We’re featuring a snapshot from an academic detailing visit with Corinne Puchalla, PharmD, BCPS, a clinical pharmacist and academic detailer at Illinois ADVANCE.
 
By Anna Morgan, MPH, RN, PMP, Senior Manager, Training & Education, NaRCAD
 
Tags: Substance Use, Detailing Visit

Hi Corinne! Can you tell us about a recent academic detailing visit that you’re proud of?
 
Academic detailing does not come naturally to me—each visit starts with excitement, nervous energy, and the tingling anticipation of the unknown:
 
Will the prescriber be in a good mood and be receptive to the key messages?
Will I be able to express myself adequately?
Will I negotiate the right “ask”?
 
NaRCAD’s training elevated my confidence in making “the ask.” I’ve learned how to set small, quantifiable goals and give the prescriber a short timeframe for follow-up.
 
My first academic detailing visit after the NaRCAD training had the potential to be a doozy. The topic for discussion was the CDC guidelines for chronic pain management, and I was scheduled to meet with someone who only dealt with acute pain management in cardiothoracic surgery. 

​Adding to my sense of foreboding was the knowledge that the prescriber had been singled out by her employer for this AD visit based on the number of opioid prescriptions she’d written. Using the communication strategies I learned at NaRCAD, I researched and prepared more for this visit than I had for any other. I practiced with multiple colleagues. On the day of my visit, I felt ready—but uncertain.
 
My practice paid off. What began as a terse, somewhat tense conversation with the prescriber turned into an educational, productive, and collegial visit. I used my AD communication skills to dovetail from one question into another, ultimately discovering how my key messages resonated with the prescriber.

​I’m proud of the strides I made during that AD visit. I remained calm despite my anxiety, used my research on acute pain management to ask open-ended questions, translated what I know about chronic pain to support her in the acute pain setting, and laid the foundation for a strong, collaborative relationship. Best of all, I made a solid “ask.” I’m motivated to do it all over again with my next prescriber and take each learning opportunity as it comes.

Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Biography. Corinne is a clinical pharmacist at the University of Illinois at Chicago (UIC) College of Pharmacy. She uses her passion for drug information and advancing patient care in her role as a clinical instructor and academic detailer. Her areas of interest include hepatitis C, migraine, and diabetes pharmacotherapy, and new drug approvals. Corinne is a proud graduate of the UIC College of Pharmacy, Class of 2016. Her enthusiasm for science, health, and helping others prompted her to pursue a career in pharmacy. Before beginning her career in pharmacy, Corinne was a symphonic bassoonist and also worked as personnel manager for The Florida Orchestra. She graduated from the University of Iowa with a Bachelor of Music in 2001 and from Indiana University with a Masters in Music in 2006.

An interview with Clement Chen, PharmD, BCPS, Clinical Pharmacist Specialist, Rutgers New Jersey Medical School.
 
by Anna Morgan, MPH, RN, PMP, Senior Manager, Training & Education, NaRCAD
 
Tags: Substance Use, Detailing Visits, Evidence Based Medicine

Anna: Hi Clement! We can’t wait to hear about all the impactful work you’ve been doing in New Jersey. Tell us a little about your academic detailing program.
 
Clement: The Northern New Jersey Medication-Assisted Treatment Center of Excellence was established in 2019 and is funded by the New Jersey Department of Human Services. Our goal is to not only increase access to medications for opioid use disorder (MOUD) in office-based addiction treatment practices, but also to ensure that providers treat this chronic disease with evidence-based practices. Our vision is to end the stigma of addiction and ensure that all people with substance use disorders have access to high quality care so they may live full and satisfied lives. I was hired as the academic detailer to provide education and identify the needs of providers in these practices.

Anna: Tell me more about the types of providers you visit.

Clement: I’ve been working with providers from all areas of care. In addition to office-based providers, they also include those from hospital settings, psychiatric hospitals, community health centers, substance use licensed facilities, and prison settings.

Addressing the substance use crisis requires an “all-hands-on-deck” approach. Any setting where patients seek care are environments where detailing can improve patient access to support.

Anna: It’s so important to approach academic detailing with a wider lens and consider where it can fit in with other community initiatives. Can you walk us through some of the work you’ve done so far, or are planning to do, in each of these settings?

Clement: I’d be happy to!

Hospital Setting: One of the inner-city hospitals that we are working with is looking to establish an addiction medicine service within their hospital system. The goal is to provide trainings and consultations on best practices for addiction medicine, in addition to technical assistance in setting up a program. I’ll be working with their attending physicians and residents to provide evidence-based practice trainings. 

Another one of our partners, an addiction medicine provider, has been pushing for greater initiation of MOUD in her own hospital system. The main issue is to ensure that providers use MOUD in an evidence-based manner and adhere to the latest findings. For example, the provider has been receiving pushback from other providers due to the lack of referral sources. These providers have shared that they believe MOUD should not be initiated without a “warm handoff.”

Furthermore, buprenorphine has been discontinued during the pre and peri-operative settings and only resumed post-operatively despite growing evidence for continuing buprenorphine in these settings. I plan to detail these providers in-person to provide literature supporting the use of MOUD, even when warm handoffs are unavailable. I’ve provided supporting literature and a summary to the addiction medicine provider to assist with her case to expand this initiative, which helped her to develop an information sheet to justify the expansion of MOUD in her hospital.

Psychiatric Hospital Setting: We’ve also partnered with physician champions at some of the psychiatric hospitals in New Jersey. Stigma and the inaccurate idea that patients do not experience acute withdrawal for opioid use has made many providers hesitant to start therapy with buprenorphine. Psychiatric hospitals have been fervently looking to provide treatment for opioid use disorders.

The goal is to implement a clinic designed for initiating and maintaining those on buprenorphine and naltrexone extended release. We’ll be assisting with the implementation of the clinic and provide individual in-person detailing visits for the providers at the hospital. To prepare for this, we’ve developed several informational sheets on MOUD and other related information to give to the providers.  

Community Health Center Setting: One of the community health centers that we’ve partnered with wants to begin providing MOUD for those already on the therapy. There are several advanced nurse practitioners and physicians at the health centers looking for more guidance and support on the appropriate prescribing of buprenorphine. I’ll be working with their team to provide them with evidence-based practices and help them with buprenorphine induction strategies. 

Substance Use Licensed Facility Setting: One of the substance use licensed facilities I’ve consulted with mentioned that fentanyl has made initiation of buprenorphine very difficult due to the increase in the number of cases with precipitated withdrawal. As a detailer, I’ve worked closely with their lead providers, providing them with available literature on alternative buprenorphine induction strategies. They're in the process of updating their protocols for the induction of buprenorphine. Another facility is working with us to start prescribing MOUD within their residential settings.
​
Prison Setting: I regularly consult with the Department of Corrections providers since access to MOUD have traditionally been low in the prison system. Their patients also have unique needs compared to those in the community setting. I meet with them on a monthly basis via a case conference and discuss clinical solutions in order to help them provide the best care to their patients. ​

Anna: Your work is incredibly comprehensive and thoughtful. It’s truly amazing to see how your team has incorporated academic detailing into so many initiatives and clinical settings within your community.

Clement: We believe that to overcome this crisis, all patients with opioid use disorder need equitable and timely access to care. With the record number of overdose deaths reaching over 100,000 in one year, this is our greatest focus. We’re confident that our academic detailing work will help us achieve this goal.

Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Biography.  Dr. Clement Chen graduated from the Ernest Mario School of Pharmacy at Rutgers University in 2013 with his Pharm.D. He then completed a one-year residency at the Hudson Valley Veterans Affairs Ambulatory Care Clinic. Thereafter, he has worked as a staff pharmacist at St. Michael’s Medical Center in Newark and as a cardiology heart failure clinical pharmacist specialist at University Hospital in Newark. In addition to working as a clinical pharmacist specialist, he was a Transitions of Care pharmacist at Hunterdon Medical Center from 2016-2020. This has helped him to balance his inpatient and outpatient roles as a pharmacist. To further demonstrate proficiency in clinical pharmacy care, he received his Board Certification in Pharmacotherapy in July of 2016.  His current role is as the academic detailer in the Northern NJ Center of Excellence, with the goal of providing education and support to increase statewide capacity to provide medications for addictions treatment (MAT) for patients with substance use disorders with a focus on opioid use disorder.

Aanchal Gupta,  NaRCAD Program Coordinator

Tags: Conference, Detailing Visits, Stigma, ​E Detailing, ​Opioid Safety
​
​Take a peek at the NaRCAD2021 conference materials on our Conference Hub.

Bevin Shagoury
NaRCAD Deputy Director

Tags: Conference, COVID 19, ​Detailing Visits

Unless you’re delightfully old school, I’m going to guess that you’re not holding the page you’re reading in your hands. That’s been a tough adjustment for those of us who prefer a paperback to a Kindle, or for those of us who miss unfolding an inky newspaper in the morning.

In either case, this trend toward the intangible has been in motion for a long time, even pre-pandemic (if you can still imagine a world without COVID). We’ve been forced to step up the transition from tangible to virtual, seemingly at warp speed. And yet, as always, we’ve found ways to adapt.

In a field like ours, where our work relies so heavily on the intricacies of human interaction, the inability to see nonverbal cues (at least, none below a clinician’s shoulders) during an e-detailing session could have easily thrown us off. If AD was the focus of a Netflix series, we could have entire episodes that depict the harsh reality of being “ghosted” after setting up a virtual visit, or trying to engage with a clinician who’s typing in chart notes while eating a sandwich.

We’re featuring a snapshot from an academic detailing visit with Reem El-ankar, MPH, an academic detailer and health educator at the Florida Department of Health in Broward County.
​
by Anna Morgan, MPH, RN, PMP, Senior Manager, Training & Education, NaRCAD

​Tags: Substance Use, Stigma, ​Detailing Visits

Hi Reem! Can you tell us about a time that you felt like you made an impact during an academic detailing visit?
 
I’ve experienced countless rewarding moments as an academic detailer working to educate healthcare providers.
 
One particular visit instilled a strong sense of satisfaction and pride in me. I was detailing a primary care clinician who manages several chronically ill patients. He was aware of the CDC guidelines and statistics on the opioid crisis. Because the clinician was well-versed in this area, it was challenging to serve as an educator. I walked through the key messages with him, and we made progress.
 
We hit a roadblock when we started discussing the topic of co-prescribing naloxone with opioids. He expressed a concern that co-prescribing naloxone could encourage patient overuse of prescription opioids; he believed that naloxone should only be used as a safety net for individuals diagnosed with substance use disorder.

​I reviewed the evidence with him, showing him that co-prescribing naloxone can save lives for all patients using opioids. After I provided the CDC data and studies that describe the benefits of co-prescribing naloxone, the clinician was more receptive to the information I was presenting.
 
At the conclusion of the detailing visit, I reminded him that saving one life with naloxone was worth the effort, and that his primary mission is to save lives. After that he smiled and said, “Okay, you got me.” I asked him if he could commit to co-prescribing naloxone to just one patient, and his response was, “Due to your clear passion for this national crisis, I will prescribe much more than just one.” This experience taught me that my passion coupled with data and statistics has the potential to impact lives.


Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Biography. Reem El-ankar is an academic detailer, health and community educator, and public health professional. She holds a bachelor’s degree in pharmaceutical science from the Hashemite Kingdom of Jordan, and a master’s degree in the public health from Purdue University Global - Indiana, US.

Before joining the department of health, she worked in the private and the non -profit sectors as a pharmaceutical representative (Kuwait), and a community outreach and a HRSA grant coordinator, respectively.
 
During her internships with the American Red Cross and the local department of emergency managements, she worked in community preparedness and emergency response field on the national and international levels.

An interview with Julia Bareham, BSP, MSc, Information Support Pharmacist, Academic Detailer, RxFiles Academic Detailing, College of Pharmacy and Nutrition, University of Saskatchewan. 

by Anna Morgan, MPH, RN, PMP, NaRCAD Program Manager

​Tags: Substance Use, Stigma, ​Detailing Visits

​Anna: Hi Julia! We’re so excited to feature your work on DETAILS. You’ve had over a decade of experience with academic detailing. Can you tell us about your academic detailing journey?
 
Julia: I was hired by RxFiles in 2009. Shortly after starting with RxFiles, the program began working on a long-term care project and that became my focus until I left in 2015 to work in the prescription monitoring program in my province in Canada. I returned to RxFiles in 2019 and have since been working on helping to increase Suboxone prescribers in Saskatchewan. 
 
Anna: It’s nice to have you back in our detailing community! What are some of the unique challenges that you’ve faced since returning to the field and detailing on this particular topic?

Julia: I think the most obvious answer is the global pandemic, which is a challenge that everyone has faced. For me, building relationships with clinicians through videoconferencing has not been easy. Reading your audience via videoconferencing is challenging, and that’s if you're fortunate enough that they'll have their cameras on!
 
In terms of the topic itself, many prescribers are unfamiliar with prescribing Suboxone and there is still some stigma related to opioid use disorder. Presenting the appropriate information to prescribers to properly assess, treat, and troubleshoot is key. Prescribers also must be authorized by their regulatory body to prescribe Suboxone in our province, which includes an educational program and mentorship.
 
To help make prescribing Suboxone less overwhelming, we created a Suboxone 101 resource for our detailing visits where we introduce clinicians to the treatment option and some of the main considerations around it. We also created a longer resource that walks through a detailed approach of assessing patients and prescribing Suboxone if clinicians indicate that they want to learn more. We’ve received positive feedback on our 101 resource and have had a lot of interest in our longer resource, which we plan to detail interested clinicians on in the near future.
 
Anna: Thanks for catching us up on some of the ways your program has approached detailing on this topic. Let’s talk a bit about being a detailer – what are some of your tips for being a successful detailer?

Julia: That’s a great question.

1. Be prepared and know your topic well. The clinicians that we detail trust that the information we provide is accurate, evidence-based, and current. I always want to make sure that I come prepared with the best information, that I’m knowledgeable, and that I can answer any question to the best of my ability during a detailing session.
2. Be comfortable saying, “I don’t know.” There’s a danger in academic detailing if a detailer is unsure of something and is uncomfortable saying that. My biggest fear as a detailer is that if I’m not confident in my answer to a clinician or if it’s incorrect, then it could result in suboptimal patient care. It’s not always easy to say that you don’t know the answer to something, especially when you value being so prepared.
3. Be flexible. Take the conversation in the direction that the clinician would like to go. I always remember that I’m there to support the needs of the clinician and let them drive the conversation, even if I have a script prepared. Being able to do that is extremely valuable to the clinician you’re detailing and makes your visit personalized and relevant.
4. Leverage your personal superpower. It’s important to be true to who you are during your detailing visits. Our personalities are all unique and bring so much value to each visit. My personal superpower is humor and that’s how I connect with clinicians and build that relationship right off the cuff. It’s not always the best tool for everyone but knowing what you’re good at and leveraging it is crucial.

Anna: These tips can be applied to work beyond detailing as well! How has your team supported you in using those skills and qualities to become such a successful detailer?
 
Julia: I have an amazing team; we all have unique personalities and different approaches to detailing. They give me insights into how I might want to approach a certain topic when I’m in the field. I always gain new perspectives through trainings with my team, observing detailing visits, and debriefing after visits.
 
It’s especially nice to be able to debrief with colleagues when things don’t go as planned during a detailing visit. Sometimes the debriefs are long discussions and sometimes they are a quick text message to share what happened. Our team is honest and vulnerable with one another, which helps elevate the work that we do because we can support each other during challenging times.
 
We share wins with one another during debrief sessions as well. There's nothing better than a visit when you feel like you did an awesome job and really helped the clinician you detailed. It’s important to put that wind back in your sails!
 
Anna: Speaking of wins, can you share a story from the field when you felt that you made an impact as a detailer?

​Julia: Absolutely. When I first started detailing, I detailed clinicians at a neighboring clinic to the pharmacy I worked at. One of the first topics I detailed on was gout and we had a key message around selecting the best non-steroidal anti-inflammatory drugs (NSAIDs) to use for treatment. I found that most of the prescribers I detailed were prescribing a less than optimal NSAID when it came to an acute gout flare. When I was later chatting with one of the clinicians at my pharmacy about a prescription that he had written, he said at the end of the conversation, “Oh, by the way, I just want you to know, I have changed how I prescribe for gout after meeting with you.” In that moment, it was clear to me that he wanted me to know that he listened to the evidence that I had shared with him and had changed his practice as a result.
 
I knew that prescribing different NSAIDs for gout was probably not going to save lives but knowing that the clinicians were listening and valued what I had to share with them let me see that I could have an impact on them.
 
Anna: That sounds like it was a nice boost of confidence for you as a new detailer. We’ll wrap up with our final question. Is there a piece of advice that you would offer to new detailers?

​Julia: For your work to be fulfilling and for you to have that sense of satisfaction, it needs to be meaningful. We want to know that the work that we do matters and that we're making a difference. I find that it can be hard to see that right away with academic detailing. Sometimes I might just be confirming that a clinician’s current practice is still the optimal approach and other times I might be causing a clinician to reassess how they might make future drug therapy decisions. Don't underestimate the impact you might be having on a clinician, and consequently patient care, in doing the work that you do.
 
Anna: Thanks for sharing your perspectives, Julia! We look forward to hearing more about your impact in the future.

Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Biography. Julia joined the RxFiles team in 2009 and until 2015 she provided academic detailing services across the province of Saskatchewan, primarily focusing on medication optimization in the long-term care population. During that time, Julia also returned to the University of Saskatchewan to pursue her Master of Science degree in the division of Pharmacy focusing on comprehensive medication management, graduating in 2014. In late 2015, Julia joined the College of Physicians and Surgeons of Saskatchewan where she held the position of Pharmacist Manager for the Prescription Review Program. In early 2019, Julia returned to RxFiles and is currently focused on opioid use disorder, in addition to medication therapy in both geriatrics and psychiatry.   

An interview with Kelsey Genovesse, PA-C, MPAS, Public Health Detailer and Clinician, AIDS Education Training Center (AETC), University of Utah Infectious Disease. The public health detailing program at the AETC is currently focused on expanding pre-exposure prophylaxis (PrEP) throughout the state of Utah and educating clinicians on STI prevention and guidelines for correct treatment.

by Anna Morgan, MPH, RN, PMP, NaRCAD Program Manager

Tags: Detailing Visits, ​E Detailing, ​PrEP

​Anna: Hi Kelsey! Thanks for joining us on DETAILS today! Can you tell us a bit about your background, your current role, and your program? 
 
Kelsey: I’m a physician associate (PA) by training and previously worked in family practice with underserved communities, including migrant farmworker populations and patients in federally qualified health centers.
 
Our program in Utah is tiny; our AETC only has three or four employees. I do the outreach, schedule the detailing sessions, detail the clinicians, collect the data, and evaluate the program. We’re fortunate that our first year was so successful and we’re looking forward to continuing to expand our program over time. This year, we were even nominated for a Utah Telehealth Education Award!
 
Anna: That’s incredible – what a great accomplishment! Your program is unique in that it started with e-Detailing right from the beginning. Can you tell us a little bit about that?

Kelsey: We attended an in-person Public Health Detailing Institute run by the San Francisco Department of Public Health in partnership with NaRCAD in March of 2020. We had planned to focus on in-person detailing only in Northern Utah because we didn’t have the capacity to drive all over the state. Shortly after we left the training, the pandemic shut everything down and we had to move our program to a virtual platform. We couldn't put the program off because our funding timeline wasn’t changeable, so we gave e-Detailing our best shot.
 
Anna: Your attempt at e-Detailing turned out to be quite successful. Can you tell us more about the nitty gritty of pivoting to e-Detailing?
 
Kelsey: Absolutely. When it became clear that we were moving to e-Detailing, we had to recreate our entire plan. We began with strategizing about outreach to clinicians.
 
Nobody in Utah knows what public health detailing is - this is not a model that has been used here before. We had to get creative about spreading the word about our program. We connected with experts on our topics and clinicians who were already doing a lot of training on PrEP and asked them if they wanted to do a detailing visit with us. This was extremely successful, and we received referrals and warm handoffs to other clinicians from those initial visits.
 
We also used a lot of listservs so that we could contact multiple clinicians at once. We worked with the Utah Department of Health and gave them a flyer we created about our program that was sent to all the clinicians on their listserv. We even connected with local medical groups, like the Utah Medical Association, a PA Association, and a Nurse Practitioner Association. These approaches brought in a lot of clinicians for detailing visits and helped us spread the word.

​Anna: Rather than emailing each clinician and sending out hundreds of individual emails, you targeted hundreds of clinicians at once – I love that approach! It sounds like you also had some great AD champions in your network.
 
Kelsey: Yes. I found that I was also doing a lot of e-Detailing sessions with folks who were not clinicians but were involved in the healthcare system in another capacity. I discovered that when I was connecting with these folks, whether it be someone at the health department or a representative from a health-based community program, they were wonderful champions who knew a lot of clinicians. Visits with these non-clinicians also helped spread the word about our program and open access even more. 
 
Anna: Many programs have faced challenges when gaining access virtually, but you were able to overcome many of these challenges with your innovative approaches. Has your program faced any other challenges with e-Detailing? 
 
Kelsey: We frequently detail clinicians who are short on time. I’ve tried to create a schedule where I have a little bit of availability, almost seven days a week, so that there are more options for clinicians whose schedules are busy. I also try to keep the detailing visits focused on the topics that clinicians are most concerned about. I always send them a comprehensive follow-up email with the resources they've asked for after the visit. 

Anna: Clinicians’ limited time is a common challenge for detailers—these strategies are helpful to employ when this challenge arises. Do you see specific opportunities with e-Detailing that you wouldn't see with in-person visits?
 
Kelsey: Yes! Within our first year, we connected with providers in rural areas that may have taken us a longer time to gain access to using an in-person approach.

Anna: That’s a great point, especially for a state as large as Utah. Do you envision incorporating any in-person detailing in the future? 
 
Kelsey: We’ve had a few clinics that have asked for us to come in person, but as we just discussed, it can be time-consuming. However, there is something to be said about showing up and seeing what a town or clinic looks like in order to understand a community structure better. We’re going to try adding it in in the future.
 
Anna: Being physically present in a clinic can certainly help with assessing the needs of a clinician. You mentioned earlier that within your role you’re not only doing outreach and detailing visits, but you’re also working on your program’s evaluation. Can you share a bit about that?
 
Kelsey: Kristefer Stojanovski, MPH, PhD, the Evaluation Specialist from San Francisco Department of Public Health, has helped us tremendously with our evaluation work. We have pre- and post- surveys for clinicians to fill out with each detailing visit to collect data related to their knowledge around the clinical topic. It has an open format at the end to allow clinicians to request certain information prior to their first visit and leave feedback and comments. I'm hoping that as our sample size increases, that the data starts to look a little bit more robust.
 
At the end of last year, we also sent an email asking clinicians to give us feedback on how they felt their experience was and if they felt like this was a program that was worth continuing. At least a third of our detailed clinicians sent back responses, and all of them were very positive. Most of the feedback reflected on how useful the information was when it was tailored and directed to their personal practice. A couple of clinicians noted they felt they were practicing to the standard on the topics, but detailing helped them gain knowledge they were unaware they were missing. It was nice to see that folks felt that it was useful.

​Anna: We’re excited to hear more about your evaluation as you gather more data. We'll wrap up with our final question: what’s one piece of advice you'd give to other programs that are just starting out, specifically with e-Detailing?
 
Kelsey: Be flexible in your approach – group detailing sessions or detailing sessions with non-clinicians can be extremely effective, and can lead to 1:1 clinician visits. Also, stay organized! Keep track of who you're reaching out to and who you're following up with. Having all that information tracked over time will help with your evaluation down the road.
 
Anna: That's fabulous advice, Kelsey. We’re looking forward to continuing to watch your program grow and succeed!

Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Biography. Kelsey Genovesse is a Physician Associate with the AIDS Education Training Center and University of Utah Infectious Disease Department. After eight years in underserved family medicine Kelsey started the Utah Public Health Detailing Program to expand support and education to providers throughout the state of Utah on evidence based practices surrounding STIs and PrEP. She also provides care in the Free HIV PrEP Clinic with the University of Utah offering in person and virtual services to help expand access to HIV Prevention throughout the state of Utah, specifically to those without insurance. In June 2021 she was Nominated for a Deborah LaMarche Telehealth Excellence Award for her work with the Utah Public Health Detailing Program.

​Anna: Hi, Alisha! Thanks so much for joining us on DETAILS today. We’re excited to chat with you about UPDATE New Mexico and the tips you have for building relationships. Can you tell us a bit about your program?
 
Alisha: Absolutely! We provide evidence-based information and recommendations around chronic non-cancer pain management. We’re expanding the service to include information on medications for opioid use disorder so healthcare professionals can better serve their patients in our rural state of New Mexico. We offer rural healthcare providers, who may feel somewhat isolated, an opportunity for continuing education that typically might only be available in bigger cities.
 
Anna: It’s wonderful that your team offers these resources – we know that there are often limited resources in rural areas. Detailing in rural areas also brings up additional challenges for the detailing team, but you do such a great job keeping your team engaged and feeling connected. Can you tell us a little about your team and the recruitment process?

​Alisha: Geographically, New Mexico is the fifth-largest state in the country, but we only have 2 million people living here. All we do is network, network, and network. Whenever we're looking for detailers, we use our existing networks to talk to people and spread the word. Many people have heard the term six degrees of separation, but here in New Mexico, there’s only about two or three degrees of separation. Word travels fast when we share job opportunities with our partners.
 
In terms of resources we’ve used for recruitment, we’ve adapted the generic job description on the NaRCAD website and circulated that throughout our network. The detailers we’ve hired all hail from different backgrounds, disciplines, and parts of the state. However, we make sure that they have a few common attributes – excellent communication skills, the time and resources needed to devote to the program, and the ability to share their perspective with others on the team.
 
Anna: Along with recruitment, you’ve also put a lot of work into building your team. Can you share one of your approaches for building a strong and effective team?
 
Alisha: One of the ways we keep our team engaged is through monthly meetings. Because of the diverse backgrounds of our detailers, there’s always a rich exchange of ideas and perspectives when we convene. We also invite our clinical support team so that the detailers have a chance to discuss the clinical content with experts. We connect, troubleshoot, and share insights - our entire team looks forward to these meetings.

​Anna: Creating a space to share and exchange with peers is key, especially for such a unique job like detailing. Your team also recently worked together to create a commercial to help get the word out about academic detailing and continue to build relationships with the larger community. What was that process like?
 
Alisha: Once the COVID-19 pandemic began, we knew we had to have another venue to capture our audience's attention in the virtual world and continue to spread the word about our academic detailing service. Near the end of 2020, we met with a couple of different video production agencies to learn more about creating a commercial and the resources required to make it come to life. We reallocated some marketing funds and picked a production team. We shared our vision of what we wanted to accomplish, outlined a few ideas, and they helped us refine a script.
 
The fun part was putting together a cast. The detailer is played by one of our own detailers, the doctor is played by one of our clinical support team members, the patient is played by my fiancé, and the clinical staff member is played by our program coordinator. We didn't have to pay for our cast, which helped us cut down on cost; however, we did have to hire a dog for the commercial since I couldn’t bring my own due to the distance to the filming location! Overall, I’m very pleased with how it turned out.

​Anna: You should be – it’s so well done. What other approaches have you taken to gain access to clinicians or get the word out about academic detailing?
 
Alisha: Relationships are key in New Mexico, as they are in every other place. We have partner organizations working in the community on overdose prevention who have been tasked to prioritize marketing our detailing service to clinicians. We also met with our medical board and asked them if our service could qualify as a mechanism for healthcare providers to receive their required pain management CME. They supported our request and that ended up being a huge win for our program. In addition to being detailed, clinicians can also get free CMEs.
 
On the marketing side of things, we've tried just about everything over the last year since we expanded statewide - postcards and flyers, newsletters, webinars, and social media. We’re now working on trying some more targeted approaches, like Google Advertisements. For example, if a provider is googling "free pain management CME in New Mexico," our program might pop to the top of the list. 

Anna: It’s clear that you’ve used approaches that align with your goal of building strong relationships throughout your state – I can’t wait to hear how your new approaches have worked next time we chat. Let’s pivot to our final question to wrap up today. What is one piece of advice you'd give other programs that are looking to replicate your program's success?
 
Alisha: I would say don't get discouraged if you don’t see as much demand as you would hope for when you’re first starting out. Like everything else, it takes time. It takes time to educate providers on what and how this service is being offered. It also takes time to alleviate some of those misconceptions that this is “just too good to be true”. So be patient, talk to people, and listen twice as much as you talk to build those relationships.
 
Anna: Thank you so much for sharing that, Alisha. It’s an honor to work and learn from you and your team. We appreciate all the tips you shared today an we hope to catch up with you soon!

​Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Biography. Alisha believes that communities should be engaged in developing solutions and driving decisions that affect them. Having lived in New Mexico for eight years, she deeply values the strengths, resiliency, and beauty of New Mexico’s communities. Alisha has facilitated CHI’s leadership team since its inception and together, they continue to challenge the status quo by creating an environment in which social and health conditions allow individuals, families and communities to thrive.
 
As a program manager at CHI, she supports opportunities for critical linkages across partners; promotes shared decision making, researches and implements innovative frameworks, and works to address social and racial inequities. Alisha manages UPDATE NM (Understanding Provider Demands and Advancing Timely Evidence), CHI’s academic detailing program; serves as PI for the HRSA RCORP (Rural Community Opioid Response Program) Implementation project and directs the organization’s Project ECHOs for systems change. Some of her past professional endeavors include health education, training and teaching medical interpretation, ESL and motivational interviewing.

Overview: Loren Regier, a NaRCAD Expert Training Facilitator, joins us to reflect on nearly 25 years of his AD career, his experiences in learning AD for the first time, and his role in being a mentor to a new generation of academic detailers. Loren is a hospital pharmacist by training and has served with the RxFiles Academic Detailing Program and the Centre for Effective Practice, both longstanding Canadian AD programs.

by Winnie Ho, Program Coordinator

​Tags: Detailing Visits, International, Program Management, Sustainability, Training

Winnie: We’re delighted to hear more about your AD journey, especially about the ways in which you continue to be a leader and supporter of the AD journeys of many others. Can you tell us a little bit about how you got started in this field?

Loren: I was a hospital pharmacist doing a lot of work related to clinical decision-making, public speaking, and education.  The Director for our Saskatoon Health Region (SK, Canada) had come across academic detailing from a colleague in Vancouver, and was interested in piloting something similar to what is now the British Columbia Provincial AD (BC PAD) Service.  

​Our region needed someone who would take on this project and build something from scratch. Only partly knowing what I was in for, I said “yes”. To train and learn more, I had the chance to shadow Terryn Naumann in June of 1997. Terryn was the pioneering solo detailer in North/West Vancouver. What was initially a 1-year project for us, became a 2-year, and then a 3-year project, eventually morphing into an ongoing AD service that expanded to cover our  province of Saskatchewan.

W: That’s incredibly fortuitous that you had Terryn to turn to for help! We’ve gotten to interview her before at DETAILS and know that she was a trailblazer for AD across Canada.
​ 
Before I ask you about your experiences now as a mentor to others, I would love your reflections on your experiences as a mentee back in the days when you were learning AD as a new trainee with Terryn as your guide.
​ 
L: There are both good days and difficult days to think back to – it involved a lot of hard work, but I was fortunate to have an awesome mandate and the opportunity to see another successful service in operation.

​Most importantly, I was able to see what a successful visit looked like. I joined Terryn for 7 visits over 2 days. After each visit, we reflected on how the visit went, what we liked, and if there was anything one might handle differently. The opportunity to shadow Terryn instilled in me the vision that academic detailing was about both relationship and service, and that clinicians could find both aspects valuable and enjoyable.

W: We do encourage a lot of new people starting AD for the first time to try and find someone to tag along with. You were especially lucky with Terryn because she had had a few years to build up her network and relationships in her community.

L: Relationships are key in AD – and witnessing those relationships and the resulting AD conversations – was educational and inspiring.
​
W: Is there a particularly strong piece of advice or a mentorship experience that sticks with you to this day? 

L: One of the things I recall is that she said, “One day, when you have a tough visit, I want you to call me, because I’m one of the only people who will understand what you’re going through.” Well, the day came when I had to call Terryn and we were able to debrief on a challenge I had faced. That was a critical moment that served to propel me forward with greater insight and confidence.

W: You bring up something important – our work is focused on creating safe learning spaces for providers in order to enact change. What we’ve been able to expand on are the connections between individual members of the detailing community. Luckily, the field has grown and new detailers have many more role models and teachers to learn from.
​
Let’s also talk about this vulnerable moment, because it requires a lot of trust to go to someone when something goes wrong.

L: The mentorship process ideally involves deep, authentic discussions about being a detailer.  Being a detailer involves constantly putting your best self forward. Trust allowed both of us to open up to each other with lots of safe space to discuss our different approaches and experiences.

Trust is essential for effectively exploring differences of opinion, and how to turn challenges into opportunities. Without it, you don’t get to understand where someone is coming from or to truly grow and learn.
​
In addition, I need to mention Frank May who also became valued mentor over the years. Frank  helped pioneer academic detailing in Australia. His thoughtful conversations and leadership were instrumental in my growth in AD, as well as my eventual role in helping train and mentor  new detailers.

W: I have definitely seen the large and small ways that mentorship has propagated through the AD community. In the process of learning and educating others in this field, we never truly stop being mentors or mentees – it’s not a binary. It’s a great lifelong process.

Let’s flash forward to now: given your experiences, how have you continued to integrate mentorship into your current work?
​ 
L: A big part of my role these days has been training, mentoring, and supporting others - both academic detailers and those who are moving into program leadership. It’s important to recognize that the world needs more people to do this kind of work and that we need to pass the baton. That involves coming alongside their journey, having good discussions, and being able to dig deep into those critical ingredients for success.

It has meant being transparent about my decisions and leadership so that my team can not only see how I’m thinking and processing things, but also provide their own input and ideas. Being a mentor to me means modeling the approach of learning together and working enthusiastically and collaboratively when pursuing opportunities.
​ 
W: You’re in a capacity now where you’re training future leaders in AD. You provide an important link and opportunity to reflect on where AD has been, but also the space to give new AD folks a chance to figure out where AD may go next. The people you mentor now will likely go on to mentor others, just as Terryn and Frank did for you. What advice would you give to those who are seeking to be strong mentors?

L: People can sense if they are respected and valued.  If they know you care and are interested in their growth, they will open up, share the important stuff, and work together to address the challenges of academic detailing.  If you add some fun and enjoyment along the way, the process serves as a model of what will eventually happen between the detailer and those they detail.
​ 
W: That’s wonderful advice, because one of the best things you can do for someone who is learning is to fully believe in their potential and strengths. They’re already a part of your team – they’re there for a reason.

L: Somebody once asked the coach for Bobby Orr, one of the greatest Canadian Hockey players of all time, “How do you coach Bobby Orr?” and the reply was, “You don’t coach Bobby Orr, you give him room to play the game.”
​
There’s some truth in applying that to leadership and in AD.  You need to appreciate where your team members excel and empower them. It means coming alongside, supporting their input, and also giving them the freedom to make their own mistakes and learn from them. Give people the support they need to do best. They’ll show you what they’re capable of.

​Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

LoLoren Regier is a Pharmacist and Consultant Editor with RxFiles Academic Detailing Service in Saskatoon, SK, Canada.  Loren has guided the development of this provincial academic detailing service since the first “ground breaking” pilot project began in 1997.  Loren is active as a member of the Canadian Academic Detailing Collaboration and provides training and consultation to various programs and initiatives.  Loren’s interests cover the practical application of evidence to practice and the ongoing development of multifaceted interventions that support academic detailing.  Additionally, Loren serves as a faculty facilitator for NaRCAD’s Academic Detailing Techniques trainings.

Loren is co-editor of the RxFiles Drug Comparison Charts – 10th Edition and a contributor/reviewer for Geri-RxFiles and the RxFiles – Bringing Evidence to Practicesection of Canadian Family Physician journal.  Loren obtained his degree from the University of Saskatchewan, College of Pharmacy in 1988 which he followed with a hospital pharmacy residency.  He serves as a lecturer, instructor and preceptor in the areas of evidence informed drug therapy decision making, educational outreach and chronic pain management in a wide variety of professional settings

Overview: Harald Langaas speaks with NaRCAD about his experiences in co-founding Norway’s first national AD program, KUPP. KUPP, which loosely stands for “Knowledge-Based Updating Visits” in Norwegian, has been actively serving Norwegian General Practitioners (GPs) for several years.

by: Winnie Ho, Program Coordinator

​Tags: Chronic Illness, Detailing Visits, Evaluation, International, Program Management

Winnie: Hi Harald, thank you for joining us all the way from Norway to talk about KUPP, the Norwegian Academic Detailing program! Can you tell us a little bit more about yourself and the work that KUPP does?
 
Harald: I’m a pharmacist by training, with experience in working at hospital pharmacies and as a pharmacy manager in the private sector. My interest has always been in how to better provide independent information about the use of medicines to healthcare professionals to improve the quality of healthcare. I work for one of the four Regional Medicines Informational Centers in Norway, one for each of the four health regions.
 
The Norwegian AD Program is strongly connected with those Centers, so my position is split between the regional center and as Director of KUPP, which operates at the national level. KUPP is a small organization – it’s myself and a consultant in clinical pharmacology handling the administration of AD.

W: I can absolutely see why AD fits a lot of your interests! Let’s talk about how KUPP got its start. You were part of the founding of a brand new AD program. What was that like, and what did you learn?
 
H: My colleague Roar Dyrkorn had visited Australia, met the NaRCAD team in Boston, and was very inspired by AD. He saw it as an opportunity to improve the quality of prescribing in primary care and began lobbying to acquire funding for an AD program.
 
Our first campaign in 2015 was put together within a month or two, focusing on NSAIDs (Non-steroidal anti-inflammatory drugs) for GPs. We were extremely fortunate to have Debra Rowett from Australia, who has been pioneering AD in Adelaide for many years, fly out to train our first detailers because we were still novices to this work. This campaign went quickly – maybe too quickly -- but we were able to implement it well, and we had success with the campaign. We’ve been continuing to detail ever since.

W: You also mentioned that Norway is divided into four health regions. Can you tell us a little bit more about these regions and the communities that you serve in each?
 
H: The four jurisdictions, all funded and overseen by the government, are responsible for hospital services in that region. However, primary care services are overseen at the national level. In each region, KUPP has between 5-10 people that are trained as detailers and conduct visits in addition to working at the Regional Medicines Information Centers or at a Clinical Pharmacology department at a hospital.
 
W: On average, how many clinicians does KUPP work with per year?
 
H: There are about 5,000 total GPs in Norway, and we visit between 1,000-1,200 GPs a year, which is about 20%. We have limited resources while trying to reach as many providers as we can nationally. For the funding we have, we’re happy with our work, but of course, we are ambitious! We want to be able to visit everybody.

W: That’s a pretty sizable population that you reach, especially on limited resources! Can you provide some context about Norway’s healthcare system that help us better understand the context in which KUPP operates?
 
H: In Norway, we have universal healthcare, which is fully funded by the government. It means that our healthcare system is quite homogenous across the country. The GPs that we focus on are mostly self-employed, but fully funded by the government. This does mean that when we make arrangements to schedule detailing visits, we have to contact GPs one at a time.
 
They have no financial incentive to see us, and since we take up their time instead of them seeing a patient, they actually lose money by seeing us. This means that we have to ensure that a visit from us is useful and that it’s a valuable investment towards improving the treatment of their patients. We keep all visits to 30 minutes or less.
 
Another important thing to mention is that patients are designated to their GPs. You can’t shop around for providers, so you have to see the same one each time or apply to change to another one. This means that a GP follows their patients for a long period of time, and have a lot of history with their patients.

W: That’s useful background information to know about. Since patients often stay with the same and only GP, how does that impact a GP’s insight into their patient population?
 
H: Because of the long shared history, it means that when we are talking with clinicians, they know their patient pool very well. Even when a GP has taken over a practice, they will be very knowledgeable about who they are serving.
 
W: I imagine that when detailing on chronic conditions, this is an advantage because a GP and a detailer can follow a patient population over time and offer continuous support! Now, we’ve been able to follow KUPP’s work for a while, especially with a lot of your recent presentations and research. How are things going with research and evaluation lately?
 
H: It’s always been useful for us to evaluate and publish our results, especially when we approach the government for more funding. While we can’t do every campaign as a research project, I’ve been working on evaluating a campaign we did on diabetes and also a study on the impact of group visits vs. 1:1 detailing.

We’re also working on a small qualitative evaluation of our virtual visits at the moment. It’s been exciting to be contacted by other research groups who want to work with us. It’s really inspiring for us to know there are groups who want to learn more about AD because of us, and that we’re being noticed and seen as a good research partner.

​W: It’s always exciting to see where AD travels and how many borders it can cross. We always learn more because the AD community is constantly growing and innovating. As someone who has been at the forefront of establishing AD abroad, what are your hopes for the international AD community at large?
 
H: I would sure hope to see more AD programs emerging in Europe. It would be very helpful to fully connect the AD initiatives that are ongoing around us, to build the same kind of network that North America has had between the United States and Canada.
 
W: We hope to see more programs emerge too! Last question – any final words of advice for detailers and programs?
 
H: The main advice would be to not give up. There will be resistance, and you will run into some troubles, but keep on working. If you believe in the method, and you believe in the work you do, it will pay off. The 1:1 approach is something that separates AD from other tactics, and makes it easier for both clinicians and funding organizations to see you as unique. This work is worth it.

Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

​Harald Langaas has been the director of a hospital-based medicines information centre (RELIS) in Trondheim, Norway since 2013. Together with colleagues at St. Olavs Hospital he started the first academic detailing program in Norway in 2015, and has been involved in AD work both as administrator and active detailer since then. Since 2018 he has been the director for KUPP – The Norwegian Academic Detailing Program. He is currently working on a PhD based on evaluation of academic detailing.

An interview with Jacki Travers, PharmD, Clinical Academic Detailing Pharmacist, Pharmacy Management Consultants (PMC). PMC operates out of the University of Oklahoma College of Pharmacy and has been providing educational and consultative services for the Oklahoma Medicaid Pharmacy Program for 25 years. PMC began its academic detailing program in 2014 and Jacki was onboarded in 2015 as the first detailer. The academic detailing work is funded primarily by the Health Services Initiative Grant received by Oklahoma Medicaid from the Children's Health Insurance Program. Jacki also serves as an expert training facilitator for the NaRCAD team.

by Anna Morgan, MPH, RN, PMP, NaRCAD Program Manager

Tags: Detailing Visits, Evaluation, ​Primary Care

Anna: Hi Jacki! We can’t wait to hear about your academic detailing work in Oklahoma! Can you tell us a little bit about your program and the clinical topics you detail on?
 
Jacki: Absolutely. Our program is smaller than other AD programs – we have one FTE dedicated to AD and that’s me! Most of our topics are pediatric-focused, based on our funding from the Children’s Health Insurance Program. I've detailed providers on topics including ADHD, appropriate use of atypical antipsychotic medications, treatment of upper respiratory infections, use of psychosocial interventions for mental health needs, implementation of shared decision-making tools, and immunizations. I've ​established a relationship with more than 800 providers and their staff across primary care and specialty care settings in the state of Oklahoma.

​Anna: That's impressive, Jacki. You detail on such unique clinical topics – can you share some challenges related to these topics and how you’ve overcome them?
 
Jacki: We're primarily a rural state, so resources can be hard to access. There's no point in asking a provider to commit to a change and then have them hit this continued wall of unforeseen lack of resources. As a result, I spend a fair bit of my time collecting information that will help providers bridge the implementation gap. I try to connect providers with resources like care management teams, electronic referral platforms, or other providers in their area who are implementing particular services like parent-child interaction therapy, medication therapy management, and applied behavioral analysis. If I'm asking a provider to do something, I want to make sure that they have the tools and the bandwidth to carry it out!
 
Anna: What a great point! You can’t expect a clinician to make changes if they don’t have the resources to do it. Are there additional challenges that have come up in your academic detailing work?
 
Jacki: Most of the challenges I face are the same as those faced by all detailers - access to clinicians, scheduling visits, handling objections, overcoming barriers, gaining commitment to change, and getting access to resources. I overcome these barriers by getting warm handoffs from previously detailed providers, using champions whenever I can, and putting myself in the mind of providers to anticipate what specific resistance there might be so that I can come up with enablers.
 
Sometimes I do a bit of out-of-the-box thinking for the specific challenges and always bring a healthy dose of flexibility. In one case, I dusted off my high school French and used Google translate to ask a French-speaking researcher for permission to modify one of her shared decision-making tools. I could have asked her in English, and it would have been just fine, but I felt like it was going to demonstrate my respect for her work if I did my best to communicate in her preferred language.
 
Whenever possible, I want to try to connect with people in the way that is the most seamless for them. And that's absolutely true for detailing too! I've had providers who want to meet over coffee and muffins at 6:00 AM because it's the only time they have in their day, or providers who need to pump their breast milk during our visit. I roll with it all and make sure I’m meeting providers where they’re at. 

​Anna: Being flexible certainly makes for effective detailing visits. Can you tell us a little more about how you meet providers where they’re at and customize your detailing approach?
 
Jacki: When I’m detailing on one topic, I’m always thinking about future topics by gathering data from providers so that I can better understand their challenges. I ask providers their biggest concerns and I’ve been really surprised at how ready they are to share gaps in resources and information. That’s how our antibiotic topic materials came about. Many providers shared that they often have patients who ask for antibiotic prescriptions and how they have to battle against patient satisfaction surveys that seem to penalize them for not prescribing antibiotics.

The antibiotic detailing materials we created had some scripting to help reduce antibiotic prescribing while also increasing patient satisfaction. The materials included shared decision-making tools with a breakdown of non-antibiotic treatment evidence like humidifiers, honey, saline spray, etc. It's all about identifying why the providers might not be feeling empowered to follow the evidence and then helping them find that empowerment through knowledge, motivation, and resources. 
 
Anna: I love that you continually assess the needs of the providers in your state to inform future work and strengthen relationships. I’m sure with the 800 providers and staff you’ve detailed that you’ve had some success stories– can you share one with us?

Jacki: Of course! I have a great story that shows how important it is to assess needs, really listen, and empathize with clinicians and what they’re going through. I was at a pediatric practice and it had taken me four solid months to get in the door. There had been some pretty strong reluctance even to schedule a visit. Once I did get on the calendar, they canceled and rescheduled multiple times. There was a sense of defensiveness, as though the staff may have been concerned that the visit would be punitive.
 
As I started my needs assessment questions, one of them mentioned that they didn't understand how this topic related to the other meetings they’ve had. I explored that comment a bit more with them and it turned out they had just undergone an extensive audit by the state agency. The whole process left them feeling examined and analyzed.
 
Once I learned about their negative experience, I put their fears to rest, let them know that our time together was completely unrelated to that audit, and that I was there to help them get the best evidence in a digestible format. You could almost see the pressure leaving the room at that point - their body language changed, they were engaged, and they were asking questions and strategizing.
 
By the end of the meeting, the practice manager told me I wouldn’t have any more trouble getting on their calendar. She said, "this was not a waste of my time, and make no mistake, I would tell you if it was!”
 
Anna: That's amazing – what a great story. Before we wrap up, let’s focus on evaluating success. I know you’ve had some remarkable results with your ADHD topic, including a cost savings of more than $226,000 - can you share some of your most recent evaluation data with us?

Jacki: We’re most proud of outcomes from when we worked with providers to reduce the number of unnecessary antibiotic prescriptions, particularly for upper respiratory infections. The providers who were receiving detailing reduced their antibiotic prescribing by more than 17% and they also reduced their use of non-first line agents for upper respiratory infections by more than 16%.
 
However, we wanted to make sure that there weren’t any unintended consequences and that patients weren't having longer or more serious infections when the antibiotics were scaled back. To accomplish this, first, we looked at the prescribing in the previous five years and then one year after the detailing campaign. We identified an oral antibiotic prescription and then looked at the following two weeks after that antibiotic was prescribed to see whether or not there was a hospitalization or an emergency department visit. We found 90% fewer emergency department visits and more than 50% fewer hospitalizations after our detailing campaign. Of the hospitalizations, patients had shortened stays by more than 50%.
 
Even though the patient outcome is, of course, the goal, you can also demonstrate cost savings for your funders and stakeholders. We looked at the dollar amounts for the avoided hospital stays and ER visits and found a total annual cost savings of more than $834,000.

Anna: Wow, that’s impressive! Thank you for taking the time to share your insights and your program’s challenges, successes, and data. You’re an asset to all the communities you detail in and bring so much value to clinicians throughout Oklahoma. We’re also extremely lucky to have you as part of our extended team and larger AD community. We’re looking forward to catching up again soon!
 
Hear more about Jacki’s reflections on the impact of AD here.

Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Biography. Jacki joined Pharmacy Management Consultants (PMC) in 2015 and serves as the chair of the academic detailing committee. She has been active in the development and implementation of PMC’s academic detailing program in service to Oklahoma Medicaid providers. Prior to joining PMC, she served in the practice settings of independent, hospital, and clinical pharmacy. She currently develops detailing materials, delivers detailing services, and analyzes program results for multiple topics as part of a statewide plan. Her program efforts focus on bridging the gap between information and application in order to provide quality health care in a fiscally responsible manner.

An interview with Ashley Allison, Lead Training Coordinator, Oregon AIDS Education and Training Center (AETC). Ashley works with health departments and clinic systems to coordinate HIV-related training across the state ranging from prevention to care and treatment. She also oversees the detailing program where their main goal is to expand PrEP access in Oregon.

by Anna Morgan, MPH, RN, PMP, NaRCAD Program Manager

Tags: COVID 19, Detailing Visits, E Detailing, ​HIV/AIDS, ​PrEP

​​Anna: It was so nice to catch up on your team’s progress at our recent virtual training with the San Francisco Department of Public Health! Your program launched about two years ago and really took off when you pivoted to e-Detailing. Can you tell us more about that?
 
Ashley: Our program started with in-person visits and we would send our detailers out with a little briefcase of materials and an iPad full of slide decks—it was pretty “old school”. When the pandemic began, we had to take a hard look at our entire program to successfully pivot to e-Detailing.
 
As we began e-Detailing, we developed an outreach process and approach that has been working well for us. Here are a few of the steps and considerations that you can share with other new programs:

• We start by mailing out packets to clinicians with our state’s endorsement letter, a very simple explanation of our program, and detailing materials.

• Our materials are bright and colorful, and we made sure they align with the state's HIV campaign branding colors.
• We also include a card with a QR code that clinicians can scan to schedule an appointment directly with a detailer. (If a clinician doesn’t respond, we send a follow-up email with information about our program and links to schedule an appointment.)
• If a clinician schedules an e-Detailing visit, we then send digital copies of our materials in advance of the visit. However, we continue to believe in the value of having hard copies that they can keep in their lab coat and pull out as needed. It’s also much easier for our detailers to reference the hard copies that we mail with our packets during their virtual detailing visits.
• Throughout our outreach process, we track how we’re targeting each clinician that engages with us (e.g., through a referral, through a training, or through the National Clinical Consultation Center’s (NCCC) line on PrEP). By tracking this information, we’re able to evaluate where we’re finding success in connecting with clinicians, and where we need to try a different approach.

 
We’re trying to find new ways to engage clinicians who’ve received the materials but haven’t yet scheduled a detailing visit. We want to provide multiple entry points and make our detailing visits more accessible. 

Anna: Thanks for outlining this process and giving us a better understanding of how your program gains access to clinicians! What do you do to connect with clinicians who have yet to set up an appointment?
 
Ashley: One of our solutions has been what we call “virtual office hours”. In the calendar slots where a detailer has no detailing visits scheduled, they can hold open office hours, and we send out a promotional email about them to clinicians. Multiple clinicians can be there at once and chat about anything under the umbrella of the HIV care continuum. The detailer slowly shifts the clinicians who attend office hours into a detailing relationship by creating opportunities to meet again 1:1 to further discuss certain topics.
​
Anna: That’s such an innovative approach in gaining access. Can you discuss some of your team's other recent successes as it relates to virtual detailing?

Ashley: Virtual detailing has allowed us to increase our number of detailing visits due to the decreased number of resources and time required to complete an e-Detailing visit, including scheduling. We spent a lot of time looking into different platforms for automated appointment scheduling and ended up finding the Appointlet scheduling app. It allows us to manage all of our detailers’ schedules in a centralized place. It’s extremely intuitive and easy to use.
 
We’ve also switched our evaluation from a handwritten survey to a digital version on Survey Monkey. We made our survey significantly longer when we moved it to Survey Monkey and pulled a lot of our questions from example surveys from other programs and the national HIV curriculum website.
 
Our questions are specific to knowledge, attitudes, and practice and allow us to distinguish if a clinician isn’t doing something because they don’t have the knowledge, they don’t feel comfortable, or they don’t see it as within the scope of their role. Despite the lengthier survey, our response rate has been much higher now that we can send follow-up emails with the survey link right in it.
 
Survey Monkey has also allowed us to quickly review the pre-evaluation data prior to detailing visits. If there are any red flags, we can highlight it for the detailers so they can customize which key messages will likely resonate with the clinician during their visit.
 
Anna: ​That's great. There are certainly advantages to using a virtual platform to conduct the different steps of the program process. What are some of your goals for the remainder of 2021?

Ashley: We want to start implementing a successful hybrid model of in-person detailing and e-Detailing while also training our new detailers in a robust and consistent way.
 
We want to continue with our main goal of increasing the number of PrEP prescribers in Oregon and making it more accessible across the state. We also want to start detailing pharmacists, depending on how the current legislation lands around providing supports for pharmacists to prescribe PrEP. We feel confident in our key messages for primary care providers. We’re excited to start crafting our key messages in ways that appeal to pharmacists and address the different barriers to implementation for them as well.
 
Anna: Those are excellent goals! What’s one tip that you would offer other academic detailing programs who’d like to replicate your success?
 
Ashley: Utilize e-Detailing; it’s a wonderful tool! Many developers are coming out with apps to serve this new digital landscape that can assist in implementing e-Detailing successfully. It’s just a matter of finding the right tools by taking a little bit of extra time and patience to experiment.
 
I would also say that it’s important to build a relationship with your state’s health department leadership and obtain an official endorsement letter from the state supporting your activities. Establishing a relationship not only positively impacts your program’s visibility and ability to gain access to clinicians, but it also helps to make sure you're aware of other outreach initiatives, which allows you to align efforts and not duplicate processes.  
 
Anna: ​Terrific advice, thanks, Ashley! You’ve given us such a unique perspective on e-Detailing. We look forward to continuing to hear about all of your team’s successes and groundbreaking ideas.
​
Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Biography. 
Ashley has been with the Oregon AETC since 2018 where she works to bridge the gap between local public health priorities and education and training opportunities available to providers.  Before joining the Oregon AETC, Ashley spent over two years working for local and international HIV focused CBOs in Johannesburg, South Africa. A majority of her work in Johannesburg focused on grant writing and managing the implementation of community-based HIV medication adherence models in partnership with provincial and municipal public health.  Prior to moving to Johannesburg, Ashley spent five years working at Planned Parenthood in Portland, OR occupying a variety of roles, including clinic assistant, phlebotomist, patient advocate, and call center representative.  Ashley credits her passion for supporting patient access to quality HIV prevention and care to the experiences she had with patients while providing HIV testing and counselling services at Planned Parenthood.   

Winnie: Liesa, thank you so much for taking the time to speak with us today about your experiences at the helm of ONE Tennessee through the past year. Can you tell us a little bit more about yourself and the AD-related work that you do?

Liesa: As the Executive Director of ONE Tennessee, I have overall responsibilities that include strategic planning, funding, communication, and staffing in addition to coordinating our AD program. I’m responsible for recruiting, training, and supporting our detailers to be as effective as possible. Our mission is to combat opioid misuse and overdose, and AD is just one of many projects and strategies we have to do that.
​
W: You certainly wear many hats in your leadership role! Can you tell us about the experiences that have shaped how you approach leadership?

​L: There were a very diverse set of experiences that influence how I’ve learned to lead. It’s also important to recognize that leadership comes in all forms. I was a foreign language teacher for 10 years, I had to learn the many different ways of communicating information to students from young teens to older adults. You learn to consider the way you present your information to help get all of your students to their goals.

I was also a director of a non-profit and managed volunteers. Just like my students, you quickly learn that people have many different motivations. A good leader knows how to cater to those motivations and learns how to maximize the team they’re working with. It’s also important to always remember to express gratitude towards your team, and as often as possible, remind them of the impact that they’re making.

W: You’ve discussed a lot of the soft skills and characteristics that good leaders have. What about some of the technical abilities that helped you be successful at managing an AD program?

L: Before coming to ONE Tennessee, I worked at both the federal and state-level in healthcare-related consulting work. It gave me exposure to federal and state-level funding procedures, as well as the decision-making process that goes on behind the scenes. You also learn about the regulations and guidelines that AD helps to keep clinicians aware of.

W: It sounds like you’ve had a fantastic journey on your way to the position that you have now in leading an AD initiative. Can you tell us a little bit more about the different community organizations that support ONE Tennessee’s AD work?

L: We have support from multiple organizations including the Tennessee Pharmacists Association, the Tennessee Hospital Association, and the Tennessee Primary Care Association. They’ve helped us recruit clinicians to serve as detailers and to participate in detailing sessions. We also have support from the East Tennessee State University’s College of Public Health and the Tennessee Department of Health supporting our data collection and program evaluation. We are thankful to other provider organizations including local community pharmacists and clinicians at Alliance Healthcare Services to assist us in development and distribution of materials

W: That’s quite a dynamic bunch! At the intersection of many different groups in the community all focused on preventing opioid-related overdose, how do you keep all these different stakeholders on the same page?

L: Even when you speak the same common language, not everything is always communicated and understood as intended. I work with a talented team from diverse career backgrounds, including finance, legal, communications, and policy professionals. They don’t all speak the same exact “language” because of their professional backgrounds.

The role I often play in group meetings is that of a facilitator. I'm comfortable asking the so-called “dumb questions” or constantly asking for explanations. As a leader, it’s my job to make sure there is clear understanding among the folks in the room who don’t work in that field. It’s important as a leader to not only communicate well, but to also make sure everyone on your team is communicating well enough so that everyone can understand and also be understood.

W: Intentional level setting is a hallmark of effective leadership and communication. It allows meetings and decisions to be productive, and it ensures that everyone’s goals are aligned. Otherwise, important details may get left behind or not fully developed.

L: Exactly. It’s also important to know that with your team, you’re never alone. You don’t need to know everything to be a leader, but you need to surround yourself with people who can collectively make decisions based on good information. Surround yourself with people who know more than you do, and listen to them.

W: You picked up this role in the middle of a pandemic and with your leadership, we were able to launch our first virtual training pilot with ONE Tennessee for about two dozen detailers. It was a huge undertaking! What would your advice be for someone who’s looking to tackle big projects in their role as the leader of an AD organization?

L: I would say first and foremost – the determination to fulfill our commitments was important to me. I knew what was in our contractual agreement with our funders, and didn’t want to start off our organization with a fail in this category! Secondly, create a timeline with the concrete things that need to be finished and the resources you need to help you monitor progress along the way.

Finally, in the face of making new things happen – it can be daunting when there’s a big mission to accomplish. When there’s nothing on the drawing board yet, a leader is someone who volunteers to put up the first “strawman” plan. It doesn’t need to be perfect, but it gives everyone something to build off of; it’s always better to start with something, like the first brick in the foundation.

W: We’ve talked a lot about how to bring a community together to support an AD intervention. Why is community involvement important to the success of an AD intervention?

​L: Well, whether you’re talking about opioids or HIV or chronic illnesses, the reality is that no one individual or organization within a community can solve a public health problem alone. Even though AD is mostly about the relationship between the detailer and the clinicians they work with, it’s informed by many other people who care about improving health outcomes. In short, the program would not be able to operate without the leadership and support of these partners! 
 
In a state as large as Tennessee, with such wide differences among rural and urban, from the Appalachian region to the Mississippi Delta, racially diverse but largely homogeneous in some places, it is important that collaboration occur at local levels as well as at state levels—both among clinical colleagues in the same community who care for the same patients, and also with support from state-level organizations who can leverage resources that may not be available in the local community.  While individuals and organizations may not agree on all points, it is usually possible to find at least one shared goal that can be worked on together. As an organization, we strive to identify and then mobilize to address those common goals. There are great things ahead for us all if we continue to work together.

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In her current role as Executive Director of ONE Tennessee, Liesa draws upon her experience as an educator, a non-profit administrator, a state-level director of community health programs and a consultant to state and federal officials, as she works to advance the organization's mission to combat the opioid epidemic through collaboration and sharing of information among health professionals and communities in Tennessee.  In her professional roles at Kingsport Tomorrow, CareSpark, Deloitte Consulting and the Tennessee Department of Health, Liesa has helped to develop and implement a broad range of collaborative projects at local, regional, state and national levels to improve community health, broadband access, education and literacy, employment opportunities, cultural arts exchanges, global trade, environmental protection, neighborhood revitalization, youth development and civic leadership.  Her skills in strategic planning, resource development, mentoring and community organizing have been recognized with awards, including being named a Paul Harris Fellow by Rotary International, a Health Care Hero by the Business Journal of Tri-Cities, and the Commissioner's Award of Excellence from the Tennessee Department of Health.
 
Liesa received her B.A. in French from King University in Bristol, Tennessee and her M.A. from the University of Kentucky in Lexington, Kentucky.  She also holds a Certificate of University Studies from the Université de Franche-Comté in Besançon, France, and is certified as a Project Management Professional by the Project Management Institute.  Liesa is a native of Glade Spring, Virginia, where she is a seventh-generation resident on her family's farm, and enjoys spending time with her three sons and their families, as well as quilting, reading, and traveling.

 An interview with Jacqueline Myers, BSP, Academic Detailer, RxFiles and Pharmacist, Infectious Diseases Clinic, Saskatchewan Health Authority – Regina Area. RxFiles is an academic detailing program that provides objective, comparative drug information to clinicians. Jackie’s work at RxFiles includes academic detailing and resource development.

by Anna Morgan, MPH, RN, PMP, NaRCAD Program Manager

Tags: COVID 19, Conference, Detailing Visits, ​Substance Use

Anna: Hi Jackie! We’re excited to feature your work as a detailer. How did you first become involved in academic detailing?
 
Jackie: RxFiles has a bit of a celebrity following in Saskatchewan. The RxFiles books, which are packed with resources and drug comparison charts covering various clinical topics, are a coveted possession. You receive one book for free as a pharmacy student and everyone looks forward to that day because it has all the study material you could ever need in one place! I think it’s a dream of pharmacy students to get involved with RxFiles at some point in their career.
 
I started with RxFiles in 2019 while working within the Saskatchewan Health Authority (SHA) Opioid Stewardship Program (OSP). A partnership was formed between the OSP and RxFiles and I was able to work both as a clinician at the Regina Chronic Pain Clinic and as a detailer providing education and creating content for RxFiles. My role in SHA has since changed, but I’ve continued detailing for the RxFiles team. 

Anna: Your passion for academic detailing is palpable. You could tell how much you love academic detailing during your presentation at NaRCAD2020. Can you tell us a little bit more about why this work is so important to you?
 
Jackie: It excites me to hear that--I’m so glad people see that I’m passionate about this. I’ve always admired musicians and artists for their passion, but I’ve never pictured myself as one of those people.
 
Many healthcare professionals - nurses, pharmacists, physicians, physiotherapists – we all go into this field because we like or love working with people. I’m no different than any other healthcare professional. I also really love to learn and then share that knowledge through teaching or mentoring. Academic detailing is such a cool combination of those things. You get to learn about a specific clinical topic, share your knowledge with another clinician and ultimately improve patient outcomes. It’s a really special process.
 
Anna: You’re absolutely right – it is special! What kind of support has been most helpful for you in becoming such a successful and passionate detailer?
 
Jackie: When I first started with RxFiles, the rest of the team was working on topics other than opioid prescribing  which left me feeling a bit isolated. Luckily, RxFiles has a great support system. My colleague Debbie, who I now consider my mentor, has been a huge resource for me. Even though we weren’t detailing on the same topic, I knew I could always talk through key messages with her, as well as recruitment strategies and other tips for approaching prescribers in our area.
 
I still know that I can always go to her for a debrief at the end of a visit, whether it’s a successful visit or a mess of a visit. Academic detailing has the potential to be really isolating, so having someone who understands and can help guide you through some of your challenges can be so beneficial.

​Anna: We know that academic detailing can be isolating, so it’s wonderful to hear how supportive your team is. On the days when you’ve had hard visits, I’m sure it’s difficult to feel that you’ve made an impact. How do you know that you’ve been successful in a detailing visit?
 
Jackie: At the 2019 NaRCAD Conference, I was amazed by the presentations and the data that different programs had collected to measure impact. When I first started detailing, I was very focused on the clinician I was detailing committing to make a change or doing something differently in their practice. Then I began to learn that success in academic detailing comes in two forms.
 
One is making an impact that changes a clinician’s practice and the second is establishing a connection and developing a relationship with a clinician. Sometimes making a connection will come first and then lead to making an impact, or sometimes they’ll occur simultaneously. Those are the two ways that I define success for myself in academic detailing.
 
Anna: That’s spot on – those are two of the main goals of academic detailing. Can you share any success stories from the field from a time when you felt you made an impact?

​Jackie: Of course! We are currently working on a special project to increase the number of buprenorphine/naloxone, or Suboxone, authorized prescribers in our province. One of the physicians I detailed was not yet authorized to prescribe buprenorphine/naloxone. He was a hospital physician and worked in internal medicine. He shared with me that he’d been thinking about becoming authorized and was apprehensive, but he saw a need for it in his patient population. A lot of his patients were being admitted for various diagnoses but would also have a concurrent substance use disorder that went unmanaged or ignored.
 
After our detailing session, he reached out to me. He described a patient that he had admitted for an infectious process who also had opioid use disorder. He said, “before our conversation, I would have normally treated the infection and probably ignored the opioid use disorder. It’s possible the patient may have left against medical advice, and I would have thought, ‘that was their choice, and I did my best.’ ”
 
After our detailing visit, he felt that he had the courage and the skills to discuss the patient’s opioid use disorder with them and think about what he could do as a physician to keep the patient comfortable and safe while they were in hospital. This honest conversation led the physician to speak with an authorized prescriber who was able to initiate the patient on buprenorphine/naloxone while they were admitted in the hospital. Even though the ask for this detailing project was to increase authorized prescribers, which he has not yet become, the interaction I had with this physician still led to a positive patient outcome and a better patient experience.
 
Anna: Thank you for sharing that - it’s so nice to hear stories from the field. Even if you don’t accomplish the messaging you were sent out to do, you’re still making an impact. Can you share a story where maybe you weren’t as successful and how were you able to bounce back from a situation that was challenging for you? 

​Jackie: During COVID, a physician reached out to request a virtual visit. We started our detailing session and I was beginning my needs assessment. I started asking about his practice and his familiarity with buprenorphine/naloxone. He said, “that’s a new weight loss drug, right?” From that point on, he was really sad that I wasn’t there to talk about a weight-loss drug. He was disinterested and I could tell he was distracted. I could hear him moving around papers through the phone and I could hear people talking in the background. I said, “if this is not a great time for you, we can definitely rebook” but he insisted that I continue. I could feel myself getting frustrated, but I finished the visit. I was able to deliver my key messages, but I left the visit not feeling great. There was no commitment to action or change and we didn’t build a connection. I felt like I wasted both of our time. In order to bounce back from something like that, I think you need to acknowledge that it will happen sometimes and debrief with colleagues who have been in your shoes. Then just pick yourself up and try again.
 
Anna: That’s great advice. It can be discouraging to have a visit like that, especially if your new in the field! One last question to wrap up - do you have any personal academic detailing goals for this upcoming year?
 
Jackie: Yes! I was previously detailing on only opioid-related topics. This year, my role has changed a bit and I will be detailing on various clinical topics and in a new geographical area with all new clinicians.  My primary goal is to connect and build relationships with these new clinicians. Fortunately, I’m taking over for a cherished detailer who is retiring and will help provide a warm handoff.
 
My secondary goal, which is a bit sillier, is to avoid troubles on the highway when we begin in-person visits again. The detailer I’m taking over for has had some very interesting car trouble heading out to his detailing visits. He’s met a lot of wildlife and his car was even once fried by lightning!
 
Anna: We certainly hope you’re able to avoid those highway issues! Thanks so much for chatting with us today, Jackie. Your stories are inspiring, and we can’t wait to connect again and hear about all your 2021 accomplishments.


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You can head on over to our Discussion Forum to continue the conversation!

Biography. 
Jackie graduated from the University of Saskatchewan with her Bachelor of Science in Pharmacy in 2012. She has practiced in numerous clinical settings including community pharmacy, long term care, and hospital in the areas of internal medicine and opioid stewardship. Jackie is currently involved in the management of people living with HIV and substance use disorders at the Infectious Diseases Clinic in Regina. She also works with RxFiles providing academic detailing services and resource development.

Overview: Dr. Nate Rickles, PharmD, PhB, BCPP, FAPhA is an associate professor pharmacy practice at the UConn School of Pharmacy with experience in developing AD programs, most recently for the CDC-funded CEDPP (Connecticut Early Detection and Prevention Program) project. Dr. Natalie Miccile, PharmD, MBA currently works as a retail pharmacy manager at ShopRite Pharmacy. She’s working with Nate to onboard pharmacies participating in the CEDPP program and working with the pharmacy students who are supporting the process of referring patients to screening, diagnostic, and prevention services. 
​
​by: Winnie Ho, Program Coordinator

Tags: Cancer, COVID-19, Detailing Visits, Health Disparities, Program Management

Winnie: We’ve been excited for a chance to speak with you both! Nate, you spoke on our Clinical Innovations in AD session at the NaRCAD2020 Conference, sharing your work to support underserved, and sometimes undocumented, women in accessing care. Thank you both for joining us today –  can you tell us a little bit more about the program and the issues it addresses?
 
Nate: CEDPP consists of two components: the Connecticut Breast and Cervical Cancer Early Detection Program (CBCCEDP) and the Well-integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN). The services are offered free of charge with the goal of significantly increasing breast and cervical cancer services for medically underserved women.
 
The Department of Public Health’s traditional outreach method of using clinical navigators at established WISEWOMAN sites could only reach a relatively small population. We received a CDC Innovation Grant to investigate the role that community pharmacies could play in increasing referrals to a free public health prevention program for vulnerable populations, as these pharmacies are accessible, front-line, and generally well-trusted in the community.

W: That’s an important goal to close this gap and to ensure more women can access the services they need. Why did your team feel that AD was a useful approach to address the lack of access to screening services?
 
Nate: I’m very passionate about the notion that building relationships through 1:1 connections are going to be more powerful long-term in creating behavioral change. AD works so well because the techniques are very persuasive in dealing with common barriers like pharmacists believing there’s little time in their day, not enough staffing, or not the right financial incentive.
 
Our project manager Peaches Udoma had sent out flyers and e-mails to local pantries and shelters, but we hadn’t received many referrals through this tactic. The predominant way we’re getting referrals is through 1:1 outreach with pharmacists and our students reaching out to the referred participants to connect them with services.

Winnie: Can you tell us more about how your intervention navigated the pharmacists’ barriers you described?
 
Natalie: We had a lot of interest from pharmacists, especially when they learned about the impact they could have. However, for a full month, we weren’t seeing results. When I checked in, we learned that they were genuinely overburdened with their workflow, which wasn’t surprising.
 
We had to think about who else in the office could do it – and it turned out to be the pharmacy technicians. They were often at the point of sale and would be more likely to know if patients were uninsured or underinsured. We began detailing the pharmacy technicians directly instead. Many of them were bilingual, which helped in distributing the right flyers to the right women.
 
We worked with the pharmacy technicians on communicating the benefits our programs offered, with attention to utilizing accessible language and avoiding unnecessarily complicated healthcare terms. We learned that emphasizing key things like free gym memberships or free nutritional services provided was very useful in getting women to agree to be referred. Addressing the language barrier and slight language changes was key to us finally getting referrals.
 
However, when COVID-19 hit, we had to reassess since we started getting zero referrals again. It made sense as few people want to wait around in a public space, and pharmacies also became overwhelmed. Our team pivoted to reaching out directly over the phone after receiving lists of potential contacts from the pharmacies. We wanted to show our partners that we could be resilient in this time and to not let this program fall through.

​Winnie: Pivoting your intervention to have team members directly contact the women you were trying to refer instead of through the pharmacy technicians must have required your team to make adjustments to accommodate language needs. How did your team tailor the AD intervention to address language barriers?
 
Nate: We noticed that we had many of the women we reached out to who spoke Spanish as a native language, and quickly realized we were probably losing a lot of patients because of the language barrier. We onboarded a pharmacy student, Isabella Hernandez, who, in addition to being a very dynamic, charismatic, and outgoing person, also spoke Spanish.
 
Once Natalie onboarded her and shared the main concepts around the screening and referral, Isabella was quickly able to pull in over 80 referrals; we didn’t have even half or a third of that through our prior efforts. We’ve been closely tailoring our work since, with flyers in Spanish, Portuguese, and in Arabic. We have also Arabic speakers to communicate with Arabic-speaking patients, and we have the capacity to expand into other languages.

Natalie: I originally worked with the lists of contacts we received and tried to engage directly. However, because we recognized our bilingual pharmacy students were able to better engage with these women, my role now is to oversee our callers, get their referrals, and help touch base with site navigators to ensure referrals are being processed, and how we can improve our screening process.
 
We’re prioritizing language accessibility because our first encounters are first impressions. Our patients matter, and we want to make things as smooth as possible for them. We’re even at a point where Isabella is running trainings with our other callers, so she can give them hints on how to be more flexible in the conversation to fit our clients’ needs.
 
Winnie: This is a really outstanding demonstration of flexibility and tailoring a program to address barriers to practice change. We hope that other programs continue to follow your example of integrating best practices to communicate with patients from diverse communities!

​Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

​Nathaniel ("Nate") Rickles is an Associate Professor in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy. He received his B.S. in psychology and chemistry from Dickinson College, Pharm.D. from the University of the Sciences in Philadelphia, M.S. and Ph.D. in the Social and Administrative Sciences from the University of Wisconsin-Madison.  Dr. Rickles also completed a psychiatric pharmacy practice residency and is board certified in this area. He was inducted as a Fellow of the American Pharmacists Association. 
His primary research interests are to develop, implement, and evaluate intervention programs that improve pharmacist communication with patients and/or other team members and subsequently to improve medication adherence and patient safety. Primary teaching interests involve courses on communication skills, mental health, health behavior change, cross-cultural health care, and research methods.  Dr. Rickles is an active researcher with several grants and publications involving enhancing the role of pharmacists in changing patient and provider behaviors.

Natalie Miccile received her PharmD from the University of Connecticut School of Pharmacy in Storrs, CT and MBA from the University of Connecticut School of Business in Hartford, CT.  Her MBA concentrations include Digital Marketing and Strategy and Investment Analysis. She works as a consultant for UConn School of Pharmacy on research initiatives that involve enhancing the role of pharmacists in the community setting and is pharmacy manager at Shop Rite Pharmacy in Milford, CT. Dr. Miccile is MTM certified and an active member of the Connecticut Pharmacists Association. 

An interview with Ellen Dancel, PharmD, MPH, Director of Clinical Materials Development, Alosa Health. Ellen completed her pharmacy practice residency at Massachusetts General Hospital and later completed her Master of Public Health at Boston University.  

by Anna Morgan, MPH, RN, PMP, NaRCAD Program Manager

Tags: Materials Development, Detailing Visits, ​CME

Anna: Hi Ellen! Thanks for joining us today – we’re excited to hear about your 6+ years of experience developing impactful detailing materials. Can you walk us through the process you take when beginning to design a detailing aid?
 
Ellen: Absolutely! The most important question to start with is, “who are you detailing with this material?” You also want to consider who is driving the goals of the intervention. Is there something your funder wants you to communicate in terms of key messages or is there new clinical information to convey?
 
You then need to think about how to engage subject matter experts (SMEs). We work with an amazing endocrinologist for our diabetes modules and often ask, “what do you wish a primary care provider (PCP) knew before they referred a patient to you?” Having a specialist’s perception on what concerns they see in practice is key.
 
We’re also fortunate to have access to focus groups at Alosa. We engage prescribers who receive our content to understand their needs on a topic. These peer-to-peer conversations are hosted by one of our clinicians. We also utilize our detailers’ years of expertise, gaining their insights on the materials. We use these two distinct focus groups to provide feedback on the content and messaging as well as the layout and visuals of our draft materials. We then take all this information and add it to the available literature to create a final detailing aid. 

Anna: These first steps are crucial when thinking about developing materials. Let’s talk about the layout of the detailing aids. What does that look like?
 
Ellen: When it comes to laying out the detailing aid, Alosa has a certain look and feel that we always use that’s part of our brand. The front of the document is a cover page with a title and graphic. Our graphic designer does a tremendous job of taking a concept that isn’t quite fleshed out and making sure that the end product is streamlined. A title that works well is something that is very clear, simple, and focuses on the overall message. Our team selects images for the cover page that relate to the topic but also tend to generate conversation. The back has our logos and a description of the authors.
 
On the inside, we start with a “why do I care?” section, so we can explain why the topic we’re focusing on is of importance to the clinicians being visited. The next page is often a summary of the content that is within the detailing aid. A summary could be an algorithm for treatment or a graphic for a framework for thinking about how to approach management (e.g., the four stages of heart failure). This is followed by the evidence, data, and tips to support a PCP in order to put the key message into practice.  We follow that with a cost page, so the clinicians are informed when presenting new medications to patients. Lastly, we include a reminder page that summarizes key points.

Anna: Wow! It’s so helpful to hear about the process your team uses for laying out content in the detailing aids at Alosa. From start to finish, how long does this entire process take?
 
Ellen: It really depends on the topic. For example, if we’re updating a topic with a SME who has previously worked with the Alosa team, then we’d expect a timeline of around two to three months.
 
For something new, such as a primary palliative care module or a serious illness module, we’d plan for a timeframe closer to four to six months, because we need the time to really look at the evidence and see how it shapes what we want to accomplish in the field. We also need the time to understand what our PCPs are interested in through feedback from a focus group and informally from our detailers.
 
For AD programs with shorter timelines, we’ve found the resources at the CDC to be incredibly useful, such as the adapted patient materials for our latest immunizations module. There’s also a lot of academic detailing programs that have publicly accessible materials. Some may even allow you to use their graphics if you request permission or cite appropriately.

Anna: It’s so important to allow enough time to not only create and build a detailing aid, but also work through multiple revisions of it.
 
Ellen: I couldn’t agree more. When I created my first detailing aid, it took me a week to even come up with the first draft, which was then subsequently torn apart. My draft looked nothing like what we ended up with at the end of the process.
 
Programs need to plan for time for back and forth communication and to engage as many viewpoints as they can. Our modules are accredited for continuing medical education and we have reviewers assess the detail aid to ensure accuracy. We also make sure that our detailers, who will be using the material in the field, have an opportunity to try out the materials. We often end up changing key graphics that we thought were fantastic but turn out to not be effective during the detailing visit through this process.
 
Anna: When thinking about the gold standard for creating a detailing aid that is accessible to both detailers and clinicians, what comes to mind?
 
Ellen: It’s really a marriage of evidence-based recommendations and clinical practice. We’re trying to find a way to bridge recommendations in the literature with usable tools for a busy primary care provider’s practice. We make sure we’re providing the best and latest evidence in a way that can be helpful for the primary care provider without them having to do a complete system redesign. Materials should be streamlined and allow clinicians to be flexible in their approach by offering different options in adopting the key messages.

Anna: Thanks for walking us through this process, Ellen- what would you say are the key tips/takeaways for detailing programs who are just starting to do this?
 
Ellen’s Tips for Creating Materials

• Understand your audience. Ask yourself, “are there key messages that my stakeholder or funder wants me to convey?” or “what new clinical information or updates are needed by busy primary care clinicians?”
• Engage with subject matter experts to help build your detailing aid.
• Organize your detailing aid in such a way that emphasizes your key messages, the evidence, and the data that supports each key message. You also want to include information about how PCPs can implement the changes into practice.
• Keep the detailing aid clear and simple. Including too many infographics or too much text in your detailing aid can distract from your key messages.
• Allow ample time to create your detailing aid. Understand that novel topics will require extensive research and frequent communication between the parties involved.
• Adapt materials when you can. The CDC has many great resources on a wide array of topics. Other agencies may also allow you to borrow their materials if granted permission.
• Be prepared for frequent revisions. The best deliverable is a result of invaluable consultation. Don’t be concerned if your final product doesn’t resemble your initial draft.
• Pilot the materials in the field. While a detailing aid may be well written, that does not guarantee that implementation by the detailers will be successful. Ensure that you get quality feedback from the detailers using the materials in the field.

 
Learn more by checking out the Alosa website, and these detailing aid building tools and examples from the NaRCAD team.

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You can head on over to our Discussion Forum to continue the conversation!

This interview features Carla Foster, MPH, who leads the conceptualization, implementation, and evaluation of Public Health Detailing as an Epidemiologist within the Bureau of Alcohol and Drug Use Prevention, Care and Treatment (BADUPCT) at the New York City Department of Health and Mental Hygiene (NYC DOHMH). She is currently activated for the COVID-19 emergency response as Lead Analyst managing the Reporting Unit within the Integrated Data Team of DOHMH’s Incident Command System.
 
By Winnie Ho, Program Coordinator

Tags: Data, Detailing Visits, Evidence-Based Medicine, Health Disparities, Program Management, Stigma, Substance Use, Training

Winnie: Hi Carla! You’ve certainly had a lot on your plate with so many diverse campaigns. Can you walk us through the conceptualization process for your detailing campaigns, and how your team came to choose cocaine use as your current detailing topic?
 
Carla: We can start with some data on this. In 2018, more New Yorkers died from drug overdose than from homicide, suicide, and motor vehicle crashes combined. Cocaine – in both crack and powder forms – has played an increasingly prominent role in this crisis. The mortality rate from overdose deaths involving cocaine more than doubled between 2014 to 2018, amounting to 52% of all drug overdose deaths in NYC. Some of the associated risks are serious - increased exposure risk to fentanyl, cardiovascular disease events and death.

W: That’s stunning data. Especially in the midst of the opioid crisis, it’s important that we don’t lose sight of other substance use issues going on right now. I’d love to learn a little more about the challenges and lessons that your team has learned by detailing on cocaine use.
 
C: First, we have to be aware that fentanyl, a powerful opioid 50 to 100 times stronger than morphine may be found in many substances, including cocaine. We’re very concerned about fentanyl and cocaine because people who use cocaine do not have tolerance to opioids and are at even higher risk for overdose.

It’s also important to address the perception of who is most impacted by high mortality rates. There’s this idea that cocaine use is more prominent in younger populations, but our data show that it’s actually impacting an older population more than many might expect. In particular, residents age 55-84 in the Bronx Borough have experienced the largest increase in cocaine overdose death rates in New York City from 2014 to 2018.

That’s why it’s critical for us to raise awareness in an effort to mitigate misconceptions and stigma around risky use and those who may have a substance use disorder (SUD). In addition to shame, there are still very real potential socioeconomic and legal consequences from disclosing substance use, which can deter folks from even seeking help.
 
We take into account the unjust consequences of policies applied unevenly according to race, and how this impacts implicit biases in terms of which patients are thought to use substances, which types of substances they might use and even more critically, which type of treatment, if any, they are offered. Implicit biases combine with the effects of systemic racism to compound these consequences. It’s important to note that it’s not race that drives poor health outcomes, but racism.

​W: Challenging stigma is one of the most powerful ways that detailing campaigns can combat the damage done by the War on Drugs, because stigma can make the difference of whether or not people receive dignified care. With a campaign so focused on addressing stigma and with a topic this important, how do you prepare your detailers for this task?
 
C: We devote a significant amount of time towards training our detailing reps – a week-long training, 8 hours a day. We spend a large amount of that time talking in detail about stigma as related to cocaine use. It’s critical to us that our detailers are comfortable and knowledgeable when speaking about this topic, because it sets the tone for the providers who then set the tone for their patients.

We ensure that our representatives are prepared to respond to a wide range of questions or comments, because this builds the provider-detailer relationship and enhances the value of the detailing visit. We’ve found during our follow-up visits that this support has led to high provider engagement with the campaign and providers reporting incorporation of the key recommendations into their daily practice, which is the aim of our public health detailing campaigns.

W: How have providers responded when detailed on a topic that carries so much stigma?
 
C: The good news is that we’ve found NYC healthcare providers to not only be receptive to our work on substance use, but they’re eager to partner with us to support their patients once they learn about the severity of the issue.
 
Our team provides statistics that relate to the provider’s specific neighborhoods and specialty, giving them real-time pictures of what’s happening with the patients they see. We know that it’s still a difficult topic to bring up, so we help address this with our action kit resources on stigmatic language and counter-top brochures that signal to patients that the provider’s office is a safe place to discuss these issues.

W: It gives me tremendous hope to hear about that there’s been enthusiastic response from providers. It means that things are changing.
 
Let’s also talk a bit about program sustainability. Your team has worked extensively on campaigns across multiple topics. What have you learned from implementing past campaigns?
 
C: Each public health detailing campaign is different, but we’ve learned some key strategies that support the growth and success of subsequent campaigns:

• ​Sending an introductory letter, about 2 weeks in advance, signed from the Deputy Commissioner of our health department outlining the campaign and encouraging participation, helps gain interest.
• Using a standardized visit workflow that all of our detailing representatives follow to ensure that key components are covered is key. Ours is still flexible enough for the detailers to meet the specific needs of each provider, which really helps with the uptake of the action kit and clinical practice recommendations.
• We meet as a team and evaluate our program weekly, allowing us to continuously adapt and to implement any necessary adjustments.
• Incorporating promotional items inscribed with the campaign’s logo and NYC DOHMH logo. For the cocaine campaign we distributed hand sanitizer and pens to detailing targets. These items serve as highly visible reminders of the campaign mission and have the potential to be incorporated into daily usage by the targeted health care providers.

 
Our overall goal is to do everything we possibly can to improve the health of our fellow New Yorkers. I like to remind our detailers of this James Baldwin quote that informs our public health detailing mission: “Not everything that is faced can be changed, but nothing can be changed until it is faced.”

Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Carla Foster, MPH is an Epidemiologist at the New York City Department of Health and Mental Hygiene (NYC DOHMH). Her research focuses on the implementation and evaluation of public health detailing campaigns across New York City with the aim of reducing overdose mortality. Prior to joining the NYC DOHMH, she led development of clinical practice guidelines at the American Urological Association. She received dual Bachelor of Arts degrees in Africana Studies and Neuroscience from Wellesley College. Carla also obtained her Master of Public Health Degree in Epidemiology from Columbia University.

An interview with Lisa Gruss, MS, MBA, Practice Transformation Project Lead, Quality Insights. Quality Insights is a non-profit organization that is focused on using data and community solutions to improve healthcare quality. The organization is based out of West Virginia and operates in Delaware, Pennsylvania, Virginia, and New Jersey. Quality Insights has developed an innovative academic detailing campaign to increase human papillomavirus (HPV) vaccination rates across Delaware.

​by Anna Morgan, MPH, RN, PMP, NaRCAD Program Manager

​​Tags: Cancer, Detailing Visits, Vaccinations

​Anna: Hi Lisa! We’re looking forward to learning about your academic detailing work as a multi-state non-profit, and your important work around HPV vaccination rates. We know these vaccinations are critical in preventing HPV, which can lead to many types of cancers. Can you tell us a little bit more about your current role and how it relates to academic detailing?

Lisa: I’m focused on new business operations, science, and innovation. I implement new contracts that we receive through the Department or Divisions of Public Health, or any other funding sources. I also work with our Information Technology (IT) team to set up databases, work through any compliance issues, and define metrics. Additionally, I help manage the AD components of our contracts. 

​Anna: You’ve had great success with many of your academic detailing campaigns, specifically your HPV campaign that you’ve been working on. Can you walk us through how the topic was chosen?
 
Lisa: We originally received a pilot grant through the Delaware Division of Public Health in 2018. The project was co-sponsored through their immunization program and the Delaware Cancer Consortium to improve the HPV vaccination rate in Delaware. According to the National Immunization Survey-Teen, the HPV vaccination rate for the initial dose in Delaware in 2018 was 73.9%.
 
The Division looked at the relationship between cancer rates and low vaccination rates and saw a huge opportunity. Per the Centers for Disease Control and Prevention (CDC), 90% of the 34,800 HPV-related annual cancer cases in the United States could have been prevented with the HPV vaccination. The pilot was small but successful. In the spring of 2019, we received additional expansion of funding and added the academic detailing component.
 
We’ve been working with practices to implement various services that tie in with academic detailing. We review data, work on evidence-based workflow modifications, provide HPV vaccination resources for staff and patients, and offer technical assistance. 

Anna: Academic detailing dovetails so nicely with other interventions and services, creating more opportunities for impact and care improvement. It sounds like clinicians have been mostly amenable to the program—have any barriers come up throughout your HPV campaign?
 
Lisa: To say we’ve had no barriers with access wouldn’t be true. We consider ourselves to be vendor neutral and ambassadors of the evidence - we don’t align and promote directly with any pharmaceutical company or insurance company.
 
When looking at the broader scope of our work, it’s certainly complementary to what pharma might do, but we’re able to offer a broader menu of interventions beyond a vaccine. We’ve had some difficulty during the pandemic, like many AD programs, but we’ve found leveraging our past relationships to be key.

Anna: I’m sure those existing relationships have helped with building new ones. Have the practices that you’ve visited been involved in your program’s other academic detailing campaigns?
 
Lisa: It’s a mix. The family medicine practices have been involved in a lot of our other projects, like opioid safety, cancer screening, prediabetes, diabetes, and maternal health campaigns. The clinics that specialize only in pediatrics, where we’ve also been implementing the HPV intervention, are new to academic detailing but have been extremely receptive to this campaign.
 
Anna: I recently saw your team’s work on your HPV project published in the Delaware Journal of Public Health. Can you briefly describe the results? 

​Lisa: Sometimes, it takes a small change to make a huge impact, and that is absolutely what we found with our project. For our engaged practices, we saw in a one-year span that the initial dose of HPV increased 8.1%.
 
It’s important to note that practices usually picked more than one intervention. For example, some chose academic detailing along with workflow modifications, like nurse reminders or scheduling the patient for their next vaccine before leaving the office. 

Anna: Those are significant results, especially in such a short timeframe! What’s one thing you’d want our detailing community to take away from this project?
 
Lisa: We found that practices were most successful when they chose an intervention, stuck with it, and set attainable goals. Some practices were at a 50% HPV vaccination rate and wanted to be at 80%. In those situations, we sat down with them and asked them to think about something more attainable, like a 5% increase in 6 months. Practices that committed to smaller increases not only met their goal, but slightly outperformed it. We’re excited to continue our work around this topic!
 
Anna: Setting attainable goals and following through is so important for all projects. We’d love to hear more about your future work and how this campaign continues to grow and succeed!

Biography.
Lisa is a Practice Transformation and Quality Improvement Project Leader with nearly 20 years of experience in the healthcare and managed care industries, with the leadership and skills to serve as a Program Manager. She is an expert in population health management, data analysis and audits, and customer engagement across payers and customer types, including Medicaid and Medicare and underserved and rural populations. She has applied leadership and project management skills to improving population health, quality results, and data integrity in Accountable Care Organizations (ACOs), Patient Center Medical Home (PCMH), and new business development and reporting. She's well versed in data analysis including Healthcare Effectiveness Data and Information Set (HEDIS) and National Quality Forum (NQF) measures, population health management tools, as well as internal Quality Insights reporting tools and state run database reporting. In the past 5 years, she has successfully managed multiple projects and people to meet deliverables and deliver value to customers.

By: Winnie Ho, Program Coordinator

2020 was a year of many hard-earned lessons. We’re so fortunate to have an AD community that’s committed to sharing best practices, tips, and experiences. This communal knowledge base is what makes us stronger and allows us to all grow together.

​Here’s a collection of the great advice some of our DETAILS Best Practice Blog and Discussion Forum guests have given us this past year:

Tags: Detailing Visits, Evaluation, Program Management

"The most critical thing is to allow enough time for the planning process – ideally, 18 months before you’re looking to launch. This allows you to gather resources, make partnerships internally and externally. If you can reach out to colleagues in the field, learn about what are good mistakes to avoid. It’ll save you a lot of time!"
-Carla Foster, NYC Dept. of Health and Mental Hygiene (NYC DOHMH)

"My best tip would be to create a standard operating procedure (SOP) or some type of guidebook for your visits. Our team developed a SOP which discusses how to conduct a needs assessment, conversational tips, how to weave in key messages, and how to address barriers. Developing the SOP really allowed me to understand the intricacies that need to be addressed before launching the campaign. It works as such a good practice guide, and you can always refer back to it whenever you need it."
-Julie Anne Bell, NYC Dept. of Health and Mental Hygiene (NYC DOHMH)

"One thing I’ve learned about AD is that it’s only as effective as your intervention across an entire system. Any work that I’m doing is irrelevant unless I’m addressing the culture of the entire system. If the front desk staff isn’t on board, or the clinical staff isn’t a believer, or the CEO doesn’t understand – there will be challenges that will be harder to overcome."
-Andrew Suchocki, Clackamas County, Oregon, Medical Director

"Building relationships with key stakeholders has made all the difference. They’ve helped me curate my detailing aids and key messages, and have even allowed me to practice my detailing sessions with them."
-Kelsey Bolton, Gundersen Health System, Wisconsin

"A strong team is an important part of a detailing campaign. Strong teamwork means supporting each other through tough detailing sessions, communicating well, and keeping a positive attitude. During virtual times, turning the camera on during staff meetings can also help keep the team spirit alive!"
-Marlys LeBras, RxFiles Academic Detailing Service in Saskatchewan, Canada

"There are numerous external pressures when it comes to AD, but the most important part is keeping the human aspect in check when reaching out to providers. We can get bogged down into the guide posts, the bench posts, or the numbers – but the COVID-19 era reminds us that it’s all about empathy."
-Tara Hensle, University of Illinois at Chicago/Illinois ADVANCE
​
"You may find it helpful to create an e-Detailing materials packet and see if you can grab some time with providers over a virtual platform. It can be a helpful foot-in-the-door for future in-person detailing!"
-Jess Alward, New Hampshire Division of Public Health, Dept. of Health and Human Services
 
"Lunch time is still the best time for visits. They were the most popular when I did it, and they’re still the most popular now, as my team tells me."
-Terryn Naumann, British Columbia Provincial Academic Detailing (BC PAD) Service

"There’s a lot of listening that happens in AD. You might spend all this time learning about the topic before you meet the providers, but if you take the time to really listen to them, you might learn more than you came with. There is so much to learn from all the incredible people you meet in AD."
-Debra Rowett, Drug and Therapeutics Information Service (DATIS) in South Australia

"The big thing I’ve learned through networking with detailers is to be flexible and be prepared for any situation, especially in the virtual environment. You might have one idea of how your session will go, and it could go in the opposite direction, which is part of the charm of detailing. Also, practice mock detailing with your colleagues!"
-Vishal Kinkhabwala, Michigan Dept. of Health and Human Services
 
"It’s important to have several different ways of presenting information to providers and to use varied approaches to barriers or objections that come up. I typically focus on emotional connection, financial concerns, and the evidence behind the key messages I’m delivering."
-Brandon Mizroch, Louisiana Dept. of Health

"No visit is ‘one-size-fits-all’. You need to consider the provider, their situation, and their environment and decide what will be the best way to deliver the evidence. It’s critical that you’re attentive to the provider you’re detailing and that you continue to focus on the needs assessment at all times."
-Mary Liz Doyle-Tadduni, Alosa Health in Pennsylvania
 
"I was delivering an in-person visit, and the skeptical questions about AD from the provider kept coming. I tried not to be defensive, but I answered everything I could. Eventually, the provider allowed me to get to the topic, and that changed everything! By the end of the visit, the opposition took an about-turn. I gained a professional friend and ally and ended up seeing this person with virtually every topic over the next 20 years. Never write someone off because of some seemingly extreme pushback – you just never know!"
-Loren Regier, Centre for Effective Practice (CEP) and Canadian Academic Detailing Collaboration (CADC)
 
"Confidence is key. You can study and practice everything with your team, but at some point you have to get out there and just do it! You have something valuable to offer and a few opportunities a year to capitalize on that value. A strong relationship can overcome a difference in clinical background or even a rough start. It just takes enough of your effort to show that you’re really there to be of service. Remember, you wouldn’t have been hired in this role if you weren’t qualified!"
-Amanda Kennedy, Vermont Academic Detailing Program

"When addressing stigma, it’s important to note that tough conversations can produce some cognitive dissonance in people. All providers are human. They care about their patients. What helps is not overwhelming them with data, but repeated snippets of information over time to help reinforce the message."
-Elisabeth Mock, Maine Independent Clinical Information Service (MICIS)
 
"Don’t be afraid to ask for a specific behavior change and remember to follow up to make sure that change occurs. The ‘ask’ can be hard for detailers, so I always tell them to frame it as, “based on what you’ve heard today, what is one thing you’d do differently?”
-Tony de Melo, Alosa Health in New England

"We encourage providers to complete a post-visit survey. We ask them to share their level of agreement that they were given new/different information, and they intend to implement practice changes as a result of AD conversations."
-Jacki Travers, Pharmacy Management Consultants in Oklahoma
 
"It’s important to track a mix of quantitative and qualitative data, and the critical components that should be tracked are the outcomes and the process of detailing. Data is absolutely critical for getting leadership buy-in, especially if it can tell a story."
-Kristefer Stojanovski, San Francisco Dept. of Public Health
 
"Once you’ve identified the problem you’re addressing and done the work to understand it, jump in! AD works!"
-Jennifer Pruskowski, University of Pittsburgh Medical Center

Thank you to the AD community for your resilience, compassion, and incredible work through a tumultuous year. We hope the AD community continues to share its pearls of wisdom with us through the new year. We are excited by all the progress made in 2020, and look forward to a brighter 2021 with you all.
 
Best,
The NaRCAD Team

An interview with Alok Kapoor, MD, MSc a cardiovascular investigator at the University of Massachusetts, Worcester about his work on the SUPPORT-AF II Study. 

​By Mike Fischer, MD, MS, NaRCAD Director and written by Winnie Ho, Program Coordinator.

​Tags: Cardiovascular Health, Data, Detailing Visits, Evaluation, Primary Care

Mike: We’re glad to have you join us to talk about your recent work using AD to improve anticoagulant use in patients with atrial fibrillation (AF). Could we start out by getting an understanding of your work and the goal you had set for your SUPPORT AF II intervention?
 
Alok: I am an internist doing cardiovascular outcomes research, and for the last few years I have been really laser-focused on how to fill the gap in anticoagulation use for patients with AF who have an elevated risk for stroke. These patients tend to be older adults with multiple co-morbidities, which presents certain challenges for primary care providers and cardiology specialists. The goal of our particular AD intervention was to provide evidence and patient case scenarios to show some of the common situations where patients go untreated for stroke prevention despite experts’ suggestions that therapy is warranted.

M: The underuse of anticoagulants is more common than we would like, and the impact of that underuse is substantial. What made you decide to utilize AD as a part of the intervention for your study?
 
A: I was thinking about an intervention that would be more than a simple reminder to providers, and thought that perhaps something more customized that would take into consideration the individual provider’s practice and experience with prescribing anticoagulants made more sense. AD was suggested as a potential strategy by our grant sponsor to address those concerns, so I began to read more into it. The SUPPORT AF II intervention is a combination of the audit and feedback reminders given in our original study, SUPPORT AF I, plus the new offering of AD.

M: How did you anticipate that those different components of the SUPPORT AF I and II interventions would work together? Were there any unanticipated surprises during the implementation?
 
A: I believed that the reminders would encourage providers to reach out to their subspecialty colleagues and also remind them to have discussions about anticoagulation with their patients. Then, AD would allow us to get closer to the underlying belief and resistance factors that might be making it more difficult to prescribe in challenging situations, such as a patient with prior falls, bleeds, or on other medications that can make bleeding more common. Some of these barriers included also unfamiliarity with initiating direct oral anticoagulants and guiding patients to coverage information for the cost of newer anticoagulants.
 
There were some specialists who were not necessarily enthusiastic about receiving messages from us. There were also providers during the course of messaging that indicated that they did not think that these messages were helpful for them, so we adapted. However, most people were appreciative or otherwise silent when receiving messages. The harder work was the convincing needed during the AD visit that could help lead to a more impactful intervention.

M: Yes, an impactful intervention is the goal. In your paper, you talked about the importance of patient choice as a factor in anticoagulant use, and this has been consistent with a few other studies of anticoagulation in AF that highlighted similar challenges. Are there any ways that you’ve thought about to adapt an AD intervention to address the importance of patient choice?
 
A: As part of our AD intervention, we gave prescribers a Jeopardy-type menu where you could choose which themes to explore, and one of those was a shared decision making module with resources including an app designed by my co-collaborator David McManus. This app allowed patients to input their unique conditions and circumstances into our risk stratification algorithm. Knowing the patient risk level, the provider would then be shown questions frequently asked by AF patients that would presumably help the provider address certain concerns during the next patient visit.

M: As you reflect on your experience implementing this intervention, were there themes that especially connected with the primary care providers or cardiology specialists who were receiving AD?
 
A: I was responsible for AD with the primary care physicians while my collaborator worked with cardiology specialists. The providers I spoke with seemed to be really drawn to the evidence in the guidelines and often requested support from me in identifying specific evidence that would be helpful as they developed their own improved management strategy around anticoagulants. I think where we could have added something more robust would be to offer providers a way to deliver these messages to their patients and how to do motivational interviewing with patients who are resistant to start a recommended therapy.  

​M: Support AF II is an impressive piece of work that provides many insights. Do you see other topics in cardiovascular care, or other clinical specialties where it might be useful to do similar studies to test AD to increase the use of evidence-based care?
 
A: There are other types of adherence issues in cardiovascular medicine that are potential targets such as blood pressure management. The issue doesn’t seem to be starting the medication, but in continuing to take it on a daily basis. The AD intervention would be done directly to the providers, but there might be value in also directly approaching the patients.
 
M: It would certainly be interesting to understand whether management issues are based on clinical inertia and hesitation in taking the next step, versus barriers in patient adherence itself. Thank you for taking the time to speak with us today, you’ve given us all a lot to think about!

​Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Alok Kapoor, MD, MSc is an investigator who has developed several projects related to anticoagulation and conditions requiring anticoagulation. He is one of the former directors of the medical consultation service at Boston Medical Center. In that role, he routinely educated other providers on the need for anticoagulation versus potential harm, particularly for underserved populations. At the University of Massachusetts, he has established a focus on filling the gap in anticoagulation of patients with atrial fibrillation. This started with SUPPORT-AF, an audit and feedback project funded to give providers a snapshot of their AC prescribing rates relative to their peers and to a national benchmark. In SUPPORT-AF II, he expanded the team's previous efforts to include educational outreach in the form of academic detailing. In his subsequent efforts, he have collaborated with informatics experts to understand the potential for electronic health record-based decision support to fill the gap in AC use.