Transforming Primary Care Practice: Lessons From the New Orleans Safety Net

Principal Investigator: Diane Rittenhouse, MD
Institution: University of California, San Francisco
AHRQ Grant Number: R18 HS019139

Overview of Transformation Efforts

One of the few positive results from Hurricane Katrina was the opportunity to substantially improve access and quality in New Orleans' primary care safety net system. In September 2007, safetynet primary care practices throughout the greater New Orleans area began to rebuild the health care system based on the patient-centered medical home (PCMH) model. The U.S. Department of Health and Human Services awarded a 3-year, $100 million Primary Care Access and Stabilization Grant to the State of Louisiana to help restore and expand safety net services in the New Orleans area, and local leaders recognized this as an opportunity to encourage a communitywide transformation in primary care delivery. They developed a quality improvement program that included minimum quality standards, such as establishing a quality assurance program, 24-hour telephone urgent access, same-day appointments, and implementing and assessing the use of clinical evidence-based guidelines.

The Louisiana Public Health Institute provided the New Orleans clinics with technical assistance, such as advice on building data collection and reporting capacity to maintain compliance with federal reporting requirements. Clinics decided individually how to implement transformation and what other forms of formal support—such as nurse care managers, practice coaches, interoperable electronic health records, and regular feedback of data on patient outcomes—they wanted to seek, according to their own organizational goals and priorities. The Louisiana Public Health Institute paid the fees required to apply for National Committee for Quality Assurance (NCQA) PCMH recognition and implemented an incentive program to provide substantial bonus payments to clinics that achieved NCQA recognition.

This study focused on the primary care transformation of five safety net practices in New Orleans, some of which had begun implementing PCMH processes before Hurricane Katrina, before funding for PCMH transformation became available.

Results of Transformation Efforts

Despite some differences between the five clinics, each showed improved or stable scores on PCMH measures, and each achieved NCQA recognition as a PCMH. It is notable that all five practices were able to improve in an environment of limited resources, high patient demand, and unstable grant funding. However, the timeline for achieving practice improvement varied considerably across the clinics, and there were substantial differences in the degree of success.

Two of the five clinics showed greater overall success, as measured by an overall PCMH score, as well as higher scores on specific PCMH measures of improved access, coordination, and quality and safety of care. Qualitative analysis based on direct observation and interviews with clinicians, staff, and patients revealed that the relative success of these two clinics was due to: 1) early adoption of PCMH innovations, 2) access to supplemental grants, 3) ability to balance competing priorities, 4) stable and committed clinic leadership, and 5) positive relationships with the communities in which their patients lived.

Key Impacts of Transformation

This information is not yet available.

Challenges to Transformation

All five clinics faced similar challenges in implementing and sustaining practice transformation, including unstable funding, inadequate supply of well-trained staff dedicated to quality improvement, the challenge of balancing comprehensive care management with maintaining access to services for new patients, lack of hospital and specialty care integration, and many complex patients with multiple comorbid conditions complicated by urgent personal and social needs. Additionally, medical school–affiliated clinics had to balance transformation efforts with their mission to train future health professionals.

Lessons Learned and Implications for Others

• Four factors appeared to be of key importance for successful practice transformation among the clinics: 1) early adoption of PCMH innovations, 2) access to adequate funding, 3) ability to balance competing priorities, 4) stability and commitment of clinic leadership, and 5) positive relationships with the community.
• To sustain change, funding for primary care transformation must be robust and stable. New Orleans safety net clinics responded to financial incentives by successfully expanding access to primary care services throughout the region's safety net and implementing medical home processes to improve access, quality and safety, and care coordination and integration. However, declines were observed in these areas when clinics were no longer eligible for bonus payments for redesign efforts and faced the loss of funding for patient care services. At this point, the clinics shifted their priorities from growth and transformation to consolidation and financial survival.
• Individual clinics' responses to market and policy forces depended on internal capabilities. Not every clinic was able and ready to implement change, regardless of the incentive, and some clinics were slow to implement change because of insufficient organizational capacity.

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