Primary Care Practice Development: A Relationship-Centered Approach

Abstract

PURPOSE Numerous primary care practice development efforts, many related to the patient-centered medical home (PCMH), are emerging across the United States with few guides available to inform them. This article presents a relationship-centered practice development approach to understand practice and to aid in fostering practice development to advance key attributes of primary care that include access to fi rst-contact care, comprehensive care, coordination of care, and a personal relationship over time. METHODSInformed by complexity theory and relational theories of organizational learning, we built on discoveries from the American Academy of Family Physicians' National Demonstration Project (NDP) and 15 years of research to understand and improve primary care practice.RESULTS Primary care practices can fruitfully be understood as complex adaptive systems consisting of a core (a practice's key resources, organizational structure, and functional processes), adaptive reserve (practice features that enhance resilience, such as relationships), and attentiveness to the local environment. The effectiveness of these attributes represents the practice's internal capability. With adequate motivation, healthy, thriving practices advance along a pathway of slow, continuous developmental change with occasional rapid periods of transformation as they evolve better fi ts with their environment. Practice development is enhanced through systematically using strategies that involve setting direction and boundaries, implementing sensing systems, focusing on creative tensions, and fostering learning conversations.CONCLUSIONS Successful practice development begins with changes that strengthen practices' core, build adaptive reserve, and expand attentiveness to the local environment. Development progresses toward transformation through enhancing primary care attributes. INTRODUCTIONF or more than a century, small, physician-led medical practices were the most common source of primary care throughout the western world.1 The future viability of this cottage industry is now in doubt, and primary care in the United States and elsewhere is seriously weakening. 2 Hopeful energy for changing and transforming primary care practices arises from this deteriorating situation.3 Practice development activities are emerging as part of state initiatives, Medicare pilot programs, health system projects, and independent innovations. [4][5][6] The diffi culties and resistances challenging this hard work are daunting, with few research-informed approaches available to help guide these critically important initiatives. [7][8][9][10] In this article, we offer a theory-based, evidence-informed relationship-centered approach for primary care practice development derived from 15 years of research on primary care practice improvement 11 and, most recently, from the American Academy of Family Physicians' National Demonstration Project (NDP) S69 R EL AT IONSHIP-CENT ER ED PR AC T ICE DE V ELOPMENTone of the fi rst research trials seeking to implemen...

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