Working with facilitation agents measurably improves the ability of motivated primary care practices to move towards improved models of care. Widespread primary care practice transformation will likely require facilitation capacity in most communities.
Carlos Roberto Jaén MD, PhD; Ray Palmer PhD; Robert Wood DrPH; Marivel Davila MPH; Paul Nutting MD, MSPH; Will L. Miller MD, MA; Benjamin F. Crabtree PhD; Kurt C. Stange MD, PhD; and Robert Phillips MD, MSPH.
Between 2006 and 2009, the American Academy of Family Physicians sponsored the country’s first Patient-Centered Medical Home National Demonstration Project. The project randomized 36 volunteer practices to facilitated or self-directed groups who were monitored and evaluated on their capacity to transform to a high performance primary care practice representing the ideals of the Patient-Centered Medical Home.
Practices were randomized into either facilitated or self-directed groups. Facilitated practices received ongoing assistance from a change facilitator and a panel of experts, and received discounted software, training, and support. Self-directed practices could access practice improvement tools and services, but did not have on-site assistance.
Figure. Change in adaptive reserve for facilitated and control practices, baseline to 28 months
*Adaptive reserve includes measures of leadership, sensemaking, diversity, mindfulness, communication, respectful interaction, learning culture, reflection and general work environment. Baseline vs. 28 months for facilitated group is statistically different. (p<0.01)
Early analyses by an external research team found practices working with facilitation agents reported significant improvement in their adaptive reserve—a measure of capacity for change— and were more likely to implement the components of the Patient-Centered Medical Home than were self-directed practices.
This finding supports the need for facilitation if small practices are to achieve the promise of the Patient-Centered Medical Home. Making this transformation widespread, and disseminating the best practices from early innovators will require facilitators in communities. Without this type of support, transformation of primary care is not likely to occur. The US did similar widespread facilitated transformation of family farms nearly 100 years ago through the US Department of Agriculture’s Cooperative Extension Service, which put facilitators in every county and connected them to land grant universities and the US Department of Agriculture. A similarly designed Primary Care Extension Agency could assist practice change, build community health connections, and help form learning healthcare communities. Moving practices to new models and cultures of care is difficult, but skilled facilitation can prepare them for change.1