Partnership in Practice: The Coronado Medical Group
Applying Patient-Centered Concepts in the Physician Practice Setting
“By being more personal, we can take better care of populations, and by analyzing our patient population, we identify which individuals we need to engage,” so explains Dr. Kenneth Warm of Coronado Medical Group in California, a four-physician primary care practice serving the Greater San Diego area, which in May 2015 was awarded Level 3 Patient-Centered Medical Home (PCMH) recognition – the highest level of achievement – by the National Committee for Quality Assurance.
What it means to be a patient-centered medical home
The Coronado Medical Group team has dedicated itself to establishing a patient-centered medical home that delivers a personalized care experience fueled by strong partnerships between patients and providers, among all members of the care team, and between the office and other community partners, including Planetree Designated Hospital Sharp Coronado Hospital. Indeed, this alignment of a patient-centered approach between the hospital and practice ensures that partnerships established in one setting extend across the patient’s healthcare experience.
Partnerships take center stage
This is hardly partnership in name only. The practice has developed and implemented numerous tools and processes to encourage the involvement of patients in decision-making, care planning and self-management. For instance, an agenda setting document is completed by the patient to highlight the top three health concerns they would like to address during the visit (honoring patients’ preferences for how the appointment time will be utilized). Goal setting procedures ensure that patients have a voice is establishing what goals would be most meaningful for them, as well as identifying any barriers they foresee in achieving them. Community partners are enlisted as appropriate as supports in achieving those patient-defined goals and priorities. These may include transportation resources, support groups, care coordination assistance, etc.
Transformation at the personal and practice levels
All of these efforts were recognized with the PCMH Level 3 certification. Far more significant, though, than this public recognition is the intrinsic value team members at this practice have found in embarking on this practice transformation work. According to Dr. Warm and office manager Pam Fallon, members of the care team have undergone their own personal transformations, eschewing a mechanical, task-oriented mentality and adopting a more purpose-driven one that draws on how each individual on the care team contributes to helping patients to meet their own health goals.
To support this shift, the responsibilities of all care team members were realigned to ensure that each position was practicing at the top of their license. The practice adopted an “Expanded Vital Signs” order, adding depression, memory and lung disease screenings on to the customary blood pressure, pulse and weight checks medical assistants would routinely complete for every patient. Beyond these expanded vital signs, the scope of medical assistants was expanded to include engaging patients in identifying their most pressing concerns to be covered during the visit, and in establishing health goals that were attainable and motivational for each patient.
Restoring professional satisfaction and joy in practice
Introducing these processes as part of the initial intake and rooming process has created multiple positive downstream effects. Medical assistants are getting to know patients in a deeper way. This creates a greater sense of familiarity for patients who now have additional points of personal contact on the care team. This, in turn, has markedly enhanced team satisfaction. By focusing on meaningful healthcare interactions, all members of the care team are buoyed by the human connections they are able to make and the real difference they see they are making in patients’ lives. And finally, by engaging with patients in this way before they meet with the doctor, doctor-patient interactions are positioned to be all the more constructive. When the doctor enters the room, s/he knows the patient’s top concerns, risk factors to be addressed, and any social, lifestyle or emotional considerations that may create obstacles to the patient managing their health.
For Dr. Warm, a physician for more than 35 years, this approach to practicing medicine is deeply satisfying. “When I started practicing, preventive medicine was a different field than day-to-day medicine, and my visits were very basic, acute medical needs. But my interest has always been in prevention and health enhancement. Now, I’m able to do what I originally wanted and intended to do,” he says. “I feel like my practice is just beginning. We’re just starting to get it right.” Perhaps that’s why when many physicians of his generation may be eyeing retirement, Dr. Warm is rediscovering a joy in practice that has him deeply committed to his work, his colleagues, his patients and his community.
From moments of despair to moments of breakthrough
Which is not to say that achieving this patient-centered office culture has been easy. Far from it. Dr. Warm is candid about the “moments of despair” experienced by the office team as they toiled to work through the requirements to become a patient-centered medical home. Staff, at times, felt overwhelmed and uncertain how to move forward. From those moments of despair, though, emerged the breakthroughs that would ultimately create the momentum the team needed to hit upon patient-centered solutions that fit for their office, their patients and their community.
A shared sense of purpose to collectively take the best possible care of patients became the practice team’s guiding star. That fairly simple point of consensus provided the motivation to alter familiar workflows, take on new challenges and find ways to leverage the value of technology to create a more personalized healthcare experience for patients.
Patient feedback, too, continues to provide valuable insights into improvement opportunities. Though patients were not actively engaged as partners in initial practice transformation efforts (“We felt too vulnerable and self-conscious at the time to imagine that,” says Dr. Warm), looking ahead, the office understands the value of creating more formalized mechanisms for capturing the patient voice – beyond surveys and the informal feedback loops already in place.
To promote sustainability and to monitor the impact of the practice changes on the patient experience, the team collects data on patients’ perceptions of their visits. Since implementing these changes, the office has steadily increased performance on global questions of satisfaction, including overall rating and likelihood to recommend. In addition, the office also receives very high marks on patients’ perceptions of the care team’s concern for them (95.5) and efforts to include patients in decision-making (95.2).
At a Glance: 5 Key Lessons in Practice Transformation
- Recognize and acknowledge that change is not easy, but tap into staff’s deepest motivations for doing this work to fuel a commitment to continuous improvement for the patient.
- Examine roles and responsibilities within the practice. Is everyone practicing to the upper limit of their licensure? Empower staff to take on more meaningful interactions with patients.
- Many practices have embarked on this work, but no practices are exactly the same. Learn and borrow from those who have gone before you. Draw on established tools and resources, but then work alongside your office team – and enlist input from patients and families – to customize the tools to work best for your office and your patient population.
- Don’t lose yourself in the gaps of what you fear your office doesn’t have the capacity to do. Seek out community resources to help narrow those gaps. For instance, Coronado Medical Group engaged a graduate student pursuing a degree in health management and policy from a local university to provide invaluable support with a number of the technical elements of the change effort, including technology upgrades and developing the office policies and procedures that provide the structure necessary to ensure sustainability of the changes.
- Involve your patients at every step in the process. Let them know what you’re up to. Gather feedback. Build an effective partnership with patients to achieve the best health outcomes.