matrix‖ to track activities toward achieving the vision and goals.
INNOVATIONS IN PRACTICE
Gratiot Family Practice providers and staff have made many innovative changes since
implementing the PCMH, including altering the way staff communicates, providing more
opportunities for professional development, making changes to roles, and improving
patient education. There are also plans in place to change the physical layout of the office
when construction of a new office building is complete.
Although most staff interviewed believe the office has generally practiced good
communication, everyone mentioned there has been a significant improvement since
PCMH implementation. The practice now conducts ―morning nurse huddles‖ to better
organize each day as the nurse staff transition from working with one doctor to another
each day. Recently the practice manager, Sandy Young, facilitated a meeting between
office staff and nurses to discuss frustrations. Young notes that not everyone has the same
work load since the implementation of the PCMH. Having open communication among
staff helps everyone understand the various roles of team members. Nurse practitioner
Lisa Bigelow also notes that since staff and nurses feel more empowered with the
implementation of the PCMH, it‘s not as intimidating to seek out supervisors or doctors
for feedback.
The physicians of the practice have begun to develop a culture of learning and growing
that was absent before PCMH implementation. The doctors encourage staff at all levels
of the practice to gain additional training for skill development. This has resulted in staff
having ―more of a can do attitude,‖ according to Young. Dr. Stefanek says that the staff is
expected to do more, and is empowered to do more. For example, the practice has
implemented a plan-study-do-act (PSDA) model for quality improvement. Any staff
member has the latitude to test a method to improve how the practice delivers care and
report back to the entire practice on its successes and challenges. The staff as a whole
then decides whether the method will be implemented office-wide or whether additional
testing needs to be done. At the time of the site visit, a medical assistant was in the
process of testing a system to gather patient information. In this system, patients are
asked to complete a card containing three questions when they arrive at the office. The
Innovation in Physician Practices 43
questions ask patients to describe the reason for their visit, what they need to gain better
control of their health, and what is most important to them regarding their health. After
the medical assistant tests the question card method for a length of time, she will report
back to the staff whether it was an efficient method for gathering information on why the
patient was in the office to see the doctor.
Through the PCMH, the doctors have also begun to use their nursing staff to their fullest
capacity. Nurses have become more involved in prepping patients before they meet with
the physician, and a new nurse educator role has been created. The practice employs a
licensed practical nurse who is used solely for patient education two days a week. The
nurse educator conducts follow-up calls with patients recently discharged from the
hospital. The practice has found that about 30 percent of newly discharged patients have
had questions that may otherwise have gone unanswered. The nurse educator also meets
with diabetic patients for 45 minutes prior to their appointments with the doctor to talk
with them about their diet, insulin usage, and how to use monitoring equipment. This has
helped doctors utilize their time with patients to reinforce and solidify what the nurse
educator went over with the patient and prescribe any medications. Dr. Stefanek notes
that patients now leave the office empowered with information about how to control their
diabetes.
The nurse educator has also started using the EMR to pull lists of diabetic patients in
order to make contact with those who have not had an office appointment in the past
year. Seventy-five patients were pulled from the records. Out of the 50 initial contacts, 8
appointments were made to see the nurse educator and doctor. They learned from this
exercise that most of the patients have moved out of the area, but those still in the area
are being seen by the nurse educator and doctor. The practice is beginning to implement
the same process for all patients who have not had a physical in the past year.
Gratiot Family Practice is in the process of building a new office so that the physical
environment is more conducive to the new ways that it delivers health care. According to
the practice manager, the new office will have physician and nurse workstations placed in
the middle of an area with patient rooms on either side. This will enable nurses and
physicians to work together more easily than the office‘s current design allows. The new
office will also provide space for conducting group visits.
Challenges
Those interviewed at Gratiot Family Practice say that adapting to changes (e.g.,
technology), maintaining internal communication, integrating new roles into the practice,
and engaging area specialists are some of the challenges they have faced in implementing
the PCMH. They have also experienced continuing struggles with implementing and
using several features of the EMR.
Adapting to change appears to be a generational issue, according to staff and providers.
While everyone is open to the changes, some have had a more difficult time adjusting to
the changes, especially some of the new technology.
Nurse educator Laura Fletcher notes that maintaining internal communication is
something that could turn into a challenge:
Innovation in Physician Practices 44
If we‘re not communicating with lots of new things going on, then that can lead
to problems. We all want to give good patient care, but if it‘s not communicated
in the group then that can get in the way.
Dr. Stefanek describes the integration of new roles—the nurse educator, in particular—as
another challenge that the practice is working through. Stefanek says that the
responsibilities of the nurse educator were pretty vague when the position was first
created, but he feels that they have laid down a strong foundation to use the nurse
educator to do even more. For example, the nurse educator is helping Stefanek develop
patient checklists for the doctors to use when seeing patients with a chronic disease.
Implementation of an EMR has also proven challenging for Gratiot Family Practice. The
electronic billing feature has never worked, according to biller Dawn Cooper, and the
billing staff still bill manually. Dr. Stefanek claims that the automatic patient checklists in
their EMR system do not work either, which is why he and the nurse educator have been
developing their own paper checklists. The practice is continuing to work with its EMR
provider to work out these issues.
The practice is working to educate specialists in the area on the PCMH model. Dr.
Stefanek regularly speaks to practices in the area about the benefits of the PCMH.
Bigelow said that under the new model, doctors want patients back in their office for
follow-up after seeing specialists or other providers, thereby improving continuity of
care. She adds that they would like to work with specialists to help treat the patient:
―Sometimes a patient is more willing to tell us what they will or won‘t do (e.g., take a
medication prescribed by a specialist).‖ Bigelow stresses that they are there to help the
specialist and the patient understand what‘s happening with treatment. Young has begun
reaching out to specialist offices to talk about a universal referral form the practice would
like to begin using and other ways the practice could strengthen relationships (e.g.,
improved communication, understanding of expectations in specialist consultation).
Although challenges continue to occur, those interviewed are confident in the team‘s
ability to work through any challenge. Bigelow claims that what has been most
bothersome to her about the innovations was ―not being able to get them implemented
fast enough. Once you start generating ideas, more and more come.‖
TRANSITION TIME
The transition to using EMR took at least two years and is still a work in progress. The
transition to the PCMH was described as an ongoing process by more than one staff
member. Dr. Stefanek says:
Changing a family practice is like changing a tire on a bike while you are riding
it. It takes time to make changes to the system. PCMH is a journey, changing the
way care is delivered. It is difficult to change proactively. You need to have
processes in place to change and people to do [the work]. We are learning that
the [current health care] system has gotten to value tests, but the PCMH is getting
back to the doctor/patient relationship, really meeting [the patient‘s] needs
instead of focusing on the test.
Innovation in Physician Practices 45
Public health intern Elizabeth Payne says that the staff is ―never really sitting back
relaxing. It‘s continually changing and challenging practices.‖
PROVIDER AND PATIENT RESPONSE
Opinions of the innovations put in place under PCMH vary among staff and providers at
Gratiot Family Practice. There are staff members and providers that have been practicing
a certain way for 35 years who find the changes difficult, but there are also people who
are excited and motivated to change. Says Dr. Stefanek:
You always need to think about how it is going to affect the patient and meeting
their needs. Most staff doesn‘t look at this just as a job, but as an opportunity to
affect a person‘s life. We emphasize that for the staff…. I like the change. For
example, I like giving a patient a physical and having their test results by noon. It
has gotten me back to the reasons that I got into medicine. I may not be able to
cure cancer or diabetes, but I am able to give patients tools they need to take care
of themselves.
Young notes that the efforts to fully engage all staff have resulted in a positive response
from staff. She says that there has been a lot of open communication with all staff. Dr.
Stefanek and Young stress that innovations and technology will not work unless you have
the people behind it and leaders who are willing to allow their staff to do what they are
capable of doing.
The patient response to PCMH implementation has been very positive, according to
providers and staff. Dr. Stefanek says that his patients e-mail him with questions, and
responding to e-mail requires no additional work on his part. He notes, though, that some
patients expect more from him and his staff now: ―The better you get the more they
demand.‖ The practice started sending out a regular newsletter and has received positive
feedback about it from patients.
Dr. Stefanek and Bigelow agree that the PCMH gives their practice a competitive
advantage in attracting patients and clinicians. Stefanek suggests that keeping the focus
on the patient and how they serve the patients will lead patients to offer positive
comments about the practice when they are asked about their doctor.
FINANCIAL (RESOURCE) IMPLICATIONS
When asked about the financial implications of implementing the PCMH, those
interviewed spoke only of financial benefits. The practice has experienced a $42,000
increase in reimbursements in one year; and the physicians have received a substantial
incentive bonus. Blue Cross Blue Shield of Michigan is paying 10 percent more for office
visits, which has covered the cost of additional staff hired since implementation of the
PCMH model.
THE FUTURE
When asked what excites him most about PCMH implementation, Dr. Stefanek says, ―I
am looking forward to every patient saying that they are getting what they need to be
confident in managing their own health.‖ Young adds that she is excited to be able to
help patients set goals and prepare them with the knowledge they need to be healthier.
Innovation in Physician Practices 46
She is also excited to use the nurse educator more to help patients manage their health.
Bigelow believes that they have built a strong framework and have the potential and
ability to be a premier practice in the state.
Stefanek, Young, and Bigelow are also looking forward to implementing group visits.
Each 90-minute appointment will be attended by 8–10 patients and facilitated by a doctor
and a social worker. Half of the group will complete the physical portion of the
appointment during the first 30 minutes. The education/self-care portion of the visit will
take place in the group setting during the second 30 minutes with all patients present.
Finally, during the last 30 minutes, the other half of the patients will complete the
physical portion of the visit.
Nurse educator Fletcher is not only happy to see how well patients have responded to the
changes, but she appreciates the opportunity to develop professionally, thereby increasing
her job satisfaction. She sees the PCMH as win-win-win for doctors, nurses, and patients.
The public health intern has been excited to see how the practice connects patients to the
resources within the community. Doctors and nurses take time to talk with the patients
about resources available in the community and direct patients to services to help them.
Innovation in Physician Practices 47
Henry Ford Health System – General Internal Medicine
PRACTICE PROFILE
The General Internal Medicine Clinic at Henry Ford Health System is housed within the
Henry Ford Hospital in Detroit. The clinic employs 19 full-time physicians, and trains
approximately 40 residents from Wayne State University each year. The clinic sees
approximately 50,000 patients per year and has 25,000 active patient files. Of those,
about half are Health Alliance Plan (HAP) beneficiaries and the others are fee-for-
service. Clinic staff estimates that 60 percent of patients are residents of Detroit, and the
remaining are suburban residents referred by specialists in the hospital.
PSC had the opportunity to speak with William Keimig, MD, division head of the
practice; Katherine Scher, registered nurse, project manager; Brian Boutell, practice
administrator; Robert Brooks, Lean project manager; Beverly Cooper-Edwards,
registered nurse, nursing supervisor; physicians Nicole Rocco, MD, Sean Drake, MD,
and Vinay Shah, MD; nurse practitioners Christine Bongo and Terri Brown; Sandra
Nowak, PharmD; and three nurse case managers: Loretta Briden, registered nurse, Juli
Testy, registered nurse, and Kelly Dimick, registered nurse. The Henry Ford System has
26 primary care sites that have received patient-centered medical home (PCMH) status
from Blue Cross Blue Shield of Michigan (BCBSM).
THE DECISION TO INNOVATE
In 2006, Dr. John Popovich Jr., then the chair of internal medicine, took great interest in
the medical home model as a mechanism to attract and retain internists. With an
impending physician shortage, especially in the field of primary care, the Henry Ford
System began exploring how to more efficiently use doctors‘ time while still serving a
growing number of patients. So, in 2006, two sites were chosen to pilot medical home
models—the general internal medicine clinic housed in the hospital and a general internal
medicine clinic in Taylor, Michigan. Senior physician leadership chose the sites because
they were very different from each other in size, patient make-up, and location.
PREPARING FOR IMPLEMENTATION
Katherine Scher was designated to implement the patient-centered medical home. The
goals for implementing the model were explicitly laid out, including promoting a
sustainable model of care; cleaning up processes; and implementing case management for
patients. Scher began by attending workshops held by Blue Cross about Lean
management. This management system looks closely at business processes to identify
waste and then makes changes to streamline those processes for improved efficiency. For
example, the practice found that, in the course of one day, a physician was interrupted on
average 90 times. By identifying what prompted those interruptions, the practice was able
to identify areas that needed improvement, including communication between nursing
staff and doctors. The check-in and check-out processes were also revised.
Innovation in Physician Practices 48
Since attempting to modify the entire practice was too difficult, one section of the
practice transitioned to the new model to work with patients who had chronic conditions.
Nurse practitioners and nurse case managers were brought into the practice for this. Two
physicians were asked to give up their offices to make room for the case managers. The
practice also decided to work with patients to create a ―patient advisory team‖ for
assistance in implementing changes that were beneficial to patients. The new model
―went live‖ in October of 2007.
INNOVATIONS IN PRACTICE
The medical home model implemented at this practice was focused on relieving
physicians of administrative responsibilities so they could concentrate on making the
most of their time with patients. This model also relies heavily on the assistance of nurse
case managers to provide follow-up and education to patients. Case managers and
physicians meet weekly, or more often if necessary, to discuss patient cases. Regular
communication is an integral part of the success of this model.
Responsibilities for patient care have been expanded for nurse practitioners to allow
doctors more time to focus on problems instead of routine, ongoing care. Case managers
have seen expanded responsibilities also. Initially, case managers had to spend a lot of
time educating physicians on the role that they could play in patient care. Guidelines
were developed to help identify patients who would most benefit from case management
referral. Case managers strive to provide as much support and education to patients as
they can. Web-based information access has become vital, and patients learn that they
can call their case manager with questions at any time, instead of going in to see the
doctor.
Medical assistants (MAs) have also become a valuable part of this model. Each physician
works with one MA, who has direct access to the physician. This has allowed for
expansion of the MA contact with patients. The MA must also be familiar with each
patient coming in to obtain the appropriate information on the problems the patient is
experiencing. This has increased the MAs‘ stake in how the practice operates, and led to
greater job satisfaction for assistants.
Physicians have learned the benefits of the model and worked to improve the patient
experience. A personal action plan has been developed to assist doctors in their
discussions with patients during appointments; the form also helps facilitate
communication between doctors and case managers about the content of the
appointments. With the action plan in hand, case managers can easily see what the
doctor‘s instructions were to each patient, and follow up appropriately. These action
plans have helped to streamline patient appointments. Additionally, physicians have
learned that occasionally they must spend more time reviewing patient records prior to
appointments in order to reduce the number of interruptions. For example, if a patient had
been instructed to have labs completed but the results have not yet been transferred to the
patient record, the appointment might be rescheduled or the labs expedited so that the
appointment can be productive.
Another mechanism employed by this practice is tel-assurance, a program for heart
failure patients who require daily monitoring. The patient can call in to an automated
Innovation in Physician Practices 49
phone number and answer questions. The case manager then reviews the answers and
determines immediately whether the patient is stable or requires closer observation.
Doctors routinely work with patients to encourage them to participate in their own care in
this way, and patients feel more invested in their health outcomes.
The practice has also implemented the shared medical appointment model for diabetic
patients. Appointments are held on weekdays in the early evenings. Eight sessions are
held, with one physician, three alternating nurse practitioners, and one medical assistant
providing care and education. Patients are referred by physicians, and then scheduled into
two-hour appointments.
Finally, the internal medicine clinic has pharmacists on the patient care team. The goal of
the pharmacist is to educate both physicians and patients on medications, primarily on the
use of generic versus brand-name pharmaceuticals. The pharmacist essentially case
manages patient prescriptions and works to identify options that will achieve the best
outcome for each patient‘s needs. While the pharmacists usually work in an advisory
capacity, they can be booked into patient appointments, have full access to each patient‘s
medical records, and have access to other specialists within the system. Consulting a
pharmacist has proven beneficial for patients with complex cases and, generally, patients
who better understand the medications they take are more compliant in their use.
Challenges
Bringing about such drastic change to the traditional patient care model certainly
involved challenges. The most common was initial resistance to a team-centered patient
care approach. Physicians were reluctant to let go of care responsibilities, feeling that
their dedication to their patients was being jeopardized by allowing others to take over
functions they deemed vital to care. Creating teams to care for each patient forced
physicians to redefine what practicing medicine means. Once the system was in place,
however, physicians learned that this model actually gave them more time to focus on
practicing medicine and looking at more complex patient issues, rather than routine day-
to-day care.
Communication was also a challenge. How did the practice ensure that all of the
necessary information reached all of the necessary people on the care team? Simple
solutions, such as checklists, were developed, so that each member of the team was
looking at and working from the same materials.
TRANSITION TIME
About one year elapsed from the time that the medical home model was introduced to its
implementation. During that time, all of the planning, training, and physical changes were
taking place to ensure success. Once the model ―went live,‖ it took about three months
before it was considered sustainable. The concepts that had initially been difficult for care
providers to grasp—discharge checklists, case management referral, pharmacist advising,
and others—became routine.
Innovation in Physician Practices 50
PROVIDER AND PATIENT RESPONSE
Both patients and providers have responded very positively to the changes at this Henry
Ford practice. Physicians feel that the time they spend with their patients is more
productive. They feel that the new model has made practicing easier and has improved
the quality of the time they spend with patients. Other staff members, such as nurse
practitioners, medical assistants, and pharmacists, have become more invested in patient
care.
Many patients have created solid relationships with case managers and feel comfortable
calling either the case manager or medical assistant with issues, instead of making an
appointment to see a physician. When they do see their physician, patients like leaving
with concrete directions and feel more engaged in their own care. As the clinic is located
in a hospital, this model has made the transition from inpatient to outpatient care much
better, and has significantly reduced hospital readmissions. The patients who have been
able to participate in this model say they are more satisfied with the quality of care—and,
by objective measures, care has improved significantly.
FINANCIAL (RESOURCE) IMPLICATIONS
Because the practice is designated a PCMH through BCBSM, a reimbursement incentive
is provided, which offsets the additional costs of this care model. Also, the
implementation of the model has been successful in retaining physicians, especially those
who have completed a residency and practiced using this model. It also helps to retain
mid-level providers, who feel more involved in the patient care continuum.
The case management portion of the model is funded separately, but because the practice
is part of such a large health system, it has been able to receive the support necessary to
maintain case managers.
THE FUTURE
In the future, the leadership and administration of this practice hope to further streamline
the patient experience, making it more efficient for all involved. Streamlining the pre-
appointment phase is one area that the practice is working diligently to improve. Offering
this model of care to all patients is also something members of this practice hope to
achieve. To do so, however, larger savings are necessary to pay for the additional staff
required to offer case management services to all patients.
Innovation in Physician Practices 51
Infinity Primary Care
PRACTICE PROFILE
Infinity Primary Care has 10 office locations in Southeast Michigan. The entire practice
has 50 physicians, 50 residents, and 200 employees who serve approximately 80,000
patients. The Livonia office, which was the subject of this site visit, serves approximately
10,000 of those patients and has 11 physicians and 25 staff members, including a clinical
nurse manager and a practice manager, 3 registered nurses, and 10 medical assistants.
Infinity Primary Care received patient-centered medical home (PCMH) designation from
the Blue Cross Blue Shield of Michigan (BCBSM) Physician Group Incentive Program
(PGIP) in 2009.
PSC spoke with two people during its visit to Infinity Primary Care: medical director
Kevin Deighton, MD, and office manager Pat Slusarz.
THE DECISION TO INNOVATE
Dr. Deighton says the ―big thing‖ that motivated Infinity Primary Care to implement
innovative practices was the health care market: ―We realized that we have to innovate in
order to provide better medical care and stay competitive.‖ Pat Slusarz adds that the
practice received a push from its affiliated hospital:
We started [with our innovations] when Providence told physicians that they had
to go on their own. We had to start looking at doing things other than how the
hospital always told us to do things. That started with the EMR, which changed
everything, including how we worked with patients.
Deighton says the practice chose the electronic medical record (EMR) after asking the
Michigan State Medical Society (MSMS) for some help. The MSMS put the practice ―in
touch with a consultant who helped us review four vendors,‖ Deighton recalls. ―This is
mainly a physician-owned group,‖ he adds, ―so physicians made a decision to go with
EMR. Most of us were ready. Only a few dragged their heels.‖
PREPARING TO INNOVATE
When preparations began to achieve PCMH status, Dr. Deighton says the practice looked
at what its EMR data could reveal about the practice‘s current level of quality:
Physicians always assume they are practicing the highest quality of medicine.
When we looked at EMR data, we realized we needed to put some changes in to
improved quality of care. But we also realized, the physician can‘t do it all by
himself. We needed to implement a team approach, which really meshes with
PCMH.
Slusarz says, ―We had a lot of meetings with staff to talk about how things would change
for them and to ask if they thought we could do things differently.‖ Also in early 2009,
Slusarz recalls,
We became a part of IPIP [Improving Performance in Practice] and we had to
start looking at everything we did at that point and decide if it was efficient or if
Innovation in Physician Practices 52
we could do things in a better way. We looked at job descriptions and what
everybody did and how to change it to benefit the patient.
INNOVATIONS IN PRACTICE
The use of data and a team approach to care have been the hallmarks of PCMH
implementation at Infinity Primary Care. Patient care is now provided by a team
comprising a physician, a medical assistant (MA), and a clerical staff person. Slusarz
says, ―The physician knows he can task a front desk person to make calls, and the MA
can put information in the EMR to help with the visit.‖
Dr. Deighton adds, ―We have involved support staff with a lot more patient care
activities.‖ Care is especially intensive for the practice‘s diabetic patients. Deighton says,
Several lead physicians in the practice have been meeting every two weeks to
look at how our IPIP process is going. We have developed a protocol to more
aggressively treat HbA1c levels. The protocol is designed for increasing levels of
intervention and addressing types of medication.
Slusarz notes, ―Front desk staff call diabetics two days before their appointment to
remind them what they need to bring with them and what they need to do to prepare for
the visit.‖ In addition, a medical assistant who was hired to head up quality assurance
―reviews EMR reports and sends out letters to get people in for visits. She also monitors
reports from insurance companies every month. They let us know if we haven‘t done
[HbA1c] tests on patients recently.‖
The practice has also hired a diabetic educator, who meets with newly diagnosed patients
individually for an hour to ―explain things about their diagnosis‖ and work with ―any
diabetics we had trouble getting under control,‖ explains Slusarz. She claims that
―patients really took to her and they did seem to improve after seeing her.‖
Another aspect of improved care for diabetic patients has been the implementation of a
guided support group called Journey for Control. A nurse meets with a group of diabetic
patients to offer education and support on a weekly basis for four to six weeks. The
program has been in place for about a year and ―patients have responded very positively,‖
according to Deighton. He notes, ―Patients are reporting they are doing better, and we‘re
seeing some improvements through our IPIP tracking.‖
For diabetic patients, Deighton says,
Now we‘re looking more at data, and if a patient hasn‘t returned in three months,
we call the patient to remind them to come in. We‘re also tracking labs and
referrals to make sure things are being completed. The big thing is eye exams for
diabetes. We contact the patient to find out who they saw and contact the
physician to send us their notes.
Tracking and follow-up is not just reserved for diabetic patients. According to Deighton,
―Now we‘re tracking all labs and referrals. We‘re making sure patients are going through
with X-rays, and then patients are called. MAs print out a tracking report every month
and they make calls to patients when necessary.‖ Data tracking and patient tracking have
helped the practice improve care across its patient population. He continues:
Innovation in Physician Practices 53
The implementation of EMR allows us to better track our data to look at our
average A1c, average LDL, and other numbers. We can then try to improve the
care of people who aren‘t hitting target goals. Now that we‘re contacting patients
we weren‘t seeing, it improves everything: our [quality] scores, the bottom line,
physician interaction with patients, and patient care.
While the providers at Infinity Primary Care are not necessarily spending more time with
patients, Deighton says they are spending ―more quality time.‖ Again, he credits the data:
―A lot of it is having the data available so you‘re not hunting after it. It‘s available right
now, so we can interact more efficiently with the patients.‖ Slusarz says MAs are
responsible for making much of the data so readily available:
When the patient comes in now, the MA will put in current medications,
vitamins, anything like that. Physicians used to do this themselves. The MA will
also ask [diabetic patients] the last time they had a foot exam or saw an
ophthalmologist, and they‘ll put this in, so the physician doesn‘t have to search
for the information.
Another big change for the practice is that ―physicians are doing their own billing,‖ says
Slusarz. She adds,
It‘s been a learning process for them. Physicians have to think about the codes
they‘re using. It‘s had a big impact. Before, they didn‘t really pay attention—the
front desk was doing most of the billing. It‘s more efficient now and the coding is
more accurate.
Challenges
Infinity Primary Care is plagued by two primary challenges, according to Deighton and
Slusarz. First, members of the practice are frustrated by the inability of their EMR to
interface with those of the local hospitals. ―Electronic interfaces are not where they
should be by now. St. Mary‘s and Providence are on two different systems, neither of
which interface with NexGen,‖ says Deighton. Slusarz adds, ―It would be much better if
[the systems] talked to each other, and we could download labs right into the system.‖
Currently, staff have to manually enter lab results into the practice‘s EMR which, Slusarz
notes, increases the possibility of errors.
Another challenge, according to Deighton, is the importance of considering which
activities are reimbursed by health insurers. He states, ―There are costs associated with
doing these things. You have to closely monitor costs. You‘re hindered by some
limitations of what will be reimbursed.‖ He adds, ―The real goal is to improve the health
of the patients we serve, but it seems like there are barriers related to reimbursement.‖ As
an example, he describes how he would like to send an MA out to people‘s homes or
workplaces to check their glucose and blood pressure, or to do immunizations or flu
shots. ―The problem,‖ he says, ―is that you can‘t get reimbursed for that. I would like to
work with some innovative insurers to do this.‖
PROVIDER AND PATIENT RESPONSE
The implementation of practice innovations at Infinity Primary Care took getting used to
for some of the providers and staff, say Deighton and Slusarz. When the practice moved
Innovation in Physician Practices 54
to a team approach to care, Deighton notes, ―For some physicians, it was difficult, but
that‘s the minority.‖ Now, he says, ―I think generally the doctors see it as improving
quality of care.‖ Speaking from the staff perspective, Slusarz notes, ―In the very
beginning, it was ‗This looks like more work for me.‘ But once we built our teams and
people started working together, the staff was much happier than they were before.‖
As for the patients, Slusarz and Deighton say are handling the changes in stride. Deighton
notes, ―Most of them embrace it, but it‘s still not crystal clear as to how it actually affects
them. A lot of it is behind the scenes. We have SMART [Specific, Measureable,
Attainable, Realistic, and Timely] goals that we want to work on with the patient, and
generally they have responded well.‖
Slusarz says ―Most of [the patients] are really happy with the changes.‖ She adds, ―They
spend less time trying to check in and less time waiting for return phone calls because
most things they are calling about can be handled right away with the EMR.‖
Deighton asserts that patients have begun using the practice‘s Web portal as well, through
which he can send them ―results from labs the same day I get them back.‖ Patients are
using the portal to request refills and appointments, and to ask questions of the
physicians.
FINANCIAL (RESOURCE) IMPLICATIONS
When asked about the impact the innovations have had on resources—financial and
otherwise—Deighton notes that implementation of the EMR has had positive
downstream affects. He says it ―brought in PCMH, which brought in additional revenue.
EMR has also helped avoid reductions in cash flow. We‘ve done a better job of collecting
owed money at the time of service.‖ Slusarz adds that the practice ―doesn‘t rely on a
billing service not located on site. We can run reports every morning on the patients
coming in and see their balance due. We have a collections department that will work
with them to set up payment plans.‖
Slusarz also says that the EMR implementation ―made us see that we were top heavy in
some positions. EMR has brought down our staffing. EMR makes the front desk more
efficient. I didn‘t need two or three people at each desk. We had seven medical record
clerks. We‘re down to one.‖ Deighton says, ―It‘s a huge financial investment, but it has
absolutely paid off, and it has created efficiencies.‖
The PCMH aspect of Infinity Primary Care has provided the practice with the potential
for new relationships with hospitals. Deighton states, ―Our innovations have allowed us
to participate in discussions about ACOs [Affordable Care Organizations]. We are
rightfully seen as a high-quality practice, so hospitals in the immediate area are
contacting us about being part of an ACO.‖
THE FUTURE
As Infinity Primary Care looks to the future, Dr. Deighton envisions trying new
approaches to patient care. For the diabetic patients, he would like to implement ―a
Saturday group visit with a pharmacist, a diabetic educator, a dietitian, and a physician.
Patients can rotate among the different providers to gain different knowledge. This builds
Innovation in Physician Practices 55
on our team approach to care.‖ He also is exploring ways to ―reach out to our patients and
team up with food services and supermarkets. For our diabetic patients, they could get a
discount for fresh fruit. That‘s something we‘re just starting to take a look at. I‘m
estimating 8,000 to 9,000 people have diabetes in our practice.‖
In the meantime, Deighton and Slusarz are happy with how their current innovations have
allowed them to improve the health of their patients. Deighton says, ―We can take a
systems approach to improving care and we‘re data driven. There are more quality
physician-patient interactions.‖ Slusarz adds,
It‘s exciting to be able to identify your patient population—how many diabetics
and asthmatics. Trying to get a handle on that was impossible with paper charts.
The data is there. You can pull up the data and get a better handle on what your
population is and what it needs.
Innovation in Physician Practices 56
Michigan Medicine Specialists
PRACTICE PROFILE
Michigan Medicine Specialists (MMS) is a primary care practice located in Sterling
Heights. The practice moved in January 2008 to its current location from St. Clair Shores,
where it had been situated for 20 years. About three-quarters of the practice‘s patients
come from the St. Clair Shores area, and the remainder are local to Sterling Heights.
MMS only sees patients aged 18 and over, and about 75 percent of its patients are on
Medicare. Dr. James Clinton is the sole physician in the practice; his wife Denise Clinton
is the practice‘s nurse practitioner. In addition, the practice employs one registered nurse,
two medical assistants, five part-time front desk staff members, and one office manager.
MMS was designated as a patient-centered medical home (PCMH) through the Blue
Cross Blue Shield of Michigan (BCBSM) Physician Group Incentive Program (PGIP) in
June 2010. PSC spoke with four people during its visit to Michigan Medicine Specialists:
Dr. Clinton; nurse practitioner Denise Clinton; office manager LeAnne Rubino; and
medical assistant Erika Kelley.
THE DECISION TO INNOVATE
According to providers and staff at MMS, applying for PCMH designation from BCBSM
was a logical next step for the practice based on the type of care they were accustomed to
providing. Dr. Clinton says that some research he did on PCMH ―combined with quality
improvements we were already making in the practice made me think this would be a
good thing to take us to the next level in patient care.‖ He recalls thinking, ―We already
do a lot of it. Let‘s just document it.‖
Denise Clinton recalls having early conversations with a BCBSM representative who
talked to the pair about what was involved in PCMH designation: ―When she started
talking about the criteria, we thought, ‗We do all this now.‘‖
Office manager LeAnne Rubino says she began researching the specifics of how to apply
and more about the requirements at Dr. Clinton‘s request. She found a helpful partner in
Physician Organized Healthcare System (POHS), a provider organization to which Dr.
Clinton belongs. POHS was willing to assist the practice with implementation, including
providing some staff training, and, Rubino says, ―POHS offered a huge incentive to
become certified.‖ She adds, ―Our doctor has already delivered this quality of care and
now he‘s getting recognized and paid for it. This is him 110 percent. The office has had
to make some changes, but the doctor didn‘t.‖
Dr. Clinton says he believes his practice may have been in a somewhat unique position to
move more or less seamlessly into a PCMH designated office.
There are a lot of practices that don‘t do what we do, and when we say it wasn‘t
that big of a change for us, they‘re gonna go, ―Yeah, right.‖ But we looked at it
as win-win situation because we were doing it already just needed to put it into
process and document it.
Innovation in Physician Practices 57
PREPARING TO INNOVATE
In describing how staff in the office were prepared to move forward with PCMH
implementation, Rubino says her strategy was to do it ―slowly and positively. It can be
overwhelming, so we had to move slowly and communicate positively about it.‖
Medical assistant (MA) Erika Kelley says that ―LeAnne started [the process]. She learned
from Carolyn at POHS and showed everyone in the office what she had learned.‖ She
says POHS also provided staff training: ―Carolyn came in to do a PowerPoint
presentation about PCMH and what we needed to do. Then we implemented Ariphron
and made some chart-based changes.‖
Ariphron is the patient registry MMS implemented as part of its bid to become designated
as a PCMH. Rubino has had primary responsibility for implementing the registry. She
notes that it is ―Web-based so there was no installation, and POHS has an arrangement
with Ariphron, so the first year has been free.‖ The work to get the registry populated,
however, has been time-consuming and is ongoing. In a span of six weeks, Rubino put a
year‘s worth of chart information into the registry for each of the practice‘s 89 diabetics.
Rubino says she is ―teaching an MA to put in the data, so she can help out [with the task].
This has to be perfect,‖ she adds, ―You can‘t put in the wrong information.‖ Once all of
the diabetic patients were in the registry, Rubino and the MA entered patients with
asthma, COPD (chronic obstructive pulmonary disease), congestive heart failure, and
coronary artery disease.
When the practice first began to move toward PCMH implementation, Dr. Clinton says,
―We began documenting procedures for the things we already did. This helped us to fine-
tune those processes and to analyze if we were wasting time doing certain things. We
wanted to identify which processes accomplished our goals for patient care.‖
Denise Clinton notes that the written protocols have been helpful, ―from the standpoint
that people are more aware of certain job responsibilities to follow through on.‖
INNOVATIONS IN PRACTICE
While MMS may already have been engaging in many of the activities required for
PCMH designation, the process of applying for and achieving the designation led to
several improvements. With the help of Prism, a firm that works with medical practices
to improve efficiency, the practice instituted improved processes for test tracking, chart
preparation, and patient visits. Rubino notes,
It almost felt chaotic and double when we first implemented some of the things
Blue Cross required. We were adding the new things on top of trying to do things
the old way. POHS suggested we have Prism come in to work with us. So we‘re
learning to work more efficiently.
For test tracking, Rubino says, ―There [used to be] a horrible log book system that
somebody had developed. You had to flip through a book to try to do follow up. Now we
do a pending file system. The new method has helped tremendously with follow up.‖ The
old method was not applied very rigorously, either, according to Denise Clinton:
Innovation in Physician Practices 58
We didn‘t have any record for the front desk to follow up with patients. This
would have been up to the provider when the patient came in for the following
office visit. Now staff regularly follow up with patients to find out if they‘ve
completed their tests.
Rubino adds, ―We‘re communicating with our patients regularly. [In the past], you
always had something that fell through the cracks, but that doesn‘t happen with PCMH.
Ariphron and the whole system ensure that doesn‘t happen.‖ Kelley notes, ―The test
tracking is definitely more efficient for finding labs that have been completed or not. It‘s
easier to know when we need to follow up with patients.‖
Obtaining lab results and physician office notes tends not to be a problem for MMS. This
is not a result of the PCMH implementation process, but a physician who has developed
relationships with the providers to whom he makes referrals. As Denise Clinton says,
―Dr. Clinton will frequently get on the phone to talk with physicians when he is unclear
about the treatment a patient has received. He really only refers to physicians who are
willing to communicate with him.‖ Rubino concurs: ―We‘ve always sent referrals and
we‘ve always followed up on referrals. You don‘t not communicate with him.‖
The task of chart preparation prior to patient visits has also been modified to improve
patient care. Again, Rubino: ―Before, staff would just pull the chart for the visit. Now we
have an MA prepping the chart by reading the previous visit and identifying what needed
doing and following up to include the results of labs or any other work.‖ As an MA,
Kelley participates in this process. She says she has ―to check to see if [the patient] is
diabetic or asthmatic. If they are, I give the chart to LeAnne and she prints out a flow
sheet from Ariphron and gives that to Dr. Clinton.‖ The flow sheets ensure that the
relevant questions are asked of patients and that any necessary procedures are completed
during the visit.
Patients also contribute to the preparation of their charts. When they arrive, patients are
asked to complete a form that asks them about any medical visits they have had with
other providers since their last visit at MMS. Office staff then obtain lab results and
office visit notes from these providers before the patient sees the physician or nurse
practitioner. Denise Clinton describes the process this way:
The front staff supplies the paperwork to the patients. Back staff is then
responsible for reading the form and making sure that we have at our fingertips
what we need to make decisions for the patients. It makes things much easier.
The process is not foolproof, Clinton acknowledges: ―The only problem is patients may
not recall that they have had something done.‖
These improvements to test tracking and chart preparation have greatly improved the
quality of the patient visit, according to staff and providers. Prior to these improvements,
it was apparently common for the physician and nurse practitioner to leave the exam
room to track down information they needed to treat the patients they were with. Denise
Clinton notes, ―We were coming out of the room a lot to ask for this or that. We‘re doing
that a lot less.‖ Dr. Clinton has found that the new processes have improved patient care:
Innovation in Physician Practices 59
The information is more at my fingertips so I can make decisions more quickly.
Patients don‘t have to wait until I get something that I want a result for, and I can
review results right away with patients.
I can concentrate on doing a little more education because I know the basic
things for quality of care are taken care of. I can do more education; I can fine-
tune some of my therapies. It‘s made me feel more confident that I‘m covering
the basics and that I‘m doing a good job.
Kelley notes that changes have also been made to ―the office visit sheets Dr. Clinton
writes on when patients are in the exam room.‖ She says the new sheets ―lay out more
clearly the assessment and the [treatment] plan, which makes it easier for me to find the
things he has ordered.‖
Implementation of PCMH innovations has increased the responsibility for patient care
among the non-primary providers in the office. As described above, MAs have greater
responsibilities with regard to chart preparation. They also, according to Denise Clinton,
are responsible for conducting in-office lab work such as testing HbA1c levels of diabetic
patients. Clinton states, ―The MAs know that HbA1c‘s are needed every three months, so
they do it before we even get in the room. They are able to do a lot more than they used
to. With PCMH, there are certain criteria that dictate what needs to be done.‖ According
to Rubino, ―MAs were already doing a lot of this work, but now it is written standard
protocol.‖
Dr. Clinton notes that the advent of the PCMH innovations has also led to some
adjustments in the role of the office‘s registered nurse, who coordinates the care team.
Clinton states,
She has the first part of the encounter with the patient. [The new processes] have
freed her up to concentrate on the clinical aspects of what we do, versus the
management aspects of what we do. She does teaching, and she will handle a lot
of coordinating of care issues.
Denise Clinton says the responsibilities of patients have increased under PCMH, too, and
she communicates this to them during office visits: ―When I explain PCMH to patients, I
say, ‗The bottom line is you are to keep us in the loop. Keep us informed as far as who
you have seen and what they have ordered.‘‖
All in all, Dr. Clinton believes that the changes have been positive for the entire office: ―I
think that the staff feel more involved in making sure that the patient gets the best care
possible. It‘s more of a team approach instead of a top down mentality. There seems to be
less drama because we‘re not reacting; we‘re better prepared.‖
From Rubino‘s point of view, most of the change has really taken place at the non-
primary provider level. She asserts,
We didn‘t have written policies in place before. We didn‘t have the level of
accountability for test tracking and standard protocols that we do now. Now
everyone‘s on the same page. We all know what we‘re doing.
Innovation in Physician Practices 60
Challenges
The progress made at MMS has, of course, not come without difficulty. Creating written
procedures and documenting the work the practice does to meet PCMH requirements has
been burdensome. Denise Clinton states, ―What we hadn‘t had was a binder that
described all of this in explicit detail. [Creating] that was the part that I‘ve found time
consuming and cumbersome. That‘s the downside unless you have someone like our
office manager who can take it all on.‖ She adds, ―Setting things into place took quite a
bit of time. This took time away from other responsibilities.‖ And Rubino has been
frustrated by her interactions with BCBSM: ―The interview with BCBSM was a grilling
on our implementation, but it didn‘t seem to matter how the doctor was caring for the
patients. They wanted to talk with me, not with Dr. Clinton.‖
Kelley says she finds most of the new processes ―to be pretty helpful.‖ But she admits the
paperwork that patients need to fill out ―seemed like a lot of work in the beginning.‖
Dr. Clinton notes that one of the primary challenges is staying on top of the detail. He
says,
You really need people who understand what they‘re looking for when they‘re
reviewing a chart and putting down on a document whether something was
performed or not, because if they look in the wrong place or they don‘t
understand what they‘re looking for it can be a problem for our records.
TRANSITION TIME
In some ways transitioning to the new processes took almost no time at all. Denise
Clinton attributes this to the way the practice already worked: ―I would say
[implementation was] almost immediate because we were doing so much already. We
just had to tweak how we were doing the documentation.‖ Kelley also asserts that
implementation was rather swift: ―I feel like it was pretty quick. But,‖ she adds,
―everything was implemented at different times.‖
Focusing on the processes related to diabetic patients, such as the patient registry and
flow sheets, ―It got to be routine after about four months.‖ Taking a broader perspective,
Dr. Clinton says that ―Everything has taken about six months. We‘re fine-tuning things
we were already doing.‖
PROVIDER AND PATIENT RESPONSE
The providers and staff at MMS have been generally pleased with the results of their
efforts to achieve PCMH designation. The clerical staff, however, may have initially been
more reticent to implement some of the new processes. Rubino notes,
Clerical staff understand that it‘s better patient care, but some of the things don‘t
make sense to them. Blue Cross wants us to survey every patient regarding every
specialist they see. We have so many older patients that we‘re sending to a lot of
specialists. So this paperwork seems totally ridiculous.
Innovation in Physician Practices 61
Kelley acknowledges that ―in the beginning it was very overwhelming, but now it‘s
become more of an everyday thing. And staff are happy with how organized everything
is.‖
Dr. Clinton also recognizes that it was hard on staff early on:
I think at first the staff just saw it as more work. But now they can see the
positive effect it is having on patient care. They feel more involved in the
patient‘s care. They can see where some of the processes that are in place are
starting to save them time.
As for the patients, there was some initial confusion about the PCMH concept among the
practice‘s older population. Denise Clinton recalls, ―When it was first initiated, I can‘t
tell you the number of senior citizens who thought we were trying to put them in a
nursing home.‖ Rubino also notes that ―patients were initially confused about the term
‗home.‘‖
Kelley says that patients initially seemed a bit annoyed with the paperwork they had to
complete: ―For every visit they have to complete a list of things they have had done since
their last visit. This used to bother them, but we explain that we want to be able to review
results with them, and they seem to understand.‖ According to Rubino, some patients are
even embracing their new responsibilities: ―Some patients seem to feel more involved in
their care. Some are even remembering to tell specialists that their doctor wants a report
back.‖
The providers and staff do not believe that the PCMH designation in and of itself will
give them a competitive advantage in attracting patients without some promotion of the
concept from the insurance companies who make the designations. Dr. Clinton asserts,
―If PCMH is properly publicized and advertised and supported by BCBSM, I think it
could be a competitive advantage.‖ Rubino agrees: ―Currently patients don‘t really know
what it is. Unless Blue Cross starts advertising this with their enrollees, it won‘t have an
effect on patient decisions.‖
Denise Clinton says the competitive advantage for MMS comes from ―the way we
provide care. Dr. Clinton tells people they may wait because he spends a lot of time with
his patients; he also requires an annual physical from his patients. He receives most of his
referrals through word of mouth.‖
FINANCIAL (RESOURCE) IMPLICATIONS
When considering the financial implications associated with PCMH designation, Rubino,
Dr. Clinton, and Denise Clinton all mentioned the increased reimbursement from
BCBSM as a factor, and at this point the benefit (or lack thereof) is yet to be determined.
Rubino notes, ―We only get the 10 percent [increased reimbursement] on patients
covered by Blue Cross. Unfortunately, not all Medicare patients have secondary Blue
Cross coverage. About half do. And I haven‘t seen any cost efficiencies yet.‖ Dr. Clinton
adds,
The financial incentive for doing PCMH was that if we were certified that our
reimbursement for what we were doing would increase. That doesn‘t happen
Innovation in Physician Practices 62
immediately. We started receiving increased reimbursements as of July 1. It
remains to be seen whether the increased intensity of staff involvement and,
therefore, the increase in our payroll is going to be offset by an increase in
reimbursement.
Rubino notes that one unexpected cost was probably the time she has spent on
implementation: ―I had to put in a lot of overtime to get things put in place.‖ She adds,
however, that there has been ―no financial investment in training staff. POHS does the
training for us. And staff is catching on to things pretty quickly.‖
THE FUTURE
As Michigan Medicine Specialists looks to the future, the providers and staff are
considering implementation of an EMR. Overall, however, they are simply excited to be
moving forward with the processes the practice has already put in place, and look
forward to making continued improvements in patient care.
Dr. Clinton also notes that the practice will ―possibly be doing some group visits. I don‘t
do those yet.‖ Rubino says she has ―sent two staff members to self-management training
to run group classes for self-management. We have to offer this at least six times a year,‖
she notes.
When it comes to the possibility of an EMR, Rubino is emphatic: ―EMR—I want EMR.
At the very least, I want to get all of our patients into Ariphron. Even though it‘s not
EMR, it‘s an easy way to access patient records.‖
The practice‘s two primary providers are less certain about the potential for implementing
an EMR for the office. Denise Clinton says, ―We are looking at EMR, and we have
looked at a number of different types. The more we talk to people who have implemented
them, though, the more hesitant we are.‖ Dr. Clinton adds, ―You‘re hopeful it will be
beneficial, but wary because of previous experiences. It‘s still unclear as to what type of
system the government will reimburse you for. The expense for a small practice can be its
undoing if it‘s not beneficial.‖
Considering where the practice has come from and where it is going, Kelley says,
I would say the most exciting thing is how organized everything is becoming and
how the relationship with the patient is growing because we have everything
ready for them that they need. It‘s overall better care for the patient.
From Dr. Clinton‘s perspective, ―Our patients are getting better care and it didn‘t require
that much more effort on our part. I know LeAnne worked really hard, but once you get
things documented, it is sort of self-sustaining.‖
Innovation in Physician Practices 63
Pine Medical Group
PRACTICE PROFILE
Pine Medical Group is a rural primary care practice with two locations. One office is in
Fremont, next door to Gerber Memorial Hospital (though the practice is not affiliated
with Spectrum Health System, which owns Gerber), and the other is in Newaygo. Pine
employs 19 physicians: 12 family practitioners, 2 pediatricians, 2 orthopedic surgeons,
and 3 general surgeons. Physicians range in age from 59 years old to 32 years old and
work anywhere from full-time to two days per week. Additionally, two nurse
practitioners see patients in the office and two physician assistants see patients in an
urgent care setting in the Newaygo location. We talked with Dr. Richard Boss, practice
administrator Marge Young, and case manager Bobby Miller, registered nurse (RN).
The practice serves 32,000 households and has 44,000 active patients. It has had an
electronic medical record (EMR) system in place since 2006. Additionally, the practice is
certified as a rural health center and approximately 30 percent of the patient caseload is
on Medicaid, uninsured, or receives services on a sliding fee scale.
THE DECISION TO INNOVATE
Once the practice‘s EMR was in place, it began looking at ways to enhance patient care
while also improving net profits and provider quality of life. The decision to move to a
patient-centered medical home (PCMH) model was made in 2008, as a result of
reimbursement incentives provided through Blue Cross Blue Shield of Michigan
(BCBSM) and Priority Health. Because the practice felt that it already offered many of
the elements necessary to qualify as a PCMH, a concerted effort began that year. The
decision to make the transition was brought about by Pine‘s medical director, Dr. Richard
Boss, who was interested in changing the current model of managing care as a catalyst to
attract and retain young physicians in the rural setting. Because the physicians in the
practice are relatively young, with an average age of around 40 years old, more flexibility
in the doctors‘ work life seemed an important incentive to offer.
PREPARING FOR IMPLEMENTATION
Because practice leadership was supportive in making the necessary changes for the
medical home, the supports to do so were readily available. An electronic registry was
installed to track patient information, in addition to the EMR already in place. A case
manager and an additional clinical nurse were brought in to the practice. The additional
staff were hired to facilitate access for patients as well as to maintain the patient
information in the registry. Meetings were held to educate staff on the changes that would
come as a result of implementation. Additionally, the practice administration began
looking at day-to-day processes with the Lean management system to improve routine
tasks.
INNOVATIONS IN PRACTICE
To expand on the current services it provided in order to fulfill the requirements of
medical home designation, Pine Medical Group began offering case management to
Innovation in Physician Practices 64
diabetic patients, collaborating with Gerber Memorial Hospital on education workshops
for those patients, and implementing ―asthma days‖ to help asthmatic patients control
their symptoms. The practice has also tried to expand the amount of information available
to patients via the Internet. Bringing in additional staff also increased access for patients,
who are now able to obtain appointments more quickly than before.
Pine Medical Group‘s first focus in changing care delivery was on high-risk diabetic
patients. Those patients received a letter explaining the addition of the case manager and
the role that she would play in their care. When those patients come in to see the
physician, the case manager generally meets with them first to get a sense of how they
are managing their conditions and offer suggestions and information for improvement, as
well as topics to be discussed with the doctor. Partnering with the Diabetic Education
Program at Gerber has allowed the practice to expand the level of service offered to
diabetic patients without having to create and finance all of the programs. Educators from
the program are in Pine‘s office twice a month to provide education to patients there.
Conversely, some patients who attend the education programs offered through Gerber are
referred to the practice because of the unique case management that it offers.
Pine Medical Group is also currently working to input and track all well-child
immunizations in its own electronic registry. While the practice does report well-child
immunizations to the state, before the registry was adopted it had no way of easily
tracking immunizations for its pediatric patients. Having this ability allows staff to better
prepare for well-child exams, making sure that all necessary services are administered
during the patient visit and maximizing both the physician‘s and patient‘s time.
Challenges
Challenges always occur when implementing any kind of change. While this practice had
a supportive administration and many key pieces of the medical home model already in
place, it still faced some difficulties. One major obstacle that the practice still deals with
daily is the use of the electronic patient registry, Well-centive. This program does not
interface with the practice‘s current EMR, so the time necessary to maintain the database
is significant. Training staff to learn to re-do what they have been doing in terms of
patient care has been challenging as well. Processes with which they were familiar, such
as open schedules and patient notification, have all been slightly modified.
Staff have not been the only members of the medical group to resist the changes; not all
of the practicing physicians had a clear understanding of how the changes being
implemented would affect the care they give patients, and some were wary of
relinquishing responsibilities to the case manager. Finally, the location of the practice has
presented challenges in distributing information to patients in more efficient ways. The
region‘s lack of Internet connectivity is an obstacle for this practice because many of its
patients do not have access to the Internet to take advantage of Web-based tools.
PROVIDER AND PATIENT RESPONSE
Both patients and providers have responded favorably to the changes at Pine Medical
Group. While an initial lack of understanding made some patients hesitant to participate,
they have become more engaged in their care since working with the case manager, and
Innovation in Physician Practices 65
many patients have seen greatly improved health outcomes. Re-hospitalization of patients
has been significantly reduced, down from as many as eight per month to zero in some
months. Patient satisfaction has increased too: all patient surveys are returned with
positive evaluations of the practice.
This model gives physicians the ability to take better care of patients and better track
health status through the registry. Patients have taken a more active role in their care
since being provided basic education materials. Physicians are able to focus their time on
some of the more complex issues that patients experience.
FINANCIAL (RESOURCE) IMPLICATIONS
Because of the need for more resources in this model, funding has been challenging.
Grants from Priority Health and incentives available through Blue Cross help maintain
the program, but so far implementing this care model has not increased the financial
success of the firm. However, it has proven effective in attracting and retaining providers.
Convincing young physicians to work in primary care has become more difficult in the
past ten years, and trying to convince young graduates to leave urban areas for rural ones
makes that task especially daunting. Offering scheduling flexibility as well as the ability
to focus on the practice of medicine, as opposed to administration and other mundane
tasks, has proved successful in keeping physicians in the practice. And, while this care
model certainly offers a competitive advantage over other practices, Pine Medical Group
is one of very few options for primary care in the area.
THE FUTURE
In the future, more benefits will be seen in patient health outcomes as they become more
educated and as staff become more comfortable with providing care in conjunction with
case management and improved education. The model for diabetic patients has been so
well received that some providers want to be able to apply it to their asthmatic patients as
well. This process is beginning in the Newaygo location. Finally, with the continued
success of this model, more young physicians may be attracted to practice primary care in
this underserved rural area, knowing that medicine can be progressive in any region.
Innovation in Physician Practices 66
St. Johns Professional Associates
PRACTICE PROFILE
St. Johns Professional Associates, a primary care practice, is located in a primarily rural
community. Patients come from an approximately 20-mile radius in all directions except
the south (where residents tend to go to Lansing for medical care). The practice has
approximately 8,000 active patients with about 15,000 visits per year. St. Johns
Professional Associates is a hospital-owned practice whose physicians earn a salary.
In March 2009, the practice started participating in activities necessary to achieve patient-
centered medical home (PCMH) designation through the Blue Cross Blue Shield of
Michigan (BCBSM) Physician Group Incentive Program (PGIP). The practice currently
has six physicians, only two of whom are engaged in the PCMH. The remaining four are
newer to the practice and will receive training and be brought on board with the PCMH
activities by early 2011, when the practice will implement an EMR.
In addition to the physicians, the practice has one registered nurse, two licensed practical
nurses, and four medical assistants on staff.
PSC spoke with four people during its visit to St. Johns Professional Associates to gain
an understanding of the implementation of PCMH in the practice: Bob Beresford,
practice administrator; Greg Holzhei, DO; Karen Keilen, licensed practical nurse (LPN);
and medical assistant Kelli Ferrier.
THE DECISION TO INNOVATE
As a member of Sparrow Medical Group, St. Johns Professional Associates was offered
assistance in achieving PCMH designation through BCBSM‘s PGIP. Practice
administrator Bob Beresford states that he, the two physicians in the practice at the time,
and Clinton Memorial Hospital agreed to take advantage of the opportunity in March
2009 for three reasons: ―We were progressive enough to see this was the way of the
future; we felt it was the right thing to do to focus on patients and provide evidence-based
medicine; and there was a financial incentive.‖ He added that the physicians ―saw
[patient-centered medical home activities] as something we were already doing, although
we hadn‘t been reporting on it or analyzing it.‖ Dr. Holzhei adds that he and the other
physician agreed PCMH would be a good way ―for the patients to be more involved in
their own care.‖
While the rest of the caregivers and staff in the office were not in on the initial decision to
attempt to achieve PCMH designation, LPN Karen Keilen says that ―Bob brought the
idea to the rest of us and explained the need for it and the desire to improve patient care
and improve patient understanding of their own health care.‖
INNOVATIONS IN PRACTICE
As practice administrator, Beresford coordinated St. Johns Professional Associates‘
efforts to obtain PCMH status. He describes it this way:
Innovation in Physician Practices 67
Initially, I took the lead to see which pieces we were most prepared to put in
place. I laid out a plan and had staff meetings to do education and training on
expectations and roles, and to identify the resources we needed. Then we got the
tools in place to make it happen.
The primary ―tool‖ put in place was a patient registry called Ariphron. Since the practice
has yet to implement an EMR, it seemed that a registry would allow it to track care and
outcomes for patients with chronic diseases. Efforts to date have focused primarily on
patients with diabetes.
The initial push to populate the registry was labor-intensive. Medical assistant Kelli
Ferrier spent many hours adding current patients to the registry based on their paper
medical records. While this work has decreased, newly diagnosed patients and new
patients continue to be entered into the registry.
Along with implementing the patient registry, St. Johns Professional Associates made
changes to the way patient information is shared among providers in the practice and to
the way care is delivered.
Beresford says that ―flow of information has changed significantly.‖ He describes a shift
from simply handing patient lab results up the ―chain of command‖ to a more active
response to labs that may or may not involve physicians. Prior to having a registry,
clerical staff would receive the lab reports and give them to nurses, who would then give
them to doctors. With Ariphron in place, clerical staff enter lab results into the registry
and give that information to the nurses. Nurses then have the responsibility for deciding
the next steps. While they may send the results to one of the practice‘s physicians, they
also have the authority to handle follow-up themselves if appropriate. Beresford says this
is part of an effort to ―move care functions to the most appropriate level of provider.‖
Keilen adds, ―We‘re getting much better at communicating within the office about
patients. In terms of the whole team being aware of what has to happen for a person. The
roles are more coordinated.‖
Other changes to the way care is delivered in the practice reflect this transition as well.
Whereas nurses used to take patients back to exam rooms, medical assistants (MAs) do
this now. MAs not only obtain basic patient information, but also have increased
responsibility for handling patient care. ―Patient flow sheets,‖ which are generated from
information in the patient registry, are printed out and attached to patient charts the day
before an office visit. The sheets list any alerts regarding the patient‘s health status and
necessary tests. Beresford says, ―When medical assistants put patients in their room, they
can see what needs to be done and get some things under way before the doctor walks in
the door.‖
Physicians maintain responsibility for medical decision making, but nurses often come in
after the physician leaves to provide patient education and write up any lab slips. In the
exam room, the practice‘s nurses and physicians are able to use registry data to work with
patients to develop goals and to focus their patient education efforts. As Keilen puts it,
―At every visit, we can talk to the patients about where they are in relation to their goals
and see what we can do to improve it.‖
Innovation in Physician Practices 68
St. Johns Medical Associates has also become more proactive in the way the practice
interacts with patients. A list of all patients with diabetes can be generated from the
registry, which enables clerical staff to see which patients are in need of an office visit or
need to complete lab work. These staff are then responsible for calling patients to
schedule their appointments and sending lab slips to the patients so the work can be done
before their next visit.
As St. Johns Professional Associates transitioned into a PCMH, patients were sent
pamphlets through the mail to make them aware of changes they could expect in the care
they received and were greeted with additional information when they visited the office.
Also, to ensure that patients come back for regular visits, Keilen says, ―We no longer
prescribe medications for a whole year. Now, patients have to come back in a few months
for a checkup.‖
As a result of implementing the registry and making changes to workflow and provider
roles, Beresford believes ―we‘re providing better care. We are more efficient in terms of
what we do during an actual physician-patient encounter. We have a plan prior to the
patient coming in the office, so we‘re more proactive.‖
Beresford believes the way the office practices under the PCMH has led to more
individualized care: ―It has helped us focus on each patient to identify what they need and
make sure they stay healthy.‖ He adds, ―We used to do this to an extent, but now it‘s
more logical and organized.‖
TRANSITION TIME
While many of the changes at St. Johns Professional Associates took place in the
immediate term, it took about six months for the registry and other changes to be fully
integrated into the way the office works. It was at that point that Beresford and the
providers in the practice had trend data—both for individual patients and the practice as a
whole. Beresford says that at the six-month mark, ―We got beyond figuring out just how
to do it, and we were able to start looking at what our results were. When we could tie it
back to our purpose, that‘s when we felt like we knew what we were doing.‖
Dr. Holzhei says:
I think it was probably about six months. At the initial evaluation, the patient
would come in and we would just have one [Hba1c] reading. After that we could
have a trend. It also took time to move toward having the patient do things ahead
of visit so we could talk at the appointment about the results.
Keilen adds that during that time, patients moved from ―just sort of being taken care of
[to being] interested in what their goals are.‖
PROVIDER AND PATIENT RESPONSE
For many of the office staff and non-physician caregivers, moving toward PCMH
designation has meant a great deal of additional work. Beresford notes, however, that ―no
one complains because they all recognize the value.‖
Innovation in Physician Practices 69
Pride in the roles that everyone is able to play in patient care is obvious. Keilen notes that
she is ―more involved with the patient and I feel more involved with their care. I‘m
familiar with what‘s happening with the patients. I review their charts so I know what has
been done and what needs to be done. I see all the labs that come back and x-rays and
referrals.‖ Ferrier believes that providers ―catch more things about the patients because
we are more thorough in our review of patients.‖
Physicians appreciate the work being done by the rest of the staff and are pleased with the
data that can be pulled from the registry. Dr. Holzhei states, ―Having labs in the charts
allows me to show the patient how they‘re doing so I can more effectively discuss
treatment with the patient.‖
While the practice has not conducted any patient satisfaction or other surveys since
becoming a PCMH, the consensus is that the patients are pleased with the changes. Dr.
Holzhei notes that ―some of the patients maybe weren‘t as aware of their conditions. Now
they‘re taking more initiative with their own health. This has been a positive thing for
them.‖ He adds, ―I think it‘s helped patients with their diabetes. They‘ve begun to
understand the disease process, and I‘ve been able to see the things that I need to improve
on with my patients.‖
Keilen believes that ―patients feel more free to call to find out what they can do if they
have questions about their health.‖ Ferrier adds that ―[Patients] were always given a lab
slip, but now we follow up so they feel like we‘re doing this for their benefit.‖
While all those interviewed during the site visit agree that the practice innovations
implemented give patients increased value, there is lack of consensus on whether they
will serve as a competitive advantage in attracting patients to the practice.
Dr. Holzhei is uncertain whether becoming a PCMH will attract more patients because
people are still so unaware of the concept: ―I don‘t think the average person will look at
that to choose their doctor. Most come to our practice through a referral from a friend or
family member.‖ Beresford, however, sees it as a clear advantage—not the PCMH
designation, necessarily, but the improved quality of care: ―They‘ll see we‘re logical and
organized and also caring, and [we] can show you that you‘re getting better. We‘re
definitely at a competitive advantage.‖
FINANCIAL (RESOURCE) IMPLICATIONS
One of St. Johns Professional Associates‘ primary incentives for taking on the work of
achieving certification as a patient-centered medical home was the potential for increased
reimbursement from BCBSM. And both Beresford and Holzhei believe it has led to
increased reimbursements and an improved bottom-line for the practice. Because they are
employed at a hospital-owned practice, however, neither can say this with certainty.
Beresford can say, though, that while the work has ―created a need for redirection of
resources, it hasn‘t caused a need for increased resources.‖ He says, ―I have different
people doing different things, and some people are doing more than they used to. But I
haven‘t had to add more staff.‖
Innovation in Physician Practices 70
THE FUTURE
Beresford states that as the practice becomes more comfortable with the innovations it
has added so far, he hopes to ―get more into self-care and counseling patients on how to
take care of themselves, and helping them to be more independent. I really want patients
to be more personally responsible.‖ He also wants to work more closely with the
specialists their patients see. He notes, ―We might get reports from them, but there isn‘t
any real dialogue.‖ He believes this should change as PCMH becomes more widely
adopted:
Through the evolution of patient-centered medical homes where the primary care
provider becomes the primary driver of care, primary care providers will be
forced to have a better relationship with the other players. We‘re required to
know more about other providers and the care our patients receive from them.
Beresford, Holzhei, and other staff at St. Johns Professional Associates are also looking
forward to having an electronic medical record (EMR) in place. The EMR they plan to
adopt is being implemented system-wide by Sparrow Health System. Beresford says,
When we move to an integrated EMR, everything will change. Right now I get
labs that we still have to enter into the registry by hand. When Sparrow has an
integrated EMR, they‘ll be using EPIC. By the end of 2012, everything should be
in place across the health system.
For Holzhei as well, ―the big thing is getting an EMR.‖ Having that, he says, ―will allow
us to access all of the information better—labs, ophthalmology reports—and e-
prescribing will be easier, too.‖
