Patient-Centered Medical Home Implementation in Indian Health Service Direct Service Facilities

Short abstract

In 2008, the Indian Health Service launched a patient-centered medical home (PCMH) initiative to improve the quality of care in its clinics. RAND researchers identified barriers and strategies to assist clinics on the path to PCMH recognition.

Abstract

In an effort to provide care that is more accessible, team-based, coordinated, and patient-focused, primary care practices are increasingly adopting patient-centered medical home (PCMH) models of care. In 2008, the Indian Health Service (IHS) launched its own PCMH initiative, Improving Patient Care (IPC), to improve the quality of care for American Indians and Alaska Natives (AI/ANs) who seek care in its clinics. The IHS provides comprehensive health care services to roughly 2.2 million AI/ANs from more than 567 federally recognized tribes across the United States.

RAND researchers examine the peer-reviewed and grey literature and identify common PCMH implementation strategies and challenges to better understand the kinds of methods used by clinics across the United States—particularly small clinics and those located in rural or remote locations. The research team then held telephone discussions with representatives from seven IHS clinics that had received PCMH recognition as of July 2017. The discussions with clinic leaders sought to identify how components of the PCMH model had been implemented at their clinics; challenges associated with PCMH implementation; and key lessons and recommendations that could benefit clinics that have not yet received PCMH recognition.

The Indian Health Service (IHS) provides comprehensive health care services to roughly 2.2 million American Indians and Alaska Natives (AI/ANs) from more than 567 federally recognized tribes across the United States (IHS, undated[a]). The IHS delivery system comprises both federally run and tribally run facilities, as well as programs that provide services exclusively to AI/AN urban populations. While the IHS is responsible for providing comprehensive medical services, the focus of the care it delivers directly is primary care (Heisler, 2016).

Primary care practices across the United States are increasingly adopting patient-centered medical home (PCMH) models of primary care in an effort to provide care that is more accessible, team-based, coordinated, and patient-focused. In 2008, the IHS initiated its own PCMH initiative, Improving Patient Care (IPC), to improve the quality of care for AI/ANs that seek care in its clinics. As of May 2017, 17 IHS clinics have applied for and received PCMH recognition.

To better understand the kinds of strategies that are used by clinics both within and outside of the IHS to implement PCMH models, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) commissioned the RAND Corporation to examine the peer-reviewed and gray literature and identify common implementation strategies and challenges (see Appendix A for the full literature review). The research team then held telephone discussions with representatives from seven IHS clinics that had received PCMH recognition as of July 2017. The discussions with clinic leaders sought to identify (1) how components of the PCMH model had been implemented at their clinic; (2) challenges associated with PCMH implementation; and (3) key lessons and recommendations that could benefit clinics that are not yet PCMH-recognized.

Chief executive officers (CEOs) from the seven clinics were invited to participate in two-hour telephone discussions with the RAND research team. CEOs were encouraged to invite administrative or clinical staff who were knowledgeable about the clinic's PCMH experience to join the discussion. All discussions were conducted between August 2017 and September 2017.

PCMH-Recognized Clinics Participating in the Study

Six of the seven clinics that participated in discussions provided detailed staffing information. These six clinics varied in size, reporting between 23 and 174 total full-time staff. All but one clinic used contracted staff to supplement vacant positions, and among those that did, the share ranged from 4 percent to 31 percent. Five of the six clinics reported that they currently empaneled their patients to primary care teams,¹ and the average number of patients empaneled to a care team ranged from 720 to more than 2,700 patients.

The decision to implement a medical home and pursue recognition among the seven clinics often stemmed from a desire to shift from a model of care that was defined by episodic relationships with patients who often sought care on a walk-in basis to a model that allowed deeper and more-continuous relationships between patients and their doctors. Improvements in efficiency, a desire to address patient complaints, and a desire to attract additional Medicaid enrollees were also cited as motivations.

All seven clinics received PCMH recognition through the Accreditation Association for Ambulatory Health Care (AAAHC) between 2009 and 2017. Respondents from multiple clinics noted that it was easier to pursue recognition through AAAHC relative to other programs, and many already had received ambulatory health care accreditation from the organization.

The majority of clinics reported a team-based approach to PCMH implementation in which teams were usually led by the CEO and included clinical directors, directors of nursing, and pharmacy and clinical support staff. CEOs often had the responsibility of communicating the vision and goals of the medical home to their staffs and attended regular meetings to provide ongoing reinforcement. Other clinics reported that their CEOs were less involved, primarily because of high turnover in that position. Many clinics reported that their implementation teams met on a weekly basis to maintain forward progress on multiple fronts. To promote communication within the clinic, implementation teams commonly provided updates on the status of various initiatives and their rationale during general staff meetings, and used these opportunities to obtain feedback from staff. Similarly, nearly all clinics reported some level of ongoing communication with tribal leadership and community members about changes to the clinic and to hear and respond to community concerns.

PCMH Implementation Strategies and Challenges

The seven clinics used a wide range of strategies to implement components of the medical home model, including expanding or retraining staff, shifting to team-based care, implementing empanelment, expanding access to the clinic, changing clinic space, using health information technology (IT), strengthening patient care processes, improving care coordination, and expanding quality measurement and improvement capabilities.

Expanding or Retraining Staff

Only a few clinics reported expanding their staff as part of their efforts to implement a medical home. Most clinics struggled with high rates of staff turnover and difficulty hiring new staff either because they were located in rural or remote locations or because of delays in IHS human resources (HR) processes. Because of these barriers, some clinics focused primarily on retraining existing staff for new roles required by the medical home. Other clinics used partnerships with universities or telemedicine to meet their staffing needs.

Shifting to Team-Based Care

Clinics reported a range of experiences in forming care teams and altering workflows that came with team-based, rather than physician-led care. Four key challenges included encouraging physicians to give up control over certain workflows, encouraging lower-level staff to perform more duties toward the top of their scope of license, establishing new workflows and protocols, and developing workarounds to address chronic staffing shortages. Overall, staff valued the shift to team-based care and patient care strategies often emerged from care teams, as well as from clinic leadership.

Implementing Empanelment

Empanelment—a system in which a patient is assigned to a primary care provider and care team that is responsible for managing the patient's ongoing care needs—was viewed as critical to establishing the “home” in the medical home for patients. Many clinics noted that implementing empanelment was not arduous, but in some cases, it did require careful attention and efforts to achieve buy-in among providers. For some clinics, however, staff shortages made it difficult or impossible to empanel patients.

Enhancing Access to Care

Each clinic pursued a range of strategies to improve access to care, usually in a way that addressed existing utilization patterns that the clinic hoped to change. The most common strategy was altering a clinic's scheduling system to allow for a greater share of same-day visits relative to previously scheduled appointments. Other clinics needed to reduce the stress on their urgent care settings by moving from a primarily walk-in system to one in which patients were encouraged to schedule appointments for their nonurgent primary care needs. Other common strategies designed to improve access were expanding a clinic's operating hours and implementing new systems to provide or arrange for after-hours care.

Changing Clinic Space

Most clinics described making changes to the physical layout of their clinic that helped to promote better interaction among staff and improve efficiency, including rearranging current space or building new facilities where care teams could work together in the same area. Other clinics described ongoing space constraints that prevented them from hiring new staff, implementing changes that might facilitate team-based care, or providing new space to support wellness or health education–related activities.

Using Health Information Technology

Clinics often noted that the transition to electronic health records preceded their medical home activities and that meaningful use requirements helped them to develop capabilities that were useful while implementing their medical home. Many clinics described iCare as an important tool in their efforts to better manage their patient panels, although many also noted that they had not yet begun to use the system to its fullest potential.²

Strengthening Patient Care Processes

To provide more patient-centered care, some clinics described efforts to better engage patients in developing care plans and setting goals, including collecting and integrating data on social determinants of health in care planning and finding novel ways of sharing patients' own health information with them during clinic visits. Other clinics sought training for their staff to better coach their patients on how to develop better self-management skills. However, many clinics mentioned that this was an area that needed additional attention.

Improving Care Coordination

To improve care coordination, clinics described their use of huddles, referral tracking systems, and more-extensive use of care managers to follow up with patients after hospitalizations to monitor their status and needs. Some clinics mentioned that they had been using these and other strategies for many years, but IPC helped them begin to document these activities in a more consistent way.

Expanding Quality Measurement and Quality Improvement Capabilities

Several clinics described transitioning to a continuous quality improvement model in which staff were involved in the design and analysis of Plan-Do-Study-Act cycles, which helped to provide reinforcement of the objectives of PCMH-related practice changes.³ To assess the effectiveness of their PCMH efforts, many clinics discussed using a range of metrics, such as “no-show” rates or cycle time metrics like “value-added time”—the amount of time that the patient spends with medical professionals during a clinic visit—in addition to Government Performance and Results Act (GPRA) quality measures, which they closely monitored.⁴

Lessons Learned and Recommendations for Clinics Pursuing PCMH Recognition

Despite differences in the strategies that each of the seven clinics pursued as part of efforts to implement and expand the medical homes, several key lessons emerged when reflecting on the clinics' collective experiences. Many of these same themes appear prominently in the PCMH literature.

1. Strong executive leadership can speed PCMH implementation. The CEOs that we engaged were truly visionary and successfully oversaw the implementation of major cultural and process changes, while ensuring that the needs of patients guided their efforts.

2. A diverse and dedicated implementation team is essential. Because all staff will be affected by the infrastructure and workflow changes that may be required to achieve PCMH recognition, a dedicated implementation team that spans multiple disciplines, that includes senior staff, and that works to secure buy-in among clinical staff can guide the effort to a successful result.

3. Staff turnover can slow development of critical PCMH capabilities. Frequent staff turnover can be disruptive—particularly for small practices. Staff shortages can limit a clinic's ability to expand access and restrict the use of both empanelment and multidisciplinary care teams. However, a dedicated implementation team that provides consistent messaging can help maintain forward progress.

4. Consistent communication with staff and the community can secure buy-in and provide reinforcement over time. Engaging staff early, sharing data, and communicating success stories can help encourage staff to pursue continuous process improvements. Working with tribal leaders and the broader community can also help secure buy-in for major changes, leverage the rich assets of the community, and build trust.

5. IPC tools are valuable in charting a course of change. The IPC self-assessments and Change Package were viewed favorably; however, the level of support from IHS Area Offices appeared to vary, with some respondents indicating that they received all the help they needed and others reporting that their area-level Improvement Support Teams were not able to consistently provide the level of assistance that clinics needed.

6. Assessing patients' needs and community resources can help focus PCMH efforts. Knowing a clinic's patient population, including its health and social service needs, was seen as critical to being able to meet the needs of the patient community and to improve a patient's health care experience. At the same time, analyzing both a clinic's expenditures for Purchased/Referred Care program services and the availability of other service providers in the community could identify ways to spend a clinic's resources more efficiently.

7. Smaller clinics may need more assistance. Smaller clinics appeared to suffer disproportionately from CEO turnover and staff vacancies. They reported a more-limited ability to apply for grants to support new models of care, and often lacked staff with a deep understanding of quality improvement, with data analytics capability, or with expertise in iCare—all factors that could substantially slow progress toward PCMH recognition.

8. Third-party revenue is critical to sustainability. Most clinics cited the Affordable Care Act's expansion of Medicaid eligibility to childless adults as a major factor in their ability to increase third-party revenue. Additional revenue helped clinics hire more staff, expand access, and invest in other infrastructure improvements, which, in turn, provided more opportunities for growth in revenue that allowed them to sustain these changes.

9. The impact of PCMH implementation has been overwhelmingly positive. The seven clinics reported overwhelmingly positive experiences, including positive feedback from staff, high performance on GPRA quality measures, and improvements in patient satisfaction and access to care.

The seven clinics also offered a few recommendations to sites still pursuing PCMH recognition.

1. Start small, do not be afraid to fail, and recognize that change takes time. Successful clinics urged others to “start small” and pursue a few “easy wins” to avoid being overwhelmed when implementing multiple process changes simultaneously. Clinics described failing numerous times before successfully implementing a new process, and noted that incremental changes take time and require persistence.

2. Expect at least some resistance from patients or staff. Shifting to team-based care and continuous quality improvement models represent large cultural shifts that can initially engender resistance from staff. In addition, patients may become frustrated with new scheduling systems or by new staffing models in which they receive care from lower-level staff.

3. Work to build your staff's adaptive reserve. Successful clinics did not exhibit symptoms of “change fatigue,” but rather embraced the concept of continuous process improvement and allowed their staff to guide practice changes using a “bottom-up” model rather than a “top-down” approach.

4. Take advantage of opportunities to learn from others. Clinic staff who were able to meet face-to-face with staff from other clinics and their improvement teams, share best practices, and, in some cases, shadow one another found those experiences to be particularly helpful and motivating.

Conclusion

Each of the seven clinics used a variety of approaches to implement aspects of the PCMH model based on size, staffing, and patient care priorities. Most clinics struggled with high rates of staff turnover and shortages that were exacerbated by bureaucratic delays in IHS HR processes, which limited clinics' ability to create more multidisciplinary care teams or to expand access to care. Clinics often relied on contracted staff to fill these shortages, which undermined the empanelment process and the formation of lasting patient-physician relationships. Strategies to enhance access to care varied based on existing utilization patterns that each clinic hoped to change, and most clinics found that optimizing changes to scheduling systems was an iterative process. In addition, some clinics were constrained in their ability to implement changes to the physical layout of their space to promote more team-based care; other clinics reported challenges leveraging the capabilities of iCare or enhancing their care planning and health coaching interventions.

Successful clinics exhibited strong executive leadership that established a consistent vision of the medical home's end state and used a diverse, dedicated implementation team to manage the overall effort, gain staff buy-in, and ensure forward progress even in the face of CEO or staff turnover. Consistent communication with staff and the community in the planning stages and over time helped to ensure that the medical home was shaped by the priorities and ideas of staff and was responsive to the unique needs of each clinic's patient community. The clinics that reported the most-positive experiences were those that took a highly participatory approach, embraced a culture of trial and error, and developed a mindset of a long-term shift toward incremental and continuous quality improvement, which helped to build high levels of adaptive reserve within clinic staff.

Taken together, these findings suggest that many of the implementation barriers identified by IHS clinics (e.g., staff shortages and turnover, limited training in key competencies) and facilitators (e.g., strong leadership, clear vision, dedicated implementation teams, technical assistance) are also some of the factors most widely cited by stakeholders outside of the IHS. Nevertheless, as the IHS reflects on its ongoing efforts to support clinics on the path toward PCMH recognition, it might consider several concrete suggestions offered by these seven clinics that could address the challenges they faced. Among these are the need for expediting clearance and approval processes for hiring new staff, providing additional resources for clinic expansion and modernization to support the implementation and sustainability of medical homes, ensuring the adequacy of technical assistance across IHS areas, and facilitating additional opportunities for collaborative learning.