Implementation Research: Lessons Learned in OKPRN

1. Implementation Research: Lessons Learned in OKPRN James W. Mold, M.D., M.P.H. Department of Family and Preventive Medicine University of Oklahoma Health Sciences Center Oklahoma City

2. Objectives • Define quality improvement research • Describe OKPRN • Review what we have learned • Discuss unanswered questions • Speculate about next steps

3. Oklahoma Physicians Resource/Research Network • Established in 1994 (HRSA Grant) • Emphasis on both resources and research • (More like R&D) • Emphasis on information technologies • Now a 501c3 non-profit organization but closely aligned with the OU DFPM • 110 practices; 235 clinician members • Members care for 10% of the state’s pop.

4. OKPRN Practices  OKC

5. Cells Diseases People Practices Will it work? Is it worth it? What’s possible? Can it work? Meta-analysis Guidelines Cost-effectiveness Best Practices Phase III Trials Re-engineering Cells/Tissues Exp. Animals Implementation Dissemination Training Facilitation Biochemistry Phase I Trials Phase II Trials Phase IV Trials Basic Research Human Research Practice- and Community- Based Research Practice and Community T1 T2 T3=QI Diffusion Not ready for humans Not ready for patients Not ready for practice

6. 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 T=Translation Not ready for humans Not ready for patients Not ready for practice

7. OKPRN Practice-Based Research Studies • Patient access to computers and e-mail • 1997 and 2007 • Brown recluse spider bites • Epidemiology and management • Night sweats • Epidemiology, associations, and consequences • Peripheral neuropathy in older patients • Epidemiology and consequences • Why older patients change doctors • Diagnosing influenza • Exemplar studies (discussed later)

8. The Challenge • It has been estimated to take an average of 17 years before 14% of biomedical innovations make it into generalized practice. • Primary care must convert to a model or models of care better suited to the current and emerging health needs of the population • Innovations are happening at an increasing rate

9. Implementation Research Projects Pneumococcal immunization Before - After Diabetes care Prospective, uncontrolled Cluster RCT Smoking during pregnancy Before - After

10. Implementation Research Projects • Mammography RCT • Cluster RCT • Preventive Services Delivery • Cluster RCT • Prescription for Health (Unhealthy Behaviors) • Phased/staggered Intervention in Practice Clusters

11. How the Process Works • For researchers and funders: Studies of specific QI strategies; development of products (software, guidebooks) • For practices, these projects look like QI • Clinician education (education, training, CME) • Practice receives tangible support (e.g. facilitator, $$) • Funding sources: Agency for Healthcare Research and Quality, Oklahoma Foundation for Medical Quality, Robert Wood Johnson Foundation, QIO, Medicaid

12. Which Practices Are Successful The QI initiative is a high priority for the practice The practice is able to change The practice is able to implement the critical components of the new process Solberg LI. Improving medical practice:A conceptual framework. Annals Fam. Med. 2007; 5(3): 251-256.

13. Priority Administration is behind it Clinicians are behind it Staff are behind it Competing priorities are less important than the desired change and won’t interfere with it.

14. Change Capacity Shared quality of care mission Collaborative, cohesive environment Well-organized, non-chaotic Clear lines of authority/decision-making Well-developed QI process Regular QI meetings Stable workforce and administration Stable finances/financial management Effective policies and procedures

15. Change Process Content Care management capabilities Patient self-management support Capable staff Patient tracking and registry functions EHR functionality Decision support options Test and referral tracking Task management systems Performance Tracking/Reporting

16. Time The time that it takes to implement an innovation in committed practices depends upon: • The complexity of the intervention • The magnitude of the changes required • The number of people in the practice who must change their methods It generally takes about 6 months.

17. Implementation Strategies Tested Feedback Benchmarking Identification of exemplars/exemplar methods Academic Detailing Literature review Exemplary practices (positive deviants) Practice facilitation HIT support Local Learning Collaboratives

18. Feedback and Benchmarking Must be accurate and believable (trusted) Measures must be relevant/agreed upon Must be repeated at least monthly during implementation

19. Exemplars and Exemplar Practices 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.

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

21. Performance Distributions • Virtually always present • Wider than you would expect • Within practices and between practices • High performers are often not the “usual suspects” • Highest performers in one area aren’t necessarily the highest performers in other areas • Some true exemplars (quest for excellence)

27. What’s the best way to … • Manage laboratory test results? • Deliver preventive services? • Improve my care for patients with diabetes? • Handle prescription refills? • Help patients remember to bring their medications with them to appointments? • Help overweight patients lose weight and keep it off?

28. What Do Exemplars Know? • Principles • Techniques • Scripts

29. From a High School Math Quiz

30. Academic Detailing Respectful sharing of information Discussion of current methods Discussion of how the principles and techniques might apply within that practice Plan for improvement

31. Practice Facilitation One-half day per week for about 6 months Relationship with clinicians and staff is key; takes several months Key functions include: assessment and feedback, coaching, team-building, technical and hands-on, assistance, training, coordination of PDSA cycles, and cross-pollination

32. PEA PEA PEA OKPRN Board of Directors NE OK NW OK Dept. of Family and Preventive Medicine PEA SW OK SE OK *PEA = Practice Enhancement Assistant

33. HIT Support Generation of reports Template development Database development Implementation of registries Clinical decision support systems Communication systems

34. Local Learning Collaboratives One-hour lunch meetings every 1 – 2 months Review performance data from all practices Share successes and failures Share anecdotes Share effective methods

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

36. Proposed effects of the QI Interventions on Change Elements Priority Change Capacity Change Process Content Performance Feedback Academic Detailing Practice Facilitation Local Learning Collaboratives HIT Support

37. Disseminating the Implementation Process Longitudinal relationships Knowledge of local factors Travel time/cost Cross-practice collaboration

38. It Takes a Village • Primary care can no longer be practiced in relative isolation from public health, mental health, social services, and community organizations • Obesity, lack of exercise, smoking, and abuse of alcohol account for 37% of all premature deaths.

39. County Health Extension Key functions: Performance monitoring/reporting Practice facilitation Local learning collaboratives HIT support PCMH capacities shared across practices

40. County Health Extension Closing gaps: • Public health • Mental Health • Social Services and Community Resources

41. Cooperative Extension • 1889: Dept of Agriculture began issuing Farmers’ Bulletins and the Yearbook of Agriculture; experimental farms issued research bulletins and “popular bulletins”; publications reached small proportion of farmers, many of whom distrusted “book farming” • 1880 -1911: Widespread establishment of “farmers institutes” and even “mobile institutes” to reach more farmers • 1906: S. A. Knapp hired the first county extension agent to develop a personal relationship with every farm family in the county and help them implement innovations

42. Cooperative Extension • 1889: Dept of Agriculture began issuing Farmers’ Bulletins and the Yearbook of Agriculture; experimental farms issued research bulletins and “popular bulletins”; publications reached small proportion of farmers, many of whom distrusted “book farming” • 1880 -1911: Widespread establishment of “farmers institutes” and even “mobile institutes” to reach more farmers • 1906: S. A. Knapp hired the first county extension agent to develop a personal relationship with every farm family in the county and help them implement innovations

43. Cooperative Extension • Funding sources – 30% federal, 70% state and local • Headquartered in the land-grant university • Staffing – 1% federal, 32% university, 67% local in nearly all of the 3,150 counties in the U.S.; plus more than 2 million volunteers • Goal is to maintain meaningful bi-directional communication between the university and the farmers and provide on-site training and assistance to farmers and farm families so they can stay abreast of advances in science Taking the University to the People by Wayne D. Rasmussen; Iowa State University Press, 1989

44. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ • The insurance companies alone (including Medicare and Medicaid) are spending (mostly wasting) more than $5 billion a year on QI • Now add in the money spent by AHRQ, the NIH, the CDC, private foundations, advocacy organizations, professional associations, etc. • Pandemic influenza preparedness • NHLBI asthma guidelines

45. Community Care of NC • Regional 501c3 organizations;owned and run by primary care clinicians; supported by Medicaid care management funds ($3 PMPM); charged with improving quality of care for Medicaid patients. • ROI $2 for every $1 invested • Saved the state $60 million in Medicaid costs in 2003 and $120 million in 2004

46. Canadian County, Oklahoma • Juvenile Justice System and community groups anteed up $10,000 • Matched through the Medicaid federal match to pay for a ½ time care manager for children • Linked to a matching contract with the OU DFPM for $120,000 to improve well child care • Drew the attention of a developmental pediatrician, who obtain a grant from a foundation for $100,000 to improve developmental screening • Now approved by Medicaid as a HAN. Will receive $5 PMPM ($340,000 per year)

47. The University of New Mexico HEROs Program • Health Extension Rural Offices (HEROs) • Mission: • Generate better health at lower cost • Increase community capacity to address local problems in order to reduce health disparities • Activities • Tele-health projects • Training • Workforce development • County health report cards

48. University of Wisconsin

49. Questions??????