Medical Home Learning Collaborative Tips and Strategies - Lessons from the Field

The following questions were asked of states who have and are currently implementing a medical home learning collaborative

1. How were practices recruited?
2. Did you have facilitators for the practices to help with improvements?
3. What were your requirements for enrollment?
4. What other types of support were offered to practices?
5. What type of strategies were used with practices struggling with the process?

1. How were practices recruited?

From the Pennsylvania EPIC IC Medical Home Program
Practices were recruited in a number of ways. We asked the ELKS home service program staff who they knew in the community who were seeing a lot of CSHCN and were good at it. We also asked some of our practices if they knew other groups that they would recommend (typically in other counties). We also checked with the PA AAP staff to see what physicians/practices were involved in other programs and tried to contact them for practice participation.
This summer we will be recruiting a minimum of 9 new practices. We have developed a marketing CD that will be sent with a cover letter and out new brochure. Since we want to target specific underserved counties, we are getting practice information for the PA AAP member list.

From the Wisconsin Medical Home Program
Practices were recruited from recommendations from Regional CSHCN Center Staff, parents, other providers like Children's Hospital of Wisconsin (CHS). We made personal contact usually by phone.

From the Illinois Medical Home Program
DSCC, the Title V agency in Illinois providing services for CYSHCN, has been actively involved in facilitating QI Teams in pediatric practices for the past three years. DSCC has a three-fold approach to promote the Medical Home Model in Illinois:

• Increasing awareness through presentations to families and professional groups, information brochures for families and physicians, articles in journals and newsletters, and as a subject for discussion at DSCC support group meetings.
• Providing facilitators for practices and pediatric/family physician residency-training programs to develop Quality Improvement Teams and integrate the Medical Home Model into residency curricula as described below.
• Integrating the Illinois Medical Home Model within the routine care coordination activities provided in the 13 Regional Offices throughout Illinois by DSCC professionals (care coordinators with backgrounds in nursing, social work, speech pathology and audiology).

In addition, the Illinois Chapter of the AAP (ICAAP) received a four-year $1,000,000 MCHB grant to expand the QI Team concept to additional primary care practices in Illinois.We therefore had to start actively recruiting for new practices to become involved in Phase II of this grant (July 2006 to June 2008). Stipends were offered to up to 9 practices that participate.

A part of the recruitment involves offering practices a free CME in-office educational presentation on how to establish a QI Team using the Illinois Medical Home Model. This is an opportunity for a practice's entire office staff to hear about Medical Home and how it can benefit both the practice as well as the children served in your community.We
explain the definition of Medical Home, what it means when families say they have a Medical Home, and what it means when physicians say they provide a Medical Home.We also address the issue of “quality health care” and how a practice can easily integrate a QI process with the assistance of a DSCC or ICAAP facilitator to guide the process.

Recommendations from the Iowa Medical Home Initiative
1. Develop a systematic way to assess a clinic’s interest from the beginning of the recruitment process to prevent wasting of time with clinics not seriously considering participation. Interest could be ascertained via a brief phone or paper survey.

2. Provide clinics with informational materials before approaching them about making a decision. These materials would give the clinic a chance to start thinking about the medical home concept, which would allow the IMHI to focus on selling the clinic’s involvement in IMHI during the initial presentation, rather than on education.

3. All clinic staff should be invited to the initial presentation by IMHI, including front desk, administrative, health care providers, and nursing staff. This general introduction to the concept for all staff would increase the likelihood of understanding the medical home approach by permeating the entire practice, thus increasing the chance for success if adopted.

4. Keep those who have declined to be involved with IMHI connected to IMHI. Although to date they have declined to be involved, they probably already know more about medical homes than clinics IMHI has yet to approach. These clinics all have the potential to become adopters in the coming years.

5. Increase exposure to the medical home concept to administrators, front office staff, and health care providers by looking for opportunities specific to each audience. For instance, consider presenting at conferences aimed at clinic staff other than physicians.

6. Use Diffusion of Innovations to make recruitment more targeted. The theory will help staff at target clinics that are more likely to be adopters in the early stages.

2. Did you have facilitators for the practices to help with improvements?

From the Pennsylvania EPIC IC Medical Home Program
We do not have practice facilitators but I can see that they would be very useful. I have tried to have regular contact with each practice and visit them yearly but it is definitely a problem for the practices located in western PA.

From the Wisconsin Medical Home Program
Yes - I think this is critical

From the Illinois Medical Home Program
A DSCC Medical Home project staff member provides facilitation for the team process by coordinating meetings, developing agendas and maintaining minutes, and keeping the momentum going so that systematic changes within the practice can be achieved. Facilitators utilize knowledge of medical home concepts, family involvement,
and QI to support practices. As part of the projects formal evaluation we have included an effort to determine the effectiveness and facilitation of the monthly QI team meetings. We will be comparing cost utilization in practices with/without facilitators’ involvement. Health insurance data to be collected and analyzed before and after the project include: (Primary care visits, ED visits, and unplanned hospital stays for patients presenting with moderate to severe asthma and diabetes.)

From the Iowa Medical Home Initiative
Facilitation Teams recruited clinics and helped them through the IMHI process of establishing a medical home. The Facilitation Teams consisted of one of the Nurse Facilitators (including the Nurse Director or Nurse Coordinator) and occasionally another member of the Planning Group. Nurse Facilitators played a significant role in helping clinics begin to adopt a medical home model. IMHI Facilitators met with each Phase 1 Clinic on a monthly basis. The first meetings involved filling out the Medical Home Index, examining the results from the Index, laying out aims and strategies for achieving change, and learning the basic concepts of the PDSA change cycle. Each Facilitation Meeting concentrated on encouraging the clinic to continue using the PDSA cycle as a method of change. Facilitators worked to support the clinics’ efforts and provide them with the knowledge and information on the changes the clinics decided to make. The Nurse Facilitators devoted time and effort to finding tools, research, and information to support the clinics. One of the positive changes in Phase 2 was the expertise available to the Facilitation Team and clinic staff. There was a general consensus that the process benefited from having experienced Nurse Facilitators to turn to and Physician Advisors. The purpose of a Nurse Facilitator was summed up best by one nurse when she wrote that the Nurse Facilitator’s role is “to help the team move forward and make changes.”

Facilitation Coordinators Survey
Administered in June 2005, this survey was for the Nurse Facilitators and assessed:
• satisfaction with the progress made so far;
  
• to describe the Phase 2 recruitment process and what was easy/ challenging about it;
• how efficient the process was;
• how effective the PDSA had been and whether it had been modified from its original published form;
• how well she feels clinic staff understand PDSA;
• what factors are barriers or facilitators to the Phase 2 recruitment process;
• what impact the change for Phase 1 Clinics from meeting monthly to quarterly has had;
• about lessons learned in Phase 1 that have been used in Phase 2;
• how the two Phases have differed-overall and in recruitment; and,
• how Phase 2 differed from her expectations.
  
  Nurse Facilitator Survey
  This survey was administered in June 2005 to three additional Nurse Facilitators who concentrated on the Phase 2 Clinics. They had never been interviewed or surveyed before on their experiences. Each was asked:
• whether her interpretation of the medical home has changed over time;
• how enthusiasm for the concept has changed over time;
• barriers and facilitators to working with the clinics;
• to describe the Facilitation Team and what the Facilitator’s role should be;
• what she was spending the majority of her time with the clinics doing;
• what the characteristics are of a successful medical home;
• what differences exist between pediatric and family practice clinics;
• to describe the recruitment of clinics;
• how clinics were doing in regards to interest in the medical home, progress, and dedication to change; and,
• satisfaction with the progress made.

The following are recommendations based on the evaluation and of the facilitation process:
1. Explicitly use the concepts in Diffusion of Innovations to ease adoption of new processes. The theory’s constructs provide a useful road map for making the facilitation process more efficient.

2. Consider using a tool to assess clinic staffs’ readiness to change so they may identify a leader or champion, as doing so from the beginning is important. These influential innovators in the clinic will institute more change than other staff members.

3. Spend more time explaining the rapid change cycle and PDSA and how these concepts relate to medical home as a continuous quality improvement process.

4. Help clinics recognize the small steps they are taking and celebrate those successes. Clinic staff get frustrated and unmotivated if they do not see the results of their efforts. Find ways to provide clinics with “pats on the back” to reinforce their work. They already receive this support from the Nurse Facilitators, but additional morale boosts might further encourage their interest and efforts. Some ideas might be a letter of thanks from one of the Academies, payors, the Governor or the IMHI staff, or assistance in receiving press from the local paper for their efforts.

5. Standards should be developed to indicate at what point a practice is considered to be a medical home. People have difficulty striving for something that is undefined. Clinics may be more willing to make efforts to change if they fully understand what they are aiming for.

6. Encourage clinic staff to be thoughtful and honest in their assessment of meetings (Facilitation Meeting Summaries). This information can provide the Planning Group with valuable feedback about the process.

7. Consider including non-key clinic staff in Facilitation Meetings on a rotation basis. This would allow for the concept to spread throughout the clinic without halting the clinic’s work. It would also democratize the process of change.

8. Recognize that not all changes regarding the patient/family level will be obvious to the patient/family population of the clinic.

9. Depending on the CSHCN focus, clinic involvement with the school district or local Area Education Agency might be appropriate. For the chronic care model clinics should consider adding specialists from the local area that would bring a new skill set and resources to the clinic. For example, if the medical home health care focus was on diabetes management, someone from the local American Diabetes Association or Iowa State University Extension Service could be included.

10. Reconsider striving for the streamlined, cookie-cutter approach to change as seen in Phase 2. It is not clear that this approach actually saved time or sped up the process a great deal. Although the workload at the beginning of Phase 1 was intense, it might have been necessary to implementing lasting change.

Virginia Medical Home Program Also Working with DC
In Virginia, we brought facilitation teams to on-site practice visits.  These teams consisted of one MD consultant, the nurse manager of the local Care Connection for Children (Virginia's Title V program for CHSCN), and one Family Voices representative.  The resource team would guide the practice through aim statements and improvement cycles, and would document improvements.

In DC, the HSC Foundation hired a care coordinator for their project.  Our care coordinator has a social work background and has worked previously in DC area health care systems.  We are in the pre-forum visit stage of the DC project right now.  We plan to come on site to the practices who sign on to the DC Collaborative.

3. What were your requirements for enrollment?

From the Illinois Medical Home Project
Primary care practices agree to the following criteria for participation:

• Request and host an in-office in-service about the Illinois Medical Home Model prior to being eligible for participation in the project (preferably NLT April 30, 2006).
• Assignment into either the implementation or control groups.
• Follow the evaluation protocol, which includes identifying 80 to 100 families of CYSHCN by June and fielding the following surveys as stipulated by the University of Illinois Institutional Review Board:
  • Medical Home Index (completed by practice staff)
  • Combined Medical Home Family Index/Caregiver Survey (completed by eligible practice families of CYSHCN)
    
  • In-Office Medical Home Practice Assessment Checklist
    
  • QI Team Meeting Surveys
    
  • Evaluation of 3 IMHP Training Sessions to be held at Shriners Hospitals for
    Children in Chicago, IL
• Identify 80 to 100 special needs families to participate in the Combined Medical Home Family Index/Caregiver Survey (Family Survey); identification of families should begin by April 1, 2006 so the family survey can be fielded with these families in July 2006. 
• Use the MCHB definition* of children with special health care needs to identify families eligible to participate.
• Establish QI Teams consisting of a lead physician; key office staff; at least two parent partners; and facilitators, if assigned to the implementation group or group leaders if assigned to the control group. 

* CYSHCN are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. (Defined by the Maternal and Child Health Bureau in July 1998.)

From the Iowa Medical Home Initiative
The criteria for selection were the clinics’ level of interest in medical homes and their physicians’ potential to influence other clinics’ physicians in their decisions to adopt a medical home model. Early in 2003, clinics signed Memorandum of Agreement(s) with IMHI following a series of informational sessions with the IMHI Facilitation Team.

Phase 1 Clinics had monthly meetings and intensive contact with the Facilitators until late 2004 when the clinics moved to meeting quarterly. Ten clinics participated in Phase 2. As early as December 2004 IMHI began work with some of the Phase 2 Clinics on a regular basis. Clinics in both phases initially completed the Medical Home Index (developed by the Center for Medical Home Improvement).

From these assessments the clinics developed aim statements and goals. Interventions and strategies were selected to achieve the goals. Clinics either focused on improving a process in their clinic that would impact the care of all children with special health care needs (CSHCN), or on a particular diagnosis such as attention deficit disorder/attention deficit disorder with hyperactivity (ADD/ADHD). A systems-based, rapid cycle change process, Plan/Do/Study/Act (PDSA), was used as a mechanism for change.

Virginia Medical Home Program Also Working with DC
In both programs, we are asking practices to recruit a staff member and a parent of a CSHCN to form their core team.  We will also ask them to attend the DC Medical Home Forum (which is all day on a Saturday), and be open to three site visits and work actively on their aim statements and improvement cycles.  We asked practices to fill out a pre- and post- Medical Home Index and Medical Home Family Index.  We also had an exit interview with the physician in each practice.

4. What other types of support were offered to practices?

From the Pennsylvania EPIC IC Medical Home Program
Practices are required to participate in monthly teleconferences where we leave a few minutes for any questions/ clarifications. We also bring all of the practices together 2X a year for ongoing QI efforts. Based on the surveys we have had the practices fill out, they get a lot out of the conferences and collaborating with the other practices in problem solving.

From the Wisconsin Medical Home Program
We offer an honorarium for family participation - otherwise nothing. This year we did a mini-grant initiative (Local Capacity Grants) and 2 new practices received them (1. an academic training site with Medical College of WI/CHW and 2. a Community Health Center along with Group Health Coop (a Managed Care Organization).

From the Illinois Medical Home Program
Implementing the “Plan-Do-Study-Act” cycle of practice improvement, the IMHP
establishes systems to support medical home initiatives utilizing the CMHI Tool
Kit, NICHQ resources, QI team facilitators, technical assistance, and modest funding for practices. Facilitators utilize knowledge of medical home concepts, family involvement,
and QI to support practices. The IMHP is implementing a public relations strategy and will host two state-wide Leadership Forums to spread implementation of medical homes. The first Forum is planned for Spring 2006.

Virginia Medical Home Program Also Working with DC
We supported the Virginia teams with conference calls, one additional conference (Resources for Medical Homes) which featured talks on Financing Your Medical Home and Working with School Nurses, and four presentations of these talks via web/conference calls.

We will do the same for DC. In addition, these practice teams will get a care coordinator on site one day a week for their practices.  In addition, the care coordinator will train one of their practice staff with regard to local resources, so that when the project ends, the practice will have one of their own staff trained to be a care coordinator.  Each practice will also receive a computer, desk, and local resources loaded on to the computer for staff or families to use.

In Virginia, the resource team was always available to help practices that are struggling.  We still get calls from some of these practices.  The connections made throughout the project are rich and ongoing, and that is a wonderful unexpected outcome.

5. What type of strategies were used with practices struggling with the process?

From the Pennsylvania EPIC IC Medical Home Program
I really tried to focus my efforts on having regular contact with the practices and meeting with them in person if possible. I emphasized taking small steps and using a PDSA cycle having them pick a goal to work on. This has been successful in many of the struggling practices but realistically, a few of them end up dropping out.

From the Wisconsin Medical Home Program
This is the part we probably didn't do as well on. Tried to brainstorm among facilitators but I think TIME is the major issue.

These training programs are not directly managed, nor sponsored by the national American Academy of Pediatrics. Local organizations are responsible for hosting and sponsoring these programs.

Last updated August 7, 2008