LEAWOOD, Kansas--Early findings from two major federally funded initiatives aimed at accelerating the development and dissemination of health care innovation in the United States were published today as a special supplement to the Annals of Family Medicine. The collective body of work, funded by the Centers for Medicare and Medicaid Services, will help inform how the United States will support medical practice transformation and community health improvement efforts in the years ahead.
In 2015, CMS launched the Transforming Clinical Practice Initiative to help transform the US health care system to one that rewards value over volume. The four-year, nearly $700 million initiative linked more than 140,000 clinicians in all specialties through networks designed to coach, mentor and assist practices in developing the core competencies required to successfully participate in value-based payment arrangements. TCPI also facilitated connections with national and regional professional associations and public-private partnerships to ensure the sustainability of transformation efforts through the active engagement of specialty societies.
The Agency for Health Care Research and Quality's EvidenceNOW initiative received $112 million in grant funding to help primary care practices across the country more rapidly improve the heart health of Americans. Specifically, aligned with the US Department of Health and Human Services Million Hearts® initiative, EvidenceNOW aimed to reduce the research-to-practice delay in implementing best practices to deliver the ABCS of cardiovascular disease prevention: aspirin in high-risk individuals, blood pressure control, cholesterol management, and smoking cessation.
The special report by Kaufman et al in this supplement reminds us of the important history behind EvidenceNOW and TCPI. Section 5405 of the Patient Protection and Affordable Care Act authorized the Primary Care Extension Program, which was modeled after the US Department of Agriculture's Cooperative Extension Program. That USDA program revolutionized farming in the United States over the last century by testing and speeding dissemination of innovation and best practices. Its application to health care was pilot-tested by the Regional Extension Centers under the Health Information Technology for Economic and Clinical Health Act of 2009. The success of that pilot program inspired the design of EvidenceNOW and further supported the decision by CMS to invest in the TCPI demonstration project.
This supplement to the Annals of Family Medicine combines early findings from multiple examples of health extension and practice transformation support. The supplement consists of seven original research articles, one research brief, three special reports, three one-page innovations in primary care, and two commentaries from nationally recognized experts in primary care research and practice transformation.
Original research findings include:
Primary care transformation requires continuing efforts to monitor and address clinician and staff burnout.
Practice changes that reduce clinician burnout may not decrease--and may potentially worsen--burnout among staff.
A Longitudinal Study of Trends in Burnout During Primary Care Transformation
By Kevin Grumbach, et al, San Francisco, California
http://www.annfammed.org/content/17/Suppl_1/S9
Small independent primary care practices perceived facilitation to be an important resource for connecting their practice to the external health care environment.
Connecting to the external health care environment helps small independent practices build their quality improvement capacity through teaching, hands-on support and EHR-driven solutions.
Clinician Perspectives on the Benefits of Practice Facilitation for Small Primary Care Practice
By Erin Rogers, DrPH, et al, New York, New York
http://www.annfammed.org/content/17/Suppl_1/S17
The Primary Care Redesign team-based model promotes simultaneous improvements in quality, access and clinician experience while maintaining staffing costs.
The model increased the ratio of medical assistants and expanded their role in patient care. Clinicians experienced a reduction in burnout without increasing staffing costs.
Practice Transformation Under the University of Colorado's Primary Care Redesign Model
By Peter Chabot Smith, MD, et al, Aurora, Colorado
http://www.annfammed.org/content/17/Suppl_1/S24
Technical assistance to help practices expand access to urgent care can be provided remotely and at scale at low per-practice cost.
Through the provision of timely, easily accessed ambulatory care, optometrists were able to improve patient experience, reduce emergency department use and lower costs.
Transformation Support Provided Remotely to a National Cohort of Optometry Practices
By Ronald Adler, MD, et al, Worcester, Massachusetts
http://www.annfammed.org/content/17/Suppl_1/S33
A practice's ability to reach improved clinical quality measurement performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation.
Smaller practices can improve their performance on cardiovascular disease risk factors with external support. However, these practices many lack the capacity to participate in these additional supports.
A Randomized Trial of External Practice Support to Improve Cardiovascular Risk Factors in Primary Care
By Michael Parchman, MD, MPH, et al, Seattle, Washington
http://www.annfammed.org/content/17/Suppl_1/S40
The methods by which cognitive clinical functions are assigned among team members is challenging and requires facilitation.
The distribution of macrocognitive functions across team members in the patient-centered medical home model is a skill that can be taught, but it cannot be learned from meetings, seminars or lists of best practices. Practice facilitation is essential.
Differences In Team Mental Models Associated With Medical Home Transformation Success
By Lee Green, MD, MPH, et al, Edmonton, Alberta
http://www.annfammed.org/content/17/Suppl_1/S50
Telemedicine is a feasible intervention in multiple primary care settings.
The TIP model (Telemedicine IMPACT - Interprofessional Model of Practice for Aging and Complex Treatments) Plus allows patients to have an active role in their health management, supported by their health care team. This model effectively addresses the needs of the most complex patients and their primary care physicians.
Connecting People With Multimorbidity to Interprofessional Teams Using Telemedicine
By Jocelyn Charles, MD, MScCH, et al, Toronto, Ontario
http://www.annfammed.org/content/17/Suppl_1/S57
EDITORIALS
Facilitating Practice Transformation in Frontline Health Care
By Robert Phillips, Jr, MD, MSPH, et al, Lexington, Kentucky
The articles published in this supplement tell a story of practices needing relationships and real support in achieving meaningful improvement, if not fundamental transformation. The researchers offer insight for helping practices make use of technology to strengthen relationships with patients and to offer complex patients expanded services. They bring to the fore the complexity and spectrum of practice culture and the need to meet them where they are in order to help the difficult process of change.
http://www.annfammed.org/content/17/Suppl_1/S24
Contribution of the Transforming Clinical Practice Initiative in Advancing the Movement to Value-Based Care
By Meena Abraham, DrPH, MPH and Paul McGann, MD, Baltimore, Maryland
This editorial provides context about the ongoing TCPI test model to help readers understand the broader effort addressed by the quality improvement articles in this supplement. To put patients first, CMS is working in concert with partners in the private, public, and nonprofit sectors to transform the nation's health care system to one that rewards value over volume, more closely aligning payment with the quality of care. One way to do this is through alternative payment models, payment approaches developed in partnership with the clinician community that provide added incentives for delivering high-quality, cost-efficient care. To ease the transition for practices, CMS launched TCPI to prepare them for success in achieving outcomes to demonstrate APM success and improvements critical to practice success. The TCPI service delivery (nonpayment) model ends in September 2019, and the continuation of practice transformation and commitment to value-based care rests with the professional associations and clinical practice that took part in the initiative. Although continued efforts will be necessary to move toward a value-based system in the future, the TCPI Practice Transformation Networks and Support and Alignment Networks have identified best practices for preparing both primary care and specialty care clinicians for participation in APMs. Practices that graduated from TCPI are well positioned to participate in APMs, including in the new models announced by the CMS Innovation Center.
http://www.annfammed.org/content/17/Suppl_1/S67
SPECIAL REPORTS
The Role of Health Extension in Practice Transformation and Community Health Improvement: Lessons From 5 Case Studies
By Arthur Kaufman, MD, et al, Albuquerque, New Mexico
http://www.annfammed.org/content/17/Suppl_1/S67
Practice Transformation Analytics Dashboard for Clinician Engagement
By Niharika Khanna, MD, MBBS, DGO, et al, Baltimore Maryland
http://www.annfammed.org/content/17/Suppl_1/S73
Supporting Physicians & Practice Teams in Efforts to Address the Opioid Epidemic
By Lisa M. Letourneau,MD, MPH, et al, Augusta, Maine
http://www.annfammed.org/content/17/Suppl_1/S77
RESEARCH BRIEF
Clinicians' Overestimation of Their Geographic Service Area
By Robert Rock, MD, et al, Bronx, New York
http://www.annfammed.org/content/17/Suppl_1/S63
INNOVATIONS IN PRIMARY CARE
Brief one-page articles that describe novel innovations from health care's front lines.
Improved Outcomes Associated With Interprofessional Collaborative Practice
By Thomas P. Guck, PhD, et al, Omaha, Nebraska
http://www.annfammed.org/content/17/Suppl_1/S82
Coaching Small Primary Care Practices to Utilize Patient Portals
By Lauren Gritzer; MPH, et al, Baltimore, Maryland
http://www.annfammed.org/content/17/Suppl_1/S83
An Empanelment Toolkit for the Safety-Net Clinic Setting
By Stella Gukasyan, EdM, and Mike Wong, MPH, San Diego, California