This interview features Carla Foster, MPH, who leads the conceptualization, implementation, and evaluation of Public Health Detailing as an Epidemiologist within the Bureau of Alcohol and Drug Use Prevention, Care and Treatment (BADUPCT) at the New York City Department of Health and Mental Hygiene (NYC DOHMH). She is currently activated for the COVID-19 emergency response as Lead Analyst managing the Reporting Unit within the Integrated Data Team of DOHMH’s Incident Command System.
 
By Winnie Ho, Program Coordinator

Winnie: Hi Carla! You’ve certainly had a lot on your plate with so many diverse campaigns. Can you walk us through the conceptualization process for your detailing campaigns, and how your team came to choose cocaine use as your current detailing topic?
 
Carla: We can start with some data on this. In 2018, more New Yorkers died from drug overdose than from homicide, suicide, and motor vehicle crashes combined. Cocaine – in both crack and powder forms – has played an increasingly prominent role in this crisis. The mortality rate from overdose deaths involving cocaine more than doubled between 2014 to 2018, amounting to 52% of all drug overdose deaths in NYC. Some of the associated risks are serious - increased exposure risk to fentanyl, cardiovascular disease events and death.

W: That’s stunning data. Especially in the midst of the opioid crisis, it’s important that we don’t lose sight of other substance use issues going on right now. I’d love to learn a little more about the challenges and lessons that your team has learned by detailing on cocaine use.
 
C: First, we have to be aware that fentanyl, a powerful opioid 50 to 100 times stronger than morphine may be found in many substances, including cocaine. We’re very concerned about fentanyl and cocaine because people who use cocaine do not have tolerance to opioids and are at even higher risk for overdose.

It’s also important to address the perception of who is most impacted by high mortality rates. There’s this idea that cocaine use is more prominent in younger populations, but our data show that it’s actually impacting an older population more than many might expect. In particular, residents age 55-84 in the Bronx Borough have experienced the largest increase in cocaine overdose death rates in New York City from 2014 to 2018.

That’s why it’s critical for us to raise awareness in an effort to mitigate misconceptions and stigma around risky use and those who may have a substance use disorder (SUD). In addition to shame, there are still very real potential socioeconomic and legal consequences from disclosing substance use, which can deter folks from even seeking help.
 
We take into account the unjust consequences of policies applied unevenly according to race, and how this impacts implicit biases in terms of which patients are thought to use substances, which types of substances they might use and even more critically, which type of treatment, if any, they are offered. Implicit biases combine with the effects of systemic racism to compound these consequences. It’s important to note that it’s not race that drives poor health outcomes, but racism.

​W: Challenging stigma is one of the most powerful ways that detailing campaigns can combat the damage done by the War on Drugs, because stigma can make the difference of whether or not people receive dignified care. With a campaign so focused on addressing stigma and with a topic this important, how do you prepare your detailers for this task?
 
C: We devote a significant amount of time towards training our detailing reps – a week-long training, 8 hours a day. We spend a large amount of that time talking in detail about stigma as related to cocaine use. It’s critical to us that our detailers are comfortable and knowledgeable when speaking about this topic, because it sets the tone for the providers who then set the tone for their patients.

We ensure that our representatives are prepared to respond to a wide range of questions or comments, because this builds the provider-detailer relationship and enhances the value of the detailing visit. We’ve found during our follow-up visits that this support has led to high provider engagement with the campaign and providers reporting incorporation of the key recommendations into their daily practice, which is the aim of our public health detailing campaigns.

W: How have providers responded when detailed on a topic that carries so much stigma?
 
C: The good news is that we’ve found NYC healthcare providers to not only be receptive to our work on substance use, but they’re eager to partner with us to support their patients once they learn about the severity of the issue.
 
Our team provides statistics that relate to the provider’s specific neighborhoods and specialty, giving them real-time pictures of what’s happening with the patients they see. We know that it’s still a difficult topic to bring up, so we help address this with our action kit resources on stigmatic language and counter-top brochures that signal to patients that the provider’s office is a safe place to discuss these issues.

W: It gives me tremendous hope to hear about that there’s been enthusiastic response from providers. It means that things are changing.
 
Let’s also talk a bit about program sustainability. Your team has worked extensively on campaigns across multiple topics. What have you learned from implementing past campaigns?
 
C: Each public health detailing campaign is different, but we’ve learned some key strategies that support the growth and success of subsequent campaigns:

• ​Sending an introductory letter, about 2 weeks in advance, signed from the Deputy Commissioner of our health department outlining the campaign and encouraging participation, helps gain interest.
• Using a standardized visit workflow that all of our detailing representatives follow to ensure that key components are covered is key. Ours is still flexible enough for the detailers to meet the specific needs of each provider, which really helps with the uptake of the action kit and clinical practice recommendations.
• We meet as a team and evaluate our program weekly, allowing us to continuously adapt and to implement any necessary adjustments.
• Incorporating promotional items inscribed with the campaign’s logo and NYC DOHMH logo. For the cocaine campaign we distributed hand sanitizer and pens to detailing targets. These items serve as highly visible reminders of the campaign mission and have the potential to be incorporated into daily usage by the targeted health care providers.

 
Our overall goal is to do everything we possibly can to improve the health of our fellow New Yorkers. I like to remind our detailers of this James Baldwin quote that informs our public health detailing mission: “Not everything that is faced can be changed, but nothing can be changed until it is faced.”

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

Carla Foster, MPH is an Epidemiologist at the New York City Department of Health and Mental Hygiene (NYC DOHMH). Her research focuses on the implementation and evaluation of public health detailing campaigns across New York City with the aim of reducing overdose mortality. Prior to joining the NYC DOHMH, she led development of clinical practice guidelines at the American Urological Association. She received dual Bachelor of Arts degrees in Africana Studies and Neuroscience from Wellesley College. Carla also obtained her Master of Public Health Degree in Epidemiology from Columbia University.

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, E-Detailing

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 Tony de Melo, RPh, Director of Clinical Education Programs, Alosa Health
​by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager

​Tags: Alosa Health, Behavior Change, ​Training

NaRCAD: Tony, thanks for chatting with us today about your role at Alosa Health! What’s been the most exciting part of the work that Alosa has done this year? 
​
 
Tony: Our partnership with Aetna, a managed health care company and health care insurer. We’ve been working with them to provide educational outreach to providers on chronic pain, acute pain, and opioid use disorder (OUD); supporting them in managing pain using non-opioid drug options; appropriately dosing opioids when they need to be used; tapering down patients who are on existing high doses of opioids; and helping to identify patients that may have opioid use disorder.  We’re now working in Pennsylvania, Virginia, West Virginia, Ohio, Illinois and Maine.

NaRCAD: That collaboration does sound exciting!  Now, let’s talk a little about your role at Alosa.  You actively detail, you manage academic detailers in the field, and you lead trainings at Alosa. Which aspect of your role is your favorite, and why? 
 
​
Tony:  When I’m training and managing detailers, I see myself more as a coach than a trainer.  I’ve always liked educating and teaching—I enjoy helping others develop their skills and seeing them improve.  Training folks and coaching them in the field is rewarding to me because I feel that I’m impacting what they’re doing in their own communities.  It brings me happiness to see others succeed.  

NaRCAD:  As a coach, how do you know when your work has been impactful?

​
Tony:  When I work with detailers in the field, I can see firsthand that they are able to be impactful with the providers because they are bringing about behavior change with their message delivery and confidence.  We can also measure how impactful our work is by reviewing our Salesforce data.  I can see from the detailer’s visit notes when providers have agreed to a behavior change, and this is a true measure of our work being impactful.

NaRCAD:  With success comes challenges.  What are some of the major challenges you see academic detailers face in training and in the field?

​
Tony: The major challenge is teaching detailers to have a conversation with clinicians rather than a lecture. Making the visit more conversational doesn’t often come as naturally as presenting the information in a lecture format, but the conversation must be about understanding where the provider is now, what their needs might be, and how to deliver content to make behavior change.  

In the field, the major challenge is access to providers. Many health systems have regulations and restrictions for those who want to meet with providers, because representatives in the pharma industry have bombarded and overloaded providers throughout the years.  As a result, we’re often seen as an outside influence or an outside visitor, so we aren’t always given the opportunity to meet with a provider. 

​
NaRCAD: With these challenges in mind, how do you instill confidence in academic detailers as a trainer and as a manager?

Tony: We spend a lot of time practicing and providing feedback during trainings.  We practice individually, with partners, and with outside folks who are playing the role of providers.  Practicing multiple situations, multiple times, over multiple days, builds confidence.  We also videotape the trainees so that they can see what they’re doing well and what they can improve upon. 

​
As a manager in the field, it’s quite similar. I usually sit down with each detailer after a visit and discuss what worked well and what they could do differently in their next visit, so that each visit becomes a learning opportunity.  Providing feedback and being a mirror for the detailers helps them to build confidence and skills as time goes on.  I also offer the detailers my perspective; having spent time doing this myself and observing others, I can share the tricks, skills, and wording I’ve heard throughout my time with the detailers.

NaRCAD:  Those are all great ways to build confidence among detailers. What’s one piece of advice that you would give to academic detailers?

​
Tony:  Don’t be afraid to ask for a specific behavior change, and remember to follow up to make sure that the behavior change occurs.  One thing that I find to be hard for academic detailers is the “ask”, where detailers are asking for commitment or behavior change from a provider at the end of the visit.  I always tell detailers to frame it as, “based on what you’ve heard today, what is one thing you’d do differently?”  Follow-up then ensures that providers are committed to change and holds them accountable for what they said they would do.  

NaRCAD:  That’s extremely helpful advice for detailers. What’s the best thing a program manager could do to maintain high levels of engagement among detailers?


Tony:  As a manager who’s coaching or guiding others, it’s important to build trust between yourself and the folks you’re coaching or managing. It can be lonely when you’re in the field detailing by yourself, so managers need to have touchpoints with their detailers.  Building trust and having your detailers know you’re all working together helps them stay self-motivated; it makes them want to go out into the field and do a good job because they know someone is backing them up.

​
NaRCAD: Thank you for taking the time to chat with us today. We value your unique perspective on detailing, managing, and training!

Biography.
​Tony de Melo manages field staff and leads academic detailer trainings at Alosa Health. He attended Massachusetts College of Pharmacy and Health Sciences in Boston, where he received a BS in Pharmacy with a minor in Business Administration.  This business interest led him to work for several pharmaceutical companies as a sales representative, account manager, training manager, district/regional manager, associate director of managed markets training, head of sales training, and development & marketing product manager. He has also worked for smaller businesses that were looking to grow their sales and marketing programs. Throughout his career, Tony has successfully sold, marketed, trained, led, designed, developed and executed solutions to meet business objectives.

​An interview with Rachel Lemons, Project Manager, ONE Tennessee
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager

​Tags: Opioid Safety, ​Project Management

NaRCAD: Thank you for taking the time to speak with us today—we’re excited to hear about you and your team! Can you tell us a bit about ONE Tennessee and how your organization first became involved with academic detailing?

​Rachel: ONE Tennessee is a state-wide nonprofit healthcare collaborative who is focused on fighting the opioid epidemic. We were founded as an outcome of a summit hosted by the Tennessee Department of Health called “Turning the Tide.”  The summit joined together healthcare professionals and stakeholders to discuss best practices for tackling the epidemic.  Academic detailing was highlighted as a best practice during the summit and it was collectively decided that it would become one of our initial projects.  ONE Tennessee brought the academic detailing pilot program to life through the opioid crisis funding the Department of Health received from the Centers for Disease Control and Prevention. ​

NaRCAD: We’re glad to know that the strategy of AD was highlighted! You’re now managing a program of detailers focused on opioid safety across the state of Tennessee—tell us what that’s like.    ​

Rachel: Exciting! Once our detailers were trained by your team, my role was very much supportive in nature.  I helped our detailers to identify clinicians in their communities, and troubleshoot any issues.  We were fortunate enough to be able to recruit a passionate group of pharmacists for our pilot, and that made my job easier from a clinical standpoint, since they’re the subject matter experts on opioid prescribing. They‘re on the front line of the epidemic, and they fit the perfect mold for engaging with clinicians to build a strong and trusting relationship.

​NaRCAD: You recently completed the pilot stage of your program. What would you say are some of the biggest lessons you’ve learned so far about building an academic detailing program? 
​
Rachel:  Getting in the door was one of the biggest barriers our detailers faced.  From a programmatic standpoint, I think ONE Tennessee could have done a little more foundational work for our detailers, like speaking with our stakeholders and educating them on academic detailing as it relates to the opioid initiative—that would have really helped our detailers gain access to clinicians.

We also learned that time was a barrier for our detailers.  Our initial grant period was only one year, and things moved very quickly.  We recruited full-time community pharmacists, so having the bandwidth to prepare and complete academic detailing visits was often difficult, especially if there was limited employer support.  

NaRCAD: Those are all familiar challenges across many of the programs we support. How did you maintain strong relationships with your detailers and support them in the work that they were doing in the field? 
​
Rachel:  I always had an open line of communication with our detailers.  We had standing monthly webinars, but it was difficult to find a time that worked for everyone because they were full-time pharmacists.  Our detailers were scattered across the state and were mostly in rural areas, so I was not able to meet with them in person; however, I was available via email, phone call, and text message.  I learned early on that I had to meet detailers where they were.  Some detailers did not have time to check email, so it was easier to do a quick call at lunch or early in the morning before their day got started.  It really depended on the needs of the detailer, but I always maintained an open line of communication.  

​NaRCAD: That’s a great model, and regular communication helps detailers feel a sense of community through a project. Other supports are often more concrete, like tools and resources. What are some that you've found to be critical to program success, and why?  ​

Rachel: I think first and foremost, our partners, specifically NaRCAD, the Tennessee Pharmacists Association, the Tennessee Hospital Association, the Tennessee Nurses Association, the Tennessee Medical Association, and the Tennessee Department of Health, were a tremendous resource that made our program incredibly successful.  Google’s  platform (Google Drive, Google Sheets, and Google Docs) was also critical to our success, as it allowed us to share data and updates in real time.  We did not have access to specific evaluation tools because we are a young organization and our grant period was only one year.  Our shared space online helped me to stay organized and capture information from our detailers all in one place, and it was free!

NaRCAD: These are all great reflections for AD program managers to learn from. Based on the successes and challenges of this pilot, where do you see your program in a year?

Rachel: I see us continuing our current model with our inaugural group of academic detailing community pharmacists while working towards designing, developing, and implementing a “train -the -trainer” model in partnership with your team.  I also see us having discussions with large and small hospital systems to customize plans to fit their unique needs related to opioid safety.  Most importantly, we want to continue to support the state and our other healthcare stakeholders who are with us on this journey. 
​
NaRCAD: We’re happy to help support that vision. Any other important advice/tip that you’d give to other young programs? 

Rachel:  Patience.  You must have an understanding that there are going to be pitfalls, but if you have the support and the right people involved, your program is going to succeed.  Also, don’t try to reinvent the wheel if you don’t have to.  There are so many other programs out there — reach out to people and have conversations!

NaRCAD: Rachel, thank you so much for sharing your experiences with us.  We're excited to see the impact of your program into the future. 

Biography.
Rachel Lemons found passion for public service early on in life. She is committed to assisting those with the greatest need in her community. She’s working to effect change socially and through public policy. She is a graduate of East Tennessee State University, where she received her Bachelor of Science in Public Health. Her involvement with Tennessee’s Opioid Epidemic began with the Department of Health, where she was exposed to the State’s rapid response in this fight which lead her to joining ONE Tennessee as a Project Manager. She continues to build her career with a practical and wide ranging set of experiences in order to gain a global perspective on health issues facing communities today. Rachel is an active member in the Junior League of Nashville, Tennessee Public Health Association and currently serves as the Board Intern at Cheekwood Estate & Gardens in Nashville.

​NaRCAD: What has your experience been as a detailer who does not have clinical experience but who does have public health expertise? Is someone able to be effective as an academic detailer without as much prior clinical training?
Victoria: My experience has been extremely positive! I care about community, and I thought this was a great opportunity to gain new expertise in this field. I’ve always felt that a community perspective is needed for us to be able to leverage our impact in this field.
​
​The NaRCAD Academic Detailing techniques training was fantastic in helping me build tools to be able to speak well and motivate clinicians around medication-assisted treatment (MAT). My goal as an individual detailer is always to present myself as being on the same team as clinicians. I really see detailing as having a solution for clinicians, rather than simply trying to sell them an idea. 

NaRCAD: You have mentioned the power of the team of detailers--can you tell us how the Manchester AD came to be so strong and effective?
Victoria: I didn’t know any of the other detailers before the project. The NaRCAD training was great as an introduction to the work and to each other. We all had a sense of hope that was immediately apparent. We have the privilege of doing work that helps save lives and because of this attitude, there was a sense of camaraderie right away. We’ve been effective because our AD team is strong, and it was strong because we were intentional about building bonds. During the implementation period, we never went more than a month without checking in with each other, and sharing successes and challenges.

​I don’t think I would have enjoyed the process as much if I didn’t have this amazing AD team of colleagues. We’ve had incredible success in building a team of detailers who are all committed to and excited about the work of connecting with frontline clinicians to improve patient care around opioid safety. ​

The NaRCAD Team is excited to kick off the latest episode in our C.O.r.E. Podcast Series, this time featuring the insights of Program Director Rebecca Edelberg, MPH, from the Boston-based non-profit academic detailing organization Alosa Health, as she shares her experiences managing field programs in clinical outreach education.

​This episode's 15-minute interview with Rebecca hones in on the "how-to's" of strong AD program management, including:

• ​​Hiring the right detailing candidates that have a combination of clinical know-how and communications savvy;
• Ensuring regular supportive check-ins with her team; &
• Planning ahead when thinking about collecting evaluation data.

Tune in here, and sound off on Twitter or in the comments section below with insights, questions for Rebecca, or topics you'd like to see featured on our next podcast. Learn more about Rebecca and Alosa Health below!

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. 

by Joy Leotsakos, PharmD

Tags: Cardiovascular Health, Detailing Visits, Evaluation, Program Management, Training

Who We Are. The Academic Detailing Service (ADS) of the Atrius Health Clinical Pharmacy Program provides clinically appropriate, evidence-based, cost-effective medication management in a multidisciplinary team setting.  Our Clinical Pharmacy Program includes 15 clinical pharmacists (CPs) serving nineteen Internal Medicine and Family Medicine (IM/FM) ambulatory care practice locations. In the past four years, our program has evolved and transformed through evaluating our impact, absorbing and implementing internal feedback, and collaborating with others in the field, including NaRCAD.

Our Start. As the program manager of our ADS, I’ve seen our service grow and change. When we began our program in 2011, it was as an administrative mandate to meet with all IM/FM prescribers once per fiscal quarter to deliver messages about cost-effective prescribing and clinical quality.  We started by formulating a menu of topics to cover in our ADS work each quarter, including individual clinician prescribing reports reflecting performance on prescribing initiatives from the Pharmacy & Therapeutics Committee, specific questions to survey clinicians on a clinical topic, targeted education for low performers on prescribing initiatives, and various other ‘hot topic’ clinical issues. CPs detailed individual clinicians via formal 1:1 scheduled appointments, and also did so less formally (such as by catching them in the hallways) or in larger groups during department meetings.

Is it Working? We documented our ADS activities by checking off the individual clinicians we detailed each quarter. At that time, there was no formal training for our CPs on how to conduct a detailing meeting. Unfortunately, this method of creating content for visits soon resulted in a large menu of topics so varied that each quarter’s detailing became unwieldy and too broadly focused. And our documentation, while it gave us a general sense of the number of clinicians detailed, did not tell us anything about the quality of this detailing.

Room for Improvement. Our group is fortunate in that our ADS activities have always been accepted and even expected by our IM/FM clinicians. We experienced almost no clinician resistance to our educational meetings. But in 2013, when attending one of NaRCAD’s 2-day Academic Detailing Training sessions, I learned that we could make changes to improve our services, as well as my own skills as a detailer. As a result, we altered the format of our ADS program, choosing to detail clinicians in a 1-1 or small group format of less than 4. We also selected a goal of 90% of clinicians receiving detailing at least once every quarter.

Evaluating Impact. We began evaluating the impact of the changes we’d made to our ADS, specifically choosing to look at its impact on a discretely measurable topic: reducing the unnecessary ordering of an ALT test (alanine transaminase) in patients on the ’statin’ cholesterol-lowering medications.  We were able to demonstrate that our detailing of all IM/FM clinicians led to significant reductions in ALT ordering and meaningful cost avoidance for our organization.

Asking for Feedback. With NaRCAD’s support, we further refined our program in 2014 based upon feedback from an internal focus group. By soliciting honest feedback from the CPs about their detailing experiences, I discovered considerable variation in how they approached the menu of topics provided each quarter and came to understand that the continuous process of visiting with each clinician at their sites often felt stale and repetitive.

New Approach, New Results.  We revised our ADS workflow to tie each round of clinician appointments directly to a specific and single P&T prescribing initiative. Furthermore, we developed a method to tag low performing clinicians for an ‘intense’ ADS visit and higher performers for a ‘touch’ ADS visit. We began this new workflow with an initiative to improve the use of evidence-based beta-blockers in patients with heart failure, a quality measure for the Medicare Pioneer Accountable Care Organization (ACO) project. Using this new approach, clinical pharmacists were able to deliver a fresh and meaningful message to the right prescribers, resulting in a change from 73.6% to 97.8%prescribing of evidence-based beta-blockers in this patient population.

Partnering with NaRCAD for Ongoing Learning. In March 2015, we coordinated with NaRCAD again, and they provided our group of clinical pharmacists with a 2.5 hour workshop to enhance our AD skills. I’d encourage anyone who does this type of educational outreach to make use of this invaluable resource. Of course, our Atrius Health Academic Detailing Service will continue to grow and change as we find additional ways to improve our workflows and messages. I look forward to continued collaboration with NaRCAD and with others in the field, so that we can all keep learning from each other and improve health outcomes through effective academic detailing.

​Bio: Joy Leotsakos is a senior clinical pharmacist and the program manager for the Academic Detailing Service (ADS) of the Atrius Health Clinical Pharmacy Program.   Joy joined Atrius Health in 2007 and became the program manager for the ADS program in 2012. Prior to joining Atrius Health, Joy worked as an assistant professor at Massachusetts College of Pharmacy and Health Sciences University in Boston, MA and provided ambulatory care pharmacy services to the South End Community Health Center also in Boston.  Joy graduated with a Doctor of Pharmacy degree from Virginia Commonwealth University School of Pharmacy and then completed her residency in Ambulatory Care and Community Pharmacy at the University of Florida College of Pharmacy.  Joy is the mother of one son, and enjoys salsa dancing, cycling and running in the summer and skiing in the winter.  You can reach Joy by email at joy_leotsakos@atriushealth.org.