By Bo Greaves, MD

We need a major overhaul in primary care. Not just an improvement here or a tweaking there - a MAJOR overhaul! I can feel it in my bones, and I bet most family physicians can too!

The end result of that overhaul, our goal, is now called a Patient Centered Medical Home (PCMH). People all over the country are working on projects aimed at major transformations of family medicine offices. Millions of dollars were invested in the Future of Family Medicine project, which laid the foundation for this wave of energy and enthusiasm for changing our practices.

PCMH's will be radically different in many ways from our practices today. The central features will include:

• Being truly Patient Centered throughout the practice.
• Convenient and open access for each patient to their care team and to all the information they need to optimize their health.
• A strong and trusting relationship between each patient and his/her care team.
• Maximum efficiency by development of strong teams in the office.
• Empowerment of each patient, based on recognition that most health problems can only be managed by an informed and activated patient. Our role is to provide optimal support.
• Systematic approach to providing high-quality and evidence-based care to all patients. This will include real-time decision support, and the wholesale adoption of a culture of on-going clinical quality improvement.
• Patient safety will by improved by wide adoption of procedures and protocols to minimize errors.

When I look at our current practice, it is almost overwhelming to see how far we have to go to build this future. How do we get from here to there? Where do we start? I believe these very basic questions, asked in primary care offices everywhere, are central to the ultimate outcome of efforts to become a Patient Centered Medical Home. If we come up with a reasonable, achievable plan that will allow us to make these major transformative changes, without going out of business in the process, we will succeed.

I'd like to share the story of our efforts, in my office and in my community, to transform our practice in this direction. We are early in the journey, but are excited by our prospects. And we are very committed to making this work.

I am in an office with four other family physicians and four nurse practitioners. Until October 2008, we were part of an independent, multi-office primary care group of family physicians and pediatricians. Last year, we decided we could not, in the long run, succeed as an independent, small group in this market. So our office decided to join Sutter Medical Group of the Redwoods, which is affiliated with the Sutter Medical Foundation of the North Bay. We joined Sutter on October 1, 2008.

As we explored our options over the past year, driven by the desire for our practice to survive and succeed, the physicians and nurse practitioners in our office met frequently, largely to develop a common vision of what we wanted to build in our practice. We were merging two different offices, and this was the ideal time to work toward a common, unified vision of how we wanted to deliver care. We looked at the principles of the PCMH, and ultimately agreed this best described what we wanted to build.

The providers want a more reasonable life. Every year, we are forced to work longer hours, see more patients and take care of more paper work and phone calls after hours. We want more time to spend with patients, and to have that time be quality, organized Patient Centered time. We think transforming to become a PCMH gives us the best chance of achieving those goals

Among the projects we plan to start are:

• Getting the office infrastructure in place, including our current go-live with a new electronic health record.
• Actively promoting patient adoption of the patient profile.
• Actively building strong care teams between providers and back office staff.
• Doing group visits.
• Actively investigating the roadblocks in our system that are faced by our patients when they call the office. This is the No. 1 complaint from our patients.

We recognize these are first steps only. In the very near future, we plan some to have major activities in the following areas:

• Robust education of the care teams (including the providers) in the chronic care model. The goal will be widespread adoption of motivational interviewing, shared agenda setting at each visit, and production of a written patient action plan at the end of each visit.
• Expansion of the role of various care team members, to improve efficiencies of the team and to optimize the value-added time the provider spends with the patient.
• Adoption of registries and other electronic tools to safeguard the care of the entire population of patients, especially those with chronic conditions such as diabetes.
• Widespread adoption of email communication between providers and patients, to improve efficiencies and the patient experience.
• Regular, office-based surveys of our patients, to gain understanding of their experience in our office, and to help us plan interventions to improve.

We are in the early stages of fleshing out this work plan. We also believe this to be true: How we try to change our office processes is more important in the long run than the changes we make. Sustainable change that transforms office practice can never be built from the top down; it must be built from the bottom, by the people who are doing the work. We are working now to build ongoing improvement teams in both the front and back office. Our office manager and back office lead are taking active roles in leading the overall effort.

It is also clear, however, that making these changes will require the commitment of significant resources. Money will need to be spent, and people must attend meetings and gain support to get this work done. We have received the active support of the senior leadership of both our medical group and foundation. Sutter is committed to building Patient Centered care, and agrees our office's experience in working to make these changes will be a valuable contribution to the whole Sutter Health system. We intend to be a Patient Centered Medical Home "learning laboratory."

Luckily, we will not be doing this alone. The Sonoma County Board of Supervisors has the wisdom to recognize there are major problems facing our community's health, and has launched a broad effort called "Health Action" to address these problems.

One of the major crises facing our county is the growing shortage of primary care physicians. In response to this, Health Action is launching a local primary care collaborative which will link six to eight local, diverse practices that are committed to transforming themselves and becoming Patient Centered Medical Homes. By working together, sharing our experiences and our learnings, we should all maximize our chances for success.

The collaborative will begin later this year. Each participant practice will commit to having a team that actively participates in multiple improvement efforts, all moving the practices closer to becoming a true PCMH. We will have regular collaborative meetings with faculty (covering core topics relating to PCMH), supported team meetings, and coaching. Each practice will share their improvement efforts, data, and lessons learned.

The outcome of this 18-month, CAFP-assisted community-wide collaborative aimed at transforming primary care office practices is attracting great interest from the broad coalition of major stakeholders (including major employers and employer groups, hospitals, unions, faith-based organizations, and local and county governments) that makes up Health Action. If everything turns out well, what we will learn over the next couple of years may be of interest to other communities across the country.

Bo Greaves, MD, is a CAFP Past President and chair of CAFP's New Directors in Diabetes Care initiative.