VICTORIA, B.C. — More than midway through the family medicine TransforMED National Demonstration Project, organizers have learned to focus on relationships, systems, and technology in converting offices into places where teams deliver efficient, patient-centered, prevention-focused care.
That was the message from Elizabeth Stewart, Ph.D., an analyst for the American Academy of Family Physicians, as she described some of the hurdles and successes experienced by 36 practices selected to test new models of care in the real world.
The task, she said, has proved daunting to the 18 facilitated and 18 self-directed practices from Scottsdale, Ariz., to Harlan, Iowa, chosen to begin to implement goals set out in the Future of Family Medicine collaborative project completed in 2004.
The TransforMED practice redesign initiative fosters a focus on the personal medical home, patient-centered care, the continuous care relationship, and a whole-person orientation.
“Implementation is an absolutely monumental undertaking,” Dr. Stewart said during a paper presentation session at the annual meeting of the North American Primary Care Research Group.
“A family medicine practice [adjusting to the TransforMED model of care] in today's world is like a 1950s DC3 trying to transform in midair to the Starship Enterprise. They have to keep seeing patients.”
One of the most difficult challenges has been the shift from individual leadership and individualistic performance goals to shared leadership systems in which everyone in an office works together in synchrony. Sometimes this requires a personal transformation by a physician who is used to making all the decisions, or by staff members who might be comfortable with the status quo and not altogether enthusiastic about being empowered to do more, said Dr. Stewart.
The most successful demonstration practices have distributed leadership among three individuals: one focused on vision, one on operations (“making it happen”), and one on finance, she explained.
As part of the TransforMED project, facilitators were assigned to help half of the practices implement changes through site visits, learning sessions, conference calls, Web seminars, referrals to national consultants, and nearly constant phone and e-mail communication.
They soon learned that some practices had “serious dysfunctional problems at baseline,” despite a high degree of motivation, evident by their willingness to participate as early adopters of the new model of care delivery, Dr. Stewart said.
Technology, initially envisioned by some participants as a “plug and play” ticket to better office efficiency, proved to be one of the most frustrating challenges for practices. One practice, for example, spent 14 months trying to integrate a disease registry into its existing electronic health record system.
“Frustration with some of these technological elements have been so difficult it tends to cloud [satisfaction with] other parts of the transformation process,” she said.
TransforMED facilitators also learned that physicians' visions for the new model varied considerably. Some practices most hoped to cultivate a proactive, population-based approach to care, rather than focusing exclusively on individual patients. Others voiced a desire to create a “joyful practice, where people like to come to work.” A few hoped the new model would mean, “I can push a button and technology does everything we want.”
At a midpoint in implementation, Dr. Stewart concluded that certain key elements seem critical to success. One is cohesive facilitation, meaning that practices have access to technical and structural guidance in adapting to goals of the future.
Perhaps more importantly, however, are lessons about how to shift from individualistic office styles to a systems approach in which staff members cooperate and perform to their highest abilities.
Some physicians started out wary of the “warm and fuzzy stuff” such as relationship building and power sharing, but most tended to give high marks to the new office equilibrium once it evolves. One skeptic, for example, said that he felt for the first time in 10 years that he was coming to work at a “real practice that works.”
Even highly motivated, highly successful practices suffer from “change fatigue,” when many new model transformations are attempted at once.