Assessing a Practice Coaching Intervention for Improving Chronic Care in Safety Net Organizations Sh

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Assessing a Practice Coaching Intervention for
Improving Chronic Care in Safety Net
OrganizationsShinyi Wu, PhDAssistant
Professor, Epstein Department ofIndustrial and
Systems EngineeringUniversity of Southern
California RANDSeptember 14, 2009, presented
at AHRQ Conference
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AcknowledgementCo-authors, Sponsor, and
Participants

• Marjorie Pearson, PhD, RAND
• Katie Coleman, MSPH, ICIC, GroupHealth
• Brian Austin, ICIC, GroupHealth
• Ed Wagner, MD, ICIC, GroupHealth
• Wendy Jameson, MPP, MPH, Safety Net Institute
• Cindy Brach, MPP, Agency for Healthcare Research
  and Quality
• The participating healthcare organizations

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Lessons Learned from CCM Collaboratives Call for
Further Implementation Research

• Teams spent considerable time searching
  for/developing tools
• Some teams felt intimidated by taking on the
  whole model asked for a sequence
• Collaboratives were time resource intensive
• Many changes were made in ways that were not
  sustainable financially

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Test A Team Coaching Approach to Help Practices
Implement CCM

• Recognizing that medical practices often need
  flexible, hands-on support when embarking on a
  program of practice improvement
• Especially safety-net organizations
• Testing a coaching intervention (coupled with a
  toolkit) to disseminate the CCM
• Funded by AHRQ

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Practice Coaching Design

• Who were coached?
• Nine randomly selected primary care teams from
  two clinics in two California public hospital
  systems
• Who were the coaches?
• Two quality improvement experts external to the
  hospital systems
• How was coaching structured?
• Two site visits
• Communicated by phone and email
• Monthly reports to coaches

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Three Intervention Phases

• Phase I Laying the foundation for success
• Form Coaching Team
• Get Acquainted with Leadership
• Orient the Practice Team to the Work
• Phase II Active practice coaching
• Conduct prework assessment prepare teams for
  site visits
• Run learning sessions
• Support the teams
• Phase III Sustaining the gains
• Close out coaching and expect teams to continue

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Logic Model Chain of Action
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Evaluation Methods

• Quasi-experimental design with three arms
• Intervention, internal control, and external
  control
• Implementation assessment through site visits
• Environmental and organizational contexts
• Practice coaching
• Implementation process
• Perceived impact lessons learned
• Process outcomes assessment
• Participants perceived impact
• HEDIS diabetes care indicators utilization
  measures

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Results Contexts

• Environment Challenging, but not about survival
• Organization Commit to improving chronic illness
  care and have some ongoing activities
• Leadership support for the project modest
• Improvement experience Have previous and ongoing
  improvement projects experience varied
• Participants Majority adopters of CCM
  randomized to participate so modest level of
  excitement
• Information system Average cumbersome

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Results Coaching

• Coaching is perceived as
• a necessary bridge to the toolkit
• motivated and prompted people to make changes
• extended the horizons of the teams
• had a positive effect on team building
• built an emotional bond which was a key success
  factor for coaching
• The coaching costs approximately 41,000 for the
  two clinic sites, including time spent in coach
  training, coaching, travel, and communication

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Suggested Modifications to Our Practice Coaching
Approach

• Coaching should include more face-to-face
  interactions
• An internal coach might be added
• Coaching intensity may need to be greater at the
  beginning
• Coaches should be more proactive and creative in
  introducing the toolkit
• Continue coaching for a longer period of time

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Coaching Effects on Workgroup and Team
Effectiveness

• Changes in self-efficacy and knowledge
• Individuals positive on gaining skills,
  knowledge, and tools to improving clinical care
• Working as a team
• Coaching did not change the working relationship
  and team structure, but did strengthen people
  working together as a team
• Acquiring health system support
• A coach can help problem-solving, but sustained
  support requires a local leader to organize the
  efforts

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Lessons Learned

• Practice Coaching is a feasible mechanism for
  facilitating CCM quality improvement in safety
  net clinic settings
• Assessing resources firsthand and tailoring
  advice
• More staff can participate in the practice
  improvement sessions
• Coaching can be delivered with minimal impact on
  patient access
• Practice coaching vs. collaborative learning
• Providing structured learning time is key
• Practice coaching can really jump-start the
  spread
• Especially when there is internal knowledge and
  experience

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Implications

• The field of practice coaching is still evolving
• Clearly defining the coaches role and regularly
  checking expectations is important
• Different models of QI facilitation may work
  better in different settings and timing
• Coaching on business improvement along with
  quality improvement needs to be further developed
  and studied

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Thank you

• For additional information
• CCM Toolkit and Coaching Manual
• http//www.ahrq.gov/populations/chronix.htm
• Integrating Chronic Care and Business
  Strategies in the Safety Net A Toolkit for
  Primary Care Practices and Clinics
• Practice Coaching Manual
• http//www.improvingchroniccare.org
• RAND Chronic Care Studies
• http//www.rand.org/health/surveys_tools/chronic_
  care_model.html
• Shinyi Wu
• Email shinyiwu_at_esc.edu