Kentucky HSR Development: Building Partnerships

1. Kentucky HSR Development: Building Partnerships Margaret M. Love, Ph.D. University of Kentucky Family & Community Medicine (Medicine) Health Behavior (Public Health)

2. Infrastructure Development Aims • Improve ability of faculty to develop proposals and publish papers in health services research (HSR) • Promote collaboration of physicians with other health services researchers • Cultivate research ideas from the Kentucky Ambulatory Network (KAN) into research designs and fundable proposals

3. University of Kentucky BRIC • Overarching structure = collaboration • College of Public Health (subsumed Center for Health Services Management & Research) • 2001-2003 PI Beaulieu/Fleming (BRIC I) • 2003-2006 PI Fleming (BRIC II) • Department of Family and Community Medicine (DFCM) • 2001-2006 Co-PI Love

4. University of Kentucky BRIC • Premises of today’s talk: • Practice-based research networks (PBRNs) can respond to community needs… and partnerships are at the core of PBRN activities • Learning collaboratives can improve health care quality • Through its support of partnerships, BRIC built HSR capacity in Kentucky

5. University of Kentucky BRIC • Two examples of building & leveraging partnerships – processes of engagement • BRIC involvement with the Kentucky Ambulatory Network (KAN) • BRIC I Prevention Research Project • BRIC II Small Research Projects • BRIC involvement with the University of Kentucky’s participation in the Academic Chronic Care Collaborative (ACCC)

6. Practice-Based Research Networks (PBRNs) • PBRNs are groups of primary care clinicians and practices working together to answer community-based health care questions and translate research findings into practice. • PBRNs engage clinicians in quality improvement activities and an evidence-based culture in primary care practice to improve the health of all Americans. http://pbrn.ahrq.gov/portal/server.pt

7. Practice-Based Research Networks (PBRNs) • Model for university-community partnership for health services research • Potential to improve quality of care • Implement and study process of adoption and outcomes in primary care practice • Respond to community • “Inside-out” vs. “outside-in” models • I.e., “Top down” vs. “bottom up” • “Bedside to bench” not just “Bench to bedside”

8. Kentucky Ambulatory Network (KAN) • Kentucky Ambulatory Network (KAN) • Statewide primary care practice-based research network founded in 2000 • More than 200 community-based clinicians • 80% are family physicians • ~75% practice in rural, medically underserved areas • KAN has practices in 31 of KY’s 51 Appalachian counties

9. BRIC I: Prevention Research Project • Planned with/for KAN • Solicited feedback from community-based PCPs about topics of prevention & intervention features • Break-out sessions at annual meeting • E.g., Wanted an intervention with evidence for high likelihood of success, i.e., not obesity • Involved community-based FP as consultant • Final planning input to focus on FOBT colorectal cancer screening (surprised own rates so low!) • Assumed leadership role when joined faculty

10. BRIC I: Prevention Research Project • Conducted pilot project in 6 KAN practices • Multiple strategies to increase FOBT rates • E.g., chart stickers, information about billing

11. BRIC I: Prevention Research Project • Outcomes included lessons learned by FP leader: • Difficulties in abstracting screening rates from billing data • Usefulness of RA assistance in scheduling and preparing for orientation visits • Necessity of ongoing contact with practice to assure fidelity to intervention, complete documentation, and access to outcomes data

12. BRIC I: Prevention Research Project • Lessons learned by BRIC team • Discussion with KAN members led to principles guiding QI focus • It takes a team • Outcomes • Directly: MPH Capstone for FP leader • Possibly contributed to track record or experience: Future KAN involvement in federally funded CRC screening research

13. BRIC II Small Research Projects:Physician “Collaborator” Model • The “real” world for tenure track academic family physicians (FPs): • Most can devote only 10 – 25% time to research • Many will not become independent researchers • Many can become physician “collaborators” • Make substantial contributions to HSR led by faculty in other departments

14. BRIC II Small Research Projects • Junior FPs partnered with experienced health services researchers (HSRers) • HSRers nominated 7 projects in own areas of expertise and interest • 3 FPs nominated selves • FPs to transition from co-I to PI • FPs 20% protected research time (1/2 in-kind) • HSRers paid protected time (10%-20%)

15. Additional Support for BRIC II Small Research Partnerships • More training for FPs • Capacity-building seminars • Professional writing workshops • HSR methods seminars • Development of Grant Applications • National HSR meetings (AcademyHealth)

16. Additional Support for BRIC II Small Research Partnerships • BRIC PI (Fleming) & Co-I (Love) • Co-investigators on projects • Facilitated partnerships • E.g., sounding board for HSR mentors • E.g., nudge for FPs • Served as program mentors/coaches for FPs • Overall grant administration

17. BRIC II Small Research Projects • 3 projects/teams: • Killip/Ireson (3 years) – Patient safety in after-hours telephone medicine • Joyce/Wackerbarth (2 years) – Colorectal cancer screening decision-making • Dassow/Costich (1 year) – Generic drug utilization (became study of Medicare Part D)

18. BRIC II Small Research Projects • Relationship to KAN: • Patient safety in after-hours telephone medicine • Designed for/conducted in residency practice • Next step was funded pilot in community practices • Colorectal cancer screening decision-making • Designed as KAN study • Generic drug utilization (Medicare Part D) • Involved KAN input & feasibility testing

19. BRIC II Small Research Projects: Pt Safety / Telephone Med • Initiative from UKy or Community? • Initiative stayed “inside” academia • Outcomes • FP came to “own” this topic as research program • FP acquired qualitative & quantitative research skills • Multiple national/international research presentations • 1 pub (so far) with FP as 1st author • FP as PI earned NPSF grant • Also… Because of process analysis, changed steps in residency’s after-hours telephone medicine (e.g., messages in charts) – good example of QI

20. BRIC II Small Research Projects: CRC Screening Decision-Making • Initiative from UKy or Community? • Idea originated “inside” academia • However, by design, study solicited input from community on what is needed to design decision-supports • Qualitative research with FPs & patients leading to identification of “barriers” and “facilitators” for CRC screening • Next steps would be design of decision supports & engaging FPs to test them

21. BRIC II Small Research Projects: CRC Screening Decision-Making • Outcomes • 2 pubs with HSRer as 1st author • FP acquired qualitative research skills • Co-Investigator on federally funded research project(s) led by other UK qualitative researchers • PI on own federally funded education grants • Could apply skills to evaluation of patient-centered care curriculum • FP tenured as Associate Professor

22. BRIC II Small Research Projects: Generic Drugs  Medicare Part D • Initiative from UKy or Community? • That’s a long story…evolution in terms of what’s meaningful and what’s feasible • Initial plan: In KAN, evaluate barriers to prescribing generic drugs • Reaction of KAN advisory committee members suggested more comprehensive approach necessary to capture prescribing issues that matter Continued…

23. BRIC II Small Research Projects: Generic Drugs  Medicare Part D • Coincided with Medicare Part D implementation • Alternative Approach: • Chart review in KAN practices to determine if prescribing practices changed following Medicare Part D coverage • Initial chart reviews showed charts don’t contain needed info Continued…

24. BRIC II Small Research Projects: Generic Drugs  Medicare Part D • Final Approach • Survey assessing physician experiences and opinions regarding Medicare Part D • Conducted during Continuing Education programs for family physicians held in Lexington, KY (attendees from many states) • In sum, iterative process informed by KAN community-based members & feasibility pretesting in KAN

25. BRIC II Small Research Projects: Generic Drugs  Medicare Part D • Outcomes • Completed survey with 98 responses • Analyses completed; manuscript in progress • FP tenured as Associate Professor

26. BRIC II Small Research Projects: Overall Outcomes • FP transition into leadership role • One effectively transitioned into leadership role (with coaching) • One maintained a co-investigator role • One already had more research experience • Did HSRers develop, too? • Better at working with FPs? & with KAN? • E.g., structuring FP input & managing logistics? • E.g., involving KAN input & evaluating feasibility?

27. BRIC meets ACCC • Academic Chronic Care Collaborative (ACCC) • American Association of Medical Colleges (AAMC) • Consortium designed to develop quality improvement programs of clinical care, evaluation, & research • University of Kentucky & Department of Family and Community Medicine selected as one of 23 academic health centers

28. BRIC meets ACCC • Features of University of Kentucky initiative • Diabetes as clinical target in the Family Medical Center • Chronic Care Model with quality improvement cycles • Implemented group visits

29. BRIC meets ACCC • To supplement College of Medicine funding, BRIC provided resources to support systematic evaluation and research • Half year RA assistance in creating, entering and managing the Family Medical Center’s Diabetes Registry • Trial period of registry software • Junior FP travel to national QI meeting

30. BRIC meets ACCC • Outcomes • Multi-year database of over 600 DM patients • Doctor of Nurse Practitioner (DNP) thesis • 2 Masters of Public Health (MPH) capstone projects • Draft manuscript under development • 3rd MPH capstone underway (for junior FP) • Medical student summer research project

31. BRIC meets ACCC • Outcomes • Greater sophistication across the department in evaluating quality improvement processes • Collaboration with “non-BRIC” faculty members in Public Health and Pharmacy • Department struggles with how to maintain database • Ongoing systematic evaluation of QI elusive

32. BRIC II – What (Seemed to) Work • Leadership from experienced HSRers invaluable in the small research project partnerships • Specialized set of topic-relevant skills and knowledge • Project management • How to get started & what to do next • Breaking the project down into steps • Establishing – and pressing – project timeline • Relationships important to FP growth

33. BRIC II – Facilitators • Flexibility built into the multi-year BRIC II award enabled research partners to adapt (e.g., Medicare Part D) • In future, solicit KAN input prior to submitting grant application or as a development phase within a funded application; but would depend on time, resources, & FOA

34. BRIC II – What (Seemed to) Work • Support for Partnerships • PI & Co-PI helped Small Research Project partners work together • HSRers had to “chase” FP Fellows; PI & Co-PI helped catch them (but also needed to know when to get out of the way) • Co-PI facilitated partnerships with KAN • PI facilitated partnerships with HSRers

35. BRIC II – Lessons Learning • Might more HSRer & PI/CoPI direction increase “scholarly productivity” UKy ACCC? • Note: Actual research using data has been conducted by professional degree candidates with significant mentorship outside our department • Do we need to facilitate FP partnering with HSR mentors? • How can we bridge QI processes and typical scholarly productivity?

36. BRIC II – What (Seemed to) Work • 25% protected time needed for junior FP to channel time & attention toward research and developing own capacity • E.g., Dedicated day away from the office & connection to a national grant-writing program helped SK protect time

37. BRIC II – Lessons Learning • It’s OK to let success overtake you • Genesis of College of Public Health • Center for Health Services Mgt & Research then School of Public Health then College • NIH Clinical & Translational Science Awards (CTSA) • University-wide restructuring to support formation of Center for Clinical and Translational Science • DFCM & KAN leadership in outreach core function

38. BRIC II – Lessons Learned • Would have been helpful to have continued “BRIC Brass” from BRIC I • Advisory group of Chair & Academic Vice Chair of Fam & Comm Med, and Director of Center for Health Services Management and Research (later Director of School of Public Health) • To promote knowledge of faculty activities, buy-in and support of program, and view to “bigger picture” of university, community, U.S.

39. Implications for Health Reform • Overall, in both KAN (PBRN) and ACCC (or other health care collaboratives), the physicians and their practices are part of the solution, that is, for improving health care and health outcomes.

40. Implications for Health Reform • As primary care plays a central role • PBRNs can link AHCs & communities to implement & evaluate programmatic change and quality improvement processes • PBRNs can help inform policy makers of barriers & facilitators to better design systems that work • PBRNs reach diverse communities and can represent diverse types of practice

41. Implications for Health Reform • Based on our experience in Kentucky, layers of specific types of support can build or leverage academic-community partnerships • Expert HSRers from multiple disciplines • Primary care physicians trained as research collaborators • Collaborative teams • Facilitators (people who help with teamwork)

42. Implications for Health Reform • However… • Quality improvement processes require ongoing, rapid evaluation • E.g., Plan-Do-Study-Act (PDSA) • This is not like traditional interventional research models in geological time • Similarities to traditional research • Systematic evaluation of impact • Evidence based change strategies

43. Implications for Health Reform • Both practice-based research and QI cycles take many university researchers outside their “comfort zone” • Less controlled circumstances • Participants can benefit from the research (not just for the greater good in the future)

44. Implications for Health Reform • Special expertise in PBR & QI needed • HSRers may want retraining to capture rapid healthcare change • Physician faculty may need HSR training/experience • Facilitated partnerships enable “on-the-job” training • Funding for partnership development could enable new “players” in federally funded research • New institutions • New disciplines

45. Family & Comm Medicine Mel Bennett MD MPH Paul Dassow MD MSPH Robert Hosey MD Jennifer Joyce MD Shersten Killip MD MPH Michael King MD Margaret Love PhD (Co-PI) Samuel Matheny MD MPH Kevin Pearce MD MPH Steve Wrightson MD College of Public Health Joyce Beaulieu PhD (1st PI) Julia Costich PhD JD Carol Ireson PhD Steve Fleming PhD (2nd PI) F. Douglas Scutchfield MD Sarah Wackerbarth PhD And thanks to AHRQ… Kay Anderson, PhD P20 HS-011845 R24 HS-011845 UKy BRIC Faculty