TransforMN Study

Principal Investigator: Leif Solberg, MD
Institution: HealthPartners Institute for Education and Research
AHRQ Grant Number: R18 HS019161

Overview of Transformation Efforts

In 2010 the Minnesota Department of Health began certifying primary care practices as Health Care Homes (HCHs). Certification standards focused on five key areas:

• Continuous access and communication between the HCH and the patient and family.
• Electronic registries to identify gaps in care and manage services.
• Care coordination for improved patient-and family-centered care.
• Care plans for patients with chronic or complex conditions and their families.
• Continuous improvement in patient experience, health outcomes, and cost effectiveness.

By 2011, 132 (18%) of the 728 primary care clinics in the State of Minnesota were certified as HCHs by the Minnesota Department of Health. Certification required documentation of meeting all five standards, which was verified through site visits, including chart audits and interviews with staff and patients. Annual recertification required demonstration of improvement on standardized performance measures and attainment of progressively more challenging structural and functional standards. HCHs received special additional monthly payments for enrolled Medicaid patients but the payments were small, were based on the patient's number of chronic conditions, and required enrollment and billing.

The Minnesota Department of Health developed written documents to explain how the five standards of transformation could be achieved. It also organized a learning collaborative for practices interested in seeking certification and a collaborative for practices that were already certified to help support their ongoing transformation efforts. Each practice, or group of practices, determined how to best implement changes to meet the standards in their setting.

Results of Transformation Efforts

Shortly after HCH certification, each clinic manager completed the Change Process Capability Questionnaire, which assessed the presence of organizational factors (i.e., learning culture, leadership, teamwork) needed for implementation of practice transformation, as well as readiness to improve care.

Seventy-nine percent of HCHs reported having nearly all of the necessary organizational factors, and most had successfully used nearly all (60% to 91%) of the 18 recommended change strategies.

Key Impacts of Transformation

Quality of Care

• In 2010, HCH clinics had higher overall performance rates for diabetes and vascular care measures than non-HCH clinics. However, there was considerable overlap in performance rates across individual clinics.
  • An average of 24.6 percent of patients at certified clinics received optimal diabetes care compared with 16.6 percent of patients at uncertified clinics.
  • An average of 41.6 percent of patients at certified clinics received optimal vascular care compared with 31.4 percent of patients at uncertified clinics.
• Practice systems that showed the strongest association with higher performance measures for diabetes and cardiovascular were:
  • Clinician reminders about needed services for chronic conditions.
  • Registries for tracking care for patients with chronic conditions.
  • Designated primary care teams collaborating in the care of complex patients.
  • Routine use of secure email to support self-management for patients and families.
  • Routine exchange of data and health records with patients through an electronic health record.
  • Process for systematically screening patients for depression and dementia.

Utilization

• Practices that adopted more medical home clinic systems were more likely to have less emergency department and health care utilization by the most complex patients, but not fewer inpatient admissions.

Challenges to Transformation

While HCHs received additional payments for enrolled Medicaid patients, these payments were small and required considerable paperwork and tracking. In general, transformation efforts cost far more than the practices received back in additional payments. Some practices decided that the payment system was more trouble than it was worth, and stopped submitting paperwork for the additional minimal payments.

Lessons Learned and Implications for Others

• Findings indicated that there was not an abrupt change in performance among clinics that became certified as medical homes.
• The study's Practice Advisory Group reported that after being certified for a while, it became clear that the following elements were necessary for primary care transformation to occur: 1) practice leaders possessing a vision of change and understanding the "big picture" reasons for transformation and 2) an overall change in practice culture.

For additional information about this grant, please visit the AHRQ Transforming Primary Care Grants: Bibliography.