Dedicating Staff Time
Because the group already had EHRs in place, most of the costs of getting started focused on personnel rather than equipment or infrastructure, says Munger. For example, a group director who had been managing the group's 11 primary-care offices switched gears to spend most of her time on PCMH issues. In addition, a full-time assistant was hired to help with preparing and uploading documents to the NCQA site.
Munger reduced his patient load by about 15 percent during the process but both he and the primary-care group director still struggled to juggle their PCMH responsibilities with the demands of their regular jobs. It was not until after the group achieved recognition in October 2013 that there was room in the budget to hire several registered nurses to help with care coordination and transitions after hospital discharge.
"Everyone had very busy lives during the transition," says Munger. "Human resources are the primary cost once you have the technology in place."
Getting buy-in from everyone in the practice was the most challenging part of the process, says Munger.
"We were embarking on a real redesign of work flows and thought processes going from an episodic model of care to thinking beyond individual patients to population-based care," he says. "Change management was very important in order to get buy-in from everyone, from physicians to office assistants, and make sure they understood how this will improve patient care."
Many employees were skeptical that the long-term benefits would eventually outweigh the costs — in both time and money — of gaining medical home status.
"At the time, Blue Cross-Blue Shield was offering to pay us for care coordination but there were no other plans in our market doing this and a lot of people wondered what we would get out of it," says Munger. "They wanted to know how this would really help the patient and whether we would see returns on adding a lot of extra work and personnel."
Adjusting to team-based care was another hurdle in the beginning, he says. While clinicians agreed with the concept of teamwork and sharing patient care with advanced practitioners, it has taken time for them to truly embrace it.
"No one would want to give them up now but a year or so ago, there were a lot of misunderstandings about what our nurse coordinators would do and how they would improve care," says Munger.
Soon after St. Luke's received recognition, Munger hired two nurse coordinators for his office and plans to add three more by September 2015. The group has also shifted more patient care responsibilities to triage nurses and medical assistants to ensure that they work at the top of their licensures.
"Achieving your recognition is just the beginning of your journey to transform your practice," says Munger. "For us, it continues to be a work in progress."
Reaping the Benefits
Patients began to take notice when St. Luke's expanded access to care. The group now offers same-day appointments at all locations and three offices have opened walk-in clinics managed by nurse practitioners, Monday through Saturday.
"The walk-in clinics have become a way to attract new patients," says Munger. We've increased our patient load by about 19 percent since the clinics opened."