We interviewed 35 participants from 25 general practices. Participants included practice principals, GP contractors, practice managers, practice nurses and an allied health practitioner. Eighteen participants were from the eight PCMH transitioning practices (all of which were also Integrated Care Program practices), two from former-PCMH practices, five from non-PCMH Integrated Care Program practices and ten from non-PCMH, non-Integrated Care practices (Table 1).
Table 1. Participant sample
Practice type
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Number of practice types in region
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Number of participating practices
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Number of individual participants
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Practice size1 and SEIFA2 rank within Australia
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Active PCMH practices
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8
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8 practices
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8 practice principals (PP)
3 GP contractors (GPC)
4 practice managers (PM)
2 practice nurses (PN)
1 allied health practitioner (AH)
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2 small; SEIFA 6; 6
2 large; SEIFA 8; 10
4 >10; SEIFA 6;8;10;10
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Former PCMH practices
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7
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2 practices
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1 practice principal (PP)
1GP contractor (GPC)
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1 solo; SEIFA 6
1 large; SEIFA 10
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Integrated Care Program (ICP) practices
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60 (approx.)
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5 practices
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5 practice principals (PP)
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1 solo; SEIFA 10
3 small; SEIFA 6;6;8
1 large; SEIFA 6
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Non-PCMH (and Non-ICP) practices
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280 (approx.)
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5 high capacity (HC) practices
5 low capacity (LC) practices
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9 practice principals (PP)
1 practice manager (PM)
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2 solo; SEIFA 6;6
6 small; SEIFA 6;6;6;10;10;10
2 >10; SEIFA 6;6
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|
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25 practices
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35 participants
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1Practice size: solo = one practitioner; small = 2-5; large = 6-10; and >10
2SEIFA decile ranking of socio-economic advantage and disadvantage, with 10 being the most advantaged and 1 being the least
We identified four overarching themes describing PCMH transformations: PCMH vision; implementation of PCMH strategies; structures and processes related to PCMH transformation; and early outcomes of a PCMH model. Each theme and related subthemes are described below and illustrated with exemplar quotations.
Table 2. Themes and subthemes
Vision
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Implementation
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Structures and Processes
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Outcomes
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Alignment of vision
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Leadership in driving change
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Working together as a team
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Patients: enhanced patient centred care and improved health
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Engagement in realising the vision
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Time required for planning and implementation
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New staffing models and organisational change
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Practices: improved provider satisfaction
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PCMH support and training
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Staffing and space implications
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Potential health system and cost efficiencies
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|
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Data driven care utilising information technologies
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|
|
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Communication with external stakeholders
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|
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Challenges of fee-for-service and funding of PCMH models
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Patient Centred Medical Home vision
A clear PCMH vision and whole of practice engagement with the vision were seen as key enabling factors for practices transitioning to a PCMH model of care. Patient Centred Medical Home transitioning practices described a “shared vision” aligned to PCMH values as crucial for transition. Similarly, participants noted that “like-mindedness” helped initiate PCMH transformation: “we came together with exactly the same philosophy” (PCMH4PP). Some participants described implementing PCMH aligned activities in their practice prior to joining the PCMH program:
We were already doing a lot of the things…and trying very hard to achieve some of the changes that are already part of the building blocks in terms of data management, engagement with patients, registration, having people choose their GP, trying for continuity (PCMH4PP).
Whole of practice engagement was also key for staff to both understand and connect with the PCMH vision and to embed PCMH values within a team-based care model. This enabled staff to “build trust between team members” (PCMH5PP), and to take on new roles:
…having the team engaged and making them understand why - not just what we're doing but why we're doing it and getting the buy-in is really important to making sure that they feel that their role is important. (PCMH5GPC)
Conversely, a lack of practice alignment with PCMH values and vision was seen as a barrier to transformation:
The mindset of the practice is probably the problem and unfortunately our practice doesn’t really have that mindset about…quality and improvement. (Former PCMH1GPC)
Lack of engagement was attributed to “inertia” and resistance to change, and seen as demoralising for those wanting to transform their practice:
It can be quite demoralising, a single voice and everyone else is just not interested in what you want to do (Former PCMH1GPC).
Non-engagement with a PCMH vision was also attributed to financial disincentive to change: “If you were a young registrar coming up, why would you do something that’s different?” (Non-PCMH5LC, PP). Some non-PCMH participants raised doubt about the value of a PCMH model and expressed concern about government agendas and additional burden for GPs:
The government wants to shift the responsibility to the GPs. It’s cost saving…give it to the GP to do rather than let us just get on with caring for the patient. I don’t see my role as a GP as supervising lots of other allied health professionals (Non-PCMH4HC, PP).
Implementation of Patient Centred Medical Home strategies
This theme, gathered participant comments related to implementation of PCMH strategies. These comments highlighted the importance of leadership in driving change and engaging the team; time required for planning and implementing ;and PCMH support and training.
Interviewees across all practice types described leadership as critical in driving change; “it’s the principals that drive the change” (Non-PCMH6HC, PP). In PCMH transitioning practices, engaged leadership was noted to facilitate team engagement:
Before, you felt it was your responsibility to do it all, but now, you’ve let go a bit more in a team, I think it’s good (PCMH8PP).
Where leaders were not engaged, it was difficult to implement PCMH transformation:
…in my position as not as an owner of the practice…as basically a GP that works in the practice…it proved very difficult to actually make changes (Former PCMH1GPC).
Many participants commented on the time and effort required for PCMH transformation describing it as a “slower” process than anticipated and requiring perseverance to see outcomes. Several interviewees from PCMH practices described breaking down implementation into manageable components and celebrating small achievements:
…you’re never going to achieve the whole thing in a very short period of time…we need to aim for small achievements and be actually happy about those small achievements (PCMH3PP).
Others advised that changes needed to be implemented slowly and commented that to avoid change fatigue they needed “to learn to not try to do too much” (PCMH5PP).
Ongoing support and training about PCMH processes, particularly use of data for quality improvement, were valued: “we couldn’t have done it without being educated” (PCMH6PP). In-practice support was seen to be “beneficial” particularly if it was “tailored for a specific practice” (Former PCMH1GPC). Yet there were also several practice managers and practice nurses who voiced uncertainty about aspects of PCMH, and felt that the training they had received was not relevant to their needs:
How does it work? I’d like a precise guideline of what it’s supposed to be because I still can’t get in my head what exactly is this PCMH (PCMH1PN).
Some interviewees from non-PCMH practices who were interested in a PCMH model of care suggested that providing customised support, “a case manager”, “an Internet website or a portal with simple answers” (ICP4PP), and guidance from PCMH practices in regards to facilitators and barriers to transformation would be useful:
…getting feedback from other people to see what they found beneficial or what they thought have been drawbacks to the system, so we don’t have the pitfalls (Non-PCMH6HC, PP).
Interviewees from all practice types acknowledged the benefits of receiving IT support, and the need for this to be ongoing. However, many participants described challenges with software required for PCMH change and noted the importance of reliable, fully functional IT systems from the beginning of PCMH transition:
We start to launch and see how it’s going and that doesn’t work. You waste lots of time. You create something, you test it and when it is waterproof then you launch it (PCMH1PP).
Also highlighted by interviewees from all practice types was the need for staff training in computer literacy, particularly for senior GPs who had a lack of exposure to and experience with IT. Resistance to using computer applications was perceived as a barrier to PCMH transformation with some interviewees noting it “a struggle” to get doctors “more IT savvy”: “The senior doctors are not used to the computer. A lot of them still don’t use it” (Former PCMH2PP).
Structures and processes related to Patient Centred Medical Home transformation
The structures and processes described by interviewees in relation to PCMH transitions included working together as a team; operational changes and new staffing models; staffing and space implications, data driven care utilising information technologies; use of electronic communication with external stakeholders; challenges of the fee-for-service approach, and inadequate funding of new models of care.
Building a multidisciplinary team was seen as important across all practice types. Interviewees particularly among ICP and PCMH transitioning practices described building teams by bringing in allied healthcare providers and specialists to work in the one location. Non-PCMH practices noted the need for support to build their multidisciplinary teams:
Ideally if you can get like a psychologist or a podiatrist then that would be better…then we can start building that sort of multidisciplinary team around which we can involve our patients (Non-PCMH6HCPP).
Practices that intended to transition to a PCMH model suggested the multidisciplinary team “might integrate into the system in a more efficient way” (ICP4PP) when it was introduced as part of a PCMH model.
Transitioning practices described a shift to a more nurse-driven model of care, enabling nurses to work at the “top of their licences”:
Doctors will need to have the input obviously, but it will be driven mainly by the nurse (PCMH7PM).
The shift to holistic, streamlined, team-based, nurse-driven care in PCMH and ICP practices was described by some as a cultural change with the emphasis no longer on individual (particularly GP) care of the patient, but on working together as a team sharing patient care:
What we’re changing is the culture of, “I don’t have to do this alone…I can just rely on my team to do things because it’s our patient” (PCMH6PP).
However it was suggested that some GPs viewed the patient as “theirs” and this limited the practice nurse role.
I think the biggest problem that needs to be overcome is the attitude of GPs, that they don’t like other people intruding into their patient care…they don’t trust that their nurse can actually operate within the scope of their licence and do much more. They have this mindset that nurses do dressings and immunisations and that’s it (PCMH3PM).
Additional activities incorporated into PCMH staff roles were said to require more time than was available and overburdening staff with new roles posed a risk. Some interviewees recommended greater clarity around staff roles, particularly in relation to the PCMH model:
Our front desk staff are already doing maximum with their time. There's no free time for them, so we have to create more time for them to do these extra roles” (PCMH5GPC)
I don’t actually know what my role will be. What will I be expected to do? Other things that I’m not currently doing? (PCMH1PN).
Communication was perceived as essential for effective team-based care with PCMH interviewees highlighting the importance of frequent “huddles” (small group meetings to plan patient care):
…morning huddles, afternoon huddles where we're talking about planning the care with the people here every day, like the nurse and the front desk so that they know who's coming and why they're coming (PCMH5GPC).
The term “huddle” was specific to PCMH practices, however, team-based discussions of patient needs and sharing and learning together were also valued among the non-PCMH practices:
Lots and lots of chats going on in corridors and people saying, “what about [name], did you see him the other day”? That sort of informal stuff that keeps the whole connectedness very real…there's no question that there's lots of that stuff happening where at least two people stand together and discuss a patient (non-PCMH9HC, PP).
Interviewees from PCMH practices described a range of staffing implications related to implementing a PCMH model. The need for recruiting committed like-minded staff with a common vision and purpose was considered imperative, yet practices faced challenges in keeping a stable team:
…you need to have all the stars aligned, have people with the right attitudes and the right skillsets coming in to interview and it is really hard. It’s hard to get good applicants and then it’s hard to keep them (PCMH3PM).
Interviewees described difficulties in retaining GP contractors and practice nurses, particularly due to the lack of financial incentive to engage in PCMH style practice:
[GP registrars] usually get a better option, better offer. It’s a totally different type, but how on earth can you compete? So it’s very hard to retain (PCMH1PP).
Working together as a multidisciplinary team in the one location was reported to require additional space. Many interviewees across all practice types, particularly from solo, small and medium-sized practices described the difficulties with providing the physical space required for PCMH transformation. Some interviewees highlighted the need for space to be considered in the initial planning stages. Some described modifications and additions that could be made to existing structures and one practice principal was buying property near the existing practice to cater for a larger team.
…we can’t add on, so we cannot give you allied health professional rooms…there’s only two consulting rooms so only two doctors can work at any one time (non-PCMH4HC, PP).
We don't have a lot of space to do things, so sometimes that actually limits what we can do in terms of group sessions and things like that (PCMH5GPC).
We haven’t got any rooms for any of the allied health personnel so I’m just buying a property next door where there will be larger space…this [PCMH] is what prompted me to do it, because we haven’t got space (ICP5PP).
Besides having a lack of physical space, solo and small group practices in particular found it difficult to attract and fund nursing staff and allied health:
It’s not easy to get a nurse for the practice. They used to come and they didn’t have enough work, and they were working part-time, and they wanted a full-time job (Former PCMH2PP).
As a solo practice, it’s very difficult for the doctor to employ the practice nurse and bring allied health in the same practice (non-PCMH8LC,PP).
PCMH interviewees described the importance of building a well coded electronic medical record to enable review and analysis of patient data. This was stated to be essential for quality improvement. Regular clinical audits enabled PCMH practices to track the health of their patient cohort, see where quality improvement was needed, and plan doctor prompts and patient reminders and recalls:
…improving data quality and then once we've got good data actually analysing it and seeing where we need to improve and then focusing on those areas (PCMH5GPC).
Interviewees described using plan-do-study-act (PDSA) improvement cycles addressing key performance indicators (KPIs) to support quality improvement. Some interviewees suggested that data comparisons between practices would help to improve data quality as well as health outcomes:
It’s good to get that feedback about how your data compares to other practices and also how your data compares over time, any improvements (Former PCMH1GPC).
Whilst IT was a key enabler for quality improvement, interviewees from all practice types highlighted challenges. The Australian national online health record (MyHealth Record), was described by interviewees as “clunky” to use and time wasting. An electronic care plan shared between the GP and the hospital, was reported to be poorly integrated with GP software, requiring time-consuming manual input of data - “double work for somebody” (PCMH4PM). Some practices refused to use it:
one of our major handicaps is our software…the toolbar does not talk to the Linked-EHR and they have to physically put the stuff…lots of GPs in our last meeting stopped using the service because it’s a headache, so I stopped and once I stopped and I don’t use it I forget it (PCMH1PP).
These IT challenges impacted on communication with external stakeholders, particularly hospitals:
We still have to call especially…the hospitals. You never get anything from the hospitals…and it’s got to be also in a format where it’s easy to read. You can’t go through a ten-page discharge summary (PCMH8PP).
A number of interviewees called for one fully integrated electronic system across primary healthcare systems and hospitals:
We have to just really get a system, one system, or a system that will talk to other systems…but it needs to be real time (PCMH4PP).
For others, however, communication had improved and hospital discharge summaries were received promptly:
What is working better is we’re getting lots of referrals from all the hospitals really good now. They come up very promptly, almost immediately. We get them electronically so that actually works really well (PCMH 6GPC).
The Australian fee-for-service remuneration in general practice was cited as a significant barrier to PCMH transformation, perceived as encouraging throughput rather than quality care. It was described as a poor fit with PCMH models of care, particularly the lack of lack of funding for nursing staff and lack of Medicare funding for non-face-to-face care provision:
In the current fee-for-service model the only way you can generate income for the practice is to see patients and then that really leaves you stuck on the same road (PCMH5GPC).
Many interviewees also considered the current HCH trial remuneration to be inadequate and not inclusive of important elements of PCMH, such as costs of non-medical staff and additional registered nurses. The HCH trial was seen by some to be a distraction from implementing a true PCMH model of care:
…if, for example HCH required more time to manage financially and more time to report on it then it actually could be a distraction…it might be damaging to the patient centred medical homes (PCMH5PP).
Outcomes of a Patient Centred Medical Home model
Outcomes attributed to a PCMH model of care included perspectives and experiences from GPs and practice staff of: enhanced patient-centred care and improved patient health; improved provider satisfaction, including through upskilling; and potentially improved health system cost efficiencies, especially through reduced hospitalisations.
Moving towards a PCMH model was described as improving relationships between patients and the practice. Interviewees highlighted PCMH values of patient-centred care where “you put your patient as number one” (PCMH1PP). Patients were included as members of the care team and involved in decisions about management of their care. A comprehensive team-based, patient-centred care model, with a focus on preventive care and follow-up was perceived by staff to improve patient/care team relationships. Interviewees also noted anecdotal evidence from patients that this model helped improve patient understanding and satisfaction:
We managed to follow through those patients more effectively than maybe five years before...and the patients are happy about that (PCMH2 PP).
Interviewees perceived co-location of services as more convenient for patients, enabling them to be seen by multiple care providers at one location and often during the same visit: “the patients find the convenience useful and they certainly like to come to one place” (ICP3PP). This reduced waiting times and enabled more efficient care: “A lot more things can be done for the patient a bit more efficiently…if everybody’s on site” (ICP1PP).
However, interviewees noted that some patients, particularly the elderly, found the shift to preventive healthcare and team-based care challenging, as it was a perceived threat to their longstanding relationship with their GP. Several interviewees suggested a role for patient education about the PCMH model and services available in primary care:
I don’t think they know of a lot of the avenues open to them…patient education to let them know…just what is available to them and why we see them and do what we do” (PCMH8PN).
Working on improving care as part of a team improved job satisfaction for interviewees from PCMH and ICP practices. There were reports of staff “very keen to be upskilled” (PCMH5GPC) and examples of multiskilling and career progression:
It's improving their job satisfaction and involvement in the whole team because they actually become part of the team (PCMH5GPC).
We’ve got our senior receptionist going through the medical assistant course…learning about cholesterol targets and blood pressure targets and how often all these different tests should be done (PCMH3PM).
Practice nurses were enabled to use their skills to best advantage, for example through following up patient care plans:
Most of the care will be done by the nurse…so we promote them and say “practice nurses this is what you do and you are a carer and you are a clinician and you help us” (PCMH2PP).
The PCMH model was perceived by most interviewees as likely to save health systems costs and improve outcomes by enhancing efficiency, and reducing hospital admissions:
My absolute conviction is that we already save so much money because we just don’t have patients go to hospital (PCMH4PP).
The holistic care provided in the PCMH model was also perceived by interviewees as resulting in positive patient outcomes. A shift to preventative care with effective follow up was noted and computer software aided PCMH practices to be proactive in providing healthcare:
…we take great pride in making sure a patient’s immediate problem is dealt with, their preventative health is dealt with, seeing what happened in the last consultation is dealt with and also formalising that in a kind of reminder list (PCMH8PP).
Proposed patient registration was perceived to provide a means of reducing duplication of medical testing:
We have so much doubling…ultimately the health dollar will be much less because the patient will be restricted to three or four doctors (Non-PCMH1HC, PP).