The National Academic Detailing Service’s
Opioid Overdose Education & Naloxone Distribution (OEND) Program
Guest Blog Authors: Melissa Christopher, PharmD, National Director
Mark Bounthavong, PharmD, MPH, National Clinical Program Manager
In 2015, the Department of Veterans Affairs (VA) invested in the National Academic Detailing Service to improve the health of our Veterans to address the call to action for the opioid crisis. Through the Opioid Overdose Education and Naloxone Distribution (OEND) Program, our goals were to reduce harm and risk of life-threatening opioid-related overdose and deaths among Veterans.
Key components of the OEND program include raising awareness about the epidemic, 1:1 academic detailing visits with clinicians to provide education and training regarding opioid overdose prevention, opioid overdose rescue response, and issuing naloxone products. We developed direct-to-consumer marketing and other e-resources, including a video, Introduction to Naloxone for People Taking Prescribed Opioids.
We also created implementation tools, including population management dashboards to aid staff in evaluating risk factors of their patient population and distributing naloxone accordingly. Academic Detailers demonstrated to VA providers these resources to help raise awareness of opioid overdose risk for their patient panel.
Decision-makers believed that funding this program would yield a good return on investment. As part of the National Academic Detailing Service, it’s our responsibility to collect data and supply decision-makers with evidence on the value and success of our program. In other words, we’re accountable for answering the question, “Is academic detailing worth it?”
To answer this question, we performed several program evaluations of the National Academic Detailing Service from 2015 to 2017, one of which we just published in the Journal of American Pharmacists Association (JAPhA) (Trends in naloxone prescriptions prescribed after implementation of a National Academic Detailing Service in the Veterans Health Administration: A preliminary analysis.)
The evaluation found that our program improved naloxone distribution rates at a seven times greater increase for Veterans at risk for opioid overdose. These results provided key empirical evidence that VA’s strategy of academic detailing was working. Just as important, these findings also gave decision-makers what they needed—proof that their investment in an area of high risk to Veterans’ health paid off by improving care.
But we learned that another group of stakeholders was just as important as the decision-makers who funded the program—the clinicians that academic detailers visited to provide outreach education as a service. Academic detailers work with clinicians to help them change practice patterns, focusing on improving health outcomes in alignment with balanced, current evidence.
As clinicians commit to sustainable behavior change, these providers need to hear the feedback about how the time they’ve invested with their patients ultimately improves outcomes and, in this case, saves lives.
Sharing program results with the clinicians in this intervention also encouraged these providers to share their own results, many of which were stories of patients returning to the clinic to relate their experiences of using naloxone to reverse an overdose. These stories, along with reversal reports from the field that tracked the outcomes of naloxone kit distribution and subsequent use, also created a tangible “return on investment” for everyone involved.
We encourage other academic detailing programs to prioritize program evaluation as we have at the VHA—no matter the size of your program, if you’re thinking, “we can’t afford to do program evaluations,“ we stress that you can’t afford not to do them.
Measuring program work builds a case not just for the success of one academic detailing intervention, but for the success of future programs—a case for sustainability. Evaluation measures the quality of a program, analyzing results to look at a program’s impact, and allowing for process improvement adjustments to be made to streamline efforts and strengthen that impact. Evaluation cannot be optional, especially when lives are at stake.
We also recommend that the results from program evaluations are shared with other stakeholders, such as clinicians, in order to encourage and sustain their behavior changes. Leveraging results from well-designed evaluation is essential for academic detailing interventions to illustrate success, share value, and provide stakeholders and community members with a clear “Yes!” in answer to their overarching question: “Was the investment worth it?”
Melissa Christopher, PharmD
National Director, Academic Detailing, US Department of Veterans Affairs Central Office, Pharmacy Benefits Management (PBM) Academic Detailing Service
Dr. Christopher is the National Director of VA Academic Detailing Services, overseeing the implementation efforts for academic detailing expansion across all Veteran Integrated Service Networks since 2014. She received her Doctor of Pharmacy from Duquesne University, Pittsburgh Pennsylvania. She completed a Pharmacy Practice Residency and Post Graduate Year 2 in Pharmacoeconomics and Formulary Management at VA San Diego Healthcare System. Dr. Christopher conducted research in health outcomes and pharmacoeconomic analysis for several chronic disease management areas. In recent years, Dr. Christopher has embraced the mission to expand efforts for educational outreach by clinical pharmacists for improvement of evidence based care in Pain Management, Depression, Schizophrenia, and Posttraumatic Stress Disorder as well as other substance use disorders. Most of her program efforts focus on development of educational materials, outcome monitors, provider specific electronic audit and feedback tools to trend practice patterns with implementation efforts for the newly developed as well as fully implemented AD programs.
Mark Bounthavong, PharmD, MPH
National Clinical Program Manager, Academic Detailing Service, Veterans Affairs
Dr. Bounthavong graduated from the College of Pharmacy at Western University of Health Sciences. He completed a PGY-1 Pharmacy Practice Residency at the Veterans Affairs Loma Linda Healthcare System followed by a fellowship in Outcomes Research and Pharmacoeconomics at Western University of Health Sciences. He started his career at the Veterans Affairs San Diego Healthcare System as a pharmacoeconomics clinical specialist. During his tenure at the VA, Mark worked on identifying cost-effective strategies and formulary management; directed the PGY-1 Managed Care Pharmacy Residency; and completed a Master of Public Health from Emory University. Mark left the VA in order to pursue a PhD in the Pharmaceutical Outcomes Research and Policy Program at the University of Washington. He recently accepted a position at the VA as one of the National Clinical Pharmacy Data Program Managers in the Academic Detailing Service.
NaRCAD's Interview Series: Public Health Detailing Program at New York City Department of Health and Mental Hygiene (DOHMH)
Featuring Michelle Dresser, MPH, Senior Manager, Programming & Strategy
Thanks for taking the time to share the great clinical outreach education work that’s being done by the NYC Department of Health and Mental Hygiene, Michelle! Tell us a bit about yourself and how you got involved in public health, specifically public health detailing.
Michelle: Thank you for the opportunity to speak about the Public Health Detailing Program. I have over 20 years of public health experience in both the non-profit and government setting, with the last 12 here at the New York City DOHMH. Throughout my professional career, my specialty has been in healthcare marketing and provider education, emphasizing how providers and consumers can better communicate with each other by tailoring complex messages using health literacy principles.
It’s essential our reps have excellent selling and communications skills, so when they engage providers and get their buy-in, providers are then equipped to get their patients “on board”. One-on-one provider engagement helps them understand how important it is to have a 2-way communication with patients.
How can an outreach representative encourage providers to “get on board” and think about care as a dialogue?
Michelle: Let’s use obesity as an example. With obesity, both providers and patients are frustrated, for different reasons. Providers may be frustrated that patients’ comorbid conditions are being exacerbated or don’t have the same kinds of tools to treat obesity as they do other conditions; patients might feel that providers aren’t using great communication techniques, like motivational interviewing (MI), to help them set goals and take small steps towards the goal.
If a patient is only told, “You need to lose weight,” which is such a broad and overarching goal, they’ll be frustrated, and frankly, non-adherent. I know I would be.
Encouraging providers to have specific dialogues using a customized approach for each patient is important. This kind of dialogue takes into account patients’ literacy beyond the written and spoken word—it looks at scientific, fundamental, health and cultural literacy, too.
We work on “coaching scripts”, which take the key recommendations and reframes them in order to custom-tailor the conversation for each patient.
One thing that’s unique about public health detailing is that we detail the whole team through one-on-one interactions. Evidence shows these types of interactions with providers and staff are more effective at changing behavior; however, sometimes due to the makeup of the practice we must conduct group presentations. It’s not ideal, but it still allows us to get the messages and materials out there.
So when an outreach representative goes into an office, they detail...everyone?
Michelle: If there are 15 people who work in an office, we’re going to detail all 15 of them. It’s a lot! Sometimes, the person who is the champion of a new behavior or workflow isn’t going to be the provider. We see the front desk staff as instrumental; they’re interacting with all of the patients. We work with our teams to ensure even the front desk staff receives the materials and information, rather than seeing them merely as a “gatekeeper” to get to the providers.
Sounds like a lot of training goes into preparing for your campaigns, and for thinking about the entire process of effective outreach. Tell us more about your trainings, and about how you prepare outreach representatives on disease content training, as well as in marketing and communications skills.
Michelle: On average, our trainings are about 5 days in length and take place the week prior to launching a new campaign. About 40 percent of the training is disease content, so we work with our internal Health Department experts, as well as external experts, where we learn about prevention strategies, treatment strategies, epidemiology and the landscape around the key recommendations chosen based on the evidence of that topic. We need to know the ‘why’ behind the campaign.
Once we have that under our belt, we shift to sessions on how to frame the issue, how to promote the materials, figuring out the “features and benefits” as well as the “barriers and objections” and finally “gaining a commitment”, which are phrases that come from pharmaceutical marketing. We’re “selling” and promoting public health interactions, so we work on those skills.
We also do a great deal of role playing, including videotaped analysis of each rep. We look at body language, what communication skills are effective, we do knowledge assessments, quizzes—we make sure our team is well-prepared to go out and detail. We take this seriously—they’re representing the New York Department of Health and Mental Hygiene.
What’s a major barrier your program has faced, and how have you tackled it?
Michelle: A big challenge, when starting a detailing program, is access. The landscape of healthcare systems in NYC has drastically changed over the past few years. As an example, several years ago, the majority of our Brooklyn territory was almost entirely made of up of small practices where access wasn’t an issue.
What’s changed since then?
Michelle: Now, many of these sites have become part of larger institutions, so there’s corporate buy-in that needs to happen for people to come in and talk to the staff. As I mentioned before, although we try and limit group presentations, this has proven to be an effective strategy when entering into a new relationship. Once they get to know us and recognize the value of the program, they’re engaged in having us come back to conduct 1:1 visits on the follow-up and subsequent campaigns.
How do you know when a campaign is working and becoming successful?
Michelle: Evaluation is always on the top of our priorities, and can be a challenge for any program to evaluate effectiveness. For every campaign we conduct an initial and follow-up visit where we assess provider practice.
This allows us to see if there has been a change in practice from the initial to the follow-up visit. Additionally, we rate what providers intend to adopt in terms of the key recommendations and supporting tools and resources. We also collect a large amount of qualitative data because it's also critical to gaining a more complete picture of the campaign’s success, especially when reporting on barriers, access and materials.
You can scale this up or down, depending on your need and organizational priorities. Our program focuses on where there’s the greatest need and potential for greatest impact.
Programs should make sure to look at their organization’s agenda and goals. It’s important to look at the data and plan the best course of action within the capacity you have.
Biography: Michelle Dresser. Michelle Dresser is the Senior Manager of Programming and Strategy for the Public Health Detailing Program within the Bureau of Chronic Disease Prevention and Tobacco Control at the New York City Department of Health and Mental Hygiene. In this role, she oversees the overall programmatic direction and strategy of the program. This includes, campaign strategy and timing, campaign content, training and economic incentive development, provider selection, identification of targets to ensure the greatest impact on populations most in need, and identification of “new needs” opportunities to expand program reach and achievement of program goals. She also oversees internal and external strategic relationships to enhance programmatic objectives.
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