Primary care in the US is undergoing a transformation--from physician-centered practices to patient-focused teams. An outpouring of energy, thought, and work has gone into this transformation, and a clear picture of this new primary care practice is emerging. To understand how practices are approaching the creation of a successful patient-centered medical home, this research involved site visits and extensive interviews with the leadership and all levels of staff at seven high-performing primary care practices. For the purposes of this report, high-performing practices are defined as those with high levels of patient and staff satisfaction, clinical quality metrics that have improved over time, and a stable financial base. This report focuses on six characteristics considered by these practices to be the building blocks of this new model of health care delivery: (1) Data-driven improvements. High-performing practices collect, clean, and summarize performance data, which are used by clinicians and staff in all corners of the organization to drive effective actions. (2) Empanelment and panel size management. High-performing clinics assign patients to a clinician and team in the process of empanelment, and they actively manage panel size, balancing capacity and demand so that continuity of care and access can be sustained. (3) Team-based care. Teams--including clinicians, medical assistants, registered nurses, front desk personnel, and behaviorists--are created, and all members are responsible for the quality of patient care. Effective teams rely on an explicit vision and clear principles, the same team members working together almost every day in a shared space, defined workflows, established channels of communication, training and cross-training to build skills, ground rules, and clinician-approved standing orders. (4) Population management. Population management addresses the needs of various subgroups of the patient population. Practices provide panel management to support the preventive care needs of all patients. They provide self-management support, or health coaching, to patients with chronic diseases. Patients with complicated medical and psychosocial needs receive a different level of care--complex care management. (5) Continuity of care. Continuity improves quality of care, improves the patient's experience, and lowers costs. To ensure continuity of care, practices require clinicians to work a minimum number of hours and days each week, train front desk personnel to encourage continuity in scheduling, and actively control panel size to ensure that demand does not exceed supply. (6) Prompt access to care. A high priority for patients, timely access to care is difficult to achieve without managing panel size to balance capacity and demand, and building teams that add new capacity. Practices improve access by opening their schedule for only a few weeks at a time, spacing visits by taking care of more needs each time, and offering visits through multiple channels, such as phone, web-based patient portals, group visits, and visits with non-clinician team members, such as registered nurses or medical assistants. The practices visited are remarkable similar in their implementation of these primary car building blocks. At their core, high-performing primary care practices require a functioning data system that is used to drive improvement, the empanelment of patients to a clinician or team with a reasonable panel size, and stable teams with the same people working together on a regular basis. These three central building blocks--which enable the other building blocks to be successfully put in place--have allowed these practices to transform into patient-centered medical homes and ultimately, to provide better care for their patients.
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