Acknowledgement: Co-authors, Sponsor, and Participants

1. Assessing a Practice Coaching Intervention for Improving Chronic Care in Safety Net OrganizationsShinyi Wu, PhDAssistant Professor, Epstein Department ofIndustrial and Systems EngineeringUniversity of Southern California & RANDSeptember 14, 2009, presented at AHRQ Conference

2. Acknowledgement:Co-authors, Sponsor, and Participants • Marjorie Pearson, PhD, RAND • Katie Coleman, MSPH, ICIC, GroupHealth • Brian Austin, ICIC, GroupHealth • Ed Wagner, MD, ICIC, GroupHealth • Wendy Jameson, MPP, MPH, Safety Net Institute • Cindy Brach, MPP, Agency for Healthcare Research and Quality • The participating healthcare organizations

3. Lessons Learned from CCM Collaboratives Call for Further Implementation Research • Teams spent considerable time searching for/developing tools • Some teams felt intimidated by taking on the whole model – asked for a sequence • Collaboratives were time & resource intensive • Many changes were made in ways that were not sustainable financially

4. Test A Team Coaching Approach to Help Practices Implement CCM • Recognizing that medical practices often need flexible, hands-on support when embarking on a program of practice improvement • Especially safety-net organizations • Testing a coaching intervention (coupled with a toolkit) to disseminate the CCM • Funded by AHRQ

5. Practice Coaching Design • Who were coached? Nine randomly selected primary care teams from two clinics in two California public hospital systems • Who were the coaches? Two quality improvement experts external to the hospital systems • How was coaching structured? • Two site visits • Communicated by phone and email • Monthly reports to coaches

6. Three Intervention Phases • Phase I: Laying the foundation for success • Form Coaching Team • Get Acquainted with Leadership • Orient the Practice Team to the Work • Phase II: Active practice coaching • Conduct prework assessment & prepare teams for site visits • Run learning sessions • Support the teams • Phase III: Sustaining the gains • Close out coaching and expect teams to continue

7. Environment& organizational contexts Practice coaching Workgroup & team effectiveness Changes in system Changes in process Changes in outcomes Logic Model: Chain of Action

8. Evaluation Methods • Quasi-experimental design with three arms • Intervention, internal control, and external control • Implementation assessment through site visits • Environmental and organizational contexts • Practice coaching • Implementation process • Perceived impact & lessons learned • Process & outcomes assessment • Participants perceived impact • HEDIS diabetes care indicators & utilization measures

9. Results: Contexts • Environment: Challenging, but not about survival • Organization: Commit to improving chronic illness care and have some ongoing activities • Leadership support for the project: modest • Improvement experience: Have previous and ongoing improvement projects; experience varied • Participants: “Majority” adopters of CCM; randomized to participate so modest level of excitement • Information system: Average cumbersome

10. Results: Coaching • Coaching is perceived as • a necessary bridge to the toolkit • motivated and prompted people to make changes • extended the horizons of the teams • had a positive effect on team building • built an emotional bond which was a key success factor for coaching • The coaching costs approximately $41,000 for the two clinic sites, including time spent in coach training, coaching, travel, and communication

11. Suggested Modifications to Our Practice Coaching Approach Coaching should include more face-to-face interactions An internal coach might be added Coaching intensity may need to be greater at the beginning Coaches should be more proactive and creative in introducing the toolkit Continue coaching for a longer period of time

12. Coaching Effects on Workgroup and Team Effectiveness • Changes in self-efficacy and knowledge: • Individuals positive on gaining skills, knowledge, and tools to improving clinical care • Working as a team: • Coaching did not change the working relationship and team structure, but did strengthen people working together as a team • Acquiring health system support • A coach can help problem-solving, but sustained support requires a local leader to organize the efforts

13. Lessons Learned • Practice Coaching is a feasible mechanism for facilitating CCM quality improvement in safety net clinic settings • Assessing resources firsthand and tailoring advice • More staff can participate in the practice improvement sessions • Coaching can be delivered with minimal impact on patient access • Practice coaching vs. collaborative learning • Providing structured learning time is key • Practice coaching can really jump-start the spread • Especially when there is internal knowledge and experience

14. Implications • The field of practice coaching is still evolving • Clearly defining the coaches’ role and regularly checking expectations is important • Different models of QI facilitation may work better in different settings and timing • Coaching on business improvement along with quality improvement needs to be further developed and studied

15. Thank you For additional information: CCM Toolkit and Coaching Manual: http://www.ahrq.gov/populations/chronix.htm “ Integrating Chronic Care and Business Strategies in the Safety Net: A Toolkit for Primary Care Practices and Clinics” “Practice Coaching Manual” http://www.improvingchroniccare.org RAND Chronic Care Studies: http://www.rand.org/health/surveys_tools/chronic_care_model.html Shinyi Wu Email: shinyiwu@esc.edu