TABLE 3.

Representative Quotations Illuminating the PCMH Best Practices Identified in the Study

Soft Practices
Knowing the patient	I know this patient; over the course of time we've developed a good relationship. Like another time he came in last year and his complaint was that he was more tired than usual. But then you look at any guy in his eighties, and you think, “Well, I mean you're eighty, what do you expect?” But I knew for a fact that he exercised every day. He competitively swims. He was complaining that he didn't win his last swim meet. He races other seniors. So he said, “I'm slowing down; I just feel kind of tired.” And because I knew this I decided to order an EKG, thinking maybe it's his heart. He had like a first-degree [avioventricular] block. They immediately hospitalized him and gave him a pacemaker. If I didn't get the EKG he would have been dead in two days. That's what the cardiologist told him (physician, practice 1).
Empathy and compassion when dealing with patients	It's all about need and just emotional support. Making the staff understand not to get frustrated with these people. I tell them, “You have to understand the elderly. They don't feel good. They're frustrated. They don't like using voice mail” (practice manager, practice 2).
	I picture my mom [when talking to an elderly patient on the phone]. She's eighty-five, so I talk to them like I would talk to my mother, only nicer. Give you an example—we have a cute little old lady. She just calls and says, “Hey, it's me,” and I know who she is right away. She was given a new medication. I'm like, “Oh, you'll be fine. My mom takes it.” She called back later and said, “Thank you for prescribing that for me.” OK, I didn't prescribe it, but the approach works well. Just do little things. Be nice to them. They just like you to take time and make them feel like they're the most important right then and there (secretary, practice 2).
Using family	I had a patient the other day who was here because she was worried about her blood pressure. When I went through her medications, she didn't know what she was taking, and, come to find out, she wasn't taking any of her medications. She didn't understand what she needed to do. So we called her family member—we were on the phone for a good hour and a half throughout the day, you know, talking back and forth with the daughter. So she's [the daughter] going to get the pills together. The patient's coming back in three weeks for a blood pressure check. The daughter's coming with her (nurse practitioner, practice 2).
Tailored communication approaches	I think that you sort of have to get to their level. I don't mean to sound degrading, but things you have to do with children, as you get older you have memory loss, forgetfulness, you don't understand things as well (nurse, practice 1).

Hard Practices
Using formal work protocols	We started doing preplanning where you call patients and ask them a series of questions before they come in for their annual physical. “Have you been in the hospital recently?” You'd be amazed at how many people have been in the hospital. “Have you been in the ER recently?” and we go through a form that has things like the last time they had their lipids checked, and so when the physician has this information and the patient comes in, he can go through and review and see exactly what they are due to have—if a female was due for a mammogram, a dexa scan, whatever (practice manager, practice 2).
Work redistribution/off-loading	Some of the things that we've also done is try to realign the front-end staff, the secretaries, to use some anticipatory guidance as to what the patients are going to need. All of the paperwork that the federal regulations require us to have done; all of the HIPAA paperwork and consents, all of that stuff can be done with the front-end staff and the medical assistants can then do what they need to do. So some of that medical home concept has pushed us to use people where we need to and when we do that, then the staff sort of take a more active role in owning the process (nurse practitioner, practice 2).
Use of triage	We have some nurses that are trained in triage, and they'll get a phone call about a respiratory tract infection, for example, and they look at the patient's chart in terms of whether the patient has chronic lung disease or sick with any other ongoing medical problems, and they'll make a clinical judgment that the patient's probably not sick enough to be seen, probably has a viral illness, and they'll recommend, “Just try this cough syrup and some antihistamine and watch for a temperature and take some Tylenol and call us if you're getting worse.” And they'll document that on the chart, send us a note about it, and we just say, “Agree with plan,” that shows that we saw it, and it becomes part of the patient's record (physician, practice 3).