Current and planned demonstration projects

In his article analyzing the practice change process, William L. Miller, M.D., M.A., with the Lehigh Valley Health Network, finds that a practice's capacity for organizational learning and development, or adaptive reserve, is critical to managing the unrelenting, continual change required to implement the PCMH. Notably, none of the self-directed practices with limited adaptive reserve at baseline did well in implementing the NDP model components. This important finding suggests that strengthening adaptive reserve will serve practices well over the next decade as they continue transformation to a PCMH and adapt to rapidly changing demands of the health care environment.Importantly, the authors point out that the NDP practices were not a representative sample of U.S. practices. They were highly motivated early adopters who are continuing to work to implement positive changes, even after two years. For most practices, the pace and magnitude of change experienced by the project participants would not be easily replicated. Jaén cautions that any interpretation of NDP findings must bear in mind what the change strategy did not include – interventions to alter the delivery system beyond individual practices. None of the practices saw a change in their payment structure or enhanced reimbursement. "Without fundamental transformation of the health care landscape that promotes coordination, close ties to community resources, payment reform, and other support for the PCMH, practices going it alone will face a daunting uphill climb," he writes. "There must be simultaneous changes in an integrated model in what has been referred to as an optimal healing landscape," concludes Crabtree. "The NDP findings must be interpreted in the context of what is being learned from other ongoing PCMH pilot projects that involve more radical reforms Discount Rosetta Stone to the larger delivery system – reforms that place greater value on the essential role of primary care."The research team also calls for the continuing evolution of the PCMH model, which they contend overemphasizes technology at the expense of the four core principles of primary care. Current and planned demonstration projects, they assert, must retain a balance of fundamental features of the PCMH that melds the core principles of primary care, relationship-centered care, reimbursement reform, and the chronic care model, as well as the emerging information technology that supports these elements.Furthermore, they point out the need for individual physicians to change their professional identity and the ways in which they deliver primary care. Training programs, they assert, need to adapt to include more collaborative team-based educational models with nurse practitioners, physician assistants, nursing staff and other health care professionals. And, medical school education needs to attend to the basics of leadership, teamwork, operations management and organizational behavior so future physicians are equipped to help the practices they join make transformational changes. In her article, Elizabeth E. Stewart, Ph.D., project evaluator and now a senior scientist with the AAFP National Research Network, relates an interesting epilogue to the intensive two-year project. At the Project's final learning session where all the participants met face-to-face for the first time, an "NDP veterans" group organically emerged, expressing a desire to stay loosely connected. Coining themselves the Touchstone Group, these physicians and practice managers committed to keep in contact so they could reflect, support and learn from each other moving forward. Many also committed to reaching a broader audience by participating in public speaking and writing about their experiences.

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