Practice Transformation Studies · 2019. 5. 22. · PCIP Program • The study focuses on the transformation process led by the Primary Care Information Project (PCIP), a bureau of

Transforming Small High-Volume Medicaid Practices to Reduce Disparities in Care: Recent Advances and Future Opportunities

November 2-3, 2011Carolyn Berry and Stephanie Albert

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Insights from Three Research Studies of

Practice TransformationPractice TransformationCarolyn Berry, PhDAssociate Professor

Stephanie Albert, MPAAssociate Research Scientist

Division of General Internal Medicine

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Division of General Internal MedicineNew York University Langone School of Medicine

Practice Transformation Studies

• Extensive process evaluation of RDPS

• Assessment of elements of PCMH in Aligning Forces for Quality (AF4Q) sites and others

• AHRQ grant studying practice transformation among small urban Primary Care Information Project (PCIP) practices in NYC

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Reducing Disparities at the Practice Site (RDPS)

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RDPS Evaluation: Overall Approach

• CHCS pursued a comprehensive evaluation strategy that allowed assessment of 1)strategy that allowed assessment of 1) program implementation at the individual sites, and 2) overall program impact. The evaluation includes:– Process and outcome evaluation;Qualitative and quantitative data collection;

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– Qualitative and quantitative data collection;– Universal and site‐specific indices; and– Multiple levels of analysis



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RDPS Process Evaluation Methods

• Document reviewM t i l bt i d th h CHCS– Materials obtained through CHCS

– Supplemental materials from sites• Site visits

– Round 1: September 2009 – February 2010– Round 2: January – May 2011

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• Interim phone interviews with 2‐3 key stakeholders– July 2010 – January 2011

Findings from RDPS Process Evaluation

• Selection of practices– Not all practices meeting objective and even subjectiveNot all practices meeting objective and even subjective criteria will stay engaged or even engage at all

– Importance of practice “readiness” and capacity– Importance of provider buy‐in

• not all providers believe in PCMH/transformation• many believe they are performing optimally • some don’t care about improving

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• some don t care about improving– HOWEVER, even the most reluctant/resistant practices made incremental change

– Can we abandon patients in unwilling, unready practices?



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RDPS Findings (cont’d)• Short term practice transformation vs. ongoing support/care coordinationongoing support/care coordination– Resource strapped practices cannot absorb all new functions immediately, if ever

– Time frame for transformation must be flexible and longer than initially anticipatedB th f ti h b id d l ti l

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– Both functions necessary; hybrid model optimal– Different skill sets and approaches suggest one person cannot do all

RDPS Findings (continued)

• Many, even most, small high volume Medicaid ti ill t “ d t ”practices will not ever “graduate”

– In one region high staff turnover necessitates frequent retraining

– Resource constraints cannot be underestimated– Ongoing support of some sort necessary– Implications for scalability and sustainability

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Ad i P i CAdvancing Primary Care (APC)

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APC Methods• CHCS assessed high‐value practices serving lower

socioeconomic populations in order to:1. Better understand high‐value practice capacities2. Assess whether certain characteristics positively

correlate with quality of care3. Inform quality improvement efforts in high‐value but

often under‐resourced practicesS d ti i i diff t k t• Surveyed practices in six different markets:• Six AF4Q sites—Cleveland, Kansas City, Maine,

Minnesota, Puget Sound, Western NY• Others—Arkansas and Oklahoma

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APC Practice Selection• High‐volume Medicaid practices that met one of the following criteria:

20% f i i M di id 500 M di id i• 20% of practice is Medicaid or 500 Medicaid patients per physician; or

• 30% of practice is Medicaid and uninsured, or 700 Medicaid and uninsured patients per physician.

• Includes family practice, internal medicine, NPs; excludes pediatric‐only practices and Physician excludes pediatric only practices and Physician Assistants.

• Fee‐for‐service and managed care• NOT limited to small practices11

APC Practice Assessment Survey• Comprehensive review of existing tools• Selected components from three existing, p g,validated measures:• Primary Care Assessment Tool (PCAT), developed by Barbara Starfield and colleagues;

• Physician Practice Connections® Tool – Research Version, developed by Lief Solberg and owned by , p y g ythe National Committee for Quality Assurance (NCQA); and

• Kurt Stange’s leadership scale.

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APC Results: Identified Gaps• First contact: Access (1‐4)• Ongoing care (1‐4)• Coordination (1‐4)

National Mean3.18 (.34)3.48 (.41)3 40 ( 50)Coordination (1 4)

• Comprehensiveness• Services available (1‐4)• Services provided (1‐4)

• Family‐centeredness (1‐4)• Community orientation (1‐4)• Culturally competent (1‐4)• Leadership (1‐5)

3.40 (.50)

3.73 (.45)3.70 (.38)3.67 (.34)3.05 (.54)3.44 (.52)3 99 ( 58)• Leadership (1‐5)

• Health system (0‐100)• Delivery system redesign (0‐100)• Clinical information systems (0‐100)• Decision support (0‐100)• Relative gaps; relative strengths

3.99 (.58)62.7 (32.1)61.0 (28.0)77.7 (21.1)74.2 (27.6)

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Means Mask Variability• Even on dimensions with high means, substantial variability– Most notably health system supports (92% ‐ 32%)– Leadership, community orientation, cultural competence

• Variability by sizeS ll ti t f d l ti– Small practices outperformed large practices on ongoing care & coordination

– Large outperformed small on cultural competence and health system supports

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Support Needed to Bridge Gaps in Primary Care

Financial resources 68%Financial resources 68%

Educational resources 44%

Technological support 43%

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Practice coach/facilitator 32%

Resources Needed to Ensure Appropriate Primary Care ServicesAssistance with implementing QI p gprocesses 31%

Assistance with HIT systems27%

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Administrative senior leadership support 14%



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APC Findings• Many high‐value practices have capacity gaps: Leadership, decision support, and health

d isystem redesign. • Practices would like to bolster: Quality improvement process implementation, administrative leadership, health information technology.technology.

• The resources they need for transformation include: Financial, educational, practice coach/facilitator, care manager.

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Health Care Transformation Among Small Urban Practices

Serving the Underserved

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Specific Aims

• Investigate small, urban, predominantly Medicaid primary care practices that have been transformedprimary care practices that have been transformed for at least one year to understand changes in management and care processes and patient outcomes

• Identify organizational and contextual factors that l d t f l i l t tiled to successful implementation

• Assess effects of practice transformation activities on quality of care and patient outcomes

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PCIP Program• The study focuses on the transformation process led by the Primary Care Informationprocess led by the Primary Care Information Project (PCIP), a bureau of the NYC health department.

• PCIP offers Medicaid providers a subsidy to p yadopt EHR technology, and provides QI visits and tech support, to improve quality processes.

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Study Sample

• Sample: 156 small practices (<5 providers) i d lt i N Y k Citserving adults in New York City

– 44 practices with NCQA PPC‐PCMH recognition– 265 providers– Mean = 1.8 providers per Practice (1.0 – 5.0)Mean = 3 425 active patients per practice– Mean = 3,425 active patients per practice

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Data• Data: EHR, Medicaid claims, practice assessment surveys, and interviews with

id ff d iproviders, staff, and patients• Survey: resources/capacity, practice readiness,

prior experience, whole‐person orientation, team‐based care, care coordination, access

• EHR: visit volume, performance on HEDIS‐type , p ypmeasures (e.g. HbA1c)

• Medicaid Claims: ED and hospitalization rates, continuity of care, medication adherence

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Preliminary Findings

• Transforming a small practice presents i h llunique challenges:

• Many small practices feel they are already operating optimally and don’t require transformation

• Among “transformed” practices, there’s significant variation in experience, expertise, level of leadership p , p , pand organization, and other practice characteristics

• For many small‐practice providers, “transformation” means “using an EHR”

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Preliminary Findings (cont’d)

• Some characteristics of the patient‐centered di l h d t t l t ll i thmedical home do not translate well in the

context of small practices– E.g., “Team based care” requires redefinition for a small practice

• The “value added” by PCMH is different• The value added by PCMH is different in adult and pediatric practices.

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Preliminary Findings (cont’d)• Driving transformation from outside the practice requires multiple approaches and interventions– Technical and monetary incentives may not be sufficient to drive significant transformation

– Except for a small number of high‐achieving pro iders practices req ire consistent laborproviders, practices require consistent, labor‐intensive support

– Some providers did not have sufficient resources to succeed beyond basic EHR implementation

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Summary

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Conclusions for Small Practices

• Externally motivated transformation is ibl b t i b t ti l ff tpossible but requires substantial effort

• Some dimensions of the PCMH model need to be re‐imagined for small practices

• Transformation is highly variable and dependent on multiple factorsdependent on multiple factors

• Patience is required!

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Conclusions for Small Practices

• Practice transformation is extremely challenging in small, high volume Medicaid practices

• Transformation is hard to institutionalize and sustain

• Ongoing external assistance is necessary in• Ongoing external assistance is necessary in many, if not most, practices

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Documents

Practice Transformation Studies · 2019. 5. 22. · PCIP Program • The study focuses on the transformation process led by the Primary Care Information Project (PCIP), a bureau of