Implementation of Patient and Family Advisory Councils in Primary Care Practices in a Large, Integrated Health System
KEY WORDSprimary care patient engagement primary care redesign
The role of patient engagement in healthcare is well recognized.1 While some guidelines exist for development of patient councils,2 and characteristics of high functioning patient advisory councils have been identified around representative patient sample recruitment, facilitation, accountability, and supportive culture,3 implementation of patient and family engagement is not well standardized. There has been interest in patient engagement in healthcare research,4, 5 but there remains a need to describe the process of patient and family involvement in primary care practice including recruitment, goals and expectations, and outcomes of the engagement process. A reporting item tied to reimbursement for The Centers for Medicare and Medicaid Services Comprehensive Primary Care Plus program (CPC+),6 (Patient and Caregiver Engagement domain), is that Patient and Family Advisory Councils (PFACs) are created with representation of care providers and patients and families from participating primary care practices and that recommendations of the group are integrated into care delivery. We describe the implementation of PFACs across primary care practices to guide care optimization and co-design solutions in a large, integrated healthcare system.
The Cleveland Clinic Health System (CCHS) includes 44 primary care practices organized into 10 hubs, with 3–7 practices per hub site. Beginning in April 2017, we integrated primary care practice-specific PFACs into our healthcare partner structure. A steering committee included representation from health system departments including Internal Medicine, Family Medicine, Finance, and the Office of Patient Experience. The PFAC meetings were offered at hub sites, with practices having the option of conducting individual practice site meetings instead of attending at the hub. At each meeting, both employee and patient representation from each practice was required. Practices identified a volunteer clinical lead (physician or advanced practice provider) and a group facilitator for the meetings, which were scheduled for both third and fourth quarters of 2017. Provider facilitators were offered online training materials and suggested topics for the first meeting, with subsequent agendas determined by local facilitators. Patients were recruited using two methods: (1) a survey sent to an established internet panel of active CCHS patients engaged in offering feedback and (2) ideal healthcare partner characteristics were shared and providers responded with nominations. Interested patients were contacted by project staff and requested to become CCHS volunteers including an onboarding process with online application, interview, background check, confidentiality agreement, education modules, and orientation session. No monetary incentive was offered to providers or patients for participation. Patient feedback was systematically elicited by the facilitator through open discussion.
Themes and Examples of Discussion Topics at Patient and Family Advisory Council Meetings
Need for explanation of role of care team members, including physicians, medical assistants, nurses, nurse care coordinators, pharmacists, social workers; need for clarity on how team members work collaboratively to care for the patient
Access to care
Appointment types, wait times for scheduling, visits with primary provider/team vs. urgent access providers, virtual visit: types of concerns appropriate to address in virtual visit, insurance coverage
Workflow related to office visits
Pre-visit test ordering, check-in procedures (automated vs. in-person, information required, privacy during process), need for assistance upon arriving/wheelchair availability
Communication with office between visits
Phone or electronic communication (through electronic medical record), test result reporting, question of option for live chat function for electronic communication
Need for explanation of medical bills, availability of patient financial advisors in health system to assist with concerns
Antibiotics for upper respiratory infections, shared decisions around initiation of new medications and patient concerns to be addressed
We implemented PFACs across primary care practices in a large health system. Meeting discussions provided significant insight into patient understanding and concerns around primary care delivery. Most themes did not relate to clinical decisions regarding care but importantly highlighted the need for improved communication with patients about care delivery structure and presented several opportunities for quality improvement. Significant barriers to PFAC implementation included (1) patient recruitment (only 35% of patients participated in both quarters) and (2) availability of providers and patients to travel to meetings. Nonetheless, participants remained engaged and meetings were well attended, representing as essential step to improving relationship-centered care delivery. Continuing with quarterly PFAC meetings, future work will focus on defining specific roles and goals for patient involvement in quality improvement initiatives, ensuring representation reflecting populations served by each practice, and measuring outcomes of PFAC integration into primary care delivery.
Dr. Misra-Hebert is supported by an Agency for Healthcare Research and Quality grant K08HS024128. Dr. Rose receives partial salary support from the National Institutes of Health #1R01HG010092-01.
Compliance with Ethical Standards
Conflict of Interest
Dr. Misra-Hebert has received research funding from the Merck Investigators Studies Program and from Novo Nordisk, both unrelated to this work.
Dr. Rose has received honoraria from Siemens Healthineers, unrelated to this report.
All other authors declare no conflicts of interest.
- 1.Patient Engagement. https://doi.org/10.1377/hpb20130214.898775/full/. Accessed July 5, 2018.
- 2.Steps to Creating a Patient Safety Advisory Council. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/patient-safety-advisory-council/chapter3.html. Published April 1, 2008. Accessed July 5, 2018.
- 6.Comprehensive Primary Care Plus | Center for Medicare & Medicaid Innovation. https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus. Accessed July 5, 2018.