Boston safety-net hospital adapting OneHealth behavioral platform to medical home

By: Neil Versel | Jul 25, 2013 

OneHealth Solutions, a company that largely has focused on employer groups, is for the first time applying its mobile and Web platform for patient behavior change to primary care, courtesy of a partnership with Boston Medical Center.

The safety-net hospital, an affiliate of Boston University School of Medicine, is adopting the OneHealth system, originally to treat substance abuse, depression and other behavioral issues, to its patient-centered medical home initiative. Boston Medical Center will offer low-income patients access to the OneHealth online and mobile platform to promote self-management of chronic diseases, offer peer support and engage them in between office visits.

“It will be an integral part of the medical home,” said psychologist Dr. Robert L. Sokolove, who is championing the rollout at the 496-bed hospital in Boston’s South End.

“BMC partnering with OneHealth was done to mitigate a very longstanding issue in disease management,” Sokolove told MobiHealthNews. Counseling patients on smoking cessation, obesity, stress reduction and depression is about teaching skills that lead to lifestyle changes. “After the skill sessions have stopped, maintaining the skills, especially a year out, becomes very, very difficult,” Sokolove said.

OneHealth, available through Android or Apple iOS apps or through the Web, is meant to provide patients with information and social support that leads to the maintenance of newly acquired skills, Sokolove explained. He said that upper-middle-class patients tend to have the social support they need, especially as they are treated for depression and diabetes, but the lower-income populations, including immigrants, that frequent BMC tend to lack such networks.

“This can be one small way for removing those barriers to access,” Sokolove said.

He called the social aspect of the mobile platform a “sort of Facebook for patients” that helps them self-manage chronic diseases and reduce anxiety that can lead to poor choices such as smoking or eating unhealthy foods. “Anxiety is reduced by two factors: attachment and mastery,” explained Sokolove. “We feel less anxious when things are predictable.”

What BMC patients do have are mobile phones, and many are starting to acquire smartphones as well, which makes a mobile platform a great means of outreach. “Many of our patients can’t use a desktop because they don’t have a desk, but they do have smartphones,” Sokolove reported.

Solana Beach, Calif.-based OneHealth, launched its OnTheGo native mobile apps, optimized for tablets, in February. “Our mobile has overtaken the Web experience,” according to CEO Bruce Springer.

The company, which was known as OneRecovery until a little more than a year ago, has its roots in treating substance abuse, but has since integrated medical resources with behavioral tools. Springer said that those with chronic medical issues such as diabetes are 50 percent more likely than others to have behavioral comorbidities like depression, and that can lead to poor lifestyle choices that exacerbate chronic conditions.

Springer said he is excited about working with an academic safety-net provider because he believes the OneHealth system works well with Medicaid and uninisured populations and because Boston University offers research opportunities to help validate the technology.

“It’s hard to reach them,” Springer said of patients BMC is trying to bring into medical homes. “It’s hard to get them activated in programs to improve their health.” With providers increasingly taking on financial risk, they have to manage patients outside the hospital or clinic, and mobile technology is an ideal way to do so, Springer added.

Sokolove said there will be a research element “eventually,” but for now, he wants to get the program launched by September for smoking cessation. “What I hope to do is build it out slowly,” Sokolove said, tailoring the language to the right health literacy levels and tweaking the interface so the OneHealth platform is easy to use.

Boston safety-net hospital adapting OneHealth behavioral platform to medical home

Medical neighborhood project aims to connect primary care practices, community providers

By: Cody Erbacher
A nationwide “medical neighborhood” pilot project aims to connect primary care practices with community-based health providers to improve care and lower costs.
The Patient-Centered Medical Neighborhood (PCMN) builds on the Patient-Centered Medical Home (PCMH) concept that’s designed to improve care coordination between primary care practices and specialists.
A total of 90 primary care practices will participate in the project, according to TransforMED, a subsidiary of the American Academy of Family Physicians (AAFP).  
“Implementing the PCMH model is critically important,” said Bruce Bagley, MD, FAAFP, interim president and CEO of TransforMED. “The context of a well-coordinated and connected medical neighborhood will not only give patients the safe, reliable and efficient care they desire, but also will increasingly empower them to manage their health in a proactive way.”
TransforMED, whose purpose is to give consultation and support to physicians transforming their practices to PCMHs, believes the project could lead to a more efficient, coordinated healthcare delivery network that improves care at a lower cost.
In attempts to understand current process and identify areas of improvement, TransforMED will meet with practice leaders to assess four areas: costs, health, patient experience, and scalability.
This three-year project, funded by a $20.75 million award by the CMS Center for Medicare and Medicaid Innovation, will involve 15 health systems in 65 cities across the country.
TransforMED plans to attain the following goals by 2015:
Reduce overall costs for Medicare and Medicaid beneficiaries by 4% ($49.5 million).
Improve the health of the eligible population by an average of 15% - and at least 3% improvement – in each selected quality measure.
A 25% improvement in patient experience measures that reflect patient engagement, access, and quality.
Demonstrate the ability to scale to additional practices within each community.

http://medicaleconomics.modernmedicine.com/node/371701

ACOs strike it hot in healthcare

John Andrews, Contributing writer

June 28, 2013

The hottest letters in healthcare right now are A, C and O. And while together they stand for accountable care organization, industry analysts say providers need to look beyond the acronym in their efforts to build a new business model.

Nick Sears, MD, chief medical officer for Atlanta-based MedAssets, understands that there is some confusion and trepidation among provider groups about how to start an ACO. As a veteran observer of industry trends over the past quarter-century, Sears realizes the magnitude of change that is being required of healthcare providers and the daunting task associated with making the necessary modifications.

“At this point, providers shouldn’t worry about what an ACO looks like, but instead focus on the building blocks that go into it,” Sears said. “Although it is part of the Affordable Care Act, which is currently under scrutiny in Congress, the intent of ACOs will continue even if parts of the ACA are stricken. So providers have to identify their risks in the whole value-based purchasing model because if they don’t they are in trouble.”

As the new healthcare model has emerged over the past couple of years, Jeremy Belinski, director of operations at MedAssets, has taken to call ACOs by another acronym – CIO, for clinically integrated organization. The description seems more apt for the machinations of putting groups together, he says.

“As we’ve dug into the process, we’ve found it is easy to form a legal entity, yet each group has its own model for doing things,” Belinski said. “But just because they’ve joined together doesn’t mean they can make it work. Making it operational has been a challenge. They have to get good at managing costs and aligning physicians, which is easier when you’re part of an organization. The challenge is to extend beyond the four walls of the hospital.”

Managing metrics

Ken Perez, director of healthcare policy for Emeryville, Calif.-based MedeAnalytics, has been studying the metrics associated with ACO configuration in both the Medicare and commercial insurance domains, developing a comprehensive report and a series of informative videos on the subject. His research found that ACO metrics can be divided into six categories: pediatric, ambulatory, prevention, acute care, outcomes, and utilization of services.

“As more ACOs become multi-payer, it is increasingly important to understand — for the sake of leverage and organizational alignment — the general themes and commonly used metrics used in ACO agreements,” Perez said. “This strategic understanding will help shape emerging best practices for successful ACOs.”

In discerning between commercial and Medicare ACOs, Perez found that commercial organizations place greater emphasis on areas of integration, pronounced cost reduction and resource utilization while Medicare ACOs are focused more on quality outcomes.

“There is a lot of variability between commercial and Medicare ACOs because of different programs and models and you have to choose what game you’re going to play,” he said. “The end game for the provider has got to be multi-payer, so whether you start with Medicare or commercial, you will have multiple payers, you must leverage costs across the board and implement a standardized level of care.”

The 9 C’s

“Medical Home” is another moniker associated with the ACO concept and while some see them as interchangeable, Tom Doerr, MD, does not. A general internal medicine practitioner who focuses on geriatric patients, Doerr also serves as director of innovation research for St. Louis-based Lumeris.

The difference between the Medical Home blueprint and a true ACO, he says, is that the Medical Home design does not go far enough in determining how care is delivered.

“There are nine key elements to care called the ‘9 C’s’ and the Medical Home only incorporates the first four elements,” Doerr said. “We architect how care is delivered at the physician practice level with workflows, metrics and behavioral strategies to convert to value-based delivery. The first four C’s are part of the primary care model, but they are not new. An accountable primary care model should include all nine elements.”

The 9 C’s as Doerr explains them are as follows: Contact with the healthcare system; Comprehensive care; Continuous care that is longitudinally focused; Care coordination; Credibility and trust with the physician; Collaborative learning between payers and providers; Cost effective care; Capacity expansion through technology; and Career satisfaction.

“Beyond the 9 C’s they need to have the collaborative payer model,” he said. “The collaborative payer model makes the payer an ally of the provider.”

Doerr appreciates the irony in his advocating alliances between two traditional adversaries, but maintains that a cooperative spirit can occur when each side sees mutual benefit.

“The national movement toward ACOs has legs and is gaining traction,” he said. “It is blending the role of payer and physician; both quality and cost. While some still aren’t comfortable with it, as the movement gains momentum, that resistance will drop.”

http://m.physbiztech.com/news/business/acos-turning-heat-healthcare

UMass Medical School Health Policy Experts to Present at AcademyHealth Conference

Sharing Knowledge on Patient-Centered Medical Homes, Behavioral Health and Dental Policy.

June 21, 2013 09:09 AM Eastern Daylight Time 

WORCESTER, Mass.--(BUSINESS WIRE)--Several health policy experts from UMass Medical School will present at AcademyHealth’s annual research meeting, taking place in Baltimore, June 23 - 25.

Bruce Barton, PhD, research professor in the Medical School’s Quantitative Health Sciences department, and team leader for research methods at the School’s Commonwealth Medicine division, Center for Health Policy and Research, will deliver a podium presentation on interim results from the Massachusetts Patient-Centered Medical Home Initiative.

Dr. Barton’s podium presentation will take place on Tuesday, June 25, 11:30 a.m., at the Baltimore Convention Center, room 317.

A multi-disciplinary team from UMass Medical School was instrumental in helping implement and evaluate the Massachusetts patient-centered medical home demonstration project, an initiative that involves 45 primary care practices and multiple payers. Dr. Barton will present findings from a study that analyzed the extent to which practices adopted characteristics central to medical homes, including increased access to care and information, improved care coordination among practice team members and delivery of care that is considered “patient-centered” – a model that supports the involvement of patients and families in all care decisions. Robin Clark, PhD, Judith Steinberg, MD, and Ann Lawthers, ScD, co-authored the study with Dr. Barton.

UMass Medical School, Commonwealth Medicine staff will also be making several pre-conference presentations on behavioral health and state health policy topics to colleagues from around the country, as well as presenting posters during the conference. Below is a complete schedule of presentation and poster sessions.

Presentations
Date and Location					Presenter Name			Title
June 22, 2013 9:45 a.m. Convention Center Room #317					Judith Steinberg, MD, MPH			State Policy Interest Group Meeting - Massachusetts Patient-Centered Medical Home Initiative: Impact on Clinical Quality at Midpoint
June 22, 2013 3:20 p.m. Convention Center Room 319/322					Judith Steinberg, MD, MPH			Behavioral Health Interest Group Meeting - Integrating Behavioral Health Care into the Patient-Centered Medical Home: The Massachusetts Experience
June 22, 2013 4:45 p.m. Convention Center Room 319/322					Robin Clark, PhD			Behavioral Health Interest Group Meeting - The Impact of Prior Authorization on Buprenorphine Dose, Cost and Relapse Rates for Massachusetts Medicaid Beneficiaries with Opioid Dependence
June 25, 2013 11:30 a.m. Convention Center Room #317					Bruce Barton, PhD			Podium Presentation: Adoption of Medical Home Characteristics: Interim Results from the Massachusetts Patient-Centered Medical Home Initiative

Posters
Date and Location			Presenter Name			Title
June 23, 2013 2:30 p.m.-4:00 p.m. Poster Session and Number: Exhibit Hall A, #423			Paul Kirby, MA			Dental Service Quality Measurement in a Medicaid Population: Testing Measure Sensitivity to Continuous Enrollment Requirements (Authored by Paul Kirby, MA, Bruce Barton, PhD, David Tringali, MA, Brent Martin, DDS, MBA)
June 23, 2013 2:30 p.m.-4:00 p.m. Poster Session and Number: Exhibit Hall A, #431			Paul Kirby, MA			Early Experiences from the Massachusetts Multi-Payer Patient-Centered Medical Home Initiative (Authored by Teresa Anderson, PhD, Linda Cabral, MM, Laura Sefton, BA, Ann Lawthers, ScD)
June 23, 2013 2:30 p.m.-4:00 p.m. Poster Session and Number: Exhibit Hall A, #477			Sai Cherala, MD			Massachusetts Patient-Centered Medical Home Initiative: Impact on Clinical Quality at Midpoint (Authored by Judith Steinberg, MD, Sai Cherala, MD, Christine Johnson, PhD, Ann Lawthers, ScD)
June 24, 2013 9:45 a.m.-11:15 a.m. Poster Session and Number: Exhibit Hall B, #616			Judith Steinberg, MD, MPH			Integrating Behavioral Health Care into the Patient-Centered Medical Home: The Massachusetts Experience (Authored by Judith Steinberg, MD, Megan Burns, MPP, (Bailit Health Purchasing), Michael Bailit, MBA, (Bailit Health Purchasing), and Alexander Blount, EdD, (UMass Medical School)

About the University of Massachusetts Medical School

The University of Massachusetts Medical School, one of the fastest-growing academic health sciences centers in the country, has built a reputation as a world-class research institution, consistently producing noteworthy advances in clinical and basic research. The Medical School attracts more than $255 million in research funding annually, 80 percent of which comes from federal funding sources. The mission of the Medical School is to advance the health and well-being of the people of Massachusetts and the world, through pioneering education, research, public service and health care delivery. Commonwealth Medicine, the Medical School’s health care consulting and operations division, provides a wide range of care management and consulting services to government agencies and health care organizations. For more information, visit commed.umassmed.edu.

Contacts

University of Massachusetts Medical School
Tom Lyons, 508-856-2115
thomas.lyons2@umassmed.edu

http://eon.businesswire.com/news/eon/20130620006033/en/%22Commonwealth-Medicine%22/Patient-Centered-Medical-Home/Bruce-Barton

NCQA Making Changes to Medical Home Program, Seeks Comment

The National Committee for Quality Assurance, a health care accreditation firm, has released for public comment proposed changes to standards for the fifth iteration of its patient-centered medical home recognition program.

Changes emphasize outcomes measures, resource stewardship such as avoiding duplicate services, and targeting resources based on patient needs. Increased applicability of standards to pediatric practices, alignment with Stage 2 EHR meaningful use requirements and integrating behavioral health with primary care also factor into changed standards. More information on accessing the changes and making public comment, due July 22, is available here.

NCQA this year has introduced two new initiatives to support the existing core medical home recognition program. In January, it announced a new program to credential medical home “content experts” and posted its first 100 credentialed experts from 29 states in May. In March, NCQA introduced a patient-centered medical home recognition program for physician specialists outside of primary care.

http://www.healthdatamanagement.com/news/ncqa-recognition-accreditation-certification-medical-home-comment-46294-1.html

BACH transitions remaining primary care services to medical home model

Written by Victoria Tarter For Blanchfield Army Community Hospital Public Affairs
Jun. 14, 2013 | theleafchronicle.com

FORT CAMPBELL, KY. — Blanchfield Army Community Hospital transformed three primary care clinics
into Patient-Centered Medical Homes (PCMH) during an Open House Ceremony Friday, June 7. The
PCMH model offers patient-centered, team-based, holistic care, which places the patient at the center of
the care model.
The Open House Ceremony took place on a windy afternoon on the lawn outside the patient entrance of
“C” building. Ceremony speakers, including hospital commander Col. Paul R. Cordts, chief of primary care
Col. David Brown, and acting senior mission commander for the 101st Airborne Division and Fort
Campbell Brig. Gen. Mark R. Stammer, explained how the Blue, Young Eagle and Byrd Family clinics
have now been reformed into the Air Assault Family Medical Home, the Young Eagle Medical Home and
the Byrd Family Medical Home.
"We are here today to recognize 343 team members and approximately 30,000 patients enrolled to the
three transforming services,” said Cordts.
Cordts also thanked the Family members who partnered with BACH to create an ideal system of care.
Cordts explained that several shifts in services occurred to support the transition to the PCMH model.
The Air Assault Family Medical Home expanded to incorporate the former Well Baby Clinic. This provided
optimal space for the four medical home teams as well as the expanded team members who integrated
into the Air Assault Family Medical Home, including behavioral health, nutrition, clinical pharmacy, case
management and population health providers.
The Emergency Center incorporated the Urgent Care Center, which allowed the Young Eagle Medical
Home to expand into two teams, with Team Soar occupying the former Urgent Care Center.
In addition to honoring the cooperative work of both patients and staff, Stammer highlighted the primary
care team’s success despite financial challenges.
“You have been working to not only improve our Soldiers’ and their Families’ patient care experience, but
also work to maximize healthy outcomes all the while working with a decreased budget,” said Stammer.
Stammer pointed out that Army Medicine is one essential part of the budget, and the relationship between
patients and their caregivers is an essential part of Army Medicine.
There are two major benefits of the PCMH model.
The first is to improve the continuity of care by ensuring patients see their dedicated care team rather than
any available provider. This helps patients build stronger relationships with a care team that understands
their specific medical history and health goals. Expanding personnel within the medical homes, along with
restructuring the workflow within each service, has made this care model possible.
Second, in addition to creating a higher degree of medical care, this new model includes the Army Secure
Messaging System powered by Relay Health. This enables patients to send secure e-mail messages to
their care teams. Patients can e-mail questions to their care team or request appointments, lab results,
medication refills and referrals.
BACH’s noncommissioned officer in charge for the Air Assault Medical Home Sgt. Mark Migala explained
the benefits of creating additional, open lines of communication between patients and caregivers.
“You can do it right there from your iPhone,” said Migala.
To register for this program, patients must simply contact their healthcare team. BACH’s appointment line
Call Center personnel will inform patients about their clinic’s transformation to a PCMH and their assigned
team.

http://www.theleafchronicle.com/viewart/20130614/NEWS01/306140036/BACH-transitions-remaining-primary-care-services-to-medical-home-model

Paladina Health Opens Its 35th Innovative Primary Care Clinic

Employer-sponsored medical home model delivers higher-quality, lower-cost health care to employers and individuals

DENVER--(BUSINESS WIRE)--Paladina Health, LLC, an innovative employer-sponsored medical home health care provider, today announced the opening of the 35th clinic in its growing nationwide network. Located at 32275 32nd Ave. S. in Federal Way, Wash., the clinic is Paladina Health’s^TM second in the state.

“Paladina Health is determined to lead the way to better, more affordable care that helps employers attract, support and retain healthier employees.”

Paladina Health’s employer-sponsored medical home model helps self-insured employers comprehensively manage the health and health care cost of their employees and employees’ families, leading to as much as 15 percent total cost savings.

These results are achieved through a physician-access model designed to deliver a differentiated employee benefit as Paladina Health's physicians proactively work with patients to improve their health and provide quality care in an easily accessible location.

The model’s components include:

• 24/7 employee access to a personal physician, who is available via mobile phone and is held accountable for their patients’ satisfaction, engagement and health;
• Convenient clinics that are located at an employer worksite or at a shared, near-worksite location;
• A broad number of medical services, including primary, preventive and basic urgent care provided for a low fixed monthly fee; and
• Assistance to patients in navigating specialty and hospital-based care to high-quality, low-cost providers as needed.

“Health care in the U.S. has to change,” said Rebecca Steinfort, Paladina Health Chief Operating Officer. “Paladina Health is determined to lead the way to better, more affordable care that helps employers attract, support and retain healthier employees.”

Paladina Health’s Tacoma, Wash., clinic has shown significant improvements in total health care costs while also driving high employee satisfaction, loyalty and productivity. The company plans to release a case study showing the Tacoma clinic’s health results data later this month.

Like the Tacoma clinic, the Federal Way clinic will be available both to employer groups and to individuals who want to purchase a membership directly.

Paladina Health currently operates in 12 states, with some of its clinics and practices currently operating under the name ModernMed®.

Paladina Health is a subsidiary of $9 billion health care services company DaVita HealthCare Partners®. Part of DaVita HealthCare Partners’ strategy includes developing innovative healthcare delivery models with the goal of dramatically improving the cost and quality of healthcare in the United States.

Paladina Health, the Paladina Health logo, DaVita, HealthCare Partners and DaVita HealthCare Partners are trademarks or registered trademarks of DaVita HealthCare Partners Inc. All other trademarks are the property of their respective owners.

About Paladina Health

Paladina Health’s mission is to provide unbiased advocacy for patients and employers in their quest to improve access to high-quality, affordable healthcare. Paladina Health strives to redefine employer-provided health care in the United States. More information is available at PaladinaHealth.com.

About DaVita HealthCare Partners

DaVita HealthCare Partners, a Fortune 500® company, is the parent company of DaVita and HealthCare Partners. DaVita is a leading provider of kidney care in the United States, delivering dialysis services to patients with chronic kidney failure and end stage renal disease. As of March 31, 2013, DaVita operated or provided administrative services at 1,991 outpatient dialysis centers located in the United States serving approximately 156,000 patients. The company also operated 41 outpatient dialysis centers located in nine countries outside the United States. HealthCare Partners manages and operates medical groups and affiliated physician networks in California, Nevada, Florida and New Mexico in its pursuit to deliver high-quality health care in a dignified and compassionate manner. For more information, please visit DaVitaHealthCarePartners.com.

Relationships Are a Critical Part of Building Medical Homes

WEDNESDAY MAY 15, 2013

The small Nebraska town where I practice family medicine has a population of about 2,000. Although my practice is only 30 minutes west of Lincoln -- the state's capital and second-largest city -- solo and small family practices are common in the rural areas to my north, south and west.

As my colleagues in these small practices ponder the patient-centered medical home (PCMH), I know that it can seem overwhelming to implement. The bodies that recognize or certify PCMH practices have numerous confusing requirements that have more to do with processes than patient care. So when I talk to family physicians who have concerns about the PCMH, I suggest they read the original articles on the subject by Barbara Starfield, M.D., M.P.H.

Instead of a large number of boxes to check, Starfield thought there were three simple things at the core of becoming a medical home.

The first is to be comprehensive in your approach to health care. It is comprehensiveness that separates us from our subspecialty colleagues who focus on a single organ system or a single disease entity. It is comprehensiveness that separates us from midlevel providers who say they can deliver care as well or better than family physicians. Ordering more tests and referring to subspecialists is not comprehensive care. Family medicine is.

The second critical factor is disease management. We all know there are certain diagnoses that predispose patients to increased morbidity and mortality. The Academy has clinical recommendationsand resources to help your practice with chronic disease management protocols that fit your practice. You also can develop disease registries to be more proactive with these patients. By doing so, we can reduce morbidity and mortality and ultimately reduce costs to our health care system.

Finally, relationships and continuity of care are important. Knowing our patients and their families facilitates caring for them. This can reduce duplication of tests and improve compliance to treatment plans by understanding each patient's culture and concerns. I recently had this brought home to me by one of my long-time patients.

Oliver was a 92-year-old, retired minister who had contracted pneumonia and required hospitalization. I have cared for his family for years. In fact, I delivered two of his grandsons.

Oliver was not responding to treatment, so as I examined him, I talked to his family -- including those grandsons -- about other interventions we could try to improve his situation. As I talked, his son, David, got out of his chair, came to me and placed his hand on my arm. He said, "Dr. Wergin, you know my dad loves you, and we all love you. You are as much a part of our family as anyone in this room. We wanted to let you know that my father does not fear death and is ready for what's to come. In fact, we are all ready for what's to come, but we're worried about you. You don't seem to be ready."

I looked at David and told him I understood. I went to the nurse's station and wrote a prescription for morphine and other comfort measures. I continued to round on him and talk to him each day. There was no new hospice nurse or shift-working hospitalist. Instead, it was just me and Oliver's family. That's family medicine.

Oliver passed away a few days later. It was a quiet death, and his family members were with him.

Medicine is always changing, and we have to be prepared. It is important to develop a plan to meet PCMH requirements if you want to be recognized or certified as a PCMH practice. We know that our strict fee-for-service model, which has not served us well, is coming to an end. To be reimbursed in a new model of payment, we must show we deliver what we promise. Don't be discouraged, and remember that patient-centered care is based on these three things: comprehensiveness, disease management and relationships.

How do you build relationships with your patients?

Robert Wergin, M.D., is a member of the AAFP Board of Directors.

Teamwork Key to Improving Quality of Care

Teamwork Key to Improving Quality of Care

I've been interested in the patient-centered medical home (PCMH) since the Future of Family Medicine report recommended that every American should have a medical home back in 2004. I was on the AAFP's Commission on Practice Enhancement (now the Commission on Quality and Practice) from 2006-2010, and the concept was a hot topic for our commission.

When my multi-specialty medical group in New Mexico decided to implement the PCMH in our own clinics, I served on an advisory committee that helped make it happen. When it was time to implement electronic health records (EHRs), my clinic was the guinea pig. We got our EHR up and running before the system was rolled out to the whole group. Today, all 10 of our primary care clinics have achieved National Committee for Quality Assurance Level 3 PCMH recognition. 

Although teamwork was critical to the progress we made as a larger organization, looking back I realized we hadn't done enough team building in our own clinic. So beginning in 2011, we worked to improve our practice -- which has 30 employees, including three physicians and three nurse practitioners -- by establishing a high-functioning team dedicated to addressing issues specific to certain diseases, conditions or issues.

We didn't dive right in. It was a deliberate process. We spent six months carefully crafting mission and vision statements and setting goals and objectives.

It might sound like slow going, but it was worth it. Our staff members -- both clinical and office -- now own the concept of working together and are invested in it. We believe in it, and that's huge.

Every Monday morning, we meet to review a list of objectives and select new projects to begin. We have made some significant strides, but quality improvement never ends.

Our diabetes team started with a simple project to become familiar with the process of foot exams. Physicians and nurses, me included, were not consistently performing foot exams for every patient with diabetes. And when they were being performed, the results were not consistently recorded in the right place in our EHR. Our team devised new protocols to ensure that the exams are performed and recorded in a consistent, retrievable manner.

Our pain management team extensively reviewed the new state regulations for opioid prescribing and monitoring to make sure patient agreements are signed and that regular screenings are performed. We added several instruments to our EHR and made it easy for everyone to learn and use them. Now, every patient on long-term opioids has a signed agreement, documentation on a statewide database, periodic urine drug screening and a treatment plan.

Some projects are more complex. One team is working toward a goal of having every patient in our practice aged 18 years and older have an advance directive. They are establishing a process to introduce the concept to patients and to follow up and ensure forms are returned. It's not an easy task. But after surveys, training and EHR modification, the process is poised to encourage and track patients' use of the advance directive at whatever level they deem appropriate with our guidance. Our method has been spread to our other primary care clinics, making it easier to approach this sensitive subject.

The work we've done is a step beyond what PCMH recognition calls for, but this is what the PCMH truly is about. It has resulted in better care for patients and more satisfying work for employees. Team building has been a very rewarding process, with no end in sight. It is the future because it is continuous quality improvement that is now part of our clinic culture.

What team work successes have you experienced on your road to PCMH transformation?

Richard Madden, M.D., is a member of the AAFP Board of Directors.