Practices that engage in patient-centered care are seeing improved quality of care, patient experiences, care coordination, access to care, and outcomes. These results demonstrate that the time and effort invested in practice transformation is very worthwhile.
HANYS Solutions Practice Advancement Strategies helps healthcare providers identify the care delivery model that best suits their practice and works closely with providers to achieve practice transformation. Examples of care delivery models include:
- Patient-Centered Medical Home: Treatment is coordinated through each patient’s primary care physician to ensure that patients receive care when and where they need it, in a manner they can understand.
- Patient-Centered Specialty Practice: Exceptional care coordination by specialty practices in the outpatient setting, leading to less duplication of procedures and fewer hospitalizations.
- Comprehensive Primary Care Plus: CPC+, the Centers for Medicare and Medicaid Services’ innovation model, is a five-year program with additional financial resources and flexibility to make investments that will improve care and reduce the number of unnecessary services for patients.
- Advanced Primary Care: This New York State initiative links a service line care delivery model with reimbursement to promote improved health and healthcare outcomes, and financial stability.
Regardless of the transformation model pursued, the initial question is always: why?
The benefits of embarking on a practice transformation journey include:
- Achieve the Triple Aim
- Improved patient experience of care (including quality and satisfaction)
- Improved population health
- Reduced healthcare costs;
- Better coordinated care and outcomes for patients
- More satisfied and engaged patients, physicians, and clinical staff
- Stronger patient-centered culture and operations
- Enhanced reimbursement through payment incentives
Patient-centered, team-based care is not just a passing fad or a certificate on the wall. It is a culture that must be established, reinforced, and woven into the fabric of site operations. Ensuring sustainability of the transformation is what makes Practice Advancement Strategies stand out from many competitors. We focus on the specific needs of the practice, group, or system. We work collaboratively with clients to assess their needs and create a fully customized plan to achieve real site transformation.
A culture of patient-centeredness, team-based care, and continuous quality improvement is embedded in the foundation of the practice organization and our approach. Throughout the journey, we challenge the transformation team to consider questions such as, “What implications does this/will this have on the team?” and “How can we best engage and communicate with the team?”
Our work and experience with practice transformation goes well beyond just understanding the standards and how to prepare supporting documents. We also understand the challenges and obstacles, as well as the rewards, associated with true site transformation.
We apply proven approaches to accomplish transformation; improve outcomes; and enhance patient, staff, and provider satisfaction while bending the cost curve. This is accomplished by engaging staff and system leadership.
Assessment and Planning
Practices often begin the transformation journey before fully understanding the current roadblocks and obstacles. This can result in stalled or blocked progress, resistance, and a frustrating environment. We conduct a gap analysis, which identifies both glaring gaps and subtle changes that need to be included in the transformation work plan.
Once the gap analysis is completed, a detailed project plan is developed reflecting the current state of the practice and the work required to achieve transformation.
We apply Lean Six Sigma concepts and support workflow redesign to ensure a smooth, efficient experience for providers, staff, and patients. We collaborate with health information technology staff to ensure the integration of requirements and “meaningful use” measures into workflow, policies, and procedures.
Solid workflow and electronic medical record (EMR) utilization results in accurate, powerful data and reporting. This is crucial for population health management, care management, and care coordination aspects of not only practice redesign, but also healthcare reform.
Another important component of practice transformation is ongoing quality improvement. We work with site leaders to identify focus areas, develop quality improvement plans, and implement “Plan-Do-Study-Act” cycles. We will also guide the site in creating effective site and provider-level performance statements that reflect the clinical and patient experience goals.
NCQA Recognition Submission Support
All of these changes support the over-arching goal of achieving the highest level of NCQA PCMH recognition. We help practices understand and navigate the preparation and submission process.
The arduous submission process is complete and your site has achieved its goal.
Now the work really begins. Maintaining the focus on newly-established quality improvement activities and detailed processes can be challenging. Transformation takes time and, with limited resources to keep things on track, some practices may find that they slowly revert back to “business as usual.”
We work with sites to maintain the momentum, continue the transformation, and reach the next level of advanced primary care.
Integrating Behavioral Health in Primary Care
Behavioral healthcare integration is defined as care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families. Studies have demonstrated the positive impact of behavioral healthcare integration on efforts to achieve the triple aim. Currently, behavioral health and physical health services are usually delivered by different providers in separate settings, often with little coordination or communication. This fragmentation of care can lead to inappropriate, disjointed, and redundant gaps in care—and increased costs.
The core tenets of primary care transformation align with the goals of behavioral health integration. To that end, we support the operational aspects of integrating primary care and behavioral health. We partner with the HANYS policy and advocacy team to ensure that clients have the most up-to-date information on issues such as licensure and billing.
We adjust our approach to meet the changing needs of the healthcare environment. We support our clients’ long-term sustainability and success, regardless of the model of care transformation.
When a practice is in the “succeed” phase of Patient-Centered Medical Home recognition, it is important they do just that—succeed in the activities on which they have diligently worked during the transformation phase. All too often, after the initial recognition is achieved, practices slide back to their old ways of doing things and the efforts they put into achieving recognition are not sustained.
With NCQA’s Annual Reporting approach, practices no longer have the luxury of slipping back into their “old ways.” Practices must be able to demonstrate sustainability. This includes all aspects of NYS PCMH. Annual Reporting requires attestation to the continuation and/or implementation of components across all of the NYS PCMH standards, not just the Annual Reporting measures that require a report or data submission. HANYS Solutions Practice Advancement Strategies offers a Sustainability Service to help ensure that this work is continued and sustained.
PAS Sustainability Service is conducted through a series of touch points throughout the year. Each touch point consists of about eight hours of advising and is done remotely. Each touch point consists of reporting, quality improvement and mini-audits geared to ensure that your practice is maintaining the workflows, roles, responsibilities and processes established during the transformation phase.
Our Practice Transformation Advisors will help identify potential risks for slipping back into old habits and recommend mitigation strategies to keep your practice, staff and clinicians on track. This includes identification of reporting measures, report timing, team responsibilities and a project plan to ensure a successful submission by your Annual Reporting date. After submission of Annual Reporting information, we will address any feedback and set our sights on next year’s strategy.
Never worked with Practice Advancement Strategies? No problem. We will include an additional five hours to get to know your transformation process and practice operations.
Can a practice receive more than eight hours per quarter? As with all of our engagements, Sustainability Service is fully customizable. Your practice can add to the base service to meet your unique needs. For example, medical groups with multiple locations may want more hours per quarter to work through strategies, reporting and individual practice level support; or your practice may be interested in annual in-person training for staff.
Examples of additional services include:
Free up your staff from the administrative activities associated with Q-PASS.
Practice Retreat Facilitation
Ensure your staff and clinicians are up to date on the fast-paced changes in healthcare reform and advancements in the medical home or medical neighborhood. PAS Transformation Advisors will develop content and facilitate your practice retreat or meetings either remotely or in person.
Quality Improvement/Performance Improvement Focus
This is especially beneficial for practices that do not have a resource dedicated to quality improvement. Our Advisors go beyond the work supplied in the base service by creating QI strategies, providing data analysis assistance, establishing Plan-Do-Study-Act cycles and engaging staff in the quality improvement process.
Value-Based Payment Focus
VBP is a core criterion for NYS PCMH. During the sustainability phase, we help ensure the base requirements are continued. If your practice is looking to analyze its performance in VBP arrangements or strategies to move to the next level of risk sharing, additional hours can be applied to support your goals.
Care Coordination Focus
Is your practice squeaking by with the bare minimum for care coordination, but want to up your game? Maybe you are in a risk-sharing VBP arrangement and want to improve care coordination along the continuum by engaging more with specialists and community-based organizations. PAS can help with that.
Social Determinants of Health Focus
A SDoH focus can help bend the cost curve and improve patient outcomes. Many practices do not have the staff to support education on SDoH or the data analytic expertise needed to incorporate a strong SDoH program into their operations. PAS can support your practice with SDoH education, identification and establishing relationships with community-based organizations and other medical neighborhood members so practices can collaborate and improve patient care outside of the practice walls.
These are just a few examples of additional services PAS provides to Sustainability Services clients.
Contact Nicole Harmon, Senior Director, HANYS Solutions Practice Advancement Strategies, at (716) 201-1170 or at firstname.lastname@example.org.
The Importance of Culture and Change Management
Ensuring sustainability of the transformation is what differentiates Practice Advancement Strategies. Our three-pronged approach: people, process, and technology, has been proven to bring about sustained change. This approach is not just about “getting the paperwork done” in order to hang the recognition certificate on the wall. Our approach focuses on ensuring that a culture of patient-centeredness, team-based care, and continuous quality improvement is embedded in the foundation of the practice organization. Throughout the journey, we challenge the transformation team to consider questions such as, “What implications does this/will this have on our team?” and “How can we best engage and communicate with our team?”
Peer and group-based learning, coupled with interaction and post-activities, is a proven educational method that ensures knowledge transfer.
We deliver education and training to best meet the needs of the client, including in-person, web-based, and train-the-trainer.
Areas of focus include:
Team Development and Facilitation: Working in team-based structures can be challenging. We help the practice team work through the team-building process so that not only your site transformation team but also your care teams, providers, and staff function at their best.
Practice Staff Education: In addition to culture and change management, we provide practice staff with training on care teams, population health management, care management, and care coordination.
Roles and Responsibilities: Being a contributing member of a team begins with having clear roles and responsibilities.