Huddling in the medical home: Sounds good on paper

“Just start work half an hour earlier.”

This is what the head of the care coordination committee for our patient-centered medical home executive committee work group recommended when we talked about our struggle getting the team together for early-morning pre-clinic huddles.

She suggested that if we started our usual practice morning at 8 o’clock we should just have everybody come in at 7:30 to load the dashboards for the morning session and have the doctors, nurse practitioners, nurses, medical techs, secretaries, and the remainder of the support staff, all get together and run the list of patients scheduled for the day.

As she said this, our practice administrator furrowed his brow.

He mentioned to her that this would require staff checking in earlier, and that our staff already works a staggered start time to accommodate people with different morning schedules, family responsibilities, and commuting times.

“A lot of overtime and a lot of cost. Who’s going to pay for this?” he asked.

She paused for a moment, and then suggested “Maybe you want to start the clinic day a half an hour later?”

Now the clinicians did the furrowing.

Who’s going to pay for that?

At the moment, volume leads directly to practitioners’ salaries, so a direct hit to a practice session in terms of number of patients seen is directly felt, unfortunately, in the pockets of providers, and, believe me, they do not take that lightly.

There are further issues with getting all the players to the table.

Our internal medicine residents in the practice have an academic conference that starts an hour before the morning practice session. Our nurses have a mandatory meeting with the entire nursing staff to go over the day’s issues. Our registrars have a mandatory 20-minute meeting before the start of their day, to go over the messages, tasks, and active issues from the day before, and any other departmental matters that have been brought up by leadership.

That’s a lot of meetings.

And now we are trying to add another one.

And with a lot of different members from a lot of different disciplines, all coming together from various places, with different start times for their work days.

This seems incredibly impractical, and trying to get this all worked out has proven to be incredibly frustrating.

Recognizing that the morning huddle has the potential to lead to remarkable improvements and efficiencies, and improved patient-centered care, this is definitely something we need to build into our work day, but figuring out how to get it done, in the right place, at the right time, with the right people, has been a daunting process.

This morning the outside temperature was 9°, the subways were jam-packed, the trains were running at least half an hour behind schedule, every intersection in the city was blocked with traffic, and the crosswalks were a foot deep in slush from the recent snowstorm. Nobody got to work on time. And yet somehow when we arrived, some providers were already three or four patients behind for the morning day practice session.

The feasibility of getting everybody together for a calm, thoughtful, purposeful morning huddle was dashed.

In an idealized world, a morning huddle will look at the schedule that lies ahead. See who’s missing necessary healthcare maintenance items, who’s overdue for disease specific testing, who had testing or a consult from an outside practitioner that needs to be entered in the current healthcare encounter for review by the clinician.

Who do we know is coming in for a preoperative evaluation, and we could set up the labs, chest x-ray, and EKG in advance of the session. We know who is coming in for their quarterly diabetes visit, and we can pre-order their point-of-care hemoglobin A1c, a visit with the diabetes educator, and time with the nutritionist. Who do we know is coming in needing a refill of a controlled substance, which would require us to pre-visit the New York State monitoring system to check on their recent prescription history.

The economies and efficiencies will ultimately make this pay off for everyone involved, but getting all the pieces of the puzzle together is going to take some doing.

In this idealized world, we know this will make us more efficient caregivers, make the patient experience at the office visit better, and hopefully lead to better care, more thorough and comprehensive care, and help make sure that things don’t slip through the cracks.

In an idealized world.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home

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  • Dr. Drake Ramoray

    I have book marked this article. If I ever need to remind myself of why I need to go into concierge medicine if my small single specialty group no longer becomes a viable practice model I will be able to read this.

    • NPPCP

      Where are places finding physicians and NPs, who can basically work where they want, to participate in this rubbish?! Are they so beat down that they have no self respect left? Use your degrees and regain your self respect!!!

      • LeoHolmMD

        But NPPCP, how is the PCMH supposed to find NPs for FM doctors to control with that kind of attitude? I think a quick review of the core principles and practice goals will reinvigorate your passion for patient centered care. There are few things more satisfying in medicine than submitting metrics on patients. This is about meeting metrics, not self respect.

        • NPPCP

          Dr. Holmes, I have met with my superiors and the experts and now understand. 2+2=5. Please forgive me. I let my entrepreneurial capitalistic spirit cloud my vision of the PCMH. Please forgive me and allow me to integrate. The needs of the many outweigh the needs of the few.

          • LeoHolmMD

            It’s Dr. Holm. Dr. “Patient Centered Medical” Holm.

          • NPPCP

            Folks, you just read the Kevinmd.com. “best response of 2014.” can’t imagine it getting better than that.

          • Dr. Drake Ramoray

            It’s like Bond….James Bond. Except that instead of a dapper ruthless spy, Dr “Patient Centered Medical” Holmes can meet meaningful use stage 2, and meet all PQRS requirements. What a team player. Licensed to kill?

          • NPPCP

            Licensed to heal…. by administrative fiat.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    It’s stuff like this that makes me angry. PCMH is not like the 10 commandments. Why does it have to be in the morning? Why should everybody be there? Why do dashboards need to be loaded (whatever that means)? Why half an hour?

    This can be done towards the end of each day for the next day. It should only include the two or three people that deal with a particular physician’s schedule. Instead of “dashboards” just print out the next day schedule for that one doctor (remember the census lists?). And it should take 5 minutes, standing up and taking notes on a clipboard.

    Is this better than a cozy half hour meeting sifting through dozens of dashboards while drinking morning coffee? Maybe not, but it’s a good way to plan the next day in advance, before the snow hits, before all the urgent things start piling up, before everybody is behind on their schedule, and before it’s too late to address all the things that came up in the meeting.

    • guest

      I can’t be sure, but I suspect that the reason that the kind of meeting you’re suggesting won’t work, because one of the thing that happens in a “patient-centered medical home” is that there is no one designated provider assigned to any given patient, so that in order to cover the patient in an integrated fashion, all the providers have to be involved.

      • Patient Kit

        A model in which patients don’t have a regular doctor that they see and get to know does not sound very patient-centered to me. What makes that concept patient-centered?

        • NPPCP

          They left a “P” out. It’s really PPCMH – Patient and Provider Controlled Medical Home. But that sounded too “pull back the curtainish.”

          • southerndoc1

            Make that “Process and Procedure Controlled Medical Home.”

        • guest

          Right! That was kind of my point…

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        The first (#1) tenet of the patient centered medical home is that each patient has a Personal Physician (i.e. not a personal “team” and not a personal “clinician”).
        Whether some folks choose to ignore that or not, is a different story altogether, and has more to do with business practices than anything else.

        • guest

          I agree that the name makes it sound that way, but look at the core principals of the PCMH as outlined by the AAFP. I don’t see anything in there about patients’ having their own personal doctor.

          Use evidence-based guidelines in the treatment of chronic conditions, acute illness, and injury, and the provision of preventive care

          Coordinate care across all settings — practices, hospitals, nursing homes, consultants, and other components of the complex health care network

          Serve as the patient’s “library” of medical records, where the essential elements of a patent’s history and health care interactions would be stored

          Use a team approach, capitalizing on the expertise of midlevel practitioners and medical subspecialists

          Use, or commit to using, health information technology (e.g., registries, electronic prescriptions, electronic health records, personal health records, secure e-mail) to guide and facilitate each patient’s care

          • NPPCP

            On the contrary, the AAFP is the primary driver of physicians being the only qualified individuals to lead the medical home. This was, in my opinion, one of the primary reasons the PCMH was included in the ACA. Special interest medical groups attempting to maintain control of all other primary clinicians through this tool. In reality, PCMHs are led by NPs all over the country and they are reimbursed by private ins companies and state Medicaid programs for their services. I certainly do not think ill of the AAFP for their attempt to propagate this as “theirs.” They do, after all, have a financial motive and a family medicine preserving motive for their stand; even if it isn’t practiced as they wish in reality.

          • southerndoc1

            ” the AAFP is the primary driver of physicians being the only qualified individuals to lead the medical home”

            This is just an attempt at saving face by the AAFP brass: they’ve long lost that battle, and know it. PCPCC, CMS, and the big insurers don’t care who leads the medical home.

            By twiddling their thumbs for three decades while primary care was systematically destroyed, the AAFP finds themselves reduced to fighting with NPs and PAs for the crumbs under the table. Something about caged rats turning on each other . . . .

          • Dr. Drake Ramoray

            Don’t worry. Eventually the PA’s and NP’s won’t want to run the medical homes either. Many would rather specialize and have an easier time than doctors doing so. We have a PA and have had several serveral unsolicited resumes over the last 6 mos or so.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Here is the original statement of PCMH from 2007:
            http://www.acponline.org/running_practice/delivery_and_payment_models/pcmh/demonstrations/jointprinc_05_17.pdf

            Yes, there are all sorts of things in there, but note that most follow “such as”.

          • guest

            I suppose it’s a like a lot of things in medicine these days: lots of resources being devoted to the development, promulgation, marketing and administration of various initiatives and improvements in how we provide care.

            Many fewer resources being devoted to those who are actually supposed to do the work, with the result being that the patients all get a watered down, disappointing version of what they thought looked great on paper….

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Yes….

          • southerndoc1

            The 2007 guidelines are toast. Most of the big players now refer to the AHRQ statement:

            http://pcmh.ahrq.gov/page/defining-pcmh.

            Tellingly, no personal physician and no fair pay for docs. When I pointed out to the AAFP president that the PCPCC and other groups who follow the new guidelines are very anti-physician, he was outraged.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Well, then they should call it something else.

            Seriously, if I start selling tents and advertise them as homes, the BBB will probably have something to say about that….

            I just noticed that my old link to the PCPCC page with the 2007 principles has changed to reflect the historical nature of the 2007 principles and the “evolved” definition of AHRQ.
            Thanks for the heads up. I can’t believe I didn’t notice this subtle substitution…

          • LeoHolmMD

            One of the main problems is that, once again, the profession has no control over this. Kiss the PCMH goodbye, it is in receivership and FM doesn’t have the keys. Look at the PCPCC stakeholders on their page, it tells the story quite clearly.

          • southerndoc1

            Exactly.

            Those morons at the AAFP can’t see what is right in front of their noses: the PCMH has been completely taken over by the for-profit insurers, and it’s ALL about improving their bottom line. The docs are being reduced to serfs working to that end, hoping to be thrown a crumb now and then.

          • LeoHolmMD

            Yes, the AAFP and other physician groups who supported it should call it “lie”. I have a patient centered medical bridge (PCMB) that may save Primary Care!

          • LeoHolmMD

            Wouldn’t it be funny if the AAFP actually had to come out against the PCMH? Extremely poorly played hand. They won’t have the guts to do anything about it.

    • NPPCP

      Why do they have to do it all!!? Thanks for sharing about your personal preference for caring for patients and the problems associated with it. Now, let’s see some articles on here for some other types of private practice care and their successes. Enough pcmh articles – this is starting to sound like it’s agenda driven….. No?

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        I don’t have personal preferences for caring for patients. And even if I had, I would not expect them to be accepted by all patients or all physicians.
        I was just suggesting that blindly following the letter of the regulations, particularly when the letter does not even say that (most likely the interpretation of some high-priced consultant), is counterproductive. And I was actually suggesting that practice should come up with its own way of doing things, regardless of the “common wisdom”.
        I didn’t expect that to be problematic for you. Remember too, that there is a huge difference between running a residency practice and a solo practice. Maybe we shouldn’t have large practices, but that’s a different conversation…

        • NPPCP

          That wasn’t directed at you. It was directed at the author and the site to diversify different types of practice articles. :)

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Oh… OK then… it looked like I reply to what I wrote, so I was a bit surprised :-)
            It’s all good….

    • LeoHolmMD

      That doesn’t sound very PCMH. You need to understand team based thinking. We bought a bumper sticker that says PCMH and now we should do things the PCMH way. Perhaps a consultant can help you understand the core principles of team based care and doing things the PCMH way. PCMH is the future.

  • guest

    At the risk of sounding cynical or pessimistic, I think the problem is, again, that so much “fat” and “inefficiency” has already been stripped out of so many healthcare systems that there is now no extra time to spend on non-revenue generating clinical tasks, even those which would lead to more efficient care.

    On my service, we used to have a morning meeting with the nurses to go over the reports on our patients for the last 24 hours and discuss care plans for the day. However, going up on EPIC added about an hour to everyone’s day and we no longer have time to have this meeting.

  • Patient Kit

    I think the phrase “patient-centered medical home executive committee work group” is too time consuming to read. :-p

  • LeoHolmMD

    “At the moment, volume leads directly to practitioners’ salaries, so a direct hit to a practice session in terms of number of patients seen is directly felt, unfortunately, in the pockets of providers, and, believe me, they do not take that lightly.”

    Thats a pretty big “by the way…”: PCMH is not being funded except through grant money. Trivial payments through some insurers. No one has shown that it is financially viable. Still a volume business. Payment reform is a dream at this stage. But don’t stop implementing because of that. Lots of people build homes on sand. That whole mortgage crisis wasn’t too bad. Building homes that people can’t afford is the American dream.

  • southerndoc1

    This is pathetic beyond words. I don’t know where to begin . . .

    • southerndoc1

      Actually, I do know where to begin:

      fire the “head of the care coordination committee for our patient-centered medical home executive committee work group,” and put the savings into real patient care.

  • buzzkillersmith

    The PCMH is the internists and FPs shooting themselves in the foot. I guess it’s good that primary care docs, a confused and sheepish and comically idealistic lot, are finally coming around to this.

    What once the cattle are penned up it’s hard to escape. The bolt gun looms.

  • buzzkillersmith

    Not as smart as you might think. Plus, we are distracted and confused and passive. And no, we do not have the spine.

    The only solution here, an imperfect solution, is for med students to avoid primary care lest they make the worst mistake of their young lives.

  • buzzkillersmith

    Hi Dike, We’re talking about the PCMH, not the huddle. The huddle or muddle or cuddle or befuddle is not the issue. I say huddle yourselves blue but please be subtle.

    • southerndoc1

      What’ll I do? Just throw it all in the puddle.

  • southerndoc1

    “Your morning huddle – if it is run well – is less than a ten minute experience”

    Actually, in a well-run office, where everyone understands everyone else’s work style and where the staff knows the patients, it takes zero minutes and zero seconds: it’s all done on the fly in between other work.

    • LeoHolmMD

      Tenet #74.3: Destroy what remains of well run practices.

    • NPPCP

      Thank you!! No huddle necessary in our clinic. We all know what we all do – I’m glad you said that. We would all talk about the game last night in a morning huddle. And I would be paying everyone for nothing.

  • guest

    Sermo is a cesspool infiltrated with pharmaceutical and administrative types mining for information on physician opinions.

    I understand conformity is probably the only way primary care docs can hope to remain profitable as we move into this new era of health “care.” That said, it’s pathetic to endorse the PCMH as a “philosophy that works” by citing physician bonuses as a measure of its effectiveness. It’s expensive bureaucratic bloat that relegates patients (even paying ones!!) to the lowest common denominator. Perhaps that’s ok for you; I plan to go concierge if I get assigned to the PCMH near me.

  • southerndoc1

    Give an example of a fire that can be prevented by a daily huddle. My experience is that the true fires are completely unpreventable. Thanks.

    • NPPCP

      3 minute huddles are useless – we “huddle” throughout the day when it is needed – no one is working too hard. Those are just words – spoken to “fit” in the PCMH. Physicians were “huddling” long before this FAD came along.

  • southerndoc1

    “PCMH is a team centered care philosophy that not only works”
    Not according to this week’s JAMA report.

    • Dr. Drake Ramoray

      It works very well for consultants (this comment is not directed at Dike as he has many good ideas and I believe he is a good egg)

      • southerndoc1

        “I believe he is a good egg”
        Agree, but I’m surprised by his enthusiasm for the PCMH.

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