Implementation Research: Lessons Learned in OKPRN

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Implementation Research Lessons Learned in OKPRN

• James W. Mold, M.D., M.P.H.
• Department of Family and Preventive Medicine
• University of Oklahoma Health Sciences Center
• Oklahoma City

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Objectives

• Describe OKPRN
• Define implementation research
• Review what we have learned
• Discuss the challenges created by that knowledge
• Speculate about next steps

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Rural Oklahoma
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Oklahoma Physicians Resource/Research Network

• Established in 1994 (HRSA Grant)
• Emphasis on both resources and research
• (More like RD)
• Emphasis on information technologies
• Now a 501c3 non-profit organization but closely
  aligned with the OU DFPM
• 110 practices 235 clinician members
• Members care for 10 of the states pop.

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OKPRN Practices
?
OKC
Oklahoma Physicians Resource/Research Network
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Cells
Diseases
People
Practices
Dissemination Research
Guidelines Development
Research Pipeline
Practice- and Community- Based Research
Basic Research
Human Research
Practice and Community
T3QI
T1
T2
Meta-analyses Systematic Reviews
Implementation Research
TTranslation
Not ready for humans
Not ready for patients
Not ready for practice
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Implementation Research (How to help practices
implement changes)

• Pneumococcal immunization
• Before - After
• Diabetes care
• Prospective, uncontrolled
• Cluster RCT
• Smoking during pregnancy
• Before - After

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Implementation Research Projects

• Mammography RCT
• Cluster RCT
• Preventive Services Delivery
• Cluster RCT
• Prescription for Health (Unhealthy Behaviors)
• Phased/staggered Intervention in Practice
  Clusters

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Phased/Staggered Intervention
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Diet/Exercise Module
Practice Clusters
Simulated (not actual data)
Aspy CA et al. Am J Prev Med. 2008 Nov35(5
Suppl)S373-80.
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How These Studies Work

• For researchers and funders Studies of specific
  QI strategies development of products (software,
  guidebooks)
• For practices QI
• Clinician education (education, training, CME)
• Practice receives tangible support (e.g.
  facilitator, )
• Funding sources Agency for Healthcare Research
  and Quality, Oklahoma Foundation for Medical
  Quality, Robert Wood Johnson Foundation

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Effective Implementation of Innovations in
Primary Care
Literature and Exemplar Methods
Academic Detailing
Performance Feedback
Facilitation
Practice Enhancement Assistants
IT Support
Local Learning Collaboratives
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Feedback and Benchmarking

• Must be accurate and believed
• Measures must be relevant/agreed upon
• Must be repeated at least monthly during
  implementation

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Exemplars and Exemplar Practices

• Okarche, Oklahoma 1998
• It doesnt help when the QIO comes in, audits
  my charts, and tells me what a lousy job I am
  doing. If they would tell me who is doing a good
  job, maybe I could talk with them and find out
  how to do it better.
• Mark Gregory,
  M.D.

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What Mark Didnt Say

• If they would just tell me
• What the literature says I should do.
• What the specialists say I should do.
• What the guidelines say I should do.
• What my academic colleagues say I should do.
• What CME resources are available.

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Performance Distributions

• Virtually always present
• Wider than you would expect
• Within practices and between practices
• High performers are often not the usual
  suspects
• Highest performers in one area arent necessarily
  the highest performers in other areas
• Some true exemplars (quest for excellence)

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Whats the best way to

• Manage laboratory test results?
• Deliver preventive services?
• Improve my care for patients with diabetes?
• Handle prescription refills?
• Help patients remember to bring their medications
  with them to appointments?
• Help overweight patients lose weight and keep it
  off?

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What Do Exemplars Know?

• Principles
• Techniques
• Scripts

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Diabetes Care Principles

• See diabetic patients every 3 months for a
  diabetes visit
• Label the charts
• Create practice protocols
• Use a registry
• Use one eye consultant
• Use flow sheets

This looks a lot like prenatal care.
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From a High School Math Quiz
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Techniques for Encouraging Patients to Bring in
Meds

• Signs in exam room facing patients chair
• Message in red on the bottom of patient education
  sheets
• Message on appointment reminder cards
• Bag with practice name and phone number in which
  to put meds

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Eskimo Construction
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Scripts

• Ohh! Dr. Stewart will be so upset with both of
  us.
• Colon cancer is a stupid way to die.
• Its time for your pneumonia shot.

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Scripts
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Academic Detailing

• Respectful sharing of information
• Discussion of current methods
• Discussion of how the principles and techniques
  might apply within that practice
• Plan for improvement

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Practice Facilitation

• One-half day per week for about 6 months
• Relationship with clinicians and staff is key
  takes several months
• Key functions include assessment and feedback,
  coaching, team-building, technical and hands-on,
  assistance, training, coordination of PDSA
  cycles, and cross-pollination

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OKPRN Board of Directors
PEA
Dept. of Family Medicine
Project Development Advisory Committee
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HIT Support

• Generation of reports
• Template development
• Database development
• Implementation of registries
• Clinical decision support systems
• Communication systems

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Local Learning Collaboratives

• One-hour lunch meetings every 1 2 months
• Review performance data from all practices
• Share successes and failures
• Share anecdotes
• Share effective methods

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Which Practices Are Successful

• The QI topic is a high priority
• The practice is able to change
• The practice is able to implement the critical
  components of the new process
• Solberg LI. Improving medical practice A
  conceptual framework. Annals Fam. Med. 2007
  5(3) 251-256.

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Priority

• Administration is behind it
• Clinicians are behind it
• Staff are behind it
• Competing priorities are less important than the
  desired change and wont interfere with it.

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Change Capacity

• Shared quality of care mission
• Collaborative, cohesive environment
• Well-organized, non-chaotic
• Clear lines of authority/decision-making
• Well-developed QI process
• Regular QI meetings
• Stable workforce and administration
• Stable finances/financial management
• Effective policies and procedures

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Change Process Content

• Care management capabilities
• Patient self-management support
• Capable staff of the right types
• Patient tracking and registry functions
• EHR functionality
• Decision support options
• Test and referral tracking
• Task management systems
• Performance Tracking/Reporting

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Time

• The time that it takes to implement an innovation
  in committed practices depends upon
• The complexity of the intervention
• The magnitude of the changes required
• The number of people in the practice who must
  change their methods
• It generally takes about 6 months.

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Proposed effects of the QI Interventions on
Change Elements
Priority
Change Capacity
Change Process Content
Performance Feedback
Academic Detailing
Practice Facilitation
HIT Support
Local Learning Collaboratives
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It requires an Infrastructure

• Feedback, exemplar practices, academic detailing,
  facilitation, IT support, local learning
  collaboratives
• Care management, registry functions
• Longitudinal relationships
• Knowledge of local factors
• Travel time/cost
• Cross-practice collaboration

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It Takes a Village

• Primary care can no longer be practiced in
  isolation from public health, mental health,
  social services, and community organizations
• Obesity, lack of exercise, lack of culinary
  culture, smoking, and abuse of alcohol account
  for 37 of all premature deaths.

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Primary Care Health Extension

• Key functions
• Performance monitoring/reporting
• Clarification of exemplar practices
• Academic detailing
• Practice facilitation
• HIT support
• Local learning collaboratives
• PCMH capacities shared across practices (e.g.
  care management patient education registries)

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Primary Care Health Extension

• Closing gaps
• Public health
• Mental Health
• Social Services and Community Resources

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• 1796 George Washington
• 1810 First agricultural journals
• 1862 Land-Grant College Act established the land
  grant college system
• 1882 Hatch Act established funding for
  experimental farms
• 1889 Dept of Agriculture began issuing Farmers
  Bulletins and the Yearbook of Agriculture
• 1880 -1911 Establishment of farmers institutes
  and mobile institutes
• 1906 S. A. Knapp hired the first county
  extension agent to develop a personal
  relationship with every farm family in the county
  and help them implement innovations

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Cooperative Extension

• Funding sources 30 federal, 70 state and
  local
• Headquartered in the land-grant university
• Staffing 1 federal, 32 university, 67 local
  in nearly all of the 3,150 counties in the U.S.
  plus more than 2 million volunteers
• Goal is to maintain meaningful bi-directional
  communication between the university and the
  farmers and provide on-site training and
  assistance to farmers and farm families so they
  can stay abreast of advances in science
• Taking the University to the People by Wayne D.
  Rasmussen Iowa State University Press, 1989

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Community Care of NC

• Regional 501c3 organizations owned and run by
  primary care clinicians supported by Medicaid
  care management funds (3 PMPM) charged with
  improving quality of care for Medicaid patients.
• ROI 2 for every 1 invested
• Saved the state 60 million in Medicaid costs in
  2003 and 120 million in 2004

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Canadian County, Oklahoma

• Juvenile Justice System and community groups
  anteed up 10,000
• Matched through the Medicaid federal match to pay
  for a ½ time care manager for children
• Linked to a matching contract with the OU DFPM
  for 120,000 to improve well child care
• Drew the attention of a developmental
  pediatrician, who obtain a grant from a
  foundation for 100,000 to improve developmental
  screening
• Now approved by Medicaid as a HAN. Will receive
  5 PMPM (340,000 per year)

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The University of New Mexico HEROs Program

• Health Extension Rural Offices (HEROs)
• Mission
• Generate better health at lower cost
• Increase community capacity to address local
  problems in order to reduce health disparities
• Activities
• Tele-health projects
• Training
• Workforce development
• County health report cards

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QUESTIONS????
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From Another Math Quiz