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The Art of Outreach Facilitation

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Title: The Art of Outreach Facilitation


1
The Art of Outreach Facilitation
  • Kate Nash and Dianne Laferriere
  • January 24 2011

2
The Art of Outreach Facilitation
  • Brief Review thus far
  • Chronic Disease Model -acute to chronic focus in
    approach to health care
  • Science of Outreach Facilitation- development of
    facilitation and how it has been used in
    prevention services
  • Facilitation is an effective and supportive way
    of changing practice behaviour, as well as being
    cost effective

3
What is a facilitator?
  • A helper and enabler whose goal is to support
    others as they achieve exceptional performance.
  • Facilitation is a way of providing leadership
    without taking the reins.
  • Ingrid Bens

4
(No Transcript)
5
Overview of presentation
  • IDOCC The Improved Delivery of Cardiovascular
    Care through Outreach Facilitation Program
  • The Primary Care Environment (in Ontario)
  • The Qualities and Skills of a Facilitator
  • Tools
  • Tailoring

6
IDOCC
  • The Improved Delivery of Cardiovascular Care
  • Through Outreach Facilitation

7
IDOCC Creation of the CCPN
  • The University of Ottawa Heart Institute
  • Prioritized Prevention of CVD
  • Recognizing the need for a true collaborative
    approach
  • Advent of Local Health Integration Networks
  • Regionalized focus
  • Allows for development of Chronic Disease
    Management in a way that has never been done
    before
  • Reorganization of Public Health in Ontario and
    Canada
  • A focus on integrated approaches to chronic
    disease prevention
  • Public Health Agency of Canada, Ministry of
    Health Promotion

8
IDOCC CCPN Priority Initiatives
  1. IDOCC initiative
  2. Hospital-based Smoking Cessation Network
  3. Champlain Get with the Guidelines Initiative
  4. Champlain Healthy School aged Children Initiative
  5. Champlain Healthy Living and Management Risk
    Factor Program
  6. Champlain Community Heart Health Survey

9
IDOCC Recruitment
  • Complex due to no single entity identifying
    primary care physicians
  • Multiple contacts with OMA, OCFP, CME events,
    pharmaceutical events,
  • Public speaking, promotion through the LHIN,
    press releases, get opinion leaders and community
    leaders on board to that they can spread the word
    and convince their colleagues
  • Cold calling- barriers, phone calls, in person
    visits
  • Printed material
  • Built our own comprehensive list of primary care
    physicians

10
IDOCC Overview
  • The Divisions were randomly assigned to begin
    the program as follows

Division Division Division Year 1 Year 2 Year 3 Year 4 Year 5
West Cen-tral East Year 1 Year 2 Year 3 Year 4 Year 5
9 8 4 Baseline Facilitation Facilitation (Sustainability phase) Facilitation (Sustainability phase) On-going program implementation sustainability phase Data analysis and evaluation
2 7 5 Baseline Baseline Facilitation Facilitation (Sustainability phase) On-going program implementation sustainability phase Data analysis and evaluation
1 6 3 Baseline Baseline Baseline Facilitation On-going program implementation sustainability phase Data analysis and evaluation
11
Evaluation-Key Indicators
  • Quality of care process indicators - 29
    evidence- and consensus-based indicators chosen
    to assess whether recommended clinical actions
    were followed in the clinical situations calling
    for those actions eg BP taken and recorded at
    least once in last year
  • Outcome of care indicators - 14 evidence-based
    reflecting whether patients achieved the the
    recommended treatment goal targets
  • Source of data Patient Chart Audit

12
IDOCC Practices
of practices of physicians
Step 1 26 59
Step 2 30 79
Step 3 27 53
Total 83 191
13
IDOCC Practices by Model
14
IDOCC EMR/ Paper/Transition
  • At the time of signing up for IDOCC there were
  • 43 Practices using paper
  • 40 Using EMR or a mix of paper/EMR
  • That figure is constantly changing

15
IDOCC Practices by Region
Program implemented in 83 practices
16
IDOCC Program Outline
  • Consent
  • Chart audit of 66 randomly abstracted charts
  • Facilitator provides audit and feedback
  • Collaborative goal setting
  • Monthly visits for intensive year, 12-16 weeks
    for sustainability year
  • Chart audit repeated at the end of the study

17
Patient Diagnoses Risk Factors (n 4,896)
HTN Hypertension CKD Chronic Kidney
DiseaseCAD Coronary Artery Disease PVD
Peripheral Vascular Disease
18
The Primary Care Environment
  • Complex
  • Evolving

19
The Primary Care Environment
  • efforts to understand practice should precede
    efforts to change practice

20
The Primary Care Environment
  • Complex
  • Changing
  • Unpredictable

21
The Primary Care Environment
  • 1. Complexity
  • 2. Payment Models
  • 3. Community
  • 4. Culture

22
The Primary Care Environment
  • 1. Complexity

23
Primary Care Environment
  • Health Care Organization
  • Scepticism
  • Not influenced by financial incentives
  • Fear of losing autonomy
  • Open to new initiatives
  • Want to maximize billing
  • Accept CDM challenge

24
Primary Care Environment
  • Local factors
  • Walk-in clinics
  • Sudden population shifts
  • Rural practices

25
Primary Care Environment
  • Appointments System
  • Patients cant get same day appointment
  • Overbooked
  • Always an hour or more late

26
Primary Care Environment
  • Self management
  • No time
  • Patients responsibility
  • Saying the same thing for years
  • The 3 questions
  • The 5 As
  • Focus on those who are ready
  • Refer

27
Primary Care Environment
  • Change
  • Change of models
  • Change of location
  • Change of records

28
The Primary Care Environment
  • A physician who has recently moved to EMR tries
    desperately to retrieve the patient records he
    has just lost.

29
The Primary Care Environment
  • Unpredictability
  • A productive relationship v a good relationship
  • The agent for change can be anyone in the team.
  • Never Never

30
The Primary Care Environment
  • The facilitator is uncertain where to go next
    with the practice

31
The Primary Care Environment
  • And then has a pleasant surprise

32
The Primary Care Environment
  • 2. Payment Models (Ontario)

33
2.Payment Models
  • FFS- accounts for largest number of practices,
    physicians and patients seen, no rostering, no
    other funding
  • FHG-(FFS remuneration) but incentives for some
    conditions, patient rostering, after hours care,
    THAS, currently some funding for IT

34
2.Payment Models
  • FHN, FHO-capitation, rostering, prevention and
    disease management incentives, provider
    governance, use of IT, some allied health
    personnel, 24/7 access
  • FHT- Capitation or salary, rostering, allied
    health personnel, prevention and disease
    management incentives, professional or community
    governance, IT, 24/7 access

35
2.Payment Models
  • CHC-salaried, rostering (operates within defined
    community), incentives, IT, allied health
    personnel, community governance, 24/7 access
  • AHAC-Aboriginal Health Access Centres- similar to
    CHCs, include traditional aboriginal approaches
    to health and wellness- salaried
  • Russell, GM et al 2009, Muldoon L et al
    2009

36
Patient Physician Perspectives
  • Payment model and organization may not affect
    day to day practice
  • A doctor in a FFS, FHG, or FHO may for most
    purposes work as a solo physician with
    receptionist
  • and /or nurse
  • There may be more similarities across models than
    within models

37
The Primary Care Environment
  • 3. Community

38
Community
  • Only CHCs have a catchment area
  • Patients often follow the doctor, therefore the
    idea of community resources and links becomes
    complex
  • Patients find doctors who speak the same language
    even if geographically distant
  • Rural/Urban differences
  • Quebec Patients

39
The Primary Care Environment
  • 4.Culture

40
Culture
  • The practice culture (shared beliefs and values
    embedded within an organization)
  • Organisational culture
  • Patient culture

41
The Primary Care Environment
  • Culture can influence the types of programs used
    to assure Quality- survey from 88 medical groups
  • Strong Information culture favoured electronic
    data systems and evidence based data
  • Quality centred culture favoured patient
    satisfaction surveys
  • Business orientated culture favoured benchmarking
  • Collegiate culture appeared to rely more on
    informal peer review
  • Autonomous culture negatively associated with all
    the programs ( but not significantly so)

42
Authors Conclusions
  • Culture does not make a difference in quality of
    care and patients safety
  • Culture does affect the slow adoption of quality
    assurance programs
  • It is important to consider congruence
  • Kaissi et al, 2004

43
The Primary Care Environment
  • practices often lack the office systems to
    support improved chronic illness self-management,
    delegation, care management and systematic
    tracking to assure optimal processes and outcomes
    of diabetes care.
  • Practices operate on a narrow financial margin,
    have minimal flexibility in resource use and are
    quite different from those systems in which
    adoption of chronic care management components
    have been demonstrated.
    Crabtree et al, 2011

44
The Qualities and Skills of a Facilitator
45
Qualities of the Facilitator
  • Skills presentation training, research and
    planning, analytical synthesis skills,
    observational skills, design customize
    interventions, ability to lead groups,
    interpersonal collaborative skills, communication
    skills
  • work independently, be flexible, creative,
    sensitive, empathetic, supportive, promotes and
    guides
  • Guiding Facilitation in the Canadian context

46
Qualities of the Facilitator
  • Knowledge skills primary health care context and
    office systems, relevant guidelines of care,
    organizational change, techniques and strategies,
    group vs individual dynamics

47
Qualities of the Facilitator
  • Personal disposition encouraging, neutral,
    inquisitive, non-authoritative leadership style,
    assertive confident, focuses on building
    capacity rather than taking ownership, share
    knowledge and strategies, change approach as
    needed, be comfortable with change and dealing
    with conflict and/or resistance

48
Qualities of the Facilitator
  • Technical, computer skills library searches,
    some familiarity with EMRs, good familiarity with
    word processing and presentation programs

49
Qualities of the Facilitator
  • Organizational skills identify processes as well
    as outcomes, work flow, create partnerships,
    knowledge of QI principles and strategies,
    provide resources and assist in development and
    implementation of evidence based practice tools

50
Tools
51
Tools
  • Audit and Feedback
  • Tailored flow sheets
  • Patient educational tools- links to community
    resources and promoting contact
  • Community Resources- specialists, awareness,
    referral forms, Ask the Experts opportunities
  • Networking Opportunities- shared experiences,
    successes and challenges
  • Summaries of conferences
  • Guidelines
  • Web sites

52
Tools
  • Relating tools to the Chronic Disease Model
  • The Community
  • Wider health community- Ministry of Health,
    professional bodies (College of Physicians and
    Surgeons), local diabetes programs
  • These organizations may offer directives,
    information, billing incentives, assistance
  • Facilitator can identify and help establish
    liaisons with these partners and/or find these
    resources for practice
  • Eg. Extra phone billing incentives at time of
    H1N1
  • Eg. Referrals to specialist care or community
    programs

53
Tools
  • Relating tools to the Chronic Disease Model
  • The Health system Organization
  • MOHLTC, Champlain LHIN and family practices are
    all focused on diabetes care- what is being done
    at all of the levels? Eg. BDDI
  • QIIP, DRCC, IDOCC, other programs
  • Transfer knowledge and facilitate linkages among
    organizations

54
Tools
  • Relating tools to the Chronic Disease Model
  • Delivery System Design
  • Define roles and tasks-writing descriptions
  • Encourage the development of planned visits for
    continuity of care, follow up
  • Help team explore improved communications
  • Will shift focus from episodic reactive focus to
    a proactive one

55
Tools
  • Relating tools to the Chronic Disease Model
  • Decision Support
  • Audit and feedback
  • Evidenced based guidelines
  • Literature searches
  • Provider education- CME opportunities, conference
    summaries, network meetings to share knowledge
    and strategies
  • Patient education- increase population awareness
    of the pertinent guidelines for care- posters in
    office, focused visit handouts
  • Increasing specialist care into primary care-
    reviewing specialist availability, updating
    accuracy of forms and contacts

56
Tools
  • Relating tools to the Chronic Disease Model
  • Clinical Information System Support
  • Registries- EMR or paper
  • Reminders in charts- EMR or paper
  • Flowsheets, practice aids- (tape measures)
  • Encourage periodic reviews to look at performance
    and efficacies

57
Tools
  • Relating tools to the Chronic Disease Model
  • Patient Self Management
  • Increase patient knowledge through education
  • Increase ownership of health self management
    programs- identify, inform and promote
  • Action plans- ranging from simple to complex,
    feedback to patients
  • Promoting the idea that patient and team are
    working together to improve or maintain health-
    both patients and staff need to agree (attitude
    change)
  • Provide ongoing support for practices and
    patients

58
Tailoring
59
Tailoring
  • Practice assessment and intervention tailoring
    are complex and intuitive processes and are
    generally not amenable to linear or sequential
    steps and simple descriptions. Ruhe, 2009
  • Tailored interventions have the potential to
    match motivations and acknowledge conditions
    within the practice environment that influence
    and sustain change efforts. Bobiak, 2009

60
Systematic Review, Baker 2009
  • 26 studies
  • Tailored interventions can change professional
    practice
  • however
  • As yet there is insufficient evidence on the most
    effective approaches to tailoring including how
    barriers should be identified and how
    interventions should be selected to address
    barriers.

61
Tailoring
  • Interventions can be tailored more effectively
    by
  • Assessing the practices capacity for change
  • Appraising the cultural-structural fit

62
The Art of Facilitation
  • Practical Considerations
  • Dont reinvent the wheel- easier and time saving
    to adapt existing tools, if possible
  • Everyone has their own style- what works for one
    practice may not in another
  • On the journey, there may be hold ups, barriers
    and detours
  • Keep the destination in sight and close the loops

63
A Complex Journey but
64
Try and close the loops
65
References
  • Baker R et al, Tailored Interventions to overcome
    identified barriers to change effects on
    professional practice
  • And health care outcomes. Cochrane Database of
    Systematic Reviews 2010
  • Bens I, Facilitation at a Glance, GOAL QPC AQP
  • Bobiak S et al, Q manage Health Care Vol. 18, No
    4, pp. 278-284, 2009
  • Carter C et al, Q Manage Health Care Vol. 16, No
    3 pp 194-204, 2007
  • Crabtree et al, Medical Care
  • Dugan et al, J. Ambulatory Care Manage, Vol. 34,
    No 1, pp.47-57, 2011
  • Guiding Facilitation in the Canadian context
    Enhancing Primary Health Care, Multi-jurisdictiona
    l Collaboration, Dept of Health and Community
    Services, Newfoundland, 2006
  • Hogg W, International Journal for Quality in
    Health Care Vol. 20, No 5, pp. 308-313, 2008
  • Kaissi et al, Health Manage Rev 2004, 29(2)
    129-138
  • Muldoon L et al Health Care Management Forum 2009
  • Ruhe M et al, Q Manage Health Care Vol. 18, No 4,
    pp 268-277
  • Russell, GM et al Annals of Family Medicine 2009,
  • Strange KC. J Family Pract. 43(4). Pp. 358-360,
    1996
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