Featuring: Robin Tuttle, RN, ER Nurse, Academic Detailer, NaRCAD Training Alumnus
Interview by Kabaye Diriba, Senior Program Analyst, NACCHO, in partnership with NaRCAD
EDITOR'S NOTE: Bell County, Kentucky, was the first site of four selected for a 2018 pilot program of the CDC (Centers for Disease Control and Prevention), NACCHO (the National Association of City and County Health Officials), and NaRCAD (The National Resource Center for Academic Detailing). This exciting pilot program focused on community-level work with local public health departments to develop customized interventions to reduce opioid overdose and death. Four sites experiencing significant public health problems related to opioids were selected to be trained in academic detailing; those trained health professionals then conducted 1:1 field visits with front line clinicians to impact behavior around prescribing, treatment referrals, and patient care, all within a rural area. As year 1 comes to a close, we’re showcasing successes from the field.
Thanks for talking with us about your on this pilot project with NACCHO, the CDC, and NaRCAD, working to support local efforts in your community.
Robin: What we’ve been doing has been a breath of fresh air! I'm proud to be a part of it, and happy to help in any way that I can.
Tell us how local detailers were selected for this project—what kinds of professional backgrounds make up your diverse team members?
Robin: I was asked by a co-worker, another detailer, who thought “I know this really outgoing, outspoken person that might fit the team.” Our team is made up of people that have hands-on knowledge about the opioid epidemic. I’ve been in healthcare since 1988 and I’ve been living here in Bell County for 30 years. I started working as a nurse aid at one of the local hospitals and then went on to college to get my RN. Our detailing team all had a common interest when we got together.
What elements of the training do you apply most often during your visits when delivering your key messages?
Robin: What helped me the most was that last day of training when we were practicing academic detailing. Asking open-ended questions is the most important thing. You get so wrapped up in wanting to deliver your messages, but it’s not necessary that you get all of your messages in on that first visit. You may feel rushed to deliver all your messages if you’re afraid you’re not going to make it back in the door, but what I found is the more I met with doctors, and the more I said things like, “What have you seen in your practice?” or “Tell me about a patient…” or “Talk to me about the problems you’re having…”, the more I saw the conversation open up. That’s something I really picked up on the second day of training—learning to turn it back around and asking [needs assessment] questions. Let them get involved, and let me really listen to what they have to say; that way it'll help contribute to the conversation going forward.
The opioid epidemic can be a sensitive topic. When you approach clinicians to discuss their behaviors around the opioid epidemic, how are you generally received? What do clinicians in Bell County see as major challenges in your community?
Robin: Almost everyone I spoke to was very receptive about everything that we talked about, including all 5 of our campaign’s key messages. Because treatment in this area is slim to none, it all circled back to, “What if I find someone [a patient] that has opioid use disorder? How can you help me?” Doctors here are telling me that even people that have overdosed and come to the hospital are having a hard time [getting access to treatment]. There are places that are not in Bell County, but we would need some sort of transportation system that could get patients to those places.
What challenges do Bell County clinicians face, along with being busy, when trying to support their patients who are prescribed opioids?
Robin: Clinicians are often challenged in identifying symptoms of someone with opioid use disorder. Also, sometimes patients are sent to a pain [management] clinic, but those don’t always work. In our community, we can send them to the local Suboxone clinic which is accessible and easy to get to.
When it comes to Suboxone, you cannot look at it as an “all-or-nothing” approach. That’s a challenge here in Bell County, trying to get the community to know that abstinence is not always the answer, and sometimes people might have to take some form of medication for life to get the wiring back together that they've already lost because of their disorder.
I also understand some of the doctors are adamant about their current patients that have been taking these medications for 25 years for this chronic pain, which they don’t think they can do much about, and they’re concerned about this newer generation [of patients] coming in.
What have been some of the more rewarding exchanges you’ve had with clinicians you’ve met with?
Robin: I've had a lot of good visits, but this one sticks out in my mind: there was one clinician where I felt immediately like I was going to get the “brush off”. But I ended up staying for an hour and a half! I sat there with this doctor, who I’ve had a challenging professional relationship with historically, and he ended up talking to me at length about patients he was seeing, and those he had inherited. I was so excited that I’d spoken with him for so long, and that I’d covered all 5 of our campaign’s key messages. I walked away from that visit with questions to follow up on that I wanted to be able to answer for him at a future visit, and I felt like I made a new friend.
What do you want to tell new detailers who are just starting to form teams and try this kind of 1:1 outreach education model out with clinicians in their communities? What piece of advice would you have appreciated when you started your first detailing visits?
Robin: Try not to get discouraged! After we divided up all the physicians, we started making phone calls. That can be discouraging. I found out we actually had more luck stopping by. We called it the “drug representative look”: you dress up, put your badge on that says academic detailer, have the clipboard and all the paperwork, and you look professional. I really found out that I had more luck by just walking in and saying, “Do you have a minute?”
Don’t get discouraged if you're making calls all day long and they keep putting you off, because receptionists are making appointments all day long too and it’s hard to explain what you’re doing over the telephone. We definitely felt discouraged during the first couple of weeks of outreach. We were feeling like we hit a brick wall, and that’s when we coined the term "drive-by” detailing visits. We started driving around and just showing up at offices. So, get out and drive if you can’t get through over the phone. Go with a card and introduce yourself. They [clinicians] all want to talk about opioids. You'll be surprised when you get in the room with them and they start talking.
Ideas? Comments? Questions? Sound off on this blog in the comments section below!
Director’s Letter: Mike Fischer, MD, MS
The opioid crisis has been recognized as a major national public health problem, but it actually reflects a collection of many thousands of local crises playing out in individual cities and counties. Each region faces a distinctive set of challenges, driven by economic and social factors, local medical practice patterns, political environment and pressures, and many other considerations.
Identifying and implementing effective solutions to address the opioid crisis requires developing an understanding of how these individual challenges interact, and what strategies are most effective in specific situations--one of which is academic detailing.
The NaRCAD team is partnering with the CDC (Centers for Disease Control and Prevention) and NACCHO (the National Association of City and County Health Officials) on an exciting pilot program working with local health officials to develop customized interventions to reduce opioid overdose and death. Four sites experiencing significant public health problems related to opioids were selected: Boone County, Kentucky; Bell County, West Virginia; Manchester, New Hampshire; and Dayton, Ohio.
Public health officials at each site identified a wide range of local stakeholders to participate in developing a community action plan and recruited trainees to complete NaRCAD’s academic detailing training course, which we customized to address the unique challenges that each community faces. We also developed a specialized online toolkit for these sites, including discussion boards, local resources, and printable resources.
We traveled to each site in March and April of this year, facilitating hands-on trainings in the techniques of academic detailing in alignment with the CDC prescribing guidelines. Trainees came from diverse backgrounds, including pharmacists, nurses, public health officials, and students in the health professions, including pharmacy students, dental students, and medical school students.
Plans for implementing AD varied by site depending on the local health care environment; some sites focused more heavily on appropriate prescribing of opioids by clinicians, while others prioritized increasing referral rates for patients with opioid use disorder (OUD), including access to medication-assisted treatment (MAT).
As the AD trainees at each pilot site continue their work in the field, we’ll learn more about how these diverse strategies succeed, and how we can support adaptations to make academic detailing more impactful. This important collaboration has allowed us to form invaluable partnerships with CDC and NACCHO, leveraging national resources to improve local responses to this epidemic through plans that respond more precisely to local needs and priorities.
We’re excited for this pilot program to serve as a model for future opioid safety AD interventions, and we’ll be providing updates here on the blog. In the meantime, tell us: what's happening in your local community around the opioid crisis? Sound off in the comments section below, and let us know if you think clinician-facing education could be a strategy that would improve outcomes for your community. And join us for our next training and our terrific annual conference to learn more about this and other exciting AD projects.
Michael Fischer, MD, MS | Director of NaRCAD
Dr. Fischer is a general internist, pharmacoepidemiologist, and health services researcher. He is an Associate Professor of Medicine at Harvard and a clinically active primary care physician and educator at Brigham & Women’s Hospital. With extensive experience in designing and evaluating interventions to improve medication use, he has published numerous studies demonstrating potential gains from improved prescribing. Read more.
We've been staying busy here at NaRCAD this spring! With public health challenges like the opioid crisis, and the continued need for HIV prevention, the team here at NaRCAD has been on the road for 5 trainings in 6 weeks, and we're not stopping yet!
On February 14th - 16th, 2018, NaRCAD joined the amazing teams at San Francisco Department of Public Health and the New York City Department of Health and Mental Hygiene for an exciting initiative: A Public Health Detailing Institute on HIV PrEP and RAPID.
Hosted in San Francisco's South Market neighborhood, 31 trainees attended, representing diverse public health departments from Texas, Connecticut, Alaska, Louisiana, Florida, Tennessee, Los Angeles, San Francisco, Mississippi, Michigan, Oregon, Nevada, Virginia, and beyond. These trainees joined the institute for a customized, 3-day event focusing on learning the techniques of academic detailing, along with showcasing best practices and success stories via special presentations and expert panels.
This past month, from March 7th through April 4th, 2018, NaRCAD hit the road four more times, as part of an exciting 4-site pilot project in partnership with our terrific colleagues at the CDC (Center for Disease Control) and NACCHO (The National Association of County and City Health Officials).
Upon identifying counties and cities with the highest burden of fatal and non-fatal opioid overdose and high prescribing rates, the CDC selected Bell County, Kentucky; Boone County, West Virginia; Manchester, New Hampshire; and Dayton, Ohio as 4 pilot sites in which to convene with key community stakeholders and roll out community action plans, along with targeted academic detailing interventions.
Our work has involved launching on-location trainings at each of these pilot sites, focusing on providing front line clinicians with tools and support to improve outcomes for patients.
Messaging and support for these campaigns include lowering prescribing rates, referring patients to treatment for opioid use disorder (OUD) including Medication Assisted Training (MAT), and using their state's PDMP (Prescription Drug Monitoring Program) to identify troubling patterns of use, which may, in turn, help to identify those patients who need more support and care.
Trainees at each site of these pilot sites work with us across two days to learn the structure of an academic detailing visit, practice role playing 1:1 visits with clinicians, and become experts at using educational materials (including a suite of materials constructed by the CDC based on their 2016 Opioid Prescribing Guidelines).
Our pilot site trainees walk away from our trainings ready to actively engage with clinicians to assess individual needs and provide customized support, and encourage behavior change for the opioid crisis in their respective communities.
NaRCAD's team will continue to focus on launching new academic detailing interventions across the U.S. well into 2018, with upcoming opioid-specific trainings being carried out in late May in Albuquerque, New Mexico, with the University of New Mexico's Health Sciences Center, and in late June in Lansing, Michigan, with the Michigan Public Health Institute.
Our next all-topic, AD techniques training in Boston will kick off at the end of this month, where we'll train 24 health professionals from across the U.S.--we'll report back after that training and share lessons learned, highlights, slide decks, and clinical topics from represented programs, and we look forward to sharing those with our community.
Join our subscription list to receive alerts for upcoming training opportunities. Want to customize a clinical topic-specific training for 15 trainees or more, on site in your community? Reach out to us to schedule a training consultation call at firstname.lastname@example.org.
We can't wait to work with you!
-The NaRCAD Team
Highlighting Best Practices
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