Guest Blogger: Monica Mais, MSN, FNP
Family Nurse Practioner/Academic Detailer
California Opioid Safety Network, Fairchild Medical Clinic
NaRCAD Training Alumnus

​In 2011, I went from 15 years as an Emergency Room nurse to a new role as a Family Nurse Practitioner in a rural healthcare setting. I couldn’t believe the amounts of prescribed opioids that were coming out of our little clinic—the average chronic pain patient was receiving 240 Morphine Equivalents/day (MEDs), and many of these patients had been receiving these medications for years without oversight. In 2013 I introduced an evidence-based protocol and policy for safe prescribing of Opiates for Chronic Non-Cancer Pain (CNCP). ​

However, patients who could not obtain opiates from our clinic quickly moved on to the clinic across town. This influx of opiate seeking patients was reason for concern from those receiving clinics. My colleagues and I opened our doors to neighboring clinics and providers and began sharing our policies and successes. Many other area clinics started adapting our policies to their own practice, reducing their opiate prescribing as well. ​

We formed a coalition called Siskiyou Against Rx Abuse (SARA), and based on our previous successes, we were all shocked to see data showing our county was among the highest opioid prescriptions per capita in California, and had a high overdose rate per capita, despite our efforts. Clearly, more needed to be done! Our coalition facilitator, Maggie Shepard, RN, along with our medical director, Dr. Sam Rabinowitz, and myself were all invited to attend training to become Academic Detailers in San Francisco with the San Francisco Department of Public Health, a partner with NaRCAD, the National Resource Center for Academic Detailing. 

​We did scripting and role-playing throughout the training, learning the important social marketing and communication skills needed to conduct a personalized visit with a provider where the goal would be to change behaviors to continue to promote safe opioid prescribing, Naloxone, and Buprenorphine out to providers in our area.
During the training, I was videotaped during a practice role-play, which was very helpful, as it reminded me to speak more slowly, and to organize my key messages and talking points. After the training, getting our detailing program into the field involved a step-by-step process. 

​I plan to continue AD throughout 2018. I believe we have experiences that we can share to encourage our colleagues to make positive changes in in their prescribing habits. Academic Detailing works due to mutual respect of one another’s experiences, professionalism, and willingness to receive new information—it’s an excellent way to foster change within a system!

​Biography
Monica Mais, MSN, FNP
Family Nurse Practioner/Academic Detailer, Fairchild Medical Clinic
Monica Mais is a Board Certified Family Nurse Practitioner working at an FQHC in Siskiyou County, located in far Northern California on the Oregon border. She is a founding member of Siskiyou Against Rx Abuse, member of the California Opioid Safety Network and an X-Waived prescriber, working with chronic pain and opioid dependent patients. As a former Emergency Room Nurse for 15 years, many of Monica’s shifts involved witnessing overdoses, drug-seeking behavior, violence, desperation, and healthcare worker burnout. It had been escalating every year to its current crisis level, and Monica wanted to be part of the solution to this heartbreaking epidemic. Questions on this piece for Monica Mais? Contact her at mmais@fairchildmed.org, or leave your thoughts in the discussion forum below.

As the Public Health Education Specialist for the WIC (Women, Infants & Children) program and the Opioid Task Force in Butte County, California, Stacy Piper, CLEC, acts as a regional liaison with the medical community as well as coalition's and various community partners. Learn more about Stacy in the bio at the end of this piece.

NaRCAD: Hi, Stacy! Thanks for joining us. Tell us a little bit about your work—we understand you, like many folks in public health, wear multiple hats. 
​
As the Butte County Public Health Education Specialist for the WIC (Women, Infants & Children) program and the Opioid Task Force in Butte County, I act as a liaison with the medical community. I collaborate with hospitals, health care providers, public health programs, and community organizations to improve public health and continuity of care.

NaRCAD: Talk to us about detailing for the opioid crisis—you do this 1/4th of your time. How did you get started?
​
After providing educational detailing for the WIC Program funded at 30 hours a week, I was asked to be an Opioid Academic Detailer for Butte County. In preparation, I attended the Academic Detailer Training in San Francisco. The training provided by the CA Health Department, San Francisco Public Health Department's Substance Use Research Unit, and NaRCAD was one of the finest training experiences - even after the countless hours of extremely comprehensive training I received in the Pharmaceutical Industry.

Regarding impact on a local level, it is indescribable how every interaction with a healthcare provider is beneficial. Academic Detailing (AD) is an equal exchange of information. I consider it a huge responsibility, and a privilege, to be an educator for doctors and medical professionals.​

NaRCAD: ​Tell us a little about your background in pharma, and how this translates to your detailing work now.
​
I was a Senior Executive Pharmaceutical Sales Representative for 15 years in Northern California, advocating for immunizations and promoting various prescription drugs. This provided first-hand experience of the astonishing evolution in the Medical, Pharmacy, and Insurance industries. Understanding the basic dynamics of medical offices has helped me navigate and gain access at a quicker pace for AD. Also, understanding the business acumen component of running a medical practice has proven to be valuable in my recent interactions.

NaRCAD: ​You mentioned that you’re committed to providing value for clinicians and patients alike.  Talk to us about how you share key messages with the clinicians you visit.

​In my experience, to truly influence the behavior of a highly-educated and experienced individual, you must come to the table with the goal of learning. With attentive listening, you ‘hear’ the medical professional, and process what you have learned. Your intuition will guide you to ask the appropriate, insightful questions needed to evaluate his/her priorities and challenges. This is a beautiful thing, because trust starts to blossom and the partnership has begun.

You can then confidently tailor key messages, valuable resources and solutions that are closely tied to those needs and challenges you uncovered. You should begin to see the individual’s genuine desire to truly change behavior and habits. 

NaRCAD: Along with telling true stories, how do you handle pushback  and stay positive, encouraging clinicians to pivot?
​
Time, or lack of time, is the biggest culprit in keeping physicians from attempting to personally assist in ending the addiction cycle for patients. I passionately believe clinicians need more time with people on opioids.

It takes several visits with an office to start moving in the right direction. Working with the medical assistants, nurses, and/ office managers is a key component. They can often have influence, give advice or insight, and even advocate when you are not there.
​
Also, I review our county’s Safe Prescribing Guidelines. If clinicians cannot institute all items in the guidelines, I ask providers to choose what they can commit to doing and to think about some specific patients they can work with. ​I also ask them to consider prescribing Naloxone for patients on high doses of opioids (above 50 morphine milligram equivalents).

Biography.
Stacy M. Piper, CLEC, Public Health Educational Specialist
​Butte County California Public Health Department
As a Public Health Education Specialist, Stacy was chosen to work with two CA State grant funded programs educating Medical Professionals, Hospitals and Community Organizations for the WIC Program and the Opioid Drug Abuse Prevention Program. She maintains an active involvement with the Butte County Opioid Task Force, as well as the Butte County Drug Addiction Prevention Coalition, ACE’s Coalition (Trauma Informed), Breastfeeding Roundtable Coalition, Butte County Breastfeeding Coalition, Mother Strong Coalition, and Perinatal Coalition. Stacy has had extensive training with the California Department of Public Health's Opioid Stewardship & Chronic Pain Detailing Program, ID Training, UCSD CLE (Certified Lactation Educator), Coalition & Equity Training, Advocacy Training and holds 14 years of ongoing training & certification in the Pharmaceutical Industry. She is a member of the team coordinating and orchestrating the 2018 Northern California Opioid Summit.

Kicking Day 1 off and setting the tone for the entire event, NaRCAD Director Dr. Mike Fischer warmly welcomed our packed room at Harvard Medical School’s Martin Center by encouraging collaboration, connection, and sharing. Our Day 1 Keynote Speaker Dr. Carolyn Clancy, the CMO of the Veteran’s Health Administration, described the VHA’s work to improve pain management in the veteran population while addressing the challenges of medication abuse and overdose. Dr. Clancy shared strategy and data behind the national effort and the critical role of academic detailing in it, connecting attendees to a big-picture view that can be adopted to look at other health epidemics and interventions.

Our first expert panel presented Practice Facilitation in Primary Care. Andy Ellner moderated the session, leading panelists Ann Lefebvre of North Carolina's AHEC Program, Lyndee Knox of LA Net, and Allyson Gottsman of HealthTeamWorks to discuss strategies, contextualize their work in relation to academic detailing and quality improvement, and share their personal approaches to challenges in primary care behavior change.  Allyson Gottsman’s much-appreciated analogy that practice facilitation is not unlike “leading a fisherman to a well-stocked pond” resonated with panelists and participants alike. Many attendees who were actively engaged in practice facilitation in their daily work shared that the panel helped them to think about their work in a new way.

The afternoon’s breakout sessions offered attendees multiple tracks with AD-related topics to explore: deconstructing and analyzing a 1:1 AD visit, exploring the skills needed to manage an effective AD program, and strategizing on ways to identify and harness stakeholder support when initiating a new program or strengthening an existing one.

The afternoon closed with two presentations; the first, by Terryn Naumann of the Canadian Academic Detailing Collaboration (CADC), offered participants a view of the power of synergy and teamwork, the historical context of the CADC’s creation and growth, and the future of the collaboration.

More examples of successful practice change were illustrated by the morning’s Themed Plenary on the Intersection of Public Health and AD. Dr. Phillip Coffin of the San Francisco Department of Public Health shared the success of an intervention focusing on co-prescribing of naloxone to reverse opioid overdose deaths in San Francisco. Another successful AD intervention was presented by Michael Kharfen of the Washington D.C. Department of Health, who highlighted the successful implementation of AD programs to increase HIV and Hepatitis C screening and treatment.

The afternoon featured our second Expert Panel, this time on the role of AD within integrated healthcare systems. Moderated by Dr. Mike Fischer of NaRCAD, panelists Joy Leotsakos of Atrius Health (MA), Sameer Awsare of Kaiser Permanente Medical Group (CA), and Valerie Royal of Greenville Health System (SC) shared their experiences using AD in systems at different stages of development. Attendees had the opportunity to discuss this topic further in the afternoon’s breakout sessions, which also included a session on practice facilitation, as well as third session to continue to explore AD and public health partnerships.

The conference’s closing discussion was led by Mike Fischer, who thanked not only the speakers, panelists, and session leaders, but the participants, whose willingness to share their experiences within an interactive setting was key in creating solutions to bring back to use in their daily work. The creative collaborations, exchange of resources, excitement in combating challenges in the field, and belief in the importance of AD for the future of healthcare transformation were felt by all at the closing of a very full and thought-provoking event.

Our Twitter feed tracks the event’s highlights through #NaRCAD2015, and you can catch our event photo album on our Facebook page. We invite you to explore these topics, learn about our speakers and attendees, and connect with us at the NaRCAD Conference Hub, where you can access on-demand video of all main sessions from the conference. Thank you again to all who attended, and to AHRQ for funding our series. Please stay in touch with us and each other, and continue the conversation and idea sharing below. ​
​We hope to see you in 2016!

by Lyndee Knox, PhD
Practice facilitation is an approach to helping primary care practices improve the quality of care they deliver to patients. Good practice facilitation is practice-centered, meaning that you start where you’re needed and work out from there.  One of my favorite stories about the practice-centered nature of facilitation was told to me by Ann LeFebvre, director of the statewide primary care facilitation program in North Carolina.

Ann was starting work with a new practice in her community. As is common at the beginning of most improvement efforts, she asked the practice what their greatest concern was at the moment. Ann expected them to tell her they were concerned about improving workflow with their electronic health records, or that they wanted to improve their performance on particular HEDIS (Healthcare Effectiveness Data and Information Set) measures, or that they wanted help engaging their patients more effectively. Instead, what they told her caught her completely by surprise.

“We’re really concerned about our patients getting to our practice.”
“Oh,” she said, “so you’re worried about access issues?”
“Well, sort of,” the staff person responded.  “Recently we’ve had a flock of geese take up residence in our parking lot, and they are biting our patients when they get out of their cars to walk inside. Some of our patients are afraid to get out of their cars.”

5 Whys Tool: Click to Learn.
As an experienced facilitator, Ann understood how important it was to meet practices where they are at the current moment, not where they “should be.”  So she rolled-up her sleeves and said, “Ok, let’s figure this one out.”  She saw the problem of the geese as an opportunity to teach practice staff basic principles of quality improvement.  She taught them to use the “5 Whys” to determine why the geese were in the parking lot in the first place, and then to use Plan-Do–Study-Act cycles (PDSA) to design and test solutions to the “goose attack” problem.

Working together, Ann and the practice discovered that a woman living next door to the practice used to keep and feed the geese.  She had recently been hospitalized and because she was no longer there to feed them, the geese had moved into the practice parking lot.   Staff developed a solution: to have another neighbor feed the geese – and tested this solution using a PDSA cycle. The geese left the parking lot, their patients no longer had to deal with hungry and aggressive geese in the practice parking lot, and staff had started to build capacity in quality improvement!
Practice facilitators are specially trained individuals who work with primary care practices “to make meaningful changes and develop the skills they need to adopt new clinical evidence and health service models in their work and to sustain these changes over time.” (Knox & Brach, 2011; DeWalt, et al., 2010). 

The primary aim of facilitators, whether working alone or as part of team, is to build practice capacity for continuous quality improvement, as well as to strengthen practice ability to adapt and implement new evidence-based treatments and health service models.

Facilitation teams develop long-term relationships with practices.  They may work with a practice intensively for 6 to 10 months to implement a specific improvement and then step back for a while.  Even though the active facilitation project has ended, they will check-in with the practice every month or two to monitor progress and maintain relationships until they are needed to support another significant improvement project at the practice.
While facilitation can be provided by a single individual, (a “practice facilitator”) it is often a “team sport.”  The facilitation team is usually led by an individual with expertise in quality improvement processes and methods. This person serves as the team leader and primary point of contact with the practice, and brings in his or her team mates to help the practice as needed.

Other members of the facilitation team include individuals with expertise with health IT who can help practices optimize their health IT systems to support the desired changes; team members with expertise in setting up data systems for monitoring performance; and most recently, patient partners. Academic detailers are also essential members of most facilitation teams.  They possess deep knowledge about clinical topics and provide 1:1 education to clinicians to increase their knowledge about specific preventive care and treatment issues, encouraging those clinicians to change their behavior to improve patient health.

A number of excellent resources are available for training members of facilitation teams, and to guide development of a practice facilitation program. These include the PF Handbook, the National PF Curriculum, and the How to Start and Run a PF Program.   Dr. Mike Fischer, the director of NaRCAD, and a team of experts in PF and practice improvement helped develop them.  These and other resources that can assist you in building a practice facilitation program in your area can be accessed here.

Lyndee Knox, PhD is founding director of LA Net, a primary care practice based research and resource network established with funding from the Agency for Healthcare Research and Quality (AHRQ) in 2002. LA Net supports research and innovation in the healthcare safety net in Los Angeles and provides practice facilitators to practices in its network to support practice-based, clinician and community-led research, evidence translation and practice improvement. Dr. Knox served as principal investigator on AHRQ’s Task Order 13 (TO 13) to examine the use of practice facilitators to implement the Care Model in the safety net, and convened the AHRQ Practice Facilitator Consensus Panel to summarize the state of the field as part of TO13. Most recently she led work for AHRQ to produce a manual to support formation of new practice facilitation programs across the U.S.  The resulting manual, Developing and Running a Primary Care Practice Facilitation Program: A How to Guide  and case studies are available on AHRQ’s website.

As director of LA Net, Lyndee has served as lead on a 2 year contract with the Greater Los Angeles Veterans Administration to create and train a cadre of internal coaches to support its primary care teamlets and PACT transformation. Currently she is working with Mathematica Policy Research to create a 30 module training curriculum for new Practice Facilitators/Coaches for the U.S. AHRQ. Dr. Knox also directs Project ECHO LA, a replication of the successful quality improvement and clinical education intervention from the University of New Mexico aimed at increasing access to specialty care services in rural and underserved areas. Project ECHO LA has been supporting ECHO Knowledge Networks for the LA safety net for 3 years in areas including: psychiatry, preventive care, geriatric medicine and quality improvement.