There were other findings besides external and internal factors that are related to the role and effectiveness of the learning collaborative.
4.3.1 Planning for Sustainability of PCMH
Practices remain worried that some of the transformation activities supported during the pilot by the MLC might not be sustainable. While there was no expectation that the learning collaborative would stay in perpetuity, the continuing requirement for sustaining NCQA
recognition remains a point of concern for some practices. They worry that maintaining NCQA recognition might not be achievable without some form of external support.
Respondents opined that while they did not expect the MLC to stay forever, that its end might affect sustainability of PCMH as a whole. One respondent summed up these concerns as follows:
“Fears from some practices on how to sustain started transformation activities are expected. However, with time for those practices that owned their own
transformation agenda, moving forward will be a lot easier. However, there are some practices that might start to give up on some aspects of PCMH” (Care Manager, Physician Group Practice).
Seven practice respondents explained that in many ways the MLC was the embodiment and face of PCMH implementation and its end without clear guidance on what happens next might have negative implications. The continuing requirements for maintaining PCMH
recognition level in some cases was one of the reasons stated for why the learning collaborative was still required. One provider respondent raised concern that the end of the MLC will take away an advocacy platform that could help galvanize practices to address key issues affecting them such as maintaining PCMH payments practices need to sustain this model of primary care. Several respondents agreed with this view and 4 out of the 9 practices were concerned about how to sustain the care management function. Six other respondents were worried that the process of change hadn’t transformed into a culture for their organizations and the learning collaborative coaches were instrumental in helping individual practices to find solutions for overcoming resistance to change especially from physicians. The MLC did not discuss the future of PCMH and practices did not feel that these lingering issues about sustainability were
adequately addressed. While these concerns remain and might be real, there is an expectation that over time practices will learn to move on without the external support. For now the MLC has been center stage of during the PCMH implementation pilot but when the learning collaborative ends practices will chart a new path in a bid to continue previously MLC supported activities.
4.3.2 Practice Size and Location
Cross-case analysis of findings did not show major differences between practices in the way they engaged in the learning collaborative. Small and large practices experienced
resistance from physicians and also reported enthusiastic support from some staff. Respondents equally reported increased workload as a concern. Across board Practice
Coaches were considered valuable. Practices large and small thought the learning collaborative played an important and valuable role in helping them implement the PCMH.
“I am sure each practice found something useful in the support provided by the learning collaborative” (Medical Director, Hospital Affiliated Practice).
Practices big and small sought MLC support depending on their needs and not because of their size or location. For example all types of practices sought MLC practice coach support to address challenges caused at times by staff resistance or physician disinterest. The findings did not show differences in the type of support sought and received. There might have been differences in the depth of the support but findings did not show these to be major.
Practices were asked whether they thought size and type of practice were factors in influencing level and extent of participation in learning collaborative activities. Broadly, respondents stated that they did not think it mattered that much. Three practice respondents thought while this was not a major influencing factor it might have played a less-than significant role. These respondents opined that decision-making processes affecting participation in learning collaborative supported activities might have differed in some instances. Small
activities supporting PCMH implementation but they also reported that their leaders were intimately involved with the process and hence had all the information needed to make a decision.
“At collaborative meetings participants from small practices often stated it was easier for them to get things done. While a practice like ours is large and we did not necessarily face major delays in seeking decisions and approvals to get things done or help with overcoming staff reluctance to fulfill their PCMH roles, we at times had to go through hoops to get decisions made” (Administrative Leader, Corporate Owned Practice).
The differences practices mentioned included getting staff assigned new roles in places where interest in PCMH was lackluster. Others included allowing more staff to attend
collaborative events and meetings. For example a small practice could close a practice and send all staff to go attend a collaborative meeting while larger practices would send 1 or 2 people only because managing schedules at large practices is more complex. These findings however were more selective and isolated and not common to materially alter the key finding that there were no major differences in the way practices engaged in the learning collaborative. There were large practices whose leaders were supportive and there were others whose leaders were not and this also applied to small practices. Location of the practice did not matter much. One practice in a rural setting stated that being in a rural setting means they have to work ahead to connect with resources for their patients in order to meet PCMH goals but that they did not see location as a disadvantage. Driving long distances to collaborative events was
mentioned but not so much as a barrier to participation and the MLC tried to address this concern through rotation of meetings to different locations within the State. While pediatric practices, mentioned that at times they felt group meetings did not take their needs into
consideration, they did not consider this a major deterrent to their support or participation in the learning collaborative.