Working with Community Clinicians: What LA Net members want you to know

1. Working with Community Clinicians: What LA Net members want you to know Lyndee Knox, PhD CEO LA Net: A Primary Care Practice Based Research and Resource Network Lyndee.knox@gmail.com www.lanetpbrn.net

2. So what are practice-based research networks (PBRNs)? • A group of ambulatory practices devoted primarily to patient care -- affiliated with each other to investigate questions related to their practice • Started 30 years ago in U.S. as a way to study process of primary care. Funded initially by AHRQ, and HRSA and now NIH

3. Why do this? 95% of patients visits in a year take place in ambulatory care settings - Need a way to study and improve these settings Many findings from research are “castles in the air” – interesting but of no real use to our clinicians and pts --- our docs rarely encounter patients w/ just 1 dx 19 years to move discoveries from bench to bedside to community is too long --- one of the reasons--- clinicians and patients not involved as partners

4. But why in primary care setting? In an average month: 21 visit a hospital outpatient clinic 14 receive home health care PBRN Focus 113 PCP Visits 13 visit an emergency department 8 are in a hospital <1 academic health center 1000 people 800 with symptoms 113 PCP visits New Ecology of Medical Care - 2000

5. Cells Diseases People Practices Guidelines Development Dissemination Research Research Pipeline Practice- and Community- Based Research Basic Research Human Research Practice and Community T3=QI T1 T2 Meta-analyses; Systematic Reviews Implementation Research Not ready for humans Not ready for patients Not ready for practice

6. Why do this? Problems in the pipeline An average of 19 years from discovery to translation into the community The story of Beta Blockers

7. PBRNs were created To overcome barriers to translation by creating a means for involving “community” in research To provide the means for clinicians to study the things that matter to them and their patients To support dissemination and effective implementation of innovation in primary care

8. Overview stats on PBRNs (2010) • 115 PBRNs in U.S. • 8,475 practices or clinics • 2.5 million patients served • 44,134 providers (MDs, NPs, Pas other) From: AHRQ National PBRN Resource Center Survey, 2009

9. In California, there are at least 4: LA Net – Southern California SurfNet – San Diego Collaborative Research Network – UCSF Rural Network – UC Davis

10. A brief history of LA Net Formed in 2002 w/ funds from HRSA and AHRQ Left USC in 2008 and is now an NPO Membership doubled overnithg 20 CHC members in LA = 165 practices and > 1 million patient visits

11. LA Net Mission To improve the primary health care services available to low-income children and families and contribute to the reduction of health disparities in LA communities by attracting,developing, and sharing resources and conducting relevant practice-based research.

12. Map of LA Net

13. LA Net’s social network Map

14. LA Net: • Is governed by 20 clinicians from safety net and researchers from local universities • Convenes CHCs to develop and implement study ideas • Provides PEAs part time to practices to help translate CEFs and support QI • Serves as a liaison between universities and practices

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

16. Okarche, Oklahoma 1998 “It doesn’t 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.

17. What Mark Didn’t Say If they would just tell me: • What the literature says I should do. • What the guidelines say I should do. • What my academic colleagues say I should do. • What the subspecialists say I should do. • What CME resources are available.

18. My Philosophy about Networks People should cultivate networks/communities if that allows them to accomplish or experience things they wouldn’t be able to as well as individuals. For example, reach goals, solve problems, attract resources, distribute burdens, influence public policies, increase job satisfaction

19. Influenza Vaccinations • A solo PCP in Grove, OK led a county-wide effort to coordinate influenza immunization efforts in his county. • He was able to persuade every entity planning to give flu shots to wait until a set date, which was announced throughout the county. • All agreed to share their flu shot supplies with any who didn’t have enough, keeping track of any exchanges for later reimbursements. • Office phone calls about flu shots decreased from around 100 to <10 per day.

20. A few things I know about working w/ clinicians in CHCs Inherently curious & interested in your work Want to help and contribute to knowledge generation Want to ensure the needs of their minority and low-income patients are represented in medical studies Want to help their patients access the best medicine can offer

21. But they are also: Working at or near capacity Experience chronic staffing shortages Responding to endless demands to compensate, improve, and meet bottom line Often cannot get their patients the care they need And are also providing some of the best primary care in the country

22. Video

23. So what is the best way to engage CHC clinicians? In the same way you need to be CULTURALLY COMPETENT in working with diverse PATIENTS You need to be CULTURALLY COMPETENT in working with their CLINICIANS To do this, you need to understand their world a bit better

24. Some things not to do Take their time away from patient care and running their clinic Ignore their mission –just do your thing Helicopter out as soon as you can Pay nothing. But if you must, use words like “stipend” or “honoraria” and make sure it doesn’t carry indirects Take years or better yet never tell them what you eventually learn Leave nothing useful behind

25. Lessons Learned • Do good things and the money will follow. • Neither top down nor bottom up • Goal driven • Collaborative • “Finger on the pulse” • Strategic • Opportunistic

26. Lessons Learned • In the end it is about relationships more than it is about data • Make home visits • Connect people to other people • Establish multiple communication channels • Long breaks at meetings • Cultivate learning communities (research is just systematic learning)

27. Things you should do…

28. Engage them as partners, NOT recruitment sites • Involve them, talk to the, listen to them at every stage of your project . Yes, at question formation, yes at findings and dissemination, yes throughout. • You may learn something. • Use different strategies – low tech works– emails, listservs, polite note, short voice mail

29. Know how your work supports THEIR MISSION & goals • How will your project/study: • help the patients they serve? • improve the care they provide? • Improve the work environment? • strengthen them financially?

30. Know about their past experience w/ research & do it differently • Clinics receive 20-30 requests a year (some receive 0) • And participate in 2- 3 • Receive little to no compensation for this • Are Informed about the outcomes of the studies < 10% time • And experience benefit from the findings of the study < 10% time • Leave the practice better than you found it

31. Know the opportunity costs of your requests: 3 min = 6.4 patients not seen • The calculus of a CHC clinician: • 15 minute (or less) per patient visit x 8 hours • 32+ patients a day • 3 minutes per patient for research = 96 minutes • = 6.4 patients not seen in a day • = 6.4 patients who may not have received primary care in years • = 6.4 patients who may not return again for another year

32. Provide MEANINGFUL support Clinicians are not grant funded – meetings cost them money – pay them to be there! It’s their clinical infrastructure and relationships that allows you to recruit – pay them for it Fund their internal research and QI staff when possible Be GENEROUS, do good things for free

33. Plan to stay long-term Aim for long-term relationships Avoid “helicopter” research where you chopper in with resources, do your thing, then chopper out -even if its cheaper -– you pay for it in the long term

34. Be useful • Do things that will make a real difference for the clinicians and patients • Will it bring new resources and better ways of doing things? • Will it improve care and patient outcomes?

35. Building Castles in the Air “And if she asks you why, you can tell her that I told youThat I’m tired of castles in the air.” Don McLean

36. Wind Power

37. Castles in the Air • Most clinical practice guidelines • Most clinical decision support systems • Most disease registries • Immunization registries • The Chronic care model • Care management • Effective patient education • The personal health record

38. Some things research that are not acknowledged • The work that is being done now affects <1% of the U.S. population. • Replication of successful programs will never achieve a system-wide infrastructure that impacts the entire population. • We pretty much know how to translate research into practice. We just can’t do it because of the lack of an infrastructure within which to deliver the effective interventions consistently to all practices and communities over time. • Aside from the CTSAs, surprisingly there is no obvious reason why AHC should be interested in community engagement

39. Infrastructure • It’s not all about research • The infrastructure we need is for dissemination, implementation, and diffusion (QI) • It should be funded primarily by the government (as a public good) and the payers (to save money) • Once in place, it will support practice- and community-based research, supported by project-specific grants and contracts.

40. Some things about CBPR that are not acknowledged • Generation of generalizable knowledge is not the primary goal of CBPR. • To a significant degree, most significant research is local • Dissemination may require home visits • The “halo effects” of CBPR may be more important than the research itself. • The process is more important than the outcomes (but it is extremely important that we believe the opposite to be true).

41. So some good ideas Encourage your funders to invest in research infrastructure not just studies Relationships are research infrastructure

42. Some good ideas Make training on CBPR and Participatory Research mandatory for researchers– these approaches create better partnerships

43. Some good ideas When possible, don’t reinvent the wheel, consider partnering with support organizations like Practice Based Research Networks to reach clinicians… and patients. ….They’ve done the difficult part already and can save you time and stress

44. Some good ideas QI and translation of CEFs into primary care may be one of your best opportunities for being useful to practices

45. Remember • Remember that Research is not a goal (Goals are desired outcomes for which it makes no sense to ask, “Why would you want to do that?” or “…so that?”) • Research is a strategy that should be applied when necessary to overcome obstacles on the way to achieving community goals (J. Mold) • This is good news. It means researchers, clinicians and patients have a lot in common.

46. Thank you