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

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 • IDOCC initiative • Hospital-based Smoking Cessation Network • Champlain Get with the Guidelines Initiative • Champlain Healthy School aged Children Initiative • Champlain Healthy Living and Management Risk Factor Program • 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:

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-basedreflecting whether patients achieved the the recommended treatment goal targets Source of data: Patient Chart Audit

12. IDOCC: Practices

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 can’t get same day appointment • Overbooked • Always an hour or more late

26. Primary Care Environment Self management • No time • Patient’s 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 orientatedculture 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