Overview: Dr. Nate Rickles, PharmD, PhB, BCPP, FAPhA is an associate professor pharmacy practice at the UConn School of Pharmacy with experience in developing AD programs, most recently for the CDC-funded CEDPP (Connecticut Early Detection and Prevention Program) project. Dr. Natalie Miccile, PharmD, MBA currently works as a retail pharmacy manager at ShopRite Pharmacy. She’s working with Nate to onboard pharmacies participating in the CEDPP program and working with the pharmacy students who are supporting the process of referring patients to screening, diagnostic, and prevention services. 
​
​by: Winnie Ho, Program Coordinator

Tags: Cancer, COVID-19, Detailing Visits, Health Disparities, Program Management

Winnie: We’ve been excited for a chance to speak with you both! Nate, you spoke on our Clinical Innovations in AD session at the NaRCAD2020 Conference, sharing your work to support underserved, and sometimes undocumented, women in accessing care. Thank you both for joining us today –  can you tell us a little bit more about the program and the issues it addresses?
 
Nate: CEDPP consists of two components: the Connecticut Breast and Cervical Cancer Early Detection Program (CBCCEDP) and the Well-integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN). The services are offered free of charge with the goal of significantly increasing breast and cervical cancer services for medically underserved women.
 
The Department of Public Health’s traditional outreach method of using clinical navigators at established WISEWOMAN sites could only reach a relatively small population. We received a CDC Innovation Grant to investigate the role that community pharmacies could play in increasing referrals to a free public health prevention program for vulnerable populations, as these pharmacies are accessible, front-line, and generally well-trusted in the community.

W: That’s an important goal to close this gap and to ensure more women can access the services they need. Why did your team feel that AD was a useful approach to address the lack of access to screening services?
 
Nate: I’m very passionate about the notion that building relationships through 1:1 connections are going to be more powerful long-term in creating behavioral change. AD works so well because the techniques are very persuasive in dealing with common barriers like pharmacists believing there’s little time in their day, not enough staffing, or not the right financial incentive.
 
Our project manager Peaches Udoma had sent out flyers and e-mails to local pantries and shelters, but we hadn’t received many referrals through this tactic. The predominant way we’re getting referrals is through 1:1 outreach with pharmacists and our students reaching out to the referred participants to connect them with services.

Winnie: Can you tell us more about how your intervention navigated the pharmacists’ barriers you described?
 
Natalie: We had a lot of interest from pharmacists, especially when they learned about the impact they could have. However, for a full month, we weren’t seeing results. When I checked in, we learned that they were genuinely overburdened with their workflow, which wasn’t surprising.
 
We had to think about who else in the office could do it – and it turned out to be the pharmacy technicians. They were often at the point of sale and would be more likely to know if patients were uninsured or underinsured. We began detailing the pharmacy technicians directly instead. Many of them were bilingual, which helped in distributing the right flyers to the right women.
 
We worked with the pharmacy technicians on communicating the benefits our programs offered, with attention to utilizing accessible language and avoiding unnecessarily complicated healthcare terms. We learned that emphasizing key things like free gym memberships or free nutritional services provided was very useful in getting women to agree to be referred. Addressing the language barrier and slight language changes was key to us finally getting referrals.
 
However, when COVID-19 hit, we had to reassess since we started getting zero referrals again. It made sense as few people want to wait around in a public space, and pharmacies also became overwhelmed. Our team pivoted to reaching out directly over the phone after receiving lists of potential contacts from the pharmacies. We wanted to show our partners that we could be resilient in this time and to not let this program fall through.

​Winnie: Pivoting your intervention to have team members directly contact the women you were trying to refer instead of through the pharmacy technicians must have required your team to make adjustments to accommodate language needs. How did your team tailor the AD intervention to address language barriers?
 
Nate: We noticed that we had many of the women we reached out to who spoke Spanish as a native language, and quickly realized we were probably losing a lot of patients because of the language barrier. We onboarded a pharmacy student, Isabella Hernandez, who, in addition to being a very dynamic, charismatic, and outgoing person, also spoke Spanish.
 
Once Natalie onboarded her and shared the main concepts around the screening and referral, Isabella was quickly able to pull in over 80 referrals; we didn’t have even half or a third of that through our prior efforts. We’ve been closely tailoring our work since, with flyers in Spanish, Portuguese, and in Arabic. We have also Arabic speakers to communicate with Arabic-speaking patients, and we have the capacity to expand into other languages.

Natalie: I originally worked with the lists of contacts we received and tried to engage directly. However, because we recognized our bilingual pharmacy students were able to better engage with these women, my role now is to oversee our callers, get their referrals, and help touch base with site navigators to ensure referrals are being processed, and how we can improve our screening process.
 
We’re prioritizing language accessibility because our first encounters are first impressions. Our patients matter, and we want to make things as smooth as possible for them. We’re even at a point where Isabella is running trainings with our other callers, so she can give them hints on how to be more flexible in the conversation to fit our clients’ needs.
 
Winnie: This is a really outstanding demonstration of flexibility and tailoring a program to address barriers to practice change. We hope that other programs continue to follow your example of integrating best practices to communicate with patients from diverse communities!

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You can head on over to our Discussion Forum to continue the conversation!

​Nathaniel ("Nate") Rickles is an Associate Professor in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy. He received his B.S. in psychology and chemistry from Dickinson College, Pharm.D. from the University of the Sciences in Philadelphia, M.S. and Ph.D. in the Social and Administrative Sciences from the University of Wisconsin-Madison.  Dr. Rickles also completed a psychiatric pharmacy practice residency and is board certified in this area. He was inducted as a Fellow of the American Pharmacists Association. 
His primary research interests are to develop, implement, and evaluate intervention programs that improve pharmacist communication with patients and/or other team members and subsequently to improve medication adherence and patient safety. Primary teaching interests involve courses on communication skills, mental health, health behavior change, cross-cultural health care, and research methods.  Dr. Rickles is an active researcher with several grants and publications involving enhancing the role of pharmacists in changing patient and provider behaviors.

Natalie Miccile received her PharmD from the University of Connecticut School of Pharmacy in Storrs, CT and MBA from the University of Connecticut School of Business in Hartford, CT.  Her MBA concentrations include Digital Marketing and Strategy and Investment Analysis. She works as a consultant for UConn School of Pharmacy on research initiatives that involve enhancing the role of pharmacists in the community setting and is pharmacy manager at Shop Rite Pharmacy in Milford, CT. Dr. Miccile is MTM certified and an active member of the Connecticut Pharmacists Association. 

Anna Morgan, MPH, RN, PMP, NaRCAD Program Manager

Tags: Conference, COVID-19, Deprescribing, Diabetes, E-Detailing, Elderly Care, Health Disparities, HIV/AIDS, International, Jerry Avorn, Mental Health 

Over 240 members of our worldwide community came together to be a part of something special--our 8th annual conference, and our first in a virtual setting. We were able to expand our reach and overcome barriers like travel time and financial constraints that have prevented our colleagues from attending previous conferences.
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There was a palpable sense of positivity, enthusiasm, and resilience, especially in a virtual space. We’re so proud of evaluations that cited a renewed sense of passion and commitment to AD based on the new lenses we applied to our programming, including comments about feeling “empowered” to continue this work in the year ahead (even amidst inevitable Zoom fatigue.) 

• Our director Mike Fischer reflected on how academic detailing can play a role in social determinants of health and health disparities.

• Presenters who’ve been working on diverse clinical interventions shared work and reflected on the ways AD can impact underserved patients, including veterans with mental health conditions and substance use disorder, as well as undocumented women who need access to comprehensive women’s health and related services.

• Interactive breakout workshops focused on peer-to-peer learning, with concentrations in AD for newcomers, using storytelling approaches with clinicians, and building program branding.

• A deprescribing plenary looked at the importance of specific approaches to detailing within long-term care settings to improve elderly patients’ health.

 

• In his annual “AD Talk”, NaRCAD co-director Jerry Avorn shared his perspectives on COVID-19’s impact on detailing, particularly a need to continue adapting to virtual AD sessions.

 

• For our e-Detailing panel, presenters shared nuggets of advice for those considering the pivot to virtual visits, including being flexible, having materials prepared ahead of the visit, and casting a wide net for provider recruitment.

• Another novel panel emphasized the key role of pharmacy to combat the opioid crisis, including a new lens on the impact of training pharmacy students in program planning and implementation.

• In a special presentation about detailing on Type 2 diabetes in ACOs and Community Health Centers, panelists reflected on the importance of preparing organizations for an AD campaign knowing your community’s unique identity, as well as highlighting community resources for providers AND patients.

• Three experienced detailers participated in a “live interview”, answering audience questions on recruitment, gaining access, defensive clinicians, how to maintain positivity, and more.

 

• A special presentation on HIV prevention and treatment gave attendees a look at robust data from the CDC, a new perspective on AD and HIV treatment through iART (immediate antiretroviral treatment), and evaluation strategies and results of a sexual health AD campaign.

 

• Global field presentations shared new perspectives on researching one-to-one visits vs. group visits in Norway, pivoting quickly to a COVID-19 campaign in Canada, and using the principles of academic detailing for patient education in Australia.

 

• Our new “Yearbook” session featured three new programs who have made impressive strides in their work over the past year, sharing 2021 plans for continued success.

With so many of you expressing a continued need around more of our peer working sessions, we’ll be focusing largely on that in 2021—we can’t wait to support your work this year. In the meantime, tell us what you need to make next year a success.

See you in 2021.
​

The NaRCAD Team




​
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You can head on over to our Discussion Forum to continue the conversation!

Bevin K. Shagoury, Communications & Education Director

Tags: COVID-19

It's a time when continuous comparisons of the COVID-19 era to that of the Spanish Flu of 1918 are frequent. More than 100 years later, we've moved from telegrams to Instagram--staying connected seems like it'd be easier than ever. With so many channels and platforms available to stay on top of the ever-changing influx of info on the current state of healthcare, why do we so often feel less connected? 

We're speaking, but we're having a hard time listening. We're viewing, but we're not reading. With platforms like Twitter, output is the main focus. Sure, we scroll through others' feeds, leave comments and likes, all with a quick tap or two. But this is the virtual version of 'speaking at' someone, rather than with. 

What will encourage us to invest in opportunities for more circular, reflective dialogues during an era where the perceived preciousness of time leaves us running at an ever amped-up, task-oriented pace? What slows us down in these moments of overstimulation?

Overview: The DETAILS blog presents a special two-part series of what it takes to build a strong provider-detailer relationship from the perspective of a long-time academic detailer and  from one of her local physician partners that she's detailed for almost 15 years. 

In Part One, we speak with Amanda Kennedy, PharmD, BCPS, who serves as the Director of the Vermont Academic Detailing Program and has been an active detailer since 2002. The Vermont Academic Detailing Program sees about 450-500 providers a year on 1-2 clinical topics. In Part Two, we hear from Dr. Robert “Bob” Schwartz, a Vermont family physician who reflects on his experiences with academic detailing visits with Amanda. Stay tuned for Part Two!
 
An interview with Winnie Ho, NaRCAD Program Coordinator.

​Tags: COVID-19, Detailing Visits, E-Detailing

Winnie: Amanda, thank you for taking the time to reflect on the relationships you’ve built through the years with local providers. What would you say are the key elements for building a strong provider-detailer relationship, and why?
 
Amanda: Trust and mutual respect. If the clinician doesn’t trust you, then it’s going to be very hard to make recommendations for practice change. Mutual respect goes both ways. As much as I am providing a service, I also expect the clinician to show up and be engaged in our visit, because only then can we have the kind of conversation that gets at the heart of the behavior change we hope to see.

​W: Engagement is such a key component of these visits, especially for creating a safe space for providers to be open and honest with the detailers about their concerns and needs. I want to take you back to the start and ask you to reflect on what it was like to be brand new to AD. What advice would you give to a new detailer in those shoes?

​A: Confidence is key. You can study and practice everything with your team, but at some point you have to get out there and just do it. Building that relationship requires confidence and the belief that you have something valuable to offer. When you only have a few opportunities a year to meet with clinicians, you have to capitalize on those moments.
 
It can be difficult to establish that rapport and trust when contact is infrequent. It’s about persistence, patience, and continuing to show the clinician that you want to be helpful. Some things can get in the way, such as not having the same clinical background as the provider you’re working with, and not always feeling qualified. But remember, you wouldn’t have been hired in this role you weren’t qualified!
 
W: That’s certainly important to keep in mind. You were also recently introduced to a new playing field – virtual visits. Compared to traditional in-person visits, what’s it like starting new relationships through e-Detailing?

​A: Virtual visits can be efficient, because we eliminate the cost of travel, we can reach more people and more often. Most of the content of that first call is the same as in person. On a first visit, most of what you’re doing is the introduction of your work and your program. I’m transparent about everything with them.
 
I don’t bring up my materials or share my screen until that clinician has had the opportunity to ask me any questions they have. I give them a chance to see me as a person first, without distractions. This takes a few minutes longer virtually than in person, and it can be harder to gauge body language, but it’s an important first step in establishing a relationship.
 
W: That’s a good piece of advice for many programs making that transition into e-Detailing, as I know it was a big concern about starting these relationships over a new medium. Do you have an example of how maintaining these relationships can support better health outcomes for patients?

A: Yes. While our team was putting together information on a COPD campaign, I was meeting with Dr. Schwartz on a different topic. At the end of our visit, I told him about the next topic and asked him what was concerning him about it. He asked for more information on benzodiazepines and patients with COPD. While this specific information wasn’t included in the overall COPD campaign, I’ve personally been looking for good articles that would be helpful for his particular interest. In attending to this specific request, I’m showing him that I’m listening to and addressing his need.
 
W: That’s some strong needs assessment! And I’m sure that information will be put to good use. You’ve been in this field for 18 years - have you seen how your support has resulted in clinical behavior changes over the years?
 
A: The most rewarding thing for me is going into a clinic and seeing a tattered version of a handout we used five years go, or a clipped out table taped up on a board. That’s how you know your information has stuck around and has had a long-term impact.

​Also, on visits, if a provider is struggling to think of how to incorporate a behavior change into their practice, I have stories from other providers and can provide suggestions and ideas that have worked for them. I can leverage a community of long-term relationships.
 
W: Have you found that these strong relationships allow you to get more out of a detailing visit, especially when there are some difficult conversations?
 
A: Yes, absolutely. It’s important to know, especially right now, that we’re suffering a community-wide trauma because of COVID-19. Out patients need their providers, but those providers have their own challenges going on too. There are family issues, financial issues, and community issues. Our jobs as detailers is to be a support as much as we can, and to help providers make beneficial changes for patients that are rooted in evidence.

​We’re currently doing a topic on managing stress related to COVID, but before we get into how providers can help their patients, we pause and ask them how they’re doing. I’ve had providers share deeply personal information with me that can be important in understanding how to best support them in addition to them supporting their patients. They know that they can trust us.
 
W: As we wrap up, what would your final advice be to other detailers looking to replicate your success?
 
A: My advice? It doesn’t take 18 years to build a relationship with someone. It just takes enough of your effort to show that you’re really trying and taking opportunities to be of service. It means showing that you’re trustworthy, and that you’re going to respect and support them just like you’re promising them that you will.
 
(Part One of Two).

Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Amanda Kennedy, PharmD, BCPS, is the Director of the Vermont Academic Detailing Program at the University of Vermont’s Office of Primary Care. She has also been an active academic detailer for nearly 20 years. Amanda regularly serves as a faculty facilitator for NaRCAD’s Academic Detailing Techniques trainings.

​In addition to her role with academic detailing, Dr. Kennedy is a Professor of Medicine at the University of Vermont’s Larner College of Medicine. She currently serves in the Department of Medicine Quality Program, teaching and mentoring physician residents, fellows and faculty in quality improvement and health services research.

Jerry Avorn, MD, Co-Director, NaRCAD

​Tags: COVID-19, Detailing Visits, E-Detailing, Jerry Avorn

​​The pandemic has changed everything about our lives and our work. Some occupations have been able to adapt to the new abnormal, such as programmers and financial traders. Others have found it harder to do their jobs as before, like brain surgeons and academic detailers. For the latter, in a socially-distant, avoid-human-contact world, how can we pursue an activity that has as its very definition in-person, interactive communication?
 
Academic detailing programs around the country and the world have been grappling with this challenge. And unlike our colleagues the brain surgeons, we have been able to come up with some plausible solutions, even if nothing is quite the same as being up close and personal. We’ve been learning about the virtues and limits of Zoom/Skype/WebEx.  If we’re paying attention, using them can bring into sharp focus the central aspect of interactivity, on steroids. It’s a little like becoming a better runner by strapping weights on your ankles (or so my athletic friends tell me). A non-adept academic detailer can mis-use a Zoom encounter even worse than a face-to-face one: “Sit still for 20 minutes while I do this presentation at you.” That will fail on a platform even more calamitously than it does in person. (One clue is when the prescriber mutes their video to read their e-mail.)  But if we’re open to it, the e-encounter can focus our attention even more on whether we’re learning where the clinician is coming from, getting feedback, actively asking what sub-topics they most want us to cover.

​The artificiality and forced intimacy of a screen-to-screen encounter, and the reason we currently have to do our work like this, can also focus us even more on another key aspect of academic detailing, empathy. “How are you holding up?” or “I bet COVID has really changed your practice” are opening statements that can address the 800-pound virus in the (virtual) room, acknowledging the obvious strangeness and discomfort that afflict so many conversations in these awful times.
 
On a more concrete level, pandemic-style education is also forcing us to come up with new ways to use our educational materials. What to do when you can’t focus a practitioner’s attention on a particular graph or table you’re showing them because they’re dozens of miles away? Displaying a PDF of a document and whizzing around your cursor is one easy, but primitive solution. What about presenting a list of topics hot-linked to a detailed display for each? Or completely re-formatting our materials (stop moaning) for better adaptability to a computer screen?

​Those of us who also used to teach in classrooms have learned that with a little work (ok, a lot of work) coronaeducation can even be better than what we’ve been used to doing: using links to video clips or animations, real-time interactive polling, techniques that maybe we could have been using in the classroom, but weren’t.
 
Another key advantage of academic e-Detailing, if we can figure out how to make it work well, is the prospect of having a virtual visit with a clinician without the sunk time of getting to their office – a major enhancement in working with practitioners who may be an hour’s drive or more from the educator’s base. The benefit for our field in productivity and cost-effectiveness could be considerable.
 
Contrary to naïve beliefs that “Soon everyone will be protected by the vaccine and we can get back to normal,” this virus probably won’t let us return fully to the old ways any time soon. Instead, it will force us to mutate our work to cope with it. And in the process, not only will we be able to continue our work, we may even discover better ways of doing it.
 
Be strong and stay safe.

Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Winnie: Hi Tara! It’s been a crazy year so far, hasn’t it? We want to check in with you and the University of Illinois, Chicago (UIC) team about your experiences in navigating the pandemic. Can you tell us a little more about yourself and your role in the ADVANCE academic detailing team?

Tara: I was hired about 7 months ago as the research coordinator, and it’s been one heck of a 7-month run. The majority of my work is focused on implementation, so I do all the scheduling and outreach to hospitals to talk to providers. I develop and establish relationships with office managers and providers, and I assign detailers to visits.

W: Our team at NaRCAD has been lucky to have worked with the UIC and ADVANCE team for a while through our trainings and your presentations at our conferences and our webinar series, and we’re excited about the research intervention that had been planned. Can you tell us a little bit more about the mission?
​
T: Our intervention is a CDC-sponsored, three pronged approach that’s built off a pilot program that we started in 2018 for Chicago-land providers. We have a team of about 30 detailers who are now trying to cover as much of the state as possible. We wanted to follow-up with providers to get a sense of whether or not the ‘dosage’ of AD made a difference, but we also wanted to expand the providers we worked with, and to introduce updated topics like the new features of the Illinois PMP or opioid alternatives. The third prong is creating a toolkit to give programs a blueprint and resources of what was effective for us. We would love to make the “how to” of AD more accessible to other groups.

W: Compared to other programs, you have quite a large and robust team at UIC. It must have been difficult for the pandemic to hit right in the middle getting your program launched.

T: It really impacted our recruitment as we had called providers from the end of January through early March 2020. There are a lot of things going on right now. Even a small ask, such as 15 minutes of their day, can feel like a big ask for providers.

W: Right, and interventions are very carefully laid out and planned ahead of time. COVID-19 has disrupted everything – especially those on the frontlines who are both detailing and being detailed. Can you tell us a little bit more about how else the impact on your original plans for the intervention?

T: We had been so focused on ramping up that by the time we hit mid-March, we had many people on deck reaching out to providers. We started hearing “No, we can’t do this right now” or “this is a really bad time” often.
​
Once the stay-at-home order came through, we stopped contacting offices for about 2 months. We had to sort out so many protocols and even our IRB to make amends for virtual visits. What we’ve found since we’ve resumed virtual visits in May is that there’s a lot of variability – some offices have capacity because they aren’t seeing many patients, while others have providers that have been transferred to hospitals and have no idea when they’ll be available. We’re also talking about layoffs and burn-out and low morale.

W: There are many of considerations on how best to proceed safely right now. One is looking at the impact on the critical work you’ve done on opioid safety. Unfortunately, the pandemic has only exacerbated the overdose epidemic. What progress has been made on your opioid initiative?

T: One of the ways our team has shifted has been moving to virtual visits. We knew that these would have its own difficulties, such as concerns about “no-shows”. But our team is relatively tech-savvy, and now my job is making sure they’re all familiar with how to troubleshoot the technological pieces of virtual visits. 

​There are a lot of tech issues that can interrupt a visit. So we do mock detailing and have the detailers practice with each other, where we introduce certain needs and obstacles, maybe even a tech problem for instance, we role play a provider not turning on the webcam, or not being able to see your screen. Practice to strengthen adaptability and resilience become important in ensuring the detailers are prepared.

W: There’s definitely no time like right now to test detailing skill and ability to think on your feet! As a research coordinator, what do you think you’ve learned in the past few months?

T: How to be flexible! There are all sorts of external pressures right now to keep our project on track, but the most important part is keeping the human aspect in check. Having some insight and empathy for providers is important to understand what they’re going through. We can get bogged down into the guide posts, the bench posts, or the numbers – but this era reminds us that it’s all about empathy.
​
​W: At the end of the day, we want better for our patients, for our communities, and for health outcomes everywhere, right?

T: Absolutely!

Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

An interview with Kelsey Bolton, Continuing Professional Development Consultant, Gundersen Health System
​
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager

​Tags: Detailing Visits, COVID-19, CME, E-Detailing, Smoking Cessation, Substance Use

Anna: Hi, Kelsey! Thanks for taking the time to chat with us today.  Can you tell us a bit about your academic detailing program in Wisconsin and your role?

Kelsey: I’m a Continuing Professional Development Consultant in the Continuing Medical Education (CME) Department at Gundersen Health System. Gundersen Health System is a teaching hospital with a multitude of specialties that serves patients in Wisconsin, Minnesota, and Iowa.

As part of my CME work, academic detailing stood out as an effective tool to disseminate our information and meet our clinicians’ educational needs. We started our detailing program last fall and have been focused on tobacco cessation.  The detailing intervention is a spinoff of a performance improvement project we are working on for diabetes.

I’m currently a one-woman show; I’m the program coordinator and the sole detailer.  I detail physicians, NPs and PAs across the health system. 

Anna: Wow, it’s incredible that you’ve been able to build your detailing program from the ground up! Can you tell us what that’s been like?

Kelsey: Academic detailing was a new concept to me prior to being introduced to it by my former manager, who sent me to the NaRCAD training in May 2019.
​
Academic detailing is not a well-known concept in our hospital system.  It was difficult to get past the gatekeepers and “enlighten” them about academic detailing.  There are still misconceptions when I walk into a room for a meeting with a clinician – they often think that I’m a drug sales rep, that I’m an internal quality control person, or that I’m there for punitive reasons.  I must quickly refute that and explain that I’m there to support and unburden them, not to make judgments about their work.

Anna:  Those misconceptions are quite common when starting a new academic detailing program. How are you able to “enlighten” the gatekeepers?

Kelsey: It was bumpy at first and we tried a few different approaches, but I think we’ve finally been able to smooth it out. I have an advantage because I’m internal and I’m contacting clinicians from an internal email or phone number.  I’ve also had our medical program coordinator, the doctor who is partnering with me to learn the clinical information, send out emails to gatekeepers prior to my detailing visits.   
​
Anna: Stakeholder buy-in is imperative when building a new detailing program.

Kelsey: Absolutely. Building relationships with key stakeholders has made all the difference.  The medical program coordinator I work with, as well as other experts in the organization, helped me curate my detailing aid and key messages. 

I practiced my detailing sessions with these stakeholders before going out in the field.  It was an easy way to build relationships and get them on board – it only took a 15-minute practice detailing session!

I’m also fortunate enough to have support from senior leadership. They’ve been able to open doors by letting people throughout the organization know that they support the academic detailing work I’m doing. 
​
Anna: It sounds like both managing your academic detailing program and being in the field has helped you be successful in getting your program off the ground. What has it been like to grow and manage your AD program?

Kelsey: It’s like herding cats! The detailing program is 25% of my workload, so completing all the administrative work plus the detailing visits is quite a commitment.  By the end of this year, I will have detailed over 200 clinicians. 

“Marathon detailing” has put me in a groove. It has definitely been challenging, but I appreciate that I know the ins and outs of it now – both the administrative tasks and the field work.  I feel prepared to help train others. I plan to start training one of my colleagues to become a detailer in the fall.
​
Anna: When thinking about team expansion, it’s also important to think about the impact of COVID-19.  How has COVID-19 impacted your program?

Kelsey: We paused our detailing visits for about 3 months, and by the time we started talking about bringing them back, NaRCAD was putting out a lot of information about e-Detailing. 
​
Before COVID, I had barely done anything with video calling, but getting thrown into working from home, we jumped into a lot of video calls. I learned how to work virtually on the fly, which made it easier to adapt to e-Detailing. 

I did a few practice e-Detailing sessions with my colleagues and I’ve now successfully completed several visits virtually.  The NaRCAD webinars were a lifesaver.  We plan to continue e-Detailing until it’s safe to return to in-person visits.
​
Anna: A lot of academic detailing programs had to adapt quickly to e-Detailing during the pandemic.  What does the future look like for your program?

Kelsey: For the more near future, we are working on collecting data for the tobacco cessation campaign to eventually publish research on the efficacy of the academic detailing intervention.  We’re going to pull patient data from the EMR, as well as look at the qualitative data from the evaluation surveys. This research will help inform our organization on the benefits of academic detailing as an educational intervention.
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We would also like to continue the program with other strategic initiatives like substance use disorder, social determinants of health, and cancer screening.  I have a soft spot for topics similar to tobacco cessation that are sometimes discouraging to clinicians because they don’t feel like they can make a difference. I know that through detailing, I’m able to give them a fresh take on these topics, and reinvigorate them in providing the best care for their patients.

​Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Biography. Kelsey Bolton is a Continuing Professional Development Consultant in the CME department at Gundersen Health System in La Crosse, WI and the program lead for its Academic Detailing program. She received her Bachelor of Arts degree in Communication Studies in 2015, Healthcare CPD Certificate in 2019, and is currently pursuing her Master’s in Organizational Leadership. She has completed over 100 detailing visits and is presently conducting a research project on the efficacy of tobacco cessation academic detailing.

Winnie: Thank you for speaking with us today Marlys! Can you tell us a little bit about your work with the RxFiles Academic Detailing team?
 
Marlys: Absolutely! I’ve been with RxFiles for just over 4 years as an Information Support Pharmacist doing both frontline academic detailing as well as co-leading various academic detailing training sessions, with the most recent being this past April. Our program covers Saskatchewan, Canada, but our website, app, and book are used outside of the province and Canada as well.

W: RxFiles is definitely one of the larger and more established programs we’ve had the honor of partnering with through the years. Can you tell me how maintaining the daily operations of your program have been impacted by COVID-19?
 
M: ​One of the bigger things that’s changed for our team has been moving our academic detailing training sessions online for our team of 12 detailers. We had to shorten our two-day in-person training, and shifted to hosting shorter sessions and offering more pre-training day and post-training day webinars to cover all of the content, including “how-to virtually detail”.

​W: No matter how well virtual substitutions are planned, it’s not the same as being together. We’re all really missing our colleagues, and it’s heightening a sense of isolation. How do you think your team has adjusted to moving the training online?
 
M: I think our team adjusted quite well to the training adaptations. We were able to give them enough notice about the shift. What came out from training days is that our team members really do miss being in-person and having that social interaction – even the chit-chat in between sessions. For in-person trainings, we typically have time for a team-building activity in the evening where people catch up. We’ve been trying to incorporate more games and fun into our virtual training to have that social aspect. Personally, I really miss debriefing with colleagues in-person after detailing visits.

W: It seems like keeping the team connected is a big part of your team culture. How has your team stayed connected through the pandemic?  
 
M: We typically do a roundtable at the mid-point of a detailing topic. We typically go around and share a little bit about our detailing experiences. Pre-COVID, no one wanted to turn on their cameras. It was never a requirement, but now everyone is turning them on. It’s been really nice just seeing people’s faces. Also, one of the things that’s been nice about going virtual is that we are able to open up staff meetings and invite more detailers to participate with us. We would have never been able to do that as easily in person.

W: We’ve seen opportunities like these spring up as teams need to be particularly innovative under tough circumstances that prevent in-person connection. Speaking of teams, dream teams don’t come out of nowhere. A lot of work goes into creating and maintaining a strong, positive, and connected team. At NaRCAD, we talk a lot about what makes a good detailer, but what are some of the hallmarks of a strong detailing team?
 
M: Team work is a really interesting thing to dive into. I reflected on this question, and think that a strong detailing team supports one another. That support can be helping each other out in the detailing session itself (e.g. co-detailing), or through communicating with each other about the providers we serve and in between detailing sessions (e.g. a prescriber moved from one detailing area to another). We want the team to be successful in moving towards our goals together. Another thing that COVID brought to my attention is that a strong detailing team also has a positive attitude. I really feel that during our transitions, everyone has been really positive and embraced the changes.

​W: You’ve shared a lot of examples of how your team regularly communicates at various points during a detailing campaign, which shows a culture of checking in and making sure no detailer is left out. Can you speak a little about how that culture’s been built up at RxFiles and how you maintain it?
 
M: I think Loren Regier, who is in charge of Projects, Transitions and Training, has been such an asset in the development of our program, has really emphasized checking in. He really showed us the value of that, and not only does he talk about it, he has made it very easy for someone to approach him and talk about how the detail went, both the successes and challenges.

​W: Having access to mentorship, and making sure a team-based approach is emphasized by leadership is key. It’s clear that the RxFiles team is doing well in adapting to these challenges faced by so many detailing teams. Maintaining positivity and seeing challenges as opportunities for growth is something that’s critical for teams to continue to have an impact.

​​Biography. 
Marlys LeBras is a clinical pharmacist with the RxFiles Academic Detailing Program at the University of Saskatchewan. She completed her Bachelor of Science in Pharmacy at the University of Saskatchewan, her Hospital Residency with the former Regina Qu’appelle Health Region, and her post-graduate Doctor of Pharmacy (PharmD) degree at the University of British Columbia.

An interview with Mary Liz Doyle Tadduni, PhD, MBA, MSN, RN, Education Consultant, Independent Drug Information Service and Expert Training Consultant, National Resource Center for Academic Detailing
​
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager

​Tags: Detailing Visits, E-Detailing, ​COVID-19

Anna: Hi, Mary Liz! We’re excited to learn more about what the pivot to e-Detailing has been like for you as an expert academic detailer for over 16 years and a NaRCAD training facilitator.  Can you tell us briefly how your role as an academic detailer at Alosa Health has changed since the COVID-19 pandemic began?

Mary Liz: The restrictions on in-person meetings has resulted in all of my detailing visits switching over to phone or video calls. The number of providers I’ve been detailing has also considerably decreased due to time constraints and office restrictions related to COVID-19. In terms of the topics I’ve been detailing on, our team has been maintaining focus on delivering our planned modules, but I do discuss the impact of COVID-19 quite a bit with providers.
​
Our current topic for Pennsylvania’s Pharmaceutical Assistance Contract for the Elderly (PACE) is dementia, which is important as it relates to COVID-19. Patients with dementia who reside in nursing care facilities in Pennsylvania can’t see their loved ones due to restrictive visiting policies. Primary care providers are dealing with the challenges and consequences of this every day – and academic detailers can’t ignore it.

Anna: It’s crucial that detailers understand the ways COVID-19 impacts the work of frontline care providers.
​
Mary Liz: Absolutely. With COVID, healthcare delivery has changed dramatically and there’s been a large increase in telehealth visits.  Many providers in Pennsylvania are working from home and not going into the office or seeing only a limited number of patients in the office setting.  Even if they are seeing patients in person, the process of seeing a patient has changed.  The offices sometimes have front desk staff working from home and require patients to wait in their cars before entering the building. Primary care providers are still trying to adjust to all of this. You need to consider what is really happening on the ground for providers during your detailing visits – it’s part of your needs assessment. The needs of the primary care provider right now differ greatly from the pre-COVID era. 

Anna: Assessing a clinician’s individual needs is an integral piece of a traditional academic detailing visit.  How have you been able to implement AD in its intended form when detailing virtually?

Mary Liz: The original model of academic detailing with Dr. Jerry Avorn has always been 1:1, face-to-face encounters, but that doesn’t mean you can’t have a productive visit virtually. It’s just another venue to deliver the evidence.  I really do believe that it’s better to be in person, but delivering the evidence, no matter what the platform, is better than having a provider not know what they need to deliver the best care.
​​
Anna: You’ve carried out this traditional, in-person model for over 16 years – what challenges have you faced when detailing providers virtually, especially during the pandemic?

Mary Liz: Time has been a barrier due to the overall stress on the healthcare system.  There are also more distractions when visits are done virtually because providers are taken out of a controlled office setting. A provider could be home with their kids, or even driving in a car during a visit.  You never know where a provider will be during a virtual detailing visit.

Some offices in my area also aren’t picking up their phones, so you can’t have conversations on the phone or "stop in" for a cold call.   Having a scheduled in-person visit with a provider is much easier than trying to connect with a provider over Zoom.  You add another step to your process when you have to work through technology glitches.
​
Virtual platforms or telephone calls can also be difficult for providers who are visual learners.  You need to be creative with the way you share materials. But there are many similarities to in-person visits; no visit is “one-size-fits-all”. You need to consider the provider, their situation, and their environment and decide what will be the best way to deliver the evidence. 

Anna: You’re right! It’s never one-size-fits-all when it comes to academic detailing.  This has become even more evident as programs around the world have pivoted to e-Detailing. Do you believe that virtual visits can be as effective as traditional, in-person visits?

Mary Liz: I do. It may not be as personal as an environment, but if you have a relationship with the provider, it shouldn’t matter whether it’s in person or virtual. I would continue to detail virtually in the future if a provider requested it, but I do favor in-person visits – it’s what I’ve done for so many years and I’d rather see the providers face-to-face. You get even more out of a detailing visit when you have that interaction.
​
Anna: There’s certainly something to be said about the impact of the original model’s focus on in-person, 1:1 interactivity; it’s what has been studied for many years as effective and impactful.
In a time where being flexible is critical, what are some tips you would offer to detailers during this time?

Mary Liz:  It’s crucial that you’re attentive to the provider you’re detailing. Continue to focus on the needs assessment. While you need to communicate your key messages, if you aren’t doing a proper needs assessment, you aren’t operating under the guidelines of academic detailing, which is all about listening and being interested in how someone is practicing.  This leads you to be able to provide the evidence in the most effective way.

Also, remember to be patient with providers! They’re still adjusting to this new world and they may even have questions about the impact of COVID-19 on the future of healthcare, as well as on their place within the healthcare system. 
​
Mitigate that impact by offering providers community resources that will support them through the pandemic – if you do that, then you’re fully realizing the true purpose of academic detailing as a supportive service that’s customized to real-world challenges.

Biography. 
​Dr. Mary Liz Doyle Tadduni’s background has included critical care and medical-surgical nursing, nursing administration, and hospital administration in major university teaching hospitals in the city of Philadelphia. Dr. Doyle Tadduni is a training facilitator at NaRCAD, and an academic detailer with the Independent Drug Information Service of the Alosa Foundation.
Dr. Doyle Tadduni is a BSN graduate of DeSales University. She completed her MSN, with a concentration in Nursing Administration, from Widener University.

Dr. Doyle Tadduni was awarded the MBA degree, with a concentration in Healthcare Management Services Administration, from Widener University where she was the recipient of the Healthcare Management Services Administration’s Student Excellence Award. Following her graduate work in both nursing and business, Dr. Doyle Tadduni completed her administrative residency at the Hospital of the University of Pennsylvania in Philadelphia. She completed her Ph.D. in Nursing from Widener University. Dr. Doyle Tadduni presented her doctoral research, “Terrorism Preparedness: Perceptions of Connectivity of Emergency Nurses of the Emergency Nurses Association,” at the 10th Annual Interdisciplinary Research Conference in Dublin, Ireland.

​The past few months have represented incredible and unexpected challenges to the world of AD, encompassing everything from adjusting to brand new work routines, transitioning AD materials into a virtual format, and deciding exactly which corner of your workspace had the best lighting for all the videoconferencing meetings being scheduled in place of face-to-face ones.

The pandemic has largely disrupted many of the best laid plans of 2020 for a majority of us. However, through all of the obstacles that the COVID-19 pandemic has represented, the NaRCAD team has also seen incredible resilience and adaptability from the AD community as we take on these challenges together.

​

An interview with Lindsay Bevan, MScHQ candidate, Project Manager, Primary Care Academic Detailing Service, Centre for Effective Practice 
​
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager

Tags: COVID-19, Detailing Visits, E-Detailing, International, Program Management

Anna: Hi Lindsay! Thanks for chatting with us today about the exciting work happening at Centre for Effective Practice (CEP) in Canada.  Can you tell us about your role and share some highlights from your team’s recent work?
​
Lindsay: I’m the manager of the primary care academic detailing service at CEP.  We have a provincial service, which started in March of 2018 that serves family physicians across Ontario.  Prior to our current service, we have run services in long-term care to support appropriate prescribing as well as primary care to support diabetes management. Our current service is still growing, but we’ve served just over 880 family physicians to date.  Our focus has mainly been around opioids and chronic pain.  We were just about to launch a series of “visits” (campaign topics) on prescribing in older adults, but we quickly pivoted to meet the needs of family physicians and began working on a visit around managing primary care in the COVID-19 context.

Anna: It’s so important to understand and meet the needs of family physicians when it comes to academic detailing, especially during a tremendously stressful time. Can you tell us a little bit more about the COVID-19 visit and the process behind its launch?

Lindsay: Our provincial government declared a state of emergency in Ontario on March 17th, so we knew COVID-19 would be top of mind for our physicians and that they’d need more information.  We also knew that we’d have to deliver the visits virtually, which was a fairly new territory for us. 
​
We had to modify our usual content development and detailer “upskilling” (bringing detailers up to speed on the content, key messages, and evidence around the topic) processes in order to meet the demands of family physicians by getting them information around COVID-19 when they needed it.  The content development process for our other visits typically takes six months, with the detailer upskilling taking the last month and a half of that six-month period.  COVID-19 turned everything upside down and made us rethink what we assumed was impossible. Within two weeks of the declaration of emergency, we started pulling together content for our COVID-19 resource centre (clinical tool for this visit, which is also available to all primary care providers), one week later we started training our detailers and within a month, we were delivering virtual visits to family physicians.  

Anna: It’s impressive how quickly your team was able to launch this visit. COVID-19 is different from other topics that your team has focused on because the information and guidelines are continuously changing.  How has your program kept detailers up to date?

Lindsay: The detailer upskilling process for other visits includes weekly webinars to review key messages and the surrounding evidence, and a two day in-person workshop where detailers get to practice their visit discussions with each other and family physicians prior to launching visits.  We also use a content development team for our detailing tools and bring those tools to the detailers to review when they’re about 90% complete.  We typically don’t edit or change those tools after visits have begun. 
​
For our COVID-19 visit however, the detailer upskilling weekly webinars and the content development for our ever-evolving online COVID-19 resource centre have been continuous, ongoing processes. Our detailers have also taken on a larger role within both processes. Each detailer has been responsible for searching for, appraising and synthesizing information on a specific sub-topic of COVID-19, and then submitting this information for inclusion in our resource centre as well as presenting it at our weekly webinars to their fellow detailers.  Our detailers need to be up-to-date on the emerging and evolving evidence and jurisdictional guidance around COVID-19 because family physicians don’t have time to sort through all the information being made available to them daily during the outbreak.

Anna: It’s critical to provide physicians with the most up-to-date information, especially in situations like the COVID-19 pandemic where they’re bombarded with new recommendations and guidelines from multiple sources on a daily basis.  How many COVID-related visits has your detailing service provided to physicians during this time?

Lindsay: We’ve had 95 initial visits to date and approximately 12% of those visits have been with physicians whom we’ve never detailed before.  We’re just starting to reach back out to physicians to see if they would like a follow-up visit since evidence has evolved and challenges have changed since we first started.  The initial conversations were focused on testing, assessing and managing patients with the virus, and we’re now seeing those conversations shift to focus on resuming primary care services within the COVID-19 context.  The detailers have done an amazing job in transitioning their detailing conversations to ensure they’re always covering the emerging areas of interest and need for family physicians.
​
We’ve seen little to no requests from physicians for detailing visits on anything but COVID-19 or on maintaining care in the context of COVID-19, which speaks to the impact this topic has had on family physicians.

Anna: Wow – it’s amazing that your service has been able to detail so many physicians on COVID-19 while also recruiting new ones. 

Lindsay:  Yes, overall, the visits have been well-received.  We were a bit more cautious with our approach to promoting our COVID-19 visit and recruiting new family physicians.  We didn’t want to add to the current noise at this time. 
​
Instead, we took a more passive but strategic approach, like adding a banner to our website where family physicians can quickly sign up for a visit, and having our partners share our visit and resource centre with their membership base.  One of the neat things about this visit is that because we’re offering it virtually, we’re able to expand our geographical reach and provide our detailing service to more physicians.

Anna: Using a virtual platform certainly has its pros, especially within the world of academic detailing!  What has your program’s experience been like with integrating e-Detailing into your service?

Lindsay:  The transition wasn’t unsurmountable for our detailers because they are quick learners, and we’ve had a lot of support through the resources offered by NaRCAD and our partnership with the Canadian Academic Detailing Collaboration (CADC).  We also did internal virtual training sessions with our detailers where they were able to practice using all the features of the Zoom videoconferencing platform. Overall, it’s been a positive learning experience, and one that has furthered our team’s ability to be adaptable and enhanced our problem-solving skills.
​
We do feel however that there’s been an impact on the detailer-physician relationship since we’ve transitioned to virtual detailing, especially for the 12% of family physicians who are new to our service.  When a detailer is in a physician’s practice, they can see how busy a waiting room is or how stressed the staff appear to be.  When family physicians join a virtual detailing visit, it’s much harder to gauge what kind of day they might be having and adjust the discussion accordingly.  Furthermore, the act of going into a physician’s practice itself can create goodwill that helps establish and strengthen the detailer-physician relationship, and that opportunity is lost during virtual detailing.

Anna:  That’s an excellent point.  Observing the waiting room and interacting with office staff is also essential to a detailer’s needs assessment.  Detailers lose this piece of a visit when the detailing is done virtually.  Is virtual detailing something that CEP will continue doing once COVID-19 related restrictions are lifted?

Lindsay: Our detailers and family physicians would like to return to in-person visits. There seems to be some conversations that lend themselves better to virtual communication, and others for which an in-person presence offers greater value and impact. When it comes to relationship building, in-person interactions still offer something special. 

We would also like to build off the momentum we’ve started with our virtual visits.  We’re exploring the idea of offering virtual detailing to family physicians who would otherwise have their visit rescheduled due to extreme weather or to family physicians located where we don’t already have a detailer covering the area.
​
We’ve all done what we thought was impossible in providing the majority of healthcare visits virtually. I hope that folks across the healthcare system will continue to use that momentum moving forward to increase access to care.

Biography.
​Lindsay Bevan works for the Centre for Effective Practice (CEP) where she collaborates with a team of amazing individuals to develop and implement evidence-based supports and services to help narrow the gap between best evidence and care in Ontario. As a project manager, she oversees the planning and implementation of the CEP’s primary care academic detailing service, which serves family physicians across Ontario. Prior to joining CEP, Lindsay worked at the University Health Network in the infection prevention and control unit, where she updated internal infection control policies and developed patient and provider educational material. Lindsay is currently completing her Master of Science in Healthcare Quality at Queen’s University. 

An interview with Nadejda Razi-Robertson, PhD, LCSW, Managing Director, Synergy Health Consulting and  Andrew Suchocki , MD, MPH, Medical Director, Clackamas Health Centers

by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager

Tags: COVID-19, Detailing Visits, Opioid Safety, ​Rural AD Program, Stigma, Substance Use

Anna: Thank you Nadejda and Andrew for spending time with us today to discuss the impressive work being done in your leadership roles around practice transformation at Synergy Health Consulting.  Can you tell us a little bit about Synergy and its impact on opioid safety-related care improvement?

​Nadejda: Our team works with health systems across the state of Oregon.  Our first phase of work started several years ago when we were largely focused on helping systems implement the CDC guidelines around opioid safety. Our work has since evolved, and we’re now focused on helping clinicians develop medication-assisted treatment programs, integrate behavioral health into primary care, and address the opioid epidemic at the community level. 

We often use academic detailing as one of the many tools in our toolbox when we work with different health systems on opioid safety. We take the basic concepts, such as conducting a needs assessment and identifying clinician barriers, from the traditional model of a detailing visit, and implement them on a larger scale.  

​Andrew: Many members of our team are practicing healthcare professionals in the field, which roots a lot of our work at Synergy.  I take what I’m seeing on the ground as both an administrator and a provider at a busy clinical practice and incorporate those experiences into my work at Synergy.

Anna: It’s so important to build teams where members have varied expertise and professional training when working together on practice transformation.  How have you incorporated academic detailing strategies into the work being done at Synergy, and how has it been received?

​Andrew: Some of the academic detailing work I’ve done has been with providers who need extra support from a peer, or from someone else working in the field.  When it comes to opioids, chronic pain, and addictions in primary care, there’s a tremendous amount of stigma and information that was accurate at one time, but as we’ve shifted as a society, many primary care providers are yet to catch up. 

​Stigma isn’t something that folks are actively choosing, it’s more of what they’ve been taught.  Changing that culture of practice is much more difficult compared to asking prescribers to prescribe cholesterol-lowering therapy.  There’s very little societal baggage when it comes to improving cholesterol than there is when it comes to destigmatizing addictions or chronic pain.

Nadejda: We use the same fundamental approach when working with systems, clinics, or individuals.  We start with a needs assessment, provide a group training based on those needs, and follow that up with 1:1 academic detailing visits to address barriers, provide materials, and explore personal bias that may be getting in the way of providing treatment. 

I’m currently working to schedule a training for several providers in a rural county in Oregon.  A number of those providers are X waivered (allowing them to prescribe medication therapy for patients with opioid use disorder), but they aren’t using their X waivers to prescribe buprenorphine.  A needs assessment will provide me with a better understanding of what the challenges and barriers are, what is working well, and where there may be bias, stigma, or gaps in knowledge.  We also use the needs assessment as a “listening session” that creates a sense of safety, fosters an experience that participants are being heard, and serves to “normalize” experiences across settings and practitioners. This process is also strategic in that it helps us understand where to focus our educational outreach and academic detailing efforts.  

The more we are doing this work, the more we are finding that this approach is effective in getting care teams, medical providers, and service providers across many sectors into increased “philosophical alignment” which is critical to effectively foster culture change around issues of pain, addiction, and trauma. 

Anna: Bias, stigma, and gaps in knowledge around chronic pain and addiction are common, especially in primary care.  We’ve found that many detailers have been successful in helping providers “catch up” to society and overcome personal bias through their detailing visits.  Speaking of detailing visits, face-to-face visits have clearly been impacted by COVID-19.  Can you tell us more about other ways that COVID-19 has impacted the work at Synergy?

Nadejda: Again, we’ve gone back to the wisdom of the original academic detailing model.  The needs of each setting have changed significantly, and we’ve been pivoting our work to meet those needs.  Providers want to know how to best support their patients who are dealing with pain during this time.  One thing we were able to provide early in the pandemic was a list of recommendations and resources around pain management for both providers and patients. ​

Andrew: We saw the need to adapt to massive changes related to COVID-19, and to do so essentially overnight.  We’ve had questions about conducting urine drug screenings, initiating treatment over the phone, and maintaining the patient-clinician relationship. 

There’s also a shared vulnerability among providers and patients when visits are conducted virtually.  Our patients have had requests for increased medication use, which is understandable because they’re not able to do activities that they’ve typically been able to do to keep themselves resilient.  That conversation is a difficult one - in some ways it is easier because you don’t have to see someone in person, but it also makes for a very ineffective conversation because you’re not able to demonstrate your humanity through body language.  Our team is struggling to wrap our head around this as we try to provide leadership and guide clinicians who are looking to us, or our state, for collective ideas around this field and how we practice. 

Anna: COVID-19 has certainly impacted the way we think about responding to changing needs for those who are trying to manage their pain.  Can you tell us about some of the other major changes you’ve seen in pain management over the past few years?

Andrew: The biggest thing I’ve seen is insurance expansion.  We’ve known for years what you need to have effective pain management and how important it is to shift the idea of living with pain and accepting pain versus eliminating pain.  We’ve seen Medicaid expansion and expansion of benefits, especially in the Northwest, that has given patients access to modalities that are effective for safer pain management. 
​
Historically, things we knew that worked like, gym memberships, physical therapy, occupational therapy, mindfulness, and chronic pain groups, were never paid for or weren’t available.  As society has changed how it believes pain should be managed, we’ve started to see the insurance side supporting these modalities more.  There’s also been heavy reporting on the opioid crisis in the media that has led patients to understand that opioids have risks. 

Nadejda: We’ve continued to grow and learn as a team over the past several years.  Our entry point into communication around chronic pain and pain management has continued to be centered around assessing if patients and their care teams have an understanding about how pain works.  We want to make sure that clinicians have the proper training and are up-to-date on evidence and resources.

Andrew: We’ve known some of this information about pain management and how pain works for a while, but it takes many years to take what we know from as a research perspective and translate it into practice.  One of our roles at Synergy is to accelerate that.  We’re seeing our evolution as a group mimic and reflect the experience we’re having as a culture as we start to dial in to the most effective ways to manage pain. 

Anna: As Synergy continues to respond to changing societal needs around pain management, what insights can you share about the impact of academic detailing to date?

Andrew: One thing I’ve learned about academic detailing is that it’s only as effective as your intervention across an entire system. I’ve realized that any work that I’m doing is irrelevant unless I’m addressing the entire system and the culture.  If the front desk staff isn’t on board, if the medical assistant isn’t a believer, if the nurse doesn’t understand addiction, if the CEO doesn’t understand that the health system is already treating these patients, there will be challenges that will be harder to overcome. 
​
Nadejda: Because academic detailing has been an arm of a larger change approach we’re using, it’s hard to measure its effects.  We don’t have data to show that only detailing has moved the needle around these topics in these ways.  Sometimes I see academic detailing as the “cherry on top” after there’s a lot of work that’s been done in prepping a system. I’ve recently been doing practice facilitation work with providers and clinics just to understand the barriers in a system—there’s an art to the change process in the pain management space.  Academic detailing comes in after you’ve truly understood what the barriers are.  After you understand the barriers, you can bring in nuggets of evidence and information in a way that the system is ready to receive. 

Biography. 
Nadejda Razi-Robertson is the Managing Director of Synergy Health Consulting, as well as Synergy’s project lead for the Oregon Health Authority’s Prescription Drug Overdose Prevention Project. Nadejda is a practice facilitator within health systems around the State of Oregon and provides technical assistance to clinics that are focusing QI efforts around safe opiate prescribing, MAT program development, and behavioral health integration. Over the past twelve years, she has worked in private practice with a specialty in trauma treatment, as a behavioral health provider in two Federally Qualified Health Centers (FQHCs), and as a consultant with Oregon’s Coordinated Care Organizations (CCOs) and the Oregon Health Authority supporting efforts in addressing the opioid epidemic throughout the state of Oregon.

Biography.
Dr. Andrew Suchocki is a family physician with additional training in Preventive Medicine. He has worked in underserved medicine with a focus on chronic pain and addiction for ten years, and has been a medical director at an FQHC in the Portland, Oregon region for the past five. Andrew provides educational outreach and consultation in the areas of system change in primary care around opiate prescribing, MAT system design and capacity growth, coordinated specialty care, and reducing risk. Dr. Suchocki is an Oregon Opioid Prescribing Guidelines Task Force member and Oregon Medical Board consultant. He provides technical support and academic detailing for the Oregon Psychiatric Assistance Line (OPAL) which provides immediate referral sources for primary care. Dr. Suchocki also provides strategic planning, creation of innovative clinical decision support tools, physician mentoring, and health system process mapping for Yamhill County Health and Human Services, Community Corrections and Specialty Behavioral Health. He is a regular presenter at national and international pain related conferences.

An interview with Sarah Ball, PharmD, Research Assistant Professor, Division of General Internal Medicine, Medical University of South Carolina and Megan Pruitt, PharmD, Clinical Pharmacy Consultant, SCORxE Academic Detailing Service and Assistant Professor, Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina 
​
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager

​Tags: COVID-19, Opioid Safety, Stigma, Substance Use, Training

Anna: Hi Sarah and Megan- thanks for taking the time to chat!  Can you tell us a bit about your program, SCORxE, and how your AD work has concentrated on improving opioid safety?
​
Sarah: SCORxE began in 2007 as an academic detailing service at the South Carolina College of Pharmacy and is now part of the Medical University of South Carolina (MUSC) College of Pharmacy. Our current efforts are around addressing the opioid epidemic. We’re fully funded by the South Carolina Department of Health and Human Services, and our agreement talks about  bringing together quality initiatives for safer opioid prescribing and expanding access to MAT.

We’ve been able to effectively bring together quality initiatives from different state agencies that span prevention and treatment. This braiding has been a unique experience for our academic detailing service. Regardless of the specific topic, our detailers promote opioid risk reduction strategies, help recruit and support MAT providers, and work to reduce stigma around MAT. We’re currently shifting our focus from chronic pain to acute pain. We’ll be detailing both primary care providers and surgeons on post-surgical pain.  

Anna: Detailing surgeons is a unique approach – we’d love to hear about the results of that process in the future. And you’re working on other topics outside of opioid safety, too – tell us more.

Sarah: Our providers always welcome new topics. While our focus is on the opioid epidemic, we try to expand our content reach when possible. We recently detailed on depression and anxiety screening, and touched on alcohol use disorder in our topic on naltrexone. We’ve always offered CME credits and our current strategy is shorter and more focused visits that offer a half hour of CME credit, as opposed to one or two hours of credit. This allows us to have multiple visits with each provider and to individualize next topic selection.
​
Megan: As a detailer, it’s helpful to have a menu of shorter topics that providers can choose from – it makes our visits more flexible.  

Anna: Speaking of flexibility - how are you continuing to detail and run your program given the current COVID-19 pandemic?

Sarah: We haven’t previously engaged in virtual visits or e-detailing. We’re planning to reach out to our network of academic detailing colleagues who’ve had e-detailing visits in the past to see what their experience has been like. It’s times like these that show how valuable it is to have a network of academic detailing services. Being able to share ideas and find out what other folks have done will help us determine what will work best in our state.

Megan: We’ve been using the past few weeks to work on creating materials and scripts for upcoming topics. It’s been a good time to refresh on a lot of our content and update various internal documents. I’m going to begin reaching out to providers within the next few weeks and gauge their interest and comfort level in using a virtual platform. 
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Sarah: We know this is a difficult time for primary care providers, so it’s important for us to be compassionate in how we go about scheduling visits. We want to be sensitive to our providers’ time and respect what they’re going through, while still offering our detailing service around topics related to the opioid epidemic.

Anna: You’re not alone in figuring out this balance! You also mentioned that peer learning is an important component to a successful intervention. Can you tell us about your own peers on your team, and how they enhance your overall detailing service?

Sarah: Our program is under the College of Pharmacy, so we’ve recruited all our detailers from there and they’ve all been clinical pharmacists. We’re fortunate to have pharmacists because they’re well-respected among providers we visit. We have two full-time detailers, which is a privilege, and they’re very passionate about their work. Being able to have two people fully commit to detailing is far greater than the number implies. Both of our detailers have different personalities and different experiences to share – I think they complement each other very well!
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Detailing can be lonely, though. When you have more detailers in your program that add up to two full time equivalents, what we have had in the past, you have more people sharing experiences during debriefs and more people to bounce ideas off; there are pros and cons to both scenarios.  

Megan: My colleague, Lauren, and I come from different clinical backgrounds. When we work on our content development and role playing, we’re able to help each other consider things differently. It’s been fun to work with somebody who differs so much from me!
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Anna: It sounds like you balance each other out well. How are the detailers in your program trained?

Sarah: All of our detailers have gone through pretty intense academic detailing training on the marketing of evidence-informed clinical ideas. Our most recent hires have gone through NaRCAD training, but before there was a NaRCAD, our pharmacists went through a training developed by a group in Australia. That training gave us a step up on everything when we first started our program, as NaRCAD also does with programs just getting started. We garnered our baseline of how we develop content, how we develop our supporting materials, and essentially how we put together our whole intervention.

Anna:  It sounds like the detailers in your program are trained well and prepared for the field.  Do you have certain strategies for getting in the door? Are there key stakeholders who your program has connected with that have helped you to do this?

Megan:  Showing up at the office has repeatedly proven to work for us. We bring a letter to share with the first gatekeeper at the front desk, so that we can get face-to-face time with the providers for introductions. We’re usually able to schedule a meeting fairly easily after that. If we can’t meet with the provider face-to-face, we try to speak with the Office Manager. 
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Recently, we’ve been leveraging our group presentations at clinics to get more 1:1 visits. We try to promote our detailing visits during our presentations and grab contact information from providers afterwards. We’ve also found that it’s been helpful to stay in the break room at an office after a visit - we might stay there all day and introduce ourselves to a number of providers who end up wanting to either schedule a visit that day or in the future. We’ve found great success in being present for providers when they’re ready. 

Sarah: When you can get face-to-face with the providers for a brief introduction, it’s a beautiful thing-it’s how we’ve gotten most of our visits over the years. When we first started, gaining access happened in different ways. We had champions in the area that supported what we were doing, and we could use that to get our detailers in the door. Our program was also previously part of a demonstration project where providers were required to have an academic detailing visit as part of the initiative. I would say that our cold calls became “warm calls” during that time because all the offices and providers knew we were coming.
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Anna: I’m sure having providers in the area know about your detailing service has helped to build your program. Can you tell us more about how your program is working towards sustainability?

Sarah: We’re more sustainable than we’ve been for a while. Part of that is due to the funding that we have for opioid-related topics, but it’s also been due to the effort our program has put into effectively bringing together different quality initiatives over the years. We’ve had funding come in from multiple sources in that process. 

One agency asked us to take on the topic of naloxone for pharmacists--our ability to respond to such requests helps up strengthen relationships, and may help us with future sustainability. It is also important that our interprofessional teams at MUSC see value in academic detailing.
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Additionally, our detailers help us with sustainability through their visit documentation and tracking. The data they collect is included in our reporting and helps illustrate the value of academic detailing. Our clinical pharmacists are amazing people, and they both bring so much to what we do in the academic detailing world– programs are only as sustainable as the strength of their individual detailers!

Biography.
Sarah Ball, PharmD is a Research Assistant Professor in the Division of General Internal Medicine at the Medical University of South Carolina (MUSC), with a focus on patient-centered care, patient safety, and educational outreach. She has had direct involvement with academic detailing for over twelve years, beginning with the development and implementation of the SCORxE Academic Service under the SC College of Pharmacy in 2007.  Current efforts include the integration of research and programmatic opportunities to identify interventions that change prescriber behavior to reduce the risk of opioid overuse, misuse, abuse, and overdose. Dr. Ball is currently leading the MUSC team partnering with the South Carolina Department of Health and Human Services for the provision of drug utilization review (DUR) services, which includes educational outreach to primary care providers and surgeons.  Dr. Ball has twenty plus years with a career focus on improving patient care through the application of technology and effective communication of clinical knowledge, information, and data-derived findings. She is a graduate of the Medical University of South Carolina, where she received both a B.S. in Pharmacy and Pharm.D.

​Biography. 
​Dr. Megan Pruitt is a South Carolina Offering Prescribing Excellence (SCORxE) clinical pharmacy consultant and assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the Medical University of South Carolina in Charleston, South Carolina. She received her bachelor of science in health science from Clemson University and her doctor of pharmacy from the South Carolina College of Pharmacy. She has published an Amazon ebook, Catalyst (pharmD): The Next Generation Pharmacy Student, and has previous experience as a community pharmacist at Federally Qualified Health Center in South Carolina. In her current role as a SCORxE clinical pharmacy consultant, she provides academic detailing visits to primary care providers on monitoring practices to promote safe opioid use and to reduce the risk of misuse and abuse in South Carolina. 

Bevin K. Shagoury, Communications & Education Director
A Letter from Our Team

Tags: COVID-19, ​E-Detailing

To our AD Community:

By the time you read this, certain adjectives will have moved to the top of your frequently-used list. Words like “unprecedented”, “strange”, and “unsettling” are just a few that our home team has been using most commonly, and we’re sure that you, our community of AD peers, have been, too.
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During the COVID-19 pandemic, priorities are changing quickly and frequently—many of our public health colleagues have found themselves focused primarily, if not entirely, on the situation at hand, with critical response demands shape-shifting hourly.

​For those of us who spend our time more removed from frontline healthcare and have been focused on clinical outreach education or adjacent health improvement initiatives, challenging questions have arisen.
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• How do I sustain focus on the priority of improving outcomes for patients during other critical health concerns, like the opioid crisis or in HIV prevention, that need to take the ‘back burner’ to the global pandemic?
• How can I visit with clinicians during a time when non-critical face-to-face interaction is on hold?
• How can we stay on track with meeting project goals for grantors who want to see progress on deliverables we can’t carry out in person for the foreseeable future?
• How can we maintain a sense of momentum in the important work that we do while taking care of ourselves and our families?

​The answers to these and other questions are context-dependent, ever-changing, and don’t always have easy solutions. There are changes and disappointments to adapt to—for us, we’ve accepted the need to prioritize safety and postpone our March and June 2020 trainings (keep your eye on our Training Series page for reschedule dates), and we appreciate your patience as we wait to figure out next steps.

But we’re equally aware that there are just as many opportunities for growth. At NaRCAD, our goal right now is to support our colleagues as we all face the very real impacts of COVID-19. Concretely, we’re working hard to bridge some of the gaps that make the original, face-to-face model of AD temporarily impossible. We’re proud to share that we just launched our first e-Detailing Community of Practice, e-Detailing Toolkit, and are shifting focus on our 2020 Webinar Series this month to tend to the needs of those programs who must pivot to e-detailing and quickly.

​As such, we encourage you to complete our 1-minute e-Detailing Needs Assessment survey, so we can design tools and resources that fit your needs. Based on your responses, we’ll translate your needs into tailored support to help you realistically maintain the work that you can, rebalance your priorities, and focus on future programming efforts during a time when the present is hard to navigate.