The genius of the American health care system is its fragmentation. And by ‘genius,’ I mean evil genius, or demented genius. And sadly, also ‘very stable genius,’ since that awful fragmentation has been stubbornly resistant to change. It’s a great way to maximize revenue and expenditures, but not the best way to provide care to patients – and it leads to much of the poor care and unaffordable costs that we face.
In many organizations caring for patients over 65, their medication use is stripped away into Medicare drug benefit plans separate from the way the rest of their clinical care is paid for and organized. Many payors in the private and public sector carve out the use of drugs for specific conditions, removing it from the organization and payment for the care of the illnesses those drugs treat.
Outside integrated health care systems, in many settings the content and costs of prescribing decisions live in a pharmacy silo separate from ambulatory care, which itself is often a world apart from inpatient care, with all of these sectors de-coupled from assessment of clinical outcomes and patient satisfaction. But sick people don’t come in silos, and the drugs we prescribe for them drive hospitalization and other clinical outcomes and the enormous human and economic costs of both.
Academic detailing can help pull these domains together in a way that can make medical care more person-based and evidence-based, as well as more cost-effective. The AD interventions that work best start from the global perspective of the practitioner: how to diagnose and care for a given clinical problem, whether it’s Alzheimer’s disease, diabetes, or incontinence, rather than focusing narrowly on simple medication use questions (“Don’t prescribe Drug X; Drug Z isn’t on the formulary”).
This holistic approach is what clinicians and patients need and want, and the one most likely to bring about optimal care decisions. Such a “beyond the drug silo” approach also has implications for the content and focus of the printed clinical materials our programs use, as well as the interactive approach employed by the outreach educator in these programs.
Focusing on silo-busting can also help the academic detailer be seen as a valued colleague helping the clinician improve overall patient care, rather than as a nag, a busybody, or a scold. And as the US health care system continues its slow transition away from the evils of fragmentation to a more rational approach that focuses more on integration of care and less on widget-based revenue maximization, the comprehensive, clinical outcome based vision of academic detailing will increasingly help to pull all the pieces back together where they belong.
Want more? Peruse the archive of Jerry's pieces here on DETAILS.
Jerry Avorn, MD, Co-Director, NaRCAD
Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use. Read more.
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.
We’ve just celebrated the 5th anniversary of NaRCAD, the only national resource center and network advancing clinical outreach education. We’re also celebrating a terrifically successful 2015. Highlights included running two sold-out academic detailing techniques trainings here in Boston; traveling to San Francisco and Oklahoma City for two customized off-site trainings; and bringing everyone together for #NaRCAD2015: Motivating Change, Transforming Care, our most successful annual conference so far.
We’re proud of it all, and more, including the brand-new NaRCAD Website—enjoy and explore a new gateway to academic detailing, including more interactive resources and expanded opportunities for connection, learning, and sharing. With so much to celebrate from 2015, we’re setting the bar high with big goals for the year ahead. Here’s what we’ll be up to in 2016, with you as our partners:
Transformative Trainings: Registration for our May training in Boston is open and already filling up fast! We’re also happy to be in high demand for at least 5 “on-the-road” educational sessions and related projects across the US this year. If you want to learn more about the ways we can share our resources and expertise to help your clinical outreach education program grow and succeed, let us know—we’d love to learn about what you’re doing and see how we can help.
#NaRCAD2016: Collaborating to Create Change. Our annual conference is the capstone of the year, so mark your calendars for November 14-15, 2016. What’s new this year? #NaRCAD2016 will feature opportunities to submit a proposal to showcase your clinical outreach education experience, data, and insights with the rest of the NaRCAD community. Keep your eyes on your e-mail and our conference page for more details about submission, coming soon.
More Collaboration for Improved Health Outcomes: With 5 years of partnerships under our belt, we’re continuing to connect every day with new colleagues working in the field of AD and clinical outreach education. We’re excited to keep expanding our community and creating opportunities for deeper collaboration across programs. We invite you to stay connected as we continue to publish new blogs and interviews, feature partners on our network directory, expand our Learning Center offerings, and recommend evidence-based health news and events on our social media feeds.
Most of all, our team wants to hear from you! Drop us a note to tell us what you’re doing, and tell us how we can help strengthen your program and highlight your successes.
See you this year!
Dr. Mike Fischer
Bevin K. Shagoury, Communications & Education Director
Our most recent 2-day Academic Detailing Techniques Training was held here in Boston on May 4th and 5th, 2015, and it was a successful and exciting convening of 18 trainees from all over the country. Clinical pharmacists, nurses, and program specialists gathered in Boston’s downtown to learn and practice social marketing techniques to use when educating front line clinicians about new evidence and important interventions.
Our trainees will take these valuable skills back to a wide range of programs, with goals including improving health for veterans with PTSD, increasing referrals to smoking cessation programs, and strengthening chronic disease lifestyle management programs.
Many of us have attended trainings and conferences heavy on Powerpoint presentations and light on practicing tangible skills. At NaRCAD, we use a dynamic curriculum wherein we integrate role-play, interactive large and small-group discussion, live demonstrations of a successful academic detailing visit, reflection through videography, ongoing networking, and the chance to learn from experts, clinicians, and colleagues through practice and skills sharing.
After their training sessions are done, trainees move forward to establish new academic detailing programs, strengthen and develop existing ones, or use our techniques in other clinical education settings. And as their work continues, so does ours—we maintain contact with our trainees, providing critical resources and featuring their work on our website and DETAILS blog. This fall, we’ll be featuring partner profiles of many of our trainees’ academic detailing programs, so that our community can learn about the critical role these programs play in improving health outcomes.
Join us at our next training this September—a program one recent trainee describes as “an excellent program, with fabulous faculty, and a well-run, valuable service to the healthcare community.” We keep improving our curriculum to ensure that each of our trainees gets personalized support to make their work easier. Their appreciation and feedback helps us to refine our training, encouraging us to think about ways we can continue to provide the best resources available. As the field continues to grow, so do we—and our trainees tell us that we’re making an impact by leveraging their work, sharing best practices, and running “the best training I’ve ever been to—seriously!”
Highlighting Best Practices
We highlight what's working in clinical education through interviews, features, event recaps, and guest blogs, offering clinical educators the chance to share successes and lessons learned from around the country & beyond.