Appendix 2: Facilitators and Barriers to Building Medical Neighborhoods
Barriers Illustrative Quotes
Misaligned financial payment for providers
We are profoundly disincented from working together in neighborhoods – why bother? It sounds like a great idea but it is going to cost me a lot of money to develop the infrastructure you are all talking about and I am not just paid that way. The more I do to promote the
neighborhood, the less money I make.
Underdeveloped communication infrastructure
We are using Microsoft products that were fabricated in 1990 so at best, the user-friendliness is not good.
[Furthermore], EHRs are designed as patient encounter tools but not as analytical tools. And to create a
neighborhood, you want the ability to look for data.
Time costs The part that’s been harder has to do with the idea of face-to-face direct communication with individual members of the medical neighborhood and
communicating about the concepts or trying to engage them to be higher functioning medical neighbors. That’s just hard. I wish I had the time, but I don’t.
Patient self- referrals that the PCMH isn’t aware of
The patient has been one of the harder things. Especially for patients who do not have to have a referral for
specialists. So they just go on their own to whoever. We want to know that patients went so that we can get information back. For example, patient had a drug change and we are called about a refill and it is denied because we don’t know about it.
Changing
culture Yet the traditional culture that a physician is an island unto him or herself – that is still hard-wired in our
culture. The notion that a provider has accountability for outcomes aside from one-on-one outcomes is new.
Changing
practice norms Change is difficult - people have practiced in a certain way for 40 years. This is new. Change takes time. We get used to doing the same thing we’ve been doing and it’s hard to break at it.
Facilitators Illustrative Quotes
Leader with a commitment to coordinated patient care
I was inspired by Fisher’s article in JAMA and being in the PCMH pilot. In getting recognition, care coordination was obviously a big gap … We wanted to get our ducks in a row so that we can be accountable/responsible and tried to reach out and include the outside world so that when a patient leaves our home, they are not left on their own.
Strategy You need culture-building and leadership to define the vision and where you are going and then start putting the
pieces of puzzle together. What we did was defined vision…Then there is wiring the neighborhood, there is the aggregation of data, there is performance
improvement and then cultural development.
Coordination
capabilities When we did our initial submission to NCQA we didn’t do any care coordination. We now have enough operational capacity. Before we didn’t have a team. Now we have the capability to do care coordination. It is difficult to do your care coordination when you don’t have your teams up to snuff …but now we do all that stuff. We also have an e- portal to communicate with our patients.
Learning
orientation Start with a couple [of compacts] and try to understand the process and how you expect it to work. See how it works with one or two providers first and work out any issues first. Then try to move on just like we do small test changes with PDSAs. Start with someone you have a good relationship with. Use it to understand the process and how it works. Then expand.
Perseverance Then you have to have a can-do attitude. Then there are many reasons you can’t do it but it has to be a priority. It has to be something you are committed to because
otherwise there are too many reasons not to do it and it becomes too easy to not do it. It is just hard, incessant work. There are many unknown and unexpected barriers that you have to deal with. When I look back at it, I don’t know why anyone would. It is too hard. We do.
Different modes of
communication
Face-to-face communication between providers
The factors that make it work include communication, just taking that step and making that connection with the different parts of the medical neighborhood. Just getting everyone to sit down and look each other in the eye.
Electronic communication
One of my medical neighbors is a GI surgeon who
communicates with me by text and that is a remarkably powerful way for me to have a brief comment with this physician about difficult patients and understanding often. A text takes care of that. I don’t have to talk to him and I’m not interrupting him.
Staff to staff communication
One of the things that we did when we set these things up, we always insisted on meeting the physician’s
important staff, the people that will actually be doing and coordinating this so that their concerns can be answered because they’re going to have a lot more concerns than
the physician. If you get two staffs working together it almost doesn’t even matter if the primary care physician and the specialist hate each other; if the two staffs work harmoniously together it’ll work well.
