NaRCAD: ​How did you get into AD? What were you doing before?
Joe: I’m a graduate student at The University of Michigan School of Public Health studying epidemiology. As a student I started working at the Ann Arbor VA Center for Clinical Management Research on a lung cancer-screening project.  Our project involves 8 different VA sites across the country. As we shifted into an implementation phase, academic detailing was selected as an implementation method.  I transitioned to an academic detailer role because of my background in epidemiology, my understanding of lung cancer screening (LCS), and my ability to communicate these principles.
I attended the NaRCAD academic detailing techniques training and things took off from there!

​NaRCAD: Why is AD for lung cancer screening so important?
​Joe: Lung cancer screening can be more complex and complicated compared to other preventative services, and most primary care physicians have very limited time to discuss lung cancer screening with patients. There are a number of potential downsides to screening – false positives, overdiagnosis, invasive procedures, and complications from invasive procedures. The benefits of the screening outweigh the challenges, and we have developed a tool for doctors to quickly evaluate a patient’s lung cancer risk, facilitate shared decision making, and make personalized screening recommendations.

NaRCAD: ​Tell us about the lung cancer screening detailing aid and related tools that you made with NaRCAD’s support. How was the process of developing the detailing aid?
Joe: Our detailing aid contains background information on lung cancer screening and some of the key evidence behind our tool.  It also outlines some of the reasons and benefits behind using this risk-based approach.  We tried to keep the detailing aid simple enough that doctors could quickly understand the concepts with little or no additional explanation.  This was our group’s first attempt at making something like this.  We worked with NaRCAD during the creation of the detailing aid to improve the clinical content, layout, and language.  There was a lot of trial and error to create the detailing aid.  We ended up going through 10 versions before it was finalized. 

NaRCAD: ​How did you decide what information was most important to put on your detailing aid?
Joe: Initially, we started out with too much information.  It was too complicated and wordy to effectively communicate our message.  We tested it out with our team to see if our message was clear.  It was obvious when sections of detailing aid didn’t work well. 
 
We really had to focus on narrowing down the main evidence and messages we wished to convey. We used the primary lung cancer screening evidence from the US Preventative Task Force and the National Lung Screening Trial.  Our tool goes a step beyond screening eligibility to look at individual risk, life expectancy, and patient preferences, which help providers get past some of the difficulties and complexities of lung cancer screening.  

​NaRCAD: How does your website complement the detailing aid when you are 1:1 detailing?
Joe: A link to the tool is embedded in the Computerized Patient Record System (CPRS), the EMR system that the VA uses.  However, it can be also accessed outside the VA with a URL.  What I typically do is I have PCPs pull up the website in their workspace after going through the detailing aid.  I have providers role play with a sample patient, and I demonstrate how the tool could be used for that specific patient.  Using the actual web tool in a detailing meeting really helps to reinforce our message.  We feel like it increases the likelihood that it’ll be adopted in an actual clinical practice.

NaRCAD: ​How have clinicians been responding to your campaign?
Joe: So far there has been a decent response from the doctors we have worked with.  Some of the doctors in the VA have met with detailers before which makes the initial contact easy.  However, the most majority of the doctors I have met were receptive to my visits.
 
We’ve been tracking the use of our tool before and after academic detailing at a site level. We don’t have exact numbers, but there has been an increase between before and after AD. We’d be happy to share more complete data in a future blog post. 

NaRCAD: That'd be terrific, we'd love to share that when it's ready! What other reflections do you have from this process that you'd like to share with our community?
 
Joe: Academic detailing is a new approach for our group.  It has been a real learning experience for discovering what does and doesn’t work and how to best address provider needs.  For me, going through this process has been a lot of fun.  I love talking with doctors about their struggles and being able to offer a tool that can help them better handle lung cancer screening with their patients. 

Our AD program is part of a 3-year demonstration project (CDC Project PrIDE), and as part of our grant-funded work our overarching goal is increasing PrEP access and prescribing to MSM (men who have sex with men) of color and transgender persons who are at substantial risk of acquiring HIV. Our goals include improving sexual health in the primary care setting, refining sexual health history-taking, increasing screening and testing for those with risks, promoting best practices around PrEP prescribing, and helping to establish relationships between our health department and our community providers.

In San Francisco, there is a need for urgency around this issue, especially because it’s become evident that as HIV transmissions continue to decrease, the disparities among new HIV positive diagnoses become more apparent. Many of these disparities are among communities who still may not be aware of PrEP, or are facing barriers to access. Our academic detailing program strives to reach the providers who work with these vulnerable communities.

When kicking off an intervention such as this, identifying the clinicians who see this target population is the first step. To do this, we used STD surveillance data to determine which providers and clinics were diagnosing syphilis and rectal gonorrhea and chlamydia, which are associated with an increased risk for HIV. However, since many providers are not performing appropriate screenings, we also reached out to clinics known to serve our priority population and those located in neighborhoods with the highest HIV incidences.

The next step is how to “get in the door” with these clinicians, which means finding a way to secure a 1:1 visit. I’ve found that initial non-responsiveness isn’t the end of the world—persistence pays off, so keep trying to get in the door, or find an entry point through other community contacts. Sometimes, choosing a different access point can really work well to start a relationship. There are many places where 1:1 visits aren’t feasible due to clinic structure or culture. If I’m able to detail to a small group, it can be a way to meet with a few providers and gain insight about how PrEP might be incorporated or enhanced in their setting.

Being invited to an all-staff meeting is often an excellent way to kick off an introduction to this important intervention, and can result in follow-up conversations with individual clinicians. One benefit of meeting in small groups is that if a clinician hears a fellow clinician say that he or she is already prescribing PrEP, there may be more openness to discussing the topic; other providers might feel comforted in having a PrEP "ally", resulting in buy-in from the clinic overall.

Some clinicians may think that this type of intervention isn’t relevant to their patient population; as I detailer, I often hear responses such as, “I don’t see this population reflected in my practice,” or “My patients don’t have this risk,”, even if it’s been proven that these clinics do, indeed, serve priority populations.  In order to talk about PrEP, you first have to talk about risks for HIV, which often means talking about sex. I think there can be discomfort on both the patient and provider side, and sex is often still a stigmatized topic. There are also overarching resource barriers, including the fact that clinicians are extremely busy and have to address competing health needs in the primary care setting. 

While a small pool of clinicians have minimal understanding of PrEP, and require a basic overview about elements like identifying potential PrEP candidates, how to take a good sexual history, and how to bring up PrEP in an appointment, I’ve found that many clinicians are aware to some extent about PrEP already, and are interested in next-level details about how to implement it. This might include what kind of testing is recommended, how to increase number of basic screens, and increasing their knowledge about comprehensive health. 

There are also providers who are very advanced in their knowledge of what options are available to populations with risks for HIV. This is where the academic detailing becomes more intricate; some providers are seeing lots of patients with risk factors, and may have been prescribing PrEP already. In a scenario such as this, my messaging focuses more on how to support clinicians in ensuring consistent follow-up with their patients, or in how to deal with multiple risk factors, such as when high-risk sexual behavior may overlap with instances of substance use or homelessness.

For those who are just getting started, it may help to know that even after meeting with 300 providers, I still get nervous each time I prepare to detail, especially if I’m unfamiliar with a practice. Regardless of the nature of my visits, I walk away feeling that I’ve accomplished something if I’ve answered only one question that’s helped the clinician with his or her practice. And I’ve found that in most cases, the people I meet with are very thankful for this service, and are appreciative of the health department. I always thank providers for the work they do and remind them what an important role they have in the community.

Biography. Alyson Decker, NP, MPH
Alyson Decker is a Clinical Prevention Consultant and nurse practitioner with Disease Prevention & Control at the San Francisco Department of Public Health. As the branch’s lead academic detailer, she helped develop San Francisco’s first HIV pre-exposure prophylaxis (PrEP) detailing program. Her role consists of detailing with community providers to increase PrEP prescribing in the primary care setting and promote best prescribing practices. In addition, she provides training assistance to healthcare providers and frontline staff around improving sexual healthcare and STD testing and treatment. She also sees patients at the municipal sexual health clinic, San Francisco City Clinic. 

​NaRCAD: Hi, Meagan and Mindy—thanks for taking the time to talk with us about your clinical outreach education programming at Colorado ABCD. Can you give us an overview about ABCD and its mission to improve child development?

Meagan Shallcross: Colorado Assuring Better Child Health & Development (ABCD) works with community partners, pediatric healthcare providers, early learning providers, and families across Colorado communities. The goal is to strengthen systems and identify children with developmental delays, connecting them with community services as early as possible.

Mindy Craig: My path to healthcare improvement is a little different than what you might expect.  I worked for Northwest Airlines as a flight attendant for several years straight out of college.  At that time the airline industry was losing a large amount of money and needed to find a new way of operating.  They decided to utilize a Total Quality Management approach and enlisted people from every department to undergo training in TQM and then facilitate small departmental groups in quality efforts.  It was through this process that I began to understand the importance of doing business with a quality framework.

Eventually, I left Northwest and started working in a Neurology clinic while going back to school with the goal of becoming a PA.   After completing my degree I worked in primary care settings for about 10 years.  I participated in small clinic QI efforts over the years and continued to be interested in quality improvement.

I was hired by ABCD 8 years ago to bring a clinical perspective to their physician outreach.   It was a natural progression for me to start approaching our work at ABCD with a quality improvement framework.  The power of engaging front line staff to implement changes that result in improvement remains as strong as it was when I worked in the airline industry. 
 
NaRCAD: Talk with us about your academic detailing programming at ABCD—you’ve been doing this for about 10 years, right?

Mindy: We started our work  encouraging the use of standardized developmental screening tools in the primary care settings.  This was supported by the American Academy of Pediatrics policy statement in 2006 recommending the use of these tools at well child visits.  We offered informal outreach to physicians providing instructions on screening tools, billing information, AAP recommendations and information on referral resources.
​
We quickly recognized that screening alone wasn’t sufficient and began talking about the referral process and how to ensure successful referrals were being made.  At around this time, research was showing us that only about 50% of children referred for Early Intervention services were actually connecting to that referral.  It was easy to identify children with concerns but not as easy to ensure they received needed support.
​
We decided to try formalizing our approach to outreach by offering Continuing Medical Education [CME] credits.  While we didn’t change content, offering CME changed the way providers saw us as detailers.  We appreciated the new credibility, but still struggled with recruiting new practices.

NaRCAD:  Recruiting practices to participate is a challenge for many programs. How did this struggle transform into quality improvement?

We now offer Quality Improvement [QI] and MOC projects for implementing developmental screening, autism screening and postpartum depression screening in addition to a project that aims to increase the percentage of children who successfully connect with Early Intervention when referred from their primary care provider.  We have been thrilled with the response from physicians for participating in these projects and just received funding to continue and grow our outreach efforts. 

NaRCAD: What have been some other challenges you’ve faced when going in to talk to clinicians about implementing developmental screening?

Mindy:  I started working at ABCD unsure of how to provide physician outreach, so I naturally modeled my efforts on the one successful approach I knew very well, which was pharmaceutical sales.  As the recipient of pharmaceutical detailing, it was pretty easy to begin my outreach efforts in a similar fashion.  I quickly learned how it feels to be a detailer.  Front office staff rejected me repeatedly, I made hundreds of phone calls that didn’t get returned, and when I did get to speak to a provider I had to speak quickly and to the point to keep their attention.  The challenge of gaining access was the biggest barrier I confronted early on and remains at the top of the list.

​NaRCAD: When dealing with those challenges, what’s helped you to build relationships with clinicians in order to gain commitment?

Meagan: To deal with the challenges that arise, we have found that it helps to get creative in our approach to gain access to clinicians and add credibility to our messages. A barrier we have encountered when trying to schedule times to meet with clinicians is the expectation that we will provide food. Our funders and budgets do not allow us to pay for food, so we have opted to provide other incentives for clinicians, such as CME or MOC credit. Not only is offering CME/MOC credits an educational incentive for providers, but it lends credibility to our messages. We facilitate our QI projects through multiple meetings at the practice and have found that, by developing relationships and a presence in the office, we can overcome clinicians’ resistance to implementing screening or other changes in their practice. 

NaRCAD:  What other advice would give to a new and emerging AD program that’s just getting started, or that you’d give yourself if you could go back in time 10 years?

Meagan: We have found NaRCAD’s training and tips to be very helpful, so we would recommend that new clinical educators attend a NaRCAD techniques training to hone their skills in communicating their messages with clinicians and gaining commitment to behavior change. One of our main takeaways from the NaRCAD conference was the importance of high-quality, professional materials, so we would recommend that new programs budget for the development of professional materials as well as food, which can be an incentive when setting up meetings with clinicians.

Over the years, we’ve realized how critical it is to work with community partners before going into healthcare practices to ensure that clinical workflows, such as processes for making referrals to external agencies, are aligned with community-defined processes and so that clinicians are aware of the resources available to patients and families in their communities.

NaRCAD: Thanks so much for sharing important insights from your program to improve childhood health outcomes. We look forward to seeing you at a future training and hearing more about your program's future successes!

Mindy Craig, PA-C, M.S., Director of Physician Outreach, has been with the ABCD team for 8 years and brings with her experience in the clinical setting.  She earned her physician assistant degree at the University of Colorado Health Science Center’s Child Health Associate/Physician Assistant program in May 2000.  Concurrently, she completed additional course work and research to earn her Master of Science degree in Pediatrics.  Ms. Craig worked as a physician assistant in a number of settings for ten years prior to joining the ABCD team.  Her medical career has included a variety of medical office positions from medical records clerk to practice manager.  This range of experience positions her to fully understand the unique dynamics and flow in a typical office, which allows her to deliver technical assistance to practices at a meaningful level.
 
Ms. Craig’s quality improvement experience began in the business sector where she was extensively trained on Total Quality Management (TQM) at Northwest Airlines.  She worked at the airline as a facilitator, training inflight and ground personnel in the principles of quality improvement.  This experience with quality continued in the clinical setting, as she has participated in and/or chaired a number of quality improvement projects over her career as a physician assistant. In addition to her work at ABCD, Ms. Craig also does consulting work for organizations needing assistance with physician outreach and education. 

Meagan Shallcross, MPH, Healthy Steps/Physician Outreach Coordinator, joined the ABCD team in June 2015 as the Healthy Steps and Physician Outreach Coordinator. Meagan is passionate about building systems and environments that support children’s healthy development through clinical-community partnerships and integrated care delivery approaches. Meagan earned a Master of Public Health degree at the University of Michigan, where she supported Patient and Family Centered Care projects at the university health system and was involved with community-based participatory research addressing health equity, as well as research focused on provider-patient communication. 

Learn more at www.coloradoabcd.org. All photos used with permission. 

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!