Welcome to the Practice Redesign Resource Page! We are a resource page for practicing community and academic internists to help you find the communities, resources, and quick links that exist to help you redesign your practice or resident practice.
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Clinical innovation is often about making small changes to an existing system. In some cases, the whole system is redesigned. Below are some examples:
Toolkits
The Quadruple Aim
The classic ‘Triple Aim’ for healthcare is a framework developed by the Institute for Healthcare Improvement (IHI) that describes an approach to optimizing health system performance. IHI asserts that new designs must be developed to simultaneously pursue three dimensions which we call the ‘Triple Aim’:
- Improving the patient experience of care (including quality and satisfaction)
- Improving the health of populations, and
- Reducing the per capita cost of health care
Numerous publications suggest that the list be expanded to a ‘Quadruple Aim’ to include: Improving the Care of and Experience of The Provider (i.e. MDs/other HCPs).
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Top References
Impact of physician satisfaction on patient care
Impact of physician satisfaction on costs of care
The Chronic Care Model
This model, developed by Ed Wagner, serves as a useful paradigm for thinking about the kind of changes needed to develop a more functional healthcare system that is aligned at all levels with the needs of patients with an increasing burden of chronic illness.
Top References
Impact of physician satisfaction on patient care
High MD satisfaction is associated with higher patient satisfaction
Impact of physician satisfaction on costs of care
Value in Primary Care
Care for medical conditions (or a patient population) usually involves multiple specialties and numerous interventions. Value fo the patient is created by providers' combined efforts over the full cycle of care. Accountability for value should be shared among the providers involved. Thus, rather than "focused factories" concentrating on narrow groups of interventions, we need integrated practice units that are accountable for the total care for a medical condition and its complications. Because care activities are interdependent, value for patients is often revealed only over time and is manifested in longer-term outcomes such as sustainable recovery, need for ongoing interventions, or occurrences of treatment-induced illnesses. The only way to accurately measure value, then, is to track patient outcomes and costs longitudinally.
Toolkits
https://www.acponline.org/clinical-information/high-value-care/resources-for-clinicians/high-value-care-coordination-hvcc-toolkit/high-value-care-coordination-project
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The Patient Centered Medical Home (PCMH)
The PCMH is a new model for primary care redesign endorsed by the pediatrics, internal medicine and family medicine specialty societies as well as many of the major healthcare payers.
Its components include patient-centered care with an orientation toward the whole person, comprehensive care, care coordinated across all the elements of the health system, superb access to care, and a systems-based approach to quality and safety. Ultimately, these components are intended to improve patient outcomes—including better patient experience with care, improved quality of care (leading to better health), and reduced costs.
The model varies in its application, but has been implemented successfully in a wide range of settings across the U.S with impressive outcomes in terms of quality, value, and clinician satisfaction.
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Top References
• Bodenheimer, T et al. Patient Self-management of Chronic Disease in Primary Care.JAMA. 2002
http://jamanetwork.com/journals/jama/article-abstract/195525
• Nutting, PA et al. Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient- Centered Medical Home. Ann Fam Med, 2009
http://www.annfammed.org/content/7/3/254.long
• Jackson, GL, et al The Patient-Centered Medical Home: A Systematic Review. Ann Intern Med. 2013
http://annals.org/aim/article/1402441/patient-centered-medical-home-systematic-review
Comprehensive Primary Care Plus (CPC+)
Comprehensive Primary Care Plus (CPC+) is a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation. CPC+ includes two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States (U.S.).
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Top References
https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus
High-Need/Complex Care Management
Atul Gawande’s “The Hot Spotters” article highlighted this concept from the Camden Coalition, Verisk Health, the Special Care Center, and others that provided aggressive care coordination and preventative care to the sickest patients.
Top References
http://www.newyorker.com/magazine/2011/01/24/the-hot-spotters
Zulman, et al. Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients.
JAMA Intern Med. 2017
http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2594282
Team Based Care
Group Health in Seattle, Washington made headlines for a couple of Health Affairs articles in which the authors clearly illustrated their transformation to team-based care with a focus on alternative visit types (phone, emails) and panel management. They were able to demonstrate improved outcomes, cost savings, and an improved patient experience, all three elements of the celebrated Triple Aim.
Featured Video: IHI
Featured Video: Intermountain
Top References
• http://www.aha.org/content/13/13-0110-wf-primary-care.pdf
• https://www.nationalahec.org/pdfs/VSRT-Team-Based-Care-Principles-Values.pdf
• Taylor, E., et al. Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers. Ann Fam Med January/February 2013
http://www.annfammed.org/content/11/1/80.long
Residency Clinic Redesign
Residency teaching program face major hurdles as poor experience in teaching clinics contribute to fewer medical students and residents enter ambulatory primary care careers. Led by the UCSF Center for Excellence in Primary Care, a AAMC report on “High Functioning Primary Care Resident Clinics” has been a pioneer along with a movement towards innovation at many programs across the country.
Quick Links
IHI paper about reforming residency primary care:
IHI 90-Day R&D Project Final Summary Report: Improving Graduate Medical Education: Innovations in Primary Care and Ambulatory Settings. Cambridge, MA: Institute for Healthcare Improvement; October 2012. (Available at www.ihi.org).
AMA Step Forward:
https://www.stepsforward.org/
UCSF High Functioning Primary Care Residency Clinics:
https://www.aamc.org/download/474510/data/aamc-ucsfprimarycareresidencyinnovationreport.pdf
IHI:
http://www.ihi.org/Pages/default.aspx
ACP practice transformation:
https://www.acponline.org/practice-resources/business-resources/practice-transformation
Patients before Paperwork:
https://www.acponline.org/advocacy/where-we-stand/patients-before-paperwork
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If you are interested in contributing your favorite links and content to the SGIM Practice Redesign Resource Page please contact, Dr. Baldeep Singh, Editor, SGIM Improving Care Resource Pages, bdsingh@standford.edu