NaRCAD's Interview Series: Public Health Detailing Program at New York City Department of Health and Mental Hygiene (DOHMH)
Featuring Michelle Dresser, MPH, Senior Manager, Programming & Strategy
Thanks for taking the time to share the great clinical outreach education work that’s being done by the NYC Department of Health and Mental Hygiene, Michelle! Tell us a bit about yourself and how you got involved in public health, specifically public health detailing.
Michelle: Thank you for the opportunity to speak about the Public Health Detailing Program. I have over 20 years of public health experience in both the non-profit and government setting, with the last 12 here at the New York City DOHMH. Throughout my professional career, my specialty has been in healthcare marketing and provider education, emphasizing how providers and consumers can better communicate with each other by tailoring complex messages using health literacy principles.
It’s essential our reps have excellent selling and communications skills, so when they engage providers and get their buy-in, providers are then equipped to get their patients “on board”. One-on-one provider engagement helps them understand how important it is to have a 2-way communication with patients.
How can an outreach representative encourage providers to “get on board” and think about care as a dialogue?
Michelle: Let’s use obesity as an example. With obesity, both providers and patients are frustrated, for different reasons. Providers may be frustrated that patients’ comorbid conditions are being exacerbated or don’t have the same kinds of tools to treat obesity as they do other conditions; patients might feel that providers aren’t using great communication techniques, like motivational interviewing (MI), to help them set goals and take small steps towards the goal.
If a patient is only told, “You need to lose weight,” which is such a broad and overarching goal, they’ll be frustrated, and frankly, non-adherent. I know I would be.
Encouraging providers to have specific dialogues using a customized approach for each patient is important. This kind of dialogue takes into account patients’ literacy beyond the written and spoken word—it looks at scientific, fundamental, health and cultural literacy, too.
We work on “coaching scripts”, which take the key recommendations and reframes them in order to custom-tailor the conversation for each patient.
One thing that’s unique about public health detailing is that we detail the whole team through one-on-one interactions. Evidence shows these types of interactions with providers and staff are more effective at changing behavior; however, sometimes due to the makeup of the practice we must conduct group presentations. It’s not ideal, but it still allows us to get the messages and materials out there.
So when an outreach representative goes into an office, they detail...everyone?
Michelle: If there are 15 people who work in an office, we’re going to detail all 15 of them. It’s a lot! Sometimes, the person who is the champion of a new behavior or workflow isn’t going to be the provider. We see the front desk staff as instrumental; they’re interacting with all of the patients. We work with our teams to ensure even the front desk staff receives the materials and information, rather than seeing them merely as a “gatekeeper” to get to the providers.
Sounds like a lot of training goes into preparing for your campaigns, and for thinking about the entire process of effective outreach. Tell us more about your trainings, and about how you prepare outreach representatives on disease content training, as well as in marketing and communications skills.
Michelle: On average, our trainings are about 5 days in length and take place the week prior to launching a new campaign. About 40 percent of the training is disease content, so we work with our internal Health Department experts, as well as external experts, where we learn about prevention strategies, treatment strategies, epidemiology and the landscape around the key recommendations chosen based on the evidence of that topic. We need to know the ‘why’ behind the campaign.
Once we have that under our belt, we shift to sessions on how to frame the issue, how to promote the materials, figuring out the “features and benefits” as well as the “barriers and objections” and finally “gaining a commitment”, which are phrases that come from pharmaceutical marketing. We’re “selling” and promoting public health interactions, so we work on those skills.
We also do a great deal of role playing, including videotaped analysis of each rep. We look at body language, what communication skills are effective, we do knowledge assessments, quizzes—we make sure our team is well-prepared to go out and detail. We take this seriously—they’re representing the New York Department of Health and Mental Hygiene.
What’s a major barrier your program has faced, and how have you tackled it?
Michelle: A big challenge, when starting a detailing program, is access. The landscape of healthcare systems in NYC has drastically changed over the past few years. As an example, several years ago, the majority of our Brooklyn territory was almost entirely made of up of small practices where access wasn’t an issue.
What’s changed since then?
Michelle: Now, many of these sites have become part of larger institutions, so there’s corporate buy-in that needs to happen for people to come in and talk to the staff. As I mentioned before, although we try and limit group presentations, this has proven to be an effective strategy when entering into a new relationship. Once they get to know us and recognize the value of the program, they’re engaged in having us come back to conduct 1:1 visits on the follow-up and subsequent campaigns.
How do you know when a campaign is working and becoming successful?
Michelle: Evaluation is always on the top of our priorities, and can be a challenge for any program to evaluate effectiveness. For every campaign we conduct an initial and follow-up visit where we assess provider practice.
This allows us to see if there has been a change in practice from the initial to the follow-up visit. Additionally, we rate what providers intend to adopt in terms of the key recommendations and supporting tools and resources. We also collect a large amount of qualitative data because it's also critical to gaining a more complete picture of the campaign’s success, especially when reporting on barriers, access and materials.
You can scale this up or down, depending on your need and organizational priorities. Our program focuses on where there’s the greatest need and potential for greatest impact.
Programs should make sure to look at their organization’s agenda and goals. It’s important to look at the data and plan the best course of action within the capacity you have.
Biography: Michelle Dresser. Michelle Dresser is the Senior Manager of Programming and Strategy for the Public Health Detailing Program within the Bureau of Chronic Disease Prevention and Tobacco Control at the New York City Department of Health and Mental Hygiene. In this role, she oversees the overall programmatic direction and strategy of the program. This includes, campaign strategy and timing, campaign content, training and economic incentive development, provider selection, identification of targets to ensure the greatest impact on populations most in need, and identification of “new needs” opportunities to expand program reach and achievement of program goals. She also oversees internal and external strategic relationships to enhance programmatic objectives.
Bevin K. Shagoury, NaRCAD Communications
The excitement and breadth of content in this November’s 3rd International Conference on Academic Detailing exceed what we can capture in this blog post. The combination of exciting speakers, engaging panelists, expert breakout session leaders, and national and international attendees eager to problem-solve created a forward-thinking event that inspired all of us working on AD and related outreach educational activities. As you reflect on our event's highlights, we encourage you to access on-demand video, speaker biographies, session descriptions, and more at our Conference Hub resource page.
Kicking Day 1 off and setting the tone for the entire event, NaRCAD Director Dr. Mike Fischer warmly welcomed our packed room at Harvard Medical School’s Martin Center by encouraging collaboration, connection, and sharing. Our Day 1 Keynote Speaker Dr. Carolyn Clancy, the CMO of the Veteran’s Health Administration, described the VHA’s work to improve pain management in the veteran population while addressing the challenges of medication abuse and overdose. Dr. Clancy shared strategy and data behind the national effort and the critical role of academic detailing in it, connecting attendees to a big-picture view that can be adopted to look at other health epidemics and interventions.
Our first expert panel presented Practice Facilitation in Primary Care. Andy Ellner moderated the session, leading panelists Ann Lefebvre of North Carolina's AHEC Program, Lyndee Knox of LA Net, and Allyson Gottsman of HealthTeamWorks to discuss strategies, contextualize their work in relation to academic detailing and quality improvement, and share their personal approaches to challenges in primary care behavior change. Allyson Gottsman’s much-appreciated analogy that practice facilitation is not unlike “leading a fisherman to a well-stocked pond” resonated with panelists and participants alike. Many attendees who were actively engaged in practice facilitation in their daily work shared that the panel helped them to think about their work in a new way.
The afternoon’s breakout sessions offered attendees multiple tracks with AD-related topics to explore: deconstructing and analyzing a 1:1 AD visit, exploring the skills needed to manage an effective AD program, and strategizing on ways to identify and harness stakeholder support when initiating a new program or strengthening an existing one.
The afternoon closed with two presentations; the first, by Terryn Naumann of the Canadian Academic Detailing Collaboration (CADC), offered participants a view of the power of synergy and teamwork, the historical context of the CADC’s creation and growth, and the future of the collaboration.
The final presentation of the day was a lively one by NaRCAD’s co-founder and co-director, Dr. Jerry Avorn, who identified major obstacles to effective evidence-based communication in the current landscape of healthcare, and provided a future-centered lens through which attendees could envision how academic detailers can address these challenges. A full day of new ideas and connections culminated in a networking reception that gave attendees a chance to relax and connect socially.
Day 2’s morning opened with another engaging Keynote Speaker; Dr. Don Goldmann, CSO & CMO of the Institute for Healthcare Improvement, combined quality improvement theory with personal anecdotes, weaving in real-life examples of successful interventions to provide context and dimension to the theory that underlies all of our work.
More examples of successful practice change were illustrated by the morning’s Themed Plenary on the Intersection of Public Health and AD. Dr. Phillip Coffin of the San Francisco Department of Public Health shared the success of an intervention focusing on co-prescribing of naloxone to reverse opioid overdose deaths in San Francisco. Another successful AD intervention was presented by Michael Kharfen of the Washington D.C. Department of Health, who highlighted the successful implementation of AD programs to increase HIV and Hepatitis C screening and treatment.
The afternoon featured our second Expert Panel, this time on the role of AD within integrated healthcare systems. Moderated by Dr. Mike Fischer of NaRCAD, panelists Joy Leotsakos of Atrius Health (MA), Sameer Awsare of Kaiser Permanente Medical Group (CA), and Valerie Royal of Greenville Health System (SC) shared their experiences using AD in systems at different stages of development. Attendees had the opportunity to discuss this topic further in the afternoon’s breakout sessions, which also included a session on practice facilitation, as well as third session to continue to explore AD and public health partnerships.
The conference’s closing discussion was led by Mike Fischer, who thanked not only the speakers, panelists, and session leaders, but the participants, whose willingness to share their experiences within an interactive setting was key in creating solutions to bring back to use in their daily work. The creative collaborations, exchange of resources, excitement in combating challenges in the field, and belief in the importance of AD for the future of healthcare transformation were felt by all at the closing of a very full and thought-provoking event.
Our Twitter feed tracks the event’s highlights through #NaRCAD2015, and you can catch our event photo album on our Facebook page. We invite you to explore these topics, learn about our speakers and attendees, and connect with us at the NaRCAD Conference Hub, where you can access on-demand video of all main sessions from the conference. Thank you again to all who attended, and to AHRQ for funding our series. Please stay in touch with us and each other, and continue the conversation and idea sharing below.
We hope to see you in 2016!
Jerry Avorn, MD, NaRCAD Co-Director
Often, in discussing academic detailing programs with current or potential sponsors, the question comes up: “Wouldn’t it be cheaper just to deliver the message to a whole group of clinicians at once, instead of the much more cumbersome process of talking to prescribers one at a time?” Sure, it would be cheaper.
So would just mailing (or e-mailing) memos to people telling them what to do, or requiring time-consuming groveling on 1-800-DROP-DEAD prior authorization numbers before a costly resource can be ordered. The problem is that cheaper solutions often don’t work, or don’t work well. We have decades of proof that putting health care professionals together in a darkened auditorium and subjecting them to a PowerPoint Tolerance Test does not reliably change behavior.
The main reason that academic detailing relies on one-on-one interactive communication is that it is the best way for the outreach educator to accomplish several key goals:
Well-trained academic detailers understand this, and they use the interactivity to craft a real-time, care-improvement message that best addresses the learning needs (and attitudes and biases!) of the person they’re visiting. Less competent academic detailers force their “targets” to sit still while they administer a canned micro-lecture monologue, which works poorly. They may feel they “got through all the points” they wanted to cover, but if there was no interactivity, no conversation, then the person they were talking at might as well have been falling asleep in a darkened amphitheatre.
We know this is the case from decades of experience and scores of randomized controlled trials. We also know, perhaps most compellingly, that when the drug industry wants to change what we know and about its products, it sends people to our offices to talk with us—it doesn’t rely only on the less expensive modalities of mailings, e-messages, and sponsored lectures.
So the next time someone suggests that it might be more inexpensive to just gather prescribers into a big room and have someone talk at them for an hour, agree with them. Then point out that it’s also less time-intensive to scarf down a Big Mac than eat a real meal, shoot off a series of emoticons rather than a personalized note, or listen to a ring tone of a Beethoven sonata rather than hear it performed by musicians. Cheaper isn’t everything.
Mike Fischer, MD, MS, NaRCAD Director
NaRCAD is thriving, thanks to the engagement and enthusiasm of our network of healthcare professionals working to improve patient outcomes. The best way to become more involved in that network is to join us for our 3rd International Conference on Academic Detailing. This year’s conference will be our most exciting and interactive event to date, with a stimulating 2-day program bringing together thought leaders for expert panels, best practices, breakout tracks, networking, and invigorating group discussions on innovations in the field.
Our keynote presentations will provide critical insights for everyone working to improve healthcare quality and patient outcomes. On Monday, Nov. 9th, Dr. Carolyn Clancy, Chief Medical Officer of the Veterans Health Administration, will highlight the VA’s use of academic detailing to address the epidemic of opioid overdose and misuse to save veteran’s lives. On Tuesday, Nov. 10th, Dr. Don Goldmann, Chief Medical and Scientific Officer at the Institute for Healthcare Improvement, will provide his insights on how to engage front-line clinicians in committing to change – drawing on IHI’s years of experience in promoting patient safety.
Many questions about academic detailing still need to be explored, new ideas generated, and connections made. We
need to foster solution-based discussion from a wide range of voices, representing clinical education, public health, practice transformation, government, the non-profit sector, hospital networks, academic institutions, and others. But the most important ingredient for the success of this event is you.
Join us as we work together to discover solutions, connect you with others that can amplify your impact and elevate your work, and share your experiences and insights on the best ways to navigate a rapidly-changing healthcare landscape. We hope you’ll join us this November 9th and 10th, and that you’ll help us spread the news about this unique, transformative event. See you in November!
Behind the Scenes with Dr. Doyle-Tadduni, NaRCAD Training Facilitator
Editor’s note: In this series, DETAILS asks Academic Detailing (AD) Techniques Training facilitators how they lead by example, challenge participants, and ensure that trainees are ready to go out into the field. Dr. Doyle-Tadduni focused on her insights and tips to success in providing excellent clinical education by building strong detailer-to-clinician relationships based on evidence, clarity, and “intrinsic trust.”
NaRCAD: Hi, Mary Liz! We’re looking forward to learning more from you about what it’s like to train prospective academic detailers. But first, tell us a little about how you became involved in detailing.
Dr. Doyle-Tadduni: I began working as an academic detailer about 10 years ago in Pennsylvania with the Independent Drug Information Service, which is sponsored by PACE (Pharmaceutical Assistance Contract for the Elderly). My clinical background in nursing and my teaching background within various university settings has served me well in this role as a clinical educator.
NaRCAD: What does a day of academic detailing look like for you? What successes and challenges do you see?
Dr. Doyle-Tadduni: My territory encompasses the westerns suburbs of Philadelphia where I visit physicians, nurse practitioners, and physician assistants. I see these providers in a variety of settings, including private practices, university-affiliated practices, and outpatient health care systems.
Since AD is a new concept to many practitioners, it’s essential to start your visit by educating providers about the importance of academic detailing and how it will benefit them and their patients. In this way, I’ve developed many long-standing relationships with providers who have said that AD has been very beneficial for their individual practices. It’s very gratifying in a follow-up appointment to hear that a provider has taken the evidence you provided and put it into practice, creating a positive outcome for patients.
NaRCAD: How do you build strong relationships with the clinicians you visit?
Dr. Doyle-Tadduni: There needs to be an intrinsic sense of trust between a detailer and the provider. You may not gain the trust in the relationship during your initial visits, but when you provide clinicians with a full understanding of the importance of your visit, along with presenting educational materials that are credible and evidence-based, you promote trust and strengthen the relationship and gain clinician commitment to changing behavior for the better.
NaRCAD: You’ve facilitated quite a few trainings with us at NaRCAD. Tell us more about the course, and why you enjoy doing it.
Dr. Doyle-Tadduni: This course is a great support for both new and seasoned trainees in enhancing their detailing skills, as well as program managers who oversee a clinical education program and need a greater understanding of how best to run an effective program. At the beginning of the training, the trainees absorb AD theoretical content and techniques, and on Day 2, they’re actively practicing the techniques and role playing different educational encounters in small groups.
The program trainees have been wonderful people to meet! I’ve had the opportunity to meet people from all over the United States, and some from Australia, Portugal, and Europe. It’s been very interesting being involved with the trainings and hearing about health care in other regions of the US and abroad. Despite the miles that separate all of us in our different demographics, we all have similar challenges in our respective health care systems.
NaRCAD: As a trainer, you “play” the role of the clinicians during breakout group sessions, presenting different personalities as well as various behavioral and content-based objections to the material or the visit. Tell us more about this part of the course.
Mary Liz practices with a trainee, teaching the importance of showcasing AD as a service that will create better outcomes for clinicians’ practices and patients.
Dr. Doyle-Tadduni: We present the trainees with many different role play scenarios where they can actively practice overcoming obstacles that get in the way of earning clinician commitment. Finding the right delivery of your messaging can be very challenging, depending on the environment, and every detailer will have a unique set of potential obstacles to face at each visit.
The key is to focus on the evidence, so that practitioners can realize how beneficial it will be to their practice. The training’s small group role play practice sessions provides trainees ample opportunity to practice, ask questions, perfect their skills, and be prepared to face inevitable obstacles in their own future visits.
NaRCAD: What do NaRCAD trainees need to have to be ready to succeed as a detailer? How does our 2-day training help to get them ready for success?
Dr. Doyle-Tadduni: The trainees need to have an expert knowledge base of the clinical topic and related materials they’ll be presenting during a visit. They also need to present AD as an on-going resource. With busy practitioners being so tightly scheduled through the day, programs designed to assist them in improving how their practice runs is a plus. By the end of the two days of training, the trainees will have a strong foundation of clinical education techniques, and they’ll be forming ideas about implementing these efforts in their respective programs.
NaRCAD: Any closing thoughts or advice for new trainees, or first time detailers as they prepare to head into the field?
As long as you’re well-versed on the material you’re delivering, and you’re presenting yourself as an “ambassador of the evidence”, you’ll have the tools you need to ensure that an academic detailing visit is truly successful.
An Interview with Frank Leone on Treating Tobacco Dependence with AD
Dr. Leone directs Penn’s Comprehensive Smoking Treatment Program and was a former trainee with NaRCAD.
NaRCAD: Tell us a bit about yourself. How did you get into academic detailing?
Frank Leone: I’m a pulmonologist, and have been focused on the treatment of tobacco dependence for over 20 years. In my early years, I had always been amazed at how infrequently my colleagues would approach the literature for solutions when facing this common problem in the clinic. It seemed to me that they relied heavily on “common sense” approaches and techniques derived from misunderstandings, rather than consulting published guidelines and available standards.
I became interested in the behavioral economics of tobacco treatment decision-making in the clinic, and realized that traditional approaches to changing physician behavior might be inadequate for dealing with a cultural problem this well-entrenched. We initially turned to NaRCAD for advice on Academic Detailing in 2011, and found the approach to have just the right potential to both meet the needs of the target audience, and allow us to deliver our message in a cost-effective and scalable way.
We were also given an opportunity to work with the Philadelphia Department of Public Health as they started up their efforts to influence the local provider culture around tobacco, and we’ve been “off to the races” working within our community, creating positive changes, ever since.
NaRCAD: What does your program focus on? (What health issue does it address, and what clinician behavior are you seeking to change?)
Dr. Leone: Our Academic Detailing (AD) program focuses exclusively on tobacco dependence treatment. As you can imagine, that problem cuts across a number of different audiences. Our detailers work with physicians, psychologists, nurses, counselors and others to impact the rate at which tobacco treatment services are delivered in our area. We use AD to address the limits in knowledge base around pharmacotherapy, as well as to shape the core assumptions about effectiveness of treatment in key patient populations (e.g. those with established lung disease or serious mental illness).
NaRCAD: Tell us about some of the growth you’ve seen and been a part of as it relates your program.
Dr. Leone: Our AD program has grown every year since its inception. We started out focused on primary care physicians in underserved parts of Philadelphia. From there, we expanded our target audience to include specialist physicians, nurses, and nurse practitioners. Most recently, our audience has expanded to include behavioral health practitioners in both inpatient and outpatient settings. Because of our success using AD to work with care providers from a variety of disciplines, we are currently exploring ways to extend AD principles to “system-wide” approaches to creating behavior change.
NaRCAD: What would you say are the greatest challenges you see in implementing this intervention?
Dr. Leone: Finding the right people to go into the field is imperative. Over the years, I’ve been impressed that success during the AD interaction is less about what degree a person has, and more about the ability to be gently directive, while willing to truly listen. Detailers need to be spontaneous and responsive to their audience, while at the same time keeping their inner eye on the target. This is a skill that takes a little time and training to develop. It sounds like it ought to be an easy thing to do, but we’ve found that an organized, logical, mentored approach to learning these skills is important to success.
NaRCAD: How about what works well? How do you know when you’ve been successful?
Dr. Leone: We always try to incorporate some sort of measurement tool into our AD projects. It might be about knowledge, attitudes, or behaviors, but having a metric to gauge our impact is important feedback ensuring we stay on mark. Our funders appreciate a concrete measure of change as well.
If I could figure out how to capture this, my favorite measure would measure the “A-ha!” moments that happen so often within the audience. I love the look of epiphany in the clinician’s eye when a detailer has found a way to make the information relevant and transformative. That’s when I know we’re really making change for the long run.
NaRCAD: You attended our Academic Detailing Techniques Training a few years back. What are the most useful resources or information that you’re still using today?
Dr. Leone: Truthfully, the greatest resource has been the continuing relationship with the NaRCAD team. On multiple occasions during the conception and start-up phases of our project, we were able to touch base with professionals who had a large collective experience in diverse disciplines to get some great tips and suggestions.
On one specific occasion, I remember sharing a written detailing piece with the NaRCAD team. We had developed it in hopes of getting some feedback. Not only did we get great advice, but it was professional advice – complete with references, examples, resources, and connections to the theoretical basis for the suggestions. To me, this is the kind of interaction that helps my team grow and learn over time.
NaRCAD: What does future success look like for you?
Dr. Leone: In twenty years, when you go visit your doctor for your annual check-up, and you hear him or her say, “Of course tobacco dependence is a chronic illness of the brain for which there are a number of effective treatments. It’s hard to believe we used to simply tell people to stop!” –then you’ll know we’ve done our job well.
Dr. Leone received his medical degree from the University of Pittsburgh, School of Medicine, and completed his postgraduate training in both general internal medicine and pulmonary / critical care medicine at Thomas Jefferson University Hospital. He also received his masters degree in clinical epidemiology and biostatistics from the University of Pennsylvania School of Medicine. Dr. Leone directs Penn’s Comprehensive Smoking Treatment Program, a clinical program of the Penn Lung Center, located at both Penn Presbyterian Medical Center, and the Perelman Center for Advanced Medicine. The new program provides state-of-the-art and individualized treatment to smokers, including those with co-morbidities.
Dr. Leone’s scholarship focuses on investigating advanced treatment strategies for tobacco use disorder, and on testing educational strategies for improving the care of the tobacco dependant patient. Dr. Leone is a member of several professional and scientific societies, including the Society for Research on Nicotine and Tobacco, the American College of Chest Physicians, and the American Thoracic Society. He has served the Commonwealth of Pennsylvania as a legislative appointee to the Governor’s Tobacco Use Prevention and Cessation Advisory Committee since 2001. Dr. Leone has been invited to speak at numerous lectures on topics of smoking treatment and pulmonary medicine, and has been published in a variety of clinical and research journals. He is board certified in pulmonary and critical care medicine. Learn more and review related publications on the University of Pennsylvania’s site.
Read more: Behavioral Economic Insights into Physician Tobacco Treatment Decision-Making : Leone, Frank
Mike Fischer, MD, MS
At NaRCAD, we work together with our many partners, collaborating on important interventions to improve patient health through clinical outreach education. This summer, we’re especially looking forward to a unique collaboration to improve cardiovascular health, as we travel to Oklahoma to support the Healthy Hearts for Oklahoma project, part of AHRQ’s EvidenceNow initiative.
EvidenceNow is a group of 7 large studies across the United States working to improve cardiovascular care in small primary care practices. Along with materials development and program support, the NaRCAD team will travel to Oklahoma City in July to train over 20 health professionals, teaching them how to provide the service of academic detailing to participating practices. Focusing on the ‘ABCS’ (aspirin use, blood pressure control, cholesterol management, and smoking cessation), the professionals we train will carry out academic detailing visits in order to present best evidence to participating practices.
By using the skills and techniques of AD to assess the needs of clinicians and practices throughout Oklahoma, the detailers we train will gain commitment from clinicians to commit to practice change. The Healthy Hearts for Oklahoma project will visit hundreds of practices, tracking these practices’ behaviors over time. Ultimately, the evidence generated by Healthy Hearts and the other EvidenceNow studies will yield key insights about how best to bring evidence to diverse practice settings and improve the cardiovascular health of all Americans.
Supporting organizations that are carrying out important work such as this is at the core of who we are and what we do. The positive impact of academic detailing can be amplified with each new intervention, program, or even a single visit to a clinician. As we enter into our 5th year as the only nationally available resource center for for academic detailing, the strength of the relationships we build makes it possible for clinical outreach education to serve more practices and have a greater impact on patient health.
We’ll share highlights from the Healthy Hearts for Oklahoma project and other exciting collaborations with our subscribers this fall. In the meantime, we’d love to see you at a future Boston-based training, or at our 3rd annual International Conference on Academic Detailing this fall—join us as we work together to advance the field of clinical outreach education.
by Lyndee Knox, PhD
Practice facilitation is an approach to helping primary care practices improve the quality of care they deliver to patients. Good practice facilitation is practice-centered, meaning that you start where you’re needed and work out from there. One of my favorite stories about the practice-centered nature of facilitation was told to me by Ann LeFebvre, director of the statewide primary care facilitation program in North Carolina.
Ann was starting work with a new practice in her community. As is common at the beginning of most improvement efforts, she asked the practice what their greatest concern was at the moment. Ann expected them to tell her they were concerned about improving workflow with their electronic health records, or that they wanted to improve their performance on particular HEDIS (Healthcare Effectiveness Data and Information Set) measures, or that they wanted help engaging their patients more effectively. Instead, what they told her caught her completely by surprise.
“We’re really concerned about our patients getting to our practice.”
“Oh,” she said, “so you’re worried about access issues?”
“Well, sort of,” the staff person responded. “Recently we’ve had a flock of geese take up residence in our parking lot, and they are biting our patients when they get out of their cars to walk inside. Some of our patients are afraid to get out of their cars.”
5 Whys Tool: Click to Learn.
As an experienced facilitator, Ann understood how important it was to meet practices where they are at the current moment, not where they “should be.” So she rolled-up her sleeves and said, “Ok, let’s figure this one out.” She saw the problem of the geese as an opportunity to teach practice staff basic principles of quality improvement. She taught them to use the “5 Whys” to determine why the geese were in the parking lot in the first place, and then to use Plan-Do–Study-Act cycles (PDSA) to design and test solutions to the “goose attack” problem.
Working together, Ann and the practice discovered that a woman living next door to the practice used to keep and feed the geese. She had recently been hospitalized and because she was no longer there to feed them, the geese had moved into the practice parking lot. Staff developed a solution: to have another neighbor feed the geese – and tested this solution using a PDSA cycle. The geese left the parking lot, their patients no longer had to deal with hungry and aggressive geese in the practice parking lot, and staff had started to build capacity in quality improvement!
Practice facilitators are specially trained individuals who work with primary care practices “to make meaningful changes and develop the skills they need to adopt new clinical evidence and health service models in their work and to sustain these changes over time.” (Knox & Brach, 2011; DeWalt, et al., 2010).
The primary aim of facilitators, whether working alone or as part of team, is to build practice capacity for continuous quality improvement, as well as to strengthen practice ability to adapt and implement new evidence-based treatments and health service models.
Facilitation teams develop long-term relationships with practices. They may work with a practice intensively for 6 to 10 months to implement a specific improvement and then step back for a while. Even though the active facilitation project has ended, they will check-in with the practice every month or two to monitor progress and maintain relationships until they are needed to support another significant improvement project at the practice.
While facilitation can be provided by a single individual, (a “practice facilitator”) it is often a “team sport.” The facilitation team is usually led by an individual with expertise in quality improvement processes and methods. This person serves as the team leader and primary point of contact with the practice, and brings in his or her team mates to help the practice as needed.
Other members of the facilitation team include individuals with expertise with health IT who can help practices optimize their health IT systems to support the desired changes; team members with expertise in setting up data systems for monitoring performance; and most recently, patient partners. Academic detailers are also essential members of most facilitation teams. They possess deep knowledge about clinical topics and provide 1:1 education to clinicians to increase their knowledge about specific preventive care and treatment issues, encouraging those clinicians to change their behavior to improve patient health.
A number of excellent resources are available for training members of facilitation teams, and to guide development of a practice facilitation program. These include the PF Handbook, the National PF Curriculum, and the How to Start and Run a PF Program. Dr. Mike Fischer, the director of NaRCAD, and a team of experts in PF and practice improvement helped develop them. These and other resources that can assist you in building a practice facilitation program in your area can be accessed here.
Lyndee Knox, PhD is founding director of LA Net, a primary care practice based research and resource network established with funding from the Agency for Healthcare Research and Quality (AHRQ) in 2002. LA Net supports research and innovation in the healthcare safety net in Los Angeles and provides practice facilitators to practices in its network to support practice-based, clinician and community-led research, evidence translation and practice improvement. Dr. Knox served as principal investigator on AHRQ’s Task Order 13 (TO 13) to examine the use of practice facilitators to implement the Care Model in the safety net, and convened the AHRQ Practice Facilitator Consensus Panel to summarize the state of the field as part of TO13. Most recently she led work for AHRQ to produce a manual to support formation of new practice facilitation programs across the U.S. The resulting manual, Developing and Running a Primary Care Practice Facilitation Program: A How to Guide and case studies are available on AHRQ’s website.
As director of LA Net, Lyndee has served as lead on a 2 year contract with the Greater Los Angeles Veterans Administration to create and train a cadre of internal coaches to support its primary care teamlets and PACT transformation. Currently she is working with Mathematica Policy Research to create a 30 module training curriculum for new Practice Facilitators/Coaches for the U.S. AHRQ. Dr. Knox also directs Project ECHO LA, a replication of the successful quality improvement and clinical education intervention from the University of New Mexico aimed at increasing access to specialty care services in rural and underserved areas. Project ECHO LA has been supporting ECHO Knowledge Networks for the LA safety net for 3 years in areas including: psychiatry, preventive care, geriatric medicine and quality improvement.
Spring 2015 Director’s Letter
Mike Fischer, MD, MS, Director of NaRCAD
Despite the difficult winter weather in Boston, NaRCAD has been off to a great start so far this year. We’ve been very excited to begin several new initiatives with terrific partners. As we move forward through 2015 and beyond, we invite those of you reading our newsletter and following us through our blog or on social media to reach out about working together on similar efforts.
Training academic detailers is a core part of our mission, and we continue to have full registrations for our Boston-based training sessions, telling us that there’s an interest and a demand for our training course. This year we were thrilled to take our training on the road for the first time, working with the San Francisco Department of Public Health on several new initiatives, focusing on diverse topics including overdose prevention, increasing use of vaccinations in pregnancy, and HIV screening and treatment. This July, we’ll again deliver training outside of Boston, this time in Oklahoma to help support a new AHRQ-funded project aimed at improving care for cardiovascular risk factors in primary care.
We also created and launched a new workshop for the experienced group of academic detailers at Atrius Health here in Boston. Similarly to our 2-day techniques training, we used role play and interactive group discussion to help clinical pharmacists work on overcoming barriers and obstacles. Interacting with Atrius’s dedicated group of outreach educators has all of us thinking about how academic detailers can best maintain and develop their skills over time, and we’re interested in hearing about how existing programs approach this challenge. If you have similar experiences to share, let us know—we’re always eager to share best practices with our network community of detailers, programs, and supporters.
We want to hear from you. Your ideas matter–tell us how you’d like to collaborate, create new opportunities for academic detailing, and improve quality of care and patient outcomes.
Highlighting Best Practices
We highlight what's working in clinical education through interviews, features, event recaps, and guest blogs, offering clinical educators the chance to share successes and lessons learned from around the country & beyond.