developing a neighborhood primary care strategy

As health systems seek to establish integrated care delivery approaches that can meet population health management goals, building and maintaining the right kind of primary care workforce is essential.

We live in an era of healthcare reform, where value-based payment, bundled services, and population risk management are becoming the norm. Increasingly, healthcare providers and commercial payers are affiliating to ensure their ability to survive, resulting in an increase in competitive intensity.

In the midst of this disruption, most stakeholders recognize the critical nature of primary care services. In fact, most understand-at least intellectually, if not politically-that primary care is the foremost strategic component of any sustainable integrated delivery system (IDS). Primary care settings provide the majority of medical services in most communities. Parents traditionally select at least one primary care provider or setting to meet the medical needs of a normal, healthy family." Traditional primary care practices still capture most patients who want a relationship with a medical provider. In essence, these practices capture and hold market share or covered lives for all other providers along the referral path.b

Urgent care settings and convenient care clinics also play a critical role in the primary care strategic equation. Primary care physicians and advanced practice professionals in these settings direct the majority of routine referrals to subspecialists and hospitals (although some hospital emergency departments [EDs] inappropriately serve as primary care access points rather than as emergent providers).

As the healthcare economy shifts to patientcentered care and healthcare delivery moves from population risk management to population health management, primary care practices and providers will play an increasingly essential role in any integrated delivery strategy. The sustainability of the primary care component will drive the sustainability of the entire integrated model. Building and maintaining the primary care workforce to staff the integrated strategy is vital to achieving high clinical and service quality, high productivity, operational sustainability, and financial viability.

Developing a sustainable primary care workforce requires the right geographic presence, the right patient care model (or models), and the right primary care professional staff and support staff.

Geographic Presence

Our zip code analysis of many traditional urban and suburban primary care practices indicates that the majority of the physicians' active patients live within a relatively short drive of the primary care office location. In fact, in many suburban settings more than 50 percent of active patients live within a ro-minute drive of their primary care physician. Consequently, an effective integrated delivery strategy is a neighborhood strategy, providing the right primary care access points in the right locations. Our experience indicates that urgent care and convenient care settings serve the same type of local patient traffic. Providing traditional, extended, urgent, or convenient access to primary care is critical to patient retention for the IDS model, especially in competitive markets.

Convenience is not the only issue, however. As the healthcare industry implements patientcentered care and moves toward population health management, aligning the needs, wants, and priorities of patients with available neighborhood services becomes increasingly critical. For example, some practices may offer the services of a social worker or advocate to help patients navigate a variety of social issues and community services that are critical but not directly related to a chief complaint. In other locations, providing safe and convenient cosmetic services such as laser hair removal, Botox injections, dermal fillers, and skin care products to patients with disposable income makes sense. It also is logical to use an open-access scheduling approach for neighborhoods in which customers rely on public transportation or unreliable vehicles, rather than charging a penalty fee for missed appointments.0 Still other neighborhoods would benefit from the availability of nearby geriatric services and visits from a rotation of subspecialists so patients don't need to drive "downtown."

A few key indicators provide valuable information and guidance for developing a neighborhood strategy that provides convenient access. Several major retailers have been veiy successful at selecting locations by paying close attention to the current and anticipated neighborhoods within a certain driving distance of their stores. For example, in pursuit of its mission, Walgreens is focused on providing convenient access through its "stores located within five minutes of seventy-five percent (75%) of Americans."d Like other successful retailers, Walgreens uses an in-depth process to determine sites for developing new stores:

There are several factors that Walgreens takes into account, such as major intersections, traffic patterns, demographics and locations near hospitals. We prepare more than 100 pages of research for every site under construction.0

A recent study confirmed the importance of convenience and access for primary care medical practices, including the fact that consumers prefer a clinic located near their home.f Like successful retailers, hospitals can investigate key elements of their primary and secondaiy markets to help guide critical location decisions and maximize the opportunity for market share capture and retention.

Four factors can inform the process of selecting locations for primaiy care facilities and services.

Demographics by neighborhood. One of the best ways to understand the unique characteristics and needs of neighborhoods is to consider factors such as population size, age, gender, and rate of population growth. Average household income is another indicator of potential needs, wants, and priorities, as well as potential payer mix. In larger communities, this information may be tracked by zip code. In more rural settings, the entire community may be the targeted neighborhood.

Behavior patterns. Understanding where current and prospective patients go for other retail services can be helpful in deciding where to place primaiy care access points. Traffic patterns can be enlightening, as can documenting the locations of successful retailers such as CVS and Walgreens (especially those with convenient care settings), Target and Walmart, and Lowe's and Home Depot. In some communities, the locations of and plans for public schools can be a useful indicator of neighborhood composition.

Healthcare organizations that already draw some patients from a neighborhood also can learn from their experiences with those patients and potentially extrapolate that information to understand the needs, wants, and priorities of the broader community that makes up the neighborhood. Evaluating common resons for admissions and office visits, patient origin data for low-acuity ED visits, and claims data, if available, can inform planning for the types of services that should be offered in particular locations.

Competition. Understanding competitive offerings and strategies also is critical in developing a market share strategy for neighborhood primary care. Identifying traditional primary care settings, extended hour locations, urgent care clinics, convenient care offerings, kiosks, and other settings is critical to gauge capacity to meet the current and potential demand in a market. Knowing who owns each location, the services offered, and access times is critical to relevant strategy development, as is estimating the provider capacity (e.g., physicians and advanced practice professionals).

Supply and demand. Traditional supply-anddemand data for primaiy care specialties by neighborhood, enhanced by the information in the categories described above, can help an organization identify neighborhoods where it could benefit from adding provider capacity, replacing aging provider capacity, or acquiring existing practices (to keep from oversaturating the neighborhood).

Developing a neighborhood primaiy care strategy starts with optimizing the practices of existing affiliated primaiy care physicians and other providers in their current settings and neighborhoods. Reviewing the services available, enhancing access, and aligning provider capacity with current and potential market share can be the least expensive and most efficient way to better meet the needs, wants, and priorities of the neighborhood-and to capture additional market share in the process.

Identifying untapped geographies (i.e., neighborhoods) for placement or acquisition of traditional primary care settings and supplementing these settings with extended hours, urgent care, convenient care, or subspecialty services is a second critical strategy. In our experience, the first reliable primary care setting in a new market has the patient retention advantage over latecomers. Making the right services available in the right place and at the right time enhances market share capture and retention, and reduces the risk of inappropriate utilization of expensive services and settings (see the exhibit below).

Population health management requires a thorough understanding of each neighborhood and the ability to engage neighborhood residents -the healthy, the chronically ill, and those near the end of life-as partners in their own care. Understanding and responding to the demographic, psychographic, economic, and social issues facing the neighborhoods served by a practice will be increasingly essential in managing both population health and financial risk.

Patient Care Modeling

With population risk shifting to providers of care, interest in patient-centered care is increasing. Hospitals that have not done so should examine the benefits of having their owned and affiliated primaiy care practices become formally recognized as patient-centered medical homes (PCMHs). Achieving this recognition may require a significant commitment to cultural and workflow change, but the benefits can be substantial.

Benefits for patients include:

* Enhanced access after-hours and online

* Long-term provider relationships

* Shared decision making

* Engagement in health and health care

* Continuity of care

* Better quality and experience of care

Each year, the Patient-Centered Primaiy Care Collaborative examines and reports on the results of peer-reviewed studies, government program evaluations, and industiy reports about the efficacy of the PCMH model. Among 28 studies in the most recent report, 24 found improvement in utilization and 17 found improvement in cost. Some of the studies also found improvement in quality (11 studies), access (10), and patient satisfaction (8).g

Benefits for providers include:

* Increased job satisfaction

* Optimal use of staff (i.e., team-based care)

* Seamless transitions of care for patients across the components of the IDS (i.e., the referral path)

* Reduced risk

* Improved outcomes

A recent study highlighted the benefits for providers of patient-centered primary care by comparing medical claims for more than 17,000 patients in 27 small primary care medical homes with 29 traditional small primaiy care practices. The results for PCMHs included statistically significant higher performance on four process measures in diabetes care and breast cancer screening; lower rates of all-cause hospitalization; lower rates of all-cause ED visits; lower rates of ambulatory visits to specialists; and higher primary care utilization rates.h

Benefits for the IDS include:

* Access to value-based incentive payments

* Increased provider productivity

* Reductions in hospital readmissions and inappropriate ED usage

These components all contribute to the Institute of Healthcare Improvement's stated Triple Aim of higher clinical quality, improved patient experience, and lower cost.

Primaiy care practices provide the foundation for ensuring that care delivered within an IDS is truly patient-centered. More than 10 percent of U.S. primaiy care practices already meet rigorous National Committee for Quality Assurance criteria for designation as PCMHs.1

The PCMH model challenges primaiy care practices to enhance the quality and coordination of care by improving access and promoting teamwork. Same-day access for routine and acute visits is rapidly becoming the accepted standard of care. Team-based care is emphasized, and scheduling patient care team meetings or other daily modes of communication in each practice to review patients' history and coordinate their care is considered essential. Another key PCMH element is having systems in place to coordinate patients' care among various providers and service points outside the primaiy care practice. Without such coordination, service deliveiy often is fragmented, and each provider along the care continuum is unlikely to understand the full patient picture.

Improvement in the health of populations also requires a higher level of patient engagement than ever before. The PCMH model encourages patients to take responsibility for their care by actively engaging and educating them, and by assessing their knowledge. When patients are well informed, they can share in decision making and be in position to make the best healthcare choices from among multiple options. Providers that empower patients in this manner send the message that patients are in charge of their health, rather than being passive recipients of medical services.

Naturally, the PCMH requires a different mindset for physicians and other providers, as do other care models and approaches. Understanding and documenting these expectations help a practice attract physicians and advanced practice professionals who are more likely to succeed and remain with the practice.

Professional Staffing

Ideally, the strategies we have discussed drive the recruitment and selection of primary care physicians and advanced practice professionals, along with the clinical assistants and care coordinators who assist in providing patientcentered care. Having a clear picture of the practice opportunity helps in the selection, recruitment, and retention of a primary care workforce. Healthcare organizations therefore should document each practice opportunity in a prospectus. The table of contents for the prospectus should include a description of the practice (new or established) and the neighborhood it serves, as well as the current providers and key support staff members.

The prospectus should include:

* A description of current productivity measures (if the practice is established) and performance expectations

* A description of the initial compensation and potential opportunity

* A pro forma income statement to help establish realistic growth expectations for the new physician or other provider

* A description of the affiliated hospital and key subspecialties

The practice opportunity prospectus should be approved in advance by the sponsoring practice or hospital, thereby helping ensure the delivery of a consistent message to candidates during the recruitment process.

Hospital executives sometimes complain about the difficulty of recruiting and retaining physicians, particularly in areas without nearby residency training programs. Some resort to recruiting those who have service obligations and who are likely to depart once they meet their obligation. These same acute care settings may already have dozens, if not hundreds, of physicians on staff. If one asks where these physicians come from, the answer invariably is, "Most are from here." They were raised in the area. Their parents live there. They were trained in the region and fell in love with the geography or community.

Hospitals should have their "recruitment/ retention engine" always running, which includes being aware of the location and status of all the physicians who have lived or trained in the region. This focus is particularly important with respect to primary care physicians, given that the loss of a trusted primary care physician is difficult for patients and risky for the practice and the IDS, especially in competitive markets.

Hiring and retaining the right support staff also is an important element in determining the success and retention of physicians and other providers. Without competent support, implementing an effective PCMH, or a similar model, is impossible. Hospitals should take care not to shortchange clinical support staff or the training required to help staff reach their potential. The impact of an effective clinical assistant and care coordinator is significant for both provider productivity and the patient experience.

Finally, another important consideration is that the task of responding to the changes in health care is contributing to an increase in dissatisfaction, low morale, and burnout among physicians, advanced practice professionals, and staff. Although most acknowledge the importance of the Triple Aim, many also are calling for the addition of a fourth "aim": "improving the experience of providing care."-i

To be able to build and maintain an effective primary care workforce in the right locations and provide the right services to meet the needs, wants, and priorities of neighborhoods, it also is necessary to engage and inspire that workforce to find joy and meaning in their daily work. Engagement does not occur by chance, but must be actively developed and nurtured as a true partnership between clinical experts and business experts at eveiy level in the IDS- especially in the medical practice setting.k

Key Takeaways

Building a sustainable primary care workforce to capture and retain market share for an IDS is a business imperative. Even the most talented subspecialists are largely dependent on referrals from affiliated primary care physicians and advanced practice professionals.

Building the workforce starts with the develop - ment of a clear primaiy care strategy that focuses on capturing market share by meeting the needs, wants, and priorities of "neighborhoods" through relevant services and access. That strategy helps dehne the practice opportunities for current and potential primaiy care physicians and other providers. Those opportunities are further defined by clarifying the preferred service delivery model, including the potential establishment of a PCMH. Documenting each opportunity in a prospectus helps recruit to the opportunity rather than simply tiyingto attract "warm bodies." Supporting physicians and other providers with well -trained staff is key to clinical and service quality, productivity, and financial viability.

Finally, the clinical experts should be engaged as partners working to achieve success both for the individual medical practices and for the IDS as a whole. Only through a strong partnership can an IDS avoid low morale and burnout and create a culture in which the joy of practicing medicine flourishes in an increasingly rigorous environment.

AT A GLANCE

For building and maintaining a primary care workforce to staff an integrated care delivery strategy, considerations include:

* Geographic presence

* Patient care modeling

* Professional staffing

a. U.S. Department of Labor, Employee Benefits Security Administration, 'General Facts on Women and Job-Based Health,' fact sheet, December 2013.

b. Halley, M.D., and Anderson, P., 'Accountable Primary Care: A Critical Investment," hfm, February 2014.

c. The term open access has several meanings. We are referring to a statistically derived appointment model that leaves adequate open slots to accommodate all patients who call each day and provides flexibility to work in those who arrive late.

d. Walgreens.com, ?About Walgreens-Offer Ultimate Convenience," newsroom fact sheet.

e. Walgreens, ?Frequently Asked Questions,' newsroom fact sheet.

f. The Advisory Board Company, "What Do Consumers Want from Primary Care? 10 Insights from the Primary Care Consumer Choice Survey," research brief, June 25,2014.

g. Nielsen, M, Gibson, A., Bueli, L. Grundy, P. and Grumbach, K., 'The Patient-Centered Medical Home's Impact on Cost and Quality,' Patient-Centered Primary Care Collaborative, January 2015.

h. Friedberg, M.W., Rosenthal, M.B, Werner, R.M., Volpp, K.G., and Schneider, E.C., 'Effects of a Medical Home and Shared Savings Intervention on Quality and Utilization of Care," JAMA Internal Medicine, August 2015.

i. National Center for Quality Assurance, "The Future of PatientCentered Medical Homes: Foundation for a Better Healthcare System.'

j. Sikka, R, Morath, J.M., and Leape, L, 'The Quadruple Aim: Care, Health, Cost, and Meaning in Work," BMJ Quality and Safety, June 2,2015.

k. Halley, M.D., Owning Medical Practices: Best Practices for Sustainable Results, Chicago: AHA Press, 2011, pp. 35-46.

About the authors

Marc D. Hallay, MBA,

is CEO, The Halley Consulting Group, Inc., Westerville, Ohio, and a member of HFMA's Northwest Ohio Chapter ([email protected]).

Sarah D. Montijo, MHA,

is director of business analytics, The Halley Consulting Group, Inc., Westerville, Ohio (smontijo@ halleyconsulting.com).

Dale L. Gentz, MBA, PCMH, CCE,

is a network executive, The Halley Consulting Group, Inc., Westerville, Ohio ([email protected]).

Lauri M. Miro, MBA, RN, PCMH, CCE,

is a consulting executive, The Halley Consulting Group, Inc., Westerville, Ohio, and a member of HFMA's Florida Chapter ([email protected]).