Teamwork

2011 keeps trying to end like a whirlwind, like the hurricane of earlier this fall, with November slipping by like a breath.  Even so, I am kind of against getting caught up in the craziness of the holidays this year.  With Mom and John here for Thanksgiving, I really intentionally slowed the pace.  I wanted to be sure to spend time with them.  It was great to take the time and enjoy a few of my Baltimore traditions like hosting the "Thanksgiving orphans", a Thanksgiving Day hike, and antique shopping in Ellicott City.  I also began rehearsing for the FCF Advent Concert, working with a group of five friends to arrange and rehearse an a capella version of "Angels We Have Heard on High" which was sung with such heart and beauty that I found myself not just singing but listening to my fellow choristers and reflecting upon those words of anticipation.

Despite all that Christmas has become in the American culture, Advent is really about the first coming of Jesus, who was born in a most awkward place and in a time of great uncertainty, homeless in a small town, to a single mother and a fill-in dad.  It wasn't the most obvious way for the Messiah to appear, yet there were those who "got it" and stood ready to welcome not just a precious and delicate newborn baby but One who would be called Holy and King.  That is deeply stirring to me.  I am reminded that God is near to the broken-hearted.

I feel that I have finally emerged from a season of great hardship.  Just a year ago, I was pretty burnt out.  As a primary care doctor, a patient, and a small business owner, I felt that I had just about reached the end of my rope.  I was considering career changes, because I could not imagine having to continue to work so hard and yet remaining under financial stress and being unable to afford bringing in another professional.  I had applied to become part of the Maryland Multi-Payor PCMH Pilot Program and had waited for months to hear the news, only to find out that we were rejected in January.  Many other hardships piled up in January, including stalemates in negotiations with insurance companies, the loss of a key employee, and tough business decisions.  I weighed options and struggled.  Then, in a strange turn of events, our MMPP PCMH application was reconsidered.  In March, we were offered a place in the program.

Here is my month-by-month, just related to the practice:

January-February:  working the equivalent of two jobs, single-handedly trying to put pieces of the Patient-Centered Medical Home together on my own and scrambling for ideas on how to accomplish it without funding; a first meeting of the Green Spring Internal Medicine Advisory Board

March: attending the National PCMH Summit Conference in Philadelphia, then finding out about our acceptance to the MMPP Pilot

April-May:  our biggest and most challenging software upgrade since launching in 2006!  interviewing and hiring Amy Luebehusen, CRNP, our amazing care manager and nurse practitioner and hiring Kweisi (CMA)

May: the MMPP Learning Collaborative - meeting with over 50 other Maryland practices to discuss what
PCMH is all about and learn more about what the NCQA application would entail; working with our software company on ways to capture data to improve patient care

June: preparing the launch of our PCMH, my first true vacation in years (2 1/2 weeks in Italy!)

July:  the official 5 year anniversary of the practice and the launch of our PCMH and pre-visit planning via daily huddles, initiation of monthly staff and transformation team meetings and countless other policy and workflow changes, Kweisi's resignation

August:  hiring Chanel (admin asst), conference calls, working with Amy and Laura (our practice transformation coach) on putting together the vastly extensive NCQA application, meeting with Wavelength MSO for help on preparing to attest for Meaningful Use with Medicare

September: a quick trip home to Aspen for rest from work on Labor Day weekend, more meetings and conference calls about PCMH and ongoing work on software glitches and changing our practice workflow, hosting a tour of the practice/reception for key partners in our work

October:  submitting our NCQA application, thanks to Amy for the difficult details, working on preparing to certify for Meaningful Use, lots and lots of software challenges, Chanel's acceptance to college! Hiring Sara (CMA)

November:  the MMPP Learning Collaborative meeting #2 which was greatly encouraging - meeting together with the other 50+ practices in our program, Amy giving a great talk and my brief summary of our history and progress, encouragement via shared values of others at the conference;  the redesign of our front desk position, finding a new way to track documents and tests

December:  running a successful test to submit vaccination report to the State of Maryland, finally working out enough of our software kinks for me to attest to Meaningful Use, 6 months of bookkeeping, Chanel letting us know that college was starting in January and preparing for that staff change, fixing breaks in the software to allow us to capture data to measure quality, organizing a software usergroup start-up meeting in January, staff party tomorrow, on the train Thursday, being closed for the next two Mondays, and finalizing the books by December 30th!

In less than a year, Green Spring Internal Medicine has gone from 1 doctor and 1 staffmember to a team of 5.  We call our PCMH transformation team "the Early Adapters."  After Chanel moves on in January, we will be hiring another team member.  Everyone has pulled together, adjusting to the many changes we have had to make to meet the ideals and expectations of a small-practice Patient-Centered Medical Home. We have had a great deal of support from the outside.  One insurance company just gave us a 10% raise, while still others stand in the way of progress.

Our patients have been key team members and have been pleased with the changes.  We were grateful to be able to continue to participate with most of the major insurance companies this year, thanks to the Pilot Program.  We have had the ongoing work of communicating to our patients and reminding ourselves what the Patient-Centered Medical Home is all about.  Thanks to Amy, our care is better coordinated.  Thanks to the staff, our charts are now more complete with notes from specialists, colonoscopy and mammogram reports, and other test results.  Our visits are more organized, and we are working more collaboratively with our patients toward their best health.  I feel so full in my heart, knowing that we are practicing better medicine as a team than I was ever able to practice on my own or in old models of care.  Sometimes we find ourselves weary and hit what has been called "change-fatigue".  Other times we are more inspired.  We are working harder than ever, yet we are also seeing the results and reaping the benefits of sharing the labor.  I now even have guarded hope for the future of internal medicine.