Participant Guide
Transforming the Primary Care Practice
June 10–12, 2014 · San Francisco, CA
Table of Contents
Section 1: Program Overview……………………………………………………………2
Section 2: Curriculum Design…………………………………………………………..2
Purpose of the System…………………………………………………………………………………………………….3
Leadership for Change……………………………………………………………………………………………………3
Partner with Patients……………………………………………………………………………………………………..4
Team-Based Care…………………………………………………………………………………………………………..4
Information Systems………………………………………………………………………………………………………4
Access…………………………………………………………………………………………………………………………..5
Underlying Capacity: Improvement for Quality……………………………………………………………….5
Section 3: Diagnostic Assessment and Reading List (To Do List)………………5
 Patient-Centered Medical Home Assessment (PCMH-A), Part 3…………………………………..5
 Primary Care Provider (PCP) Panel Worksheet…………………………………………………………..5
 Delay for a Routine Appointment, also known as “Third Next Available”………………………5
 Continuity Rate……………………………………………………………………………………………………….6
 Clinical Quality Measures…………………………………………………………………………………………6
 Accessing Patient-Centered Care Using the Advanced Access Model…………………………….6
 A Systems Approach to Patient-Centered Care……………………………………………………………7
 Building Teams in Primary Care: Lessons Learned………………………………………………….….7
 Building Teams in Primary Care: 15 Case Studies………………………………………………….……7
Patient Centered Medial Home Assessment (PCMH-A)…………………………………………………………….….8
Primary Care Provider (PCP) Panel Worksheet……………………………………………………………………………11
Continuity Rating Grid……………………………………………………………………………………………………………..12
Page 1 of 12
Welcome to IHI’s
Transforming Primary Care Practice Program
Section 1: Program Overview
In this rapidly changing health care environment, now is the time for primary care practices to
rethink their approaches to providing care. Doing things “the way we’ve always done it” is no longer
enough; primary care organizations must learn how to transform their systems of care in a way that
will lead to better, sustainable results. Meaningful use, the patient-centered medical home, advanced
primary care, person- and family-centered care, and electronic health records all constitute new
challenges for office practices, yet they also present new opportunities. When equipped with
foundational skills and knowledge, organizations that have a will to change and improve can thrive in
this new environment.
This intensive program is designed to help primary care practices adapt and succeed, by bringing
together the best knowledge available on high leverage changes for primary care transformation.
During the three-day intensive program, participants will engage in an interactive environment to
learn about and share experiences relating to accessible, continuous, and coordinated family-centered
care using a team approach, health information technology, and shared decision making. The vision is
that the program will lay the foundation for ongoing improvement, while also providing the
opportunity for practices to immerse themselves in key changes that will propel them towards a
system that works better, is more cost effective, and meets the needs of the community.
The program will consist of improvement-minded organizations working together with The Institute
for Healthcare Improvement (IHI) staff and faculty to explore effective designs and approaches to
foster relationships between the customer, families, community, and care team for optimal health and
wellness, while responsibly managing resources.
Section 2: Curriculum Design
Major change in the system of care will not happen easily for a long list of reasons. Comprehensive
models exist to guide organizations on their improvement journey, yet the diagrams tend to
oversimplify the reality and magnitude of the change. The same applies to the following visual of the
curriculum offered for this intensive program to transform the primary care practice, but it does give
us a starting point.
The model of the curriculum is not intended to replace any of the comprehensive models that pervade
our healthcare “universe” at this time (such as the Chronic Care Model, the Patient Centered Medical
Home, etc.), but instead is intended to actually use the success and effectiveness of such models to
identify high leverage changes that might accelerate progress toward a system of advanced primary
care.
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The Transforming Primary Care Practice Curriculum can be depicted as follows:
Purpose of the System:
Foster relationships between the patients, families, community, and care team for
optimal health and wellness, while responsibly managing resources
Leadership for Change
Partner with Patients
Team-Based Care
• Build an interdisciplinary
Care Team
• Optimize the Care Team
• Provide clinical Care
Management services
for complex patients
Information Systems
• Embed evidence-based guidelines
• Provide reminders, recalls, and clinical
summaries to patients and care teams
• Understand the population
• Track and report progress
and clinical quality measures
Access
• Empanel patients with a
PCP and promote continuity
• Reduce waits and delays
for all care and services
• Apply demand and supply
forecasting tools to create
and sustain improvement
Underlying Capacity:
Improvement for Quality
Purpose of the System
We started at the top of our model with the purpose of the system in its ideal state: to foster
relationships between the patient, families, community, and care team for optimal health and
wellness, while responsibly managing resources.
Your practices exist to provide great service and care for your community that emphasizes not only
the prevention of disease and injury, but also self- responsibility for nutrition, exercise, and other
aspects of lifestyle that promote wellness. To do that effectively, you must foster positive relationships
and partnerships with the patients, their families, and other community entities, providing those
services and developing those relationships in a cost effective manner.
The outcome that everyone is working toward is optimal health (medical outcomes) and wellness
(taking us away from simply the medical model, but also the mind and spirit of each patient as well as
their ability to function at the level that they desire).
Responsibly managing resources refers to the need for a business case and preservation of
organizational financial viability.
Leadership for Change
The element of creating a Will to Change, eliminating complacency, and communicating and
interacting with the community falls in the leadership domain. We will help leaders of organizations
understand that they have to define what the future should look like, align people with that vision,
then inspire them to make it happen. They have responsibility for leading and spreading
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improvement, while also paying attention to the need to build systems and processes to sustain that
spread.
Partner with Patients
To the casual observer, it might seem that health care has always been person- and family-centered,
but in many ways, the health care system is more about serving the needs of itself rather than those it
serves. How often do we take the time to really listen to what our patients need and want and what
really matters to them? Organizations will understand the value and importance of listening to their
customers about their experience and the impact of moving from simply being a recipient of care to be
a partner in care.
The curriculum focuses on opportunities for engaging persons and families in the design and
functioning of a practice that is person and family centered in three contexts: care for the individual,
practice improvement, and policy design and implementation. More than a full day of activity will be
available relating to this aspect of the curriculum.
Team-Based Care
The process of developing a care team within primary care practices is not something that you can
“take off the shelf.” It needs to be individualized for each practice, their patients, and their
community. The curriculum will address how to take a close look into the practice to develop a greater
understanding of the patient population that is served and the processes that are used to meet the
needs of the patient and family.
The specific mix of staff (number of physicians, nurses, assistants, technicians, clerks, etc.) may vary
from clinic to clinic and determines the extent and type of work that can be driven away from any
constraints in the system. The care team composition of each clinic will emerge from an
understanding of the types of services it provides, the most common diagnoses, referral patterns,
clinical outcomes, etc. Once the care team composition is determined, there are many ways to
optimize the care team. This aspect of change—becoming an optimized care team—is vital in your
transformation journey.
The curriculum model addresses the importance of care coordination in today’s complex
environment. With an exposure and understanding of evidence-based principles for systems of care
coordination and care management, the curriculum will help organizations understand how to
identify the populations most appropriate for care/case management and will recognize what
constitutes successful programs. As primary care practices serve as the focal point of care
coordination across health care delivery, methods to facilitate, coordinate, and track care and services
with other clinical and community entities will be identified.
Information Systems
Health information technology (HIT) has the potential to enable better care for patients, and to help
clinicians achieve continual improvements in the quality of care in primary care settings, but simply
implementing current health IT tools will not bring about these results. To generate substantial and
ongoing improvements in care, health IT adoption must go hand in hand with the implementation of
a robust change package and the routine use of solid improvement methods and data by clinicians
and other staff.
Page 4 of 12
Access
Long waits and delays for care and discontinuity are epidemic in our health care system. As we
struggle to get through today, and cope with what seems to be insatiable demand we inevitably push
some work into the future. This further mortgages future capacity and continuity is sacrificed. The
curriculum solidly addresses the importance of breaking this cycle and moving to models that reliably
provide improved Access and Continuity. The second day of the current curriculum model provides
an opportunity for an intensive session on access, with an introduction to advanced access on Day 1.
Pragmatic ideas will be provided to accomplish the following:
• Match Demand and Supply Daily
• Work down the Backlog
• Decrease appointment types and times
• Develop Contingency Plans
• Reduce Demand for Unnecessary Visits
• Optimize the Care Team
Underlying Capacity: Improvement for Quality
The list of capabilities required to drive system-level improvement is long, but includes, at a
minimum, the Model for Improvement, a simple, yet powerful tool for accelerating improvement.
Building the capacity and capability for improvement is vital in any organization that is interested in
transformation.
Participants will leave with an understanding how to develop an aim, set goals, and establish
measures for improvement, using some of their own data to develop an action plan for improvement.
Section 3: Diagnostic Assessment and
Reading List (To Do List)
A checklist of assessments to be completed and brought to the seminar and articles to be read include:
 Patient-Centered Medical Home Assessment (PCMH-A), Part 3
Complete the assessment on Page 8-10 and bring a 2 copies with you to the seminar. Turn
one copy in at the registration desk when checking in for the seminar.
 Primary Care Provider (PCP) Panel Worksheet
Located on Page 11 of this document, please complete and bring the results with you to the
seminar.
 Delay for a Routine Appointment, also known as“Third Next Available”
Access to care is a key determinant of patient satisfaction and will be one area of the focus on
Day 2 of the seminar. The recommended measure of access is the number of calendar days to
third next available routine appointment. To understand current access to your PCPs or
specialists, we are asking you to focus on one specific appointment type, a request for a
routine appointment. The delay for the third available appointment is used (rather than the
first or second) because it is a more reliable reflection of your system’s availability. It more
closely reflects the patient experience in terms of delay. The first or second appointment
available is often due to a cancellation or some other random event.
Page 5 of 12
Use your scheduling system (whether it is computerized or manual) to count the number of
days from today to the day when the third next appointment is available. Experience shows
that measuring the 3rd next available appointment first thing on Monday morning, before
the phones are open, is a great way to reliably capture this data.
Do not count appointments that have been held or reserved for same day urgent needs as
these are generally not available to patients unless they qualify with specific clinical criteria.
Remember, we want to understand the delay patients experience for routine care.
Measure the third next available routine appointment for each PCP or each specialist on your
clinical team. Make this measurement the same day and time each week, every week prior to
the seminar. If you already collect and have this data readily available, bring historical data
and graphs with you! Please remember to bring this data with you to the seminar.
 Continuity Rate
Continuity is the rate at which your patients see their PCP when coming in for primary care.
It is a retrospective look at the patient experience in your system and should be measured
monthly.
If you are already regularly measuring and reporting this data, please bring that information
with you to the seminar. If you are not regularly collecting the data, please do at least a onemonth review of visits and determine the rate of continuity. Ideally, it would be continuity for
each PCP in your organization, but we would be happy with a subset or team or average, if
that is more do-able.
A worksheet is included on Page 12
 Clinical Quality Measures
Bring the results of some clinical quality measures that you have identified for improvement
for the session on Day 2: Identifying Improvement Opportunities.
Reading List
Please read the following articles prior to participation in the seminar. They will help provide a
foundation for some of the content we will be discussing at the seminar.
 Accessing Patient-Centered Care Using the Advanced Access Model
Access the article at:
http://journals.lww.com/ambulatorycaremanagement/Fulltext/2009/01000/Accessing_Pati
ent_Centered_Care_Using_the_Advanced.6.aspx
Abstract: Waits and delays for healthcare are legendary. These delays are not only frustrating
and potentially hazardous for patients and providers but also represent significant cost to
office practices. The traditional medical model that defines urgent care versus routine care is
a vain and futile attempt to sort demand. This approach is at constant odds with patients'
definition of urgency. Trusting patients to determine when and how they want to access care
makes sense from a customer service perspective. If approached systematically using the
principles of Advanced Access, patient demand patterns can be tracked to forecast demand.
These demand patterns become the template for deploying the resources necessary to meet
patients' needs. Although not a simple journey, the transformation to Advanced Access
Page 6 of 12
provides an entree to patient-centered care where patients can say, I get exactly the care I
want and need, when I want and need it. There are some article tools in the right hand
column of the website that will allow you to change the format to PDF and print off the article
if desired.
 A Systems Approach to Patient-Centered Care
Access the article at:
http://azlend.peds.arizona.edu/sites/azlend.peds.arizona.edu/files/care2.pdf
Summary: Providing care centered on patients' needs and expectations is a key attribute of
quality care. Unfortunately, despite the intent and efforts of many to improve patient
centeredness, the quality of patient- clinician relationships, patient access, and continuity of
care appear to be worsening in the US and lag behind other countries. Clinicians do not
consistently address patients’ concerns, do not always assess patients’ beliefs and
understanding of their illness, and often do not share management options with patients. In
this Commentary, the authors propose four specific changes that should help the medical
profession meet patients' needs.
 Building Teams in Primary Care: Lessons Learned
Access the article at:
http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/B/PDF%20BuildingTea
msInPrimaryCareLessons.pdf
This report was prepared for the California HealthCare Foundation by Thomas Bodenheimer
MD. Between June 2006 and January 2007, 112 people were interviewed for this report. This
introductory volume of the report summarizes some general issues regarding teams in
primary care and points readers to the overall lessons provided by the case studies.
 Building Teams in Primary Care: 15 Case Studies
Access the article at:
http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/B/PDF%20BuildingTea
msInPrimaryCareCaseStudies.pdf
This report was prepared for the California HealthCare Foundation by Thomas Bodenheimer
MD. This segment of the report provides case studies of practices and clinics making
considerable progress in forging primary care teams. The detail provided is likely to be found
helpful to the primary care practices involved in the program, offering lots of ideas for
different models of care.
Page 7 of 12
Patient Centered Medial Home Assessment (PCMH-A)
Part 3 of the PATIENT-CENTERED MEDICAL
HOME ASSESSMENT (PCMH-A)
Modified from the PCMH-A Survey © 2010 MacColl Institute for Healthcare Innovation, Group
Health Cooperative
Background
The PCMH-A survey is a product of the Safety Net Medical Home Initiative
www.safetynetmedicalhome.org, which is supported by The Commonwealth Fund, a national, private
foundation based in New York City that supports independent research on health care issues and
makes grants to improve health care practice policy The PCMH-A was created by The Safety Net
Medical Home Initiative team to help clinical practices gauge their progress in implementation of the
Patient-Centered Medical Home change concepts. The full survey was designed to help systems and
provider practices move toward the “state-of-the-art” in delivering patient-centered care in the
context of a medical home.
For the purpose of the Transforming the Primary Care Practice Seminar, we are asking you to
complete Part 3 of the PCMH-A on the next 2 pages of this document. Please follow the instructions
below, complete the attached survey and bring the results with you to the seminar on
June 11th in San Francisco.
Instructions
1.
Answer each question from the perspective of one physical site (e.g., a practice, clinic,
hospital, health plan).
2. For each row, circle the point value that best describes the level of care that currently exists in
the site. The rows in this form present key aspects of patient-centered care. Each aspect is
divided into levels showing various stages in development toward a patient-centered medical
home. The stages are represented by points that range from 1 to 12. The higher point values
indicate that the actions described in that box are more fully implemented.
Page 8 of 12
PART 3: PATIENT-CENTERED INTERACTIONS
3a. Respect patient and family values and expressed needs.
3b. Encourage patients to expand their role in decision-making, health-related behaviors, and self-management.
3c. Communicate with their patients in a culturally appropriate manner, in a language and at a level that the patient understands.
3d. Provide self-management support at every visit through goal setting and action planning.
3e. Obtain feedback from patients/family about their healthcare experience and use this information for quality improvement.
Components
Level D
Level C
Level B
Level A
8. Assessing patient
and family values
and preferences
…is not done.
…is done, but not used in
planning and organizing care.
…is done and providers
incorporate it in planning and
organizing care on an ad
hoc basis.
…is systematically done and
incorporated in planning and
organizing care.
Score
9. Involving patients in
decision-making
and care
Score
10. Patient
comprehension of
verbal and written
materials
Score
1
2
3
…is not a priority.
1
2
2
5
6
…is accomplished by provision of
patient education materials or
referrals to classes.
3
…is not assessed.
1
4
4
5
6
…is assessed and accomplished
by assuring that materials are at
a level and language that patients
understand.
3
4
5
6
7
8
9
…is supported and documented
by practice teams.
7
8
9
…is assessed and accomplished
by hiring multi-lingual staff, and
assuring that both materials
and communications are at a level
and language that patients
understand.
7
8
9
10
11
12
…is systematically supported by
practice teams trained in decision
making techniques.
10
11
12
…is supported at an organizational
level by translation services, hiring
multi-lingual staff, and training staff in
health literacy and communication
techniques (such as closing the loop)
assuring that patients know what to do
to manage conditions at home.
10
11
12
PART 3: PATIENT-CENTERED INTERACTIONS CONTINUED ON THE NEXT PAGE
Page 9 of 12
PART 3: PATIENT-CENTERED INTERACTIONS CONTINUED
3a. Respect patient and family values and expressed needs.
3b. Encourage patients to expand their role in decision-making, health-related behaviors, and self-management.
3c. Communicate with their patients in a culturally appropriate manner, in a language and at a level that the patient understands.
3d. Provide self-management support at every visit through goal setting and action planning.
3e. Obtain feedback from patients/family about their healthcare experience and use this information for quality improvement.
Components
Level D
Level C
Level B
Level A
11. Self-management
support
…is limited to the distribution of
information (pamphlets,
booklets).
…is accomplished by referral to
self-management classes or
educators.
…is provided by goal setting and
action planning with members of the
practice team.
…is provided by members of the
practice team trained in patient
empowerment and problem-solving
methodologies.
Score
12. The principles of
patient-centered
care
Score
New (#1):
Measurement of
Patient Centered
Interactions
Score
1
2
3
…are included in the
organization’s vision and
mission statement.
1
2
2
5
6
…are a key organizational priority
and included in training and
orientation.
3
…is not done or is
accomplished using a
survey administered
sporadically at the
organization level.
1
4
4
5
6
… is accomplished through patient
representation on boards and
regularly soliciting patient input
through surveys.
3
4
5
6
7
8
9
…are explicit in job descriptions
and performance metrics for
all staff.
7
8
9
… is accomplished by getting
frequent input from patients and
families using a variety of
methods such as point of care
surveys, focus groups and
ongoing patient advisory groups.
7
8
9
10
11
12
…are consistently used to guide
organizational changes and measure
system performance as well as care
interactions at the practice level.
10
11
12
…is accomplished by getting frequent
and actionable input from patients
and families on all care delivery
issues, and incorporating their
feedback in quality improvement
activities.
10
11
12
Page 10 of 12
Primary Care Provider (PCP) Panel Worksheet
Complete the table below and bring with you to the seminar. You can use your department, your
entire organization, or your clinic as an example.
Total Patient Population Served
Current Clinical FTE (PCPs) Count
If evenly divided, what would be the panel size per PCP FTE?
What is the actual panel size per provider in your department?
Provider
Actual Panel Size
A
B
C
D
E
F
G
H
I
J
L
L
M
N
O
P
Q
R
S
Page 11 of 12
Continuity Rating Grid
Provider
# Total Visits to Primary
Care during April
# Visits to PCP in April
% Continuity
A
B
C
D
E
Page 12 of 12