Practice Transformation Under the University of Colorado’s Primary Care Redesign Model

Abstract

PURPOSE We compared the transformation experience of 2 family medicine practices that implemented the Primary Care Redesign (PCR) team-based model to improve access, quality, and experience without increasing cost. The University of Colorado's A.F. Williams Family Medicine clinic (pilot practice) implemented the model in February 2015, and a smaller, community-based practice (wave 2 practice) did so 2 years later, in February 2017. METHODS The PCR model increased the ratio of medical assistants to clinicians from about 1:2 to 2.5:1 while expanding the role of the medical assistants, through enhanced rooming procedures, in-room support (eg, scribing), postclinician wrap-up, and in-basket assistance. We assessed access, clinical quality metrics, staffing costs, and clinician and staff experience and burnout for at least 7 months before and 42 months after the intervention. RESULTS In the pilot practice, compared with preimplementation, there were improvements in total appointments and rates of hypertension control, colorectal cancer screening, and most diabetic quality metrics. In the wave 2 practice, total appointments increased slightly when clinicians were added pre-PCR and then increased substantially after implementation; initially variable hypertension control improved rapidly after implementation. The wave 2 practice's colorectal cancer screening improved gradually, then accelerated postimplementation, while diabetic metrics initially remained stable or declined, then improved postimplementation. New patient appointments began to increase for both practices in late 2015, but grew faster in the pilot practice under PCR. Over time, all experiential domains improved for clinicians; most remained stable for staff. Clinician burnout was reduced by at least one-half in both practices except during low staffing periods, which also adversely affected staff. After a ramp-up period, the number of staff hours per visit remained stable. CONCLUSIONS The PCR model is associated with simultaneous improvements in quality, access, and clinician experience, as well as reductions in burnout, while maintaining staffing costs.

Lessons Learned During COVID-19 That Can Move Telehealth in Primary Care Forward

“…People working in these settings are used to continually thinking about, planning, and implementing change. 12 Being practiced at trying new things and learning from prior failures made it possible to move quickly. Even if the telehealth system had been in place, but everyone panicked and could not make the mental shift quickly, or argued about change, things would not have worked so well.…”

The Built Environment for Professionalism

“…Clinical and payment policies that enable change Sinsky, 27 Basu et al, 37 Peikes et al, 38 Smith et al, 17 Phillips et al, 18 Facilitation Facilitation that enable change Phillips et al, 28,39 Cohen et al, 40 Kaufman et al, 41 Ono et al, 42 Adler et al 43 doi: 10.3122/jabfm.2020.S1.…”

“…While these changes require more investment up front, there are good examples that they are eventually cost neutral or associated with significant savings. [17][18][19][20][21][22][23] Coming back to the Cruess's admonitions, facilitating professionalism via a built environment calls for experimentation, partnerships, policy, and implementation (Table 1). Again, the relationship between a built environment for professionalism and one that supports effective primary care is very tight, and while the experimentation, partnership, and advocacy base for the former is just forming, that for the latter is becoming more robust.…”

Facilitating Practice Transformation in Frontline Health Care

“…This strategy was used in the Primary Care Redesign team-based model tested by Smith and colleagues. 12 This model increased the ratio of medical assistants to clinicians from about 1:2 to 2.5:1 while also expanding the role of medical assistants, and was facilitated by practice coaches. Clinician burnout was reduced by one-half with simultaneous improvements in quality, patient access, and clinician panel size-all while maintaining staffing costs.…”

“…Most speak to the need for meaningful relationships and work, without which in-person support does not work, and some show how remote support can work when it is available. Two articles 11,12 remind us that the hard work of change can produce stress and even burnout, sometimes differently across the team, but others suggest that engaging the whole team can enable meaningful improvements. Many are instructive about the important functions of practice facilitators and how these functions may differ by practice type, offering guidance on preparing this workforce.…”