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					       Kentucky HSR
        Development:
Building Partnerships
           Margaret M. Love, Ph.D.
            University of Kentucky
     Family & Community Medicine (Medicine)
              Health Behavior (Public Health)
Infrastructure Development
Aims
   Improve ability of faculty to develop proposals
    and publish papers in health services
    research (HSR)
   Promote collaboration of physicians with
    other health services researchers
   Cultivate research ideas from the Kentucky
    Ambulatory Network (KAN) into research
    designs and fundable proposals
University of Kentucky BRIC
   Overarching structure = collaboration
       College of Public Health (subsumed Center for
        Health Services Management & Research)
           2001-2003 PI Beaulieu/Fleming (BRIC I)
           2003-2006 PI Fleming (BRIC II)
       Department of Family and Community Medicine
        (DFCM)
           2001-2006 Co-PI Love
University of Kentucky BRIC
   Premises of today’s talk:
       Practice-based research networks (PBRNs) can
        respond to community needs… and partnerships
        are at the core of PBRN activities
       Learning collaboratives can improve health care
        quality
       Through its support of partnerships, BRIC built
        HSR capacity in Kentucky
University of Kentucky BRIC
   Two examples of building & leveraging
    partnerships – processes of engagement
       BRIC involvement with the Kentucky Ambulatory
        Network (KAN)
           BRIC I Prevention Research Project
           BRIC II Small Research Projects
       BRIC involvement with the University of
        Kentucky’s participation in the Academic Chronic
        Care Collaborative (ACCC)
Practice-Based Research
Networks (PBRNs)
   PBRNs are groups of primary care clinicians
    and practices working together to answer
    community-based health care questions and
    translate research findings into practice.
   PBRNs engage clinicians in quality
    improvement activities and an evidence-
    based culture in primary care practice to
    improve the health of all Americans.
                     http://pbrn.ahrq.gov/portal/server.pt
Practice-Based Research
Networks (PBRNs)
   Model for university-community partnership
    for health services research
   Potential to improve quality of care
       Implement and study process of adoption and
        outcomes in primary care practice
       Respond to community
   “Inside-out” vs. “outside-in” models
       I.e., “Top down” vs. “bottom up”
       “Bedside to bench” not just “Bench to bedside”
Kentucky Ambulatory Network
(KAN)
   Kentucky Ambulatory Network (KAN)
       Statewide primary care practice-based research
        network founded in 2000
       More than 200 community-based clinicians
           80% are family physicians
           ~75% practice in rural, medically underserved areas
       KAN has practices in 31 of KY’s 51 Appalachian
        counties
BRIC I:
Prevention Research Project
   Planned with/for KAN
       Solicited feedback from community-based PCPs
        about topics of prevention & intervention features
           Break-out sessions at annual meeting
           E.g., Wanted an intervention with evidence for high
            likelihood of success, i.e., not obesity
       Involved community-based FP as consultant
           Final planning input to focus on FOBT colorectal
            cancer screening (surprised own rates so low!)
           Assumed leadership role when joined faculty
BRIC I:
Prevention Research Project
    Conducted pilot project in 6 KAN practices
        Multiple strategies to increase FOBT rates
        E.g., chart stickers, information about billing
BRIC I:
Prevention Research Project
   Outcomes included lessons learned by FP
    leader:
       Difficulties in abstracting screening rates from
        billing data
       Usefulness of RA assistance in scheduling and
        preparing for orientation visits
       Necessity of ongoing contact with practice to
        assure fidelity to intervention, complete
        documentation, and access to outcomes data
BRIC I:
Prevention Research Project
   Lessons learned by BRIC team
       Discussion with KAN members led to principles
        guiding QI focus
       It takes a team
   Outcomes
       Directly: MPH Capstone for FP leader
       Possibly contributed to track record or experience:
        Future KAN involvement in federally funded CRC
        screening research
BRIC II Small Research Projects:
Physician “Collaborator” Model
   The “real” world for tenure track academic
    family physicians (FPs):
       Most can devote only 10 – 25% time to research
       Many will not become independent researchers
       Many can become physician “collaborators”
           Make substantial contributions to HSR led by faculty in
            other departments
BRIC II Small Research Projects
   Junior FPs partnered with experienced health
    services researchers (HSRers)
       HSRers nominated 7 projects in own areas of
        expertise and interest
       3 FPs nominated selves
       FPs to transition from co-I to PI
       FPs 20% protected research time (1/2 in-kind)
       HSRers paid protected time (10%-20%)
Additional Support for BRIC II
Small Research Partnerships
   More training for FPs
       Capacity-building seminars
           Professional writing workshops
           HSR methods seminars
       Development of Grant Applications
       National HSR meetings (AcademyHealth)
Additional Support for BRIC II
Small Research Partnerships
   BRIC PI (Fleming) & Co-I (Love)
       Co-investigators on projects
       Facilitated partnerships
           E.g., sounding board for HSR mentors
           E.g., nudge for FPs
       Served as program mentors/coaches for FPs
       Overall grant administration
BRIC II Small Research Projects
   3 projects/teams:
       Killip/Ireson (3 years) – Patient safety in after-
        hours telephone medicine
       Joyce/Wackerbarth (2 years) – Colorectal cancer
        screening decision-making
       Dassow/Costich (1 year) – Generic drug utilization
        (became study of Medicare Part D)
BRIC II Small Research Projects
   Relationship to KAN:
       Patient safety in after-hours telephone medicine
           Designed for/conducted in residency practice
           Next step was funded pilot in community practices
       Colorectal cancer screening decision-making
           Designed as KAN study
       Generic drug utilization (Medicare Part D)
           Involved KAN input & feasibility testing
BRIC II Small Research Projects:
Pt Safety / Telephone Med

   Initiative from UKy or Community?
       Initiative stayed “inside” academia

   Outcomes
       FP came to “own” this topic as research program
       FP acquired qualitative & quantitative research skills
       Multiple national/international research presentations
       1 pub (so far) with FP as 1st author
       FP as PI earned NPSF grant
       Also… Because of process analysis, changed steps in
        residency’s after-hours telephone medicine (e.g.,
        messages in charts) – good example of QI
BRIC II Small Research Projects:
CRC Screening Decision-Making
   Initiative from UKy or Community?
       Idea originated “inside” academia
       However, by design, study solicited input from
        community on what is needed to design decision-
        supports
           Qualitative research with FPs & patients leading to
            identification of “barriers” and “facilitators” for CRC
            screening
           Next steps would be design of decision supports &
            engaging FPs to test them
BRIC II Small Research Projects:
CRC Screening Decision-Making
   Outcomes
       2 pubs with HSRer as 1st author
       FP acquired qualitative research skills
           Co-Investigator on federally funded research project(s)
            led by other UK qualitative researchers
           PI on own federally funded education grants
           Could apply skills to evaluation of patient-centered
            care curriculum
       FP tenured as Associate Professor
BRIC II Small Research Projects:
Generic Drugs  Medicare Part D
   Initiative from UKy or Community?
       That’s a long story…evolution in terms of what’s
        meaningful and what’s feasible
       Initial plan: In KAN, evaluate barriers to
        prescribing generic drugs
           Reaction of KAN advisory committee members
            suggested more comprehensive approach necessary
            to capture prescribing issues that matter

                                                 Continued…
BRIC II Small Research Projects:
Generic Drugs  Medicare Part D
    Coincided with Medicare Part D implementation
    Alternative Approach:
        Chart review in KAN practices to determine if
         prescribing practices changed following Medicare Part
         D coverage
        Initial chart reviews showed charts don’t contain
         needed info

                                                  Continued…
BRIC II Small Research Projects:
Generic Drugs  Medicare Part D
    Final Approach
        Survey assessing physician experiences and opinions
         regarding Medicare Part D
        Conducted during Continuing Education programs for
         family physicians held in Lexington, KY (attendees
         from many states)
    In sum, iterative process informed by KAN
     community-based members & feasibility
     pretesting in KAN
BRIC II Small Research Projects:
Generic Drugs  Medicare Part D
   Outcomes
       Completed survey with 98 responses
       Analyses completed; manuscript in progress
       FP tenured as Associate Professor
BRIC II Small Research Projects:
Overall Outcomes
   FP transition into leadership role
       One effectively transitioned into leadership role
        (with coaching)
       One maintained a co-investigator role
       One already had more research experience
   Did HSRers develop, too?
       Better at working with FPs? & with KAN?
           E.g., structuring FP input & managing logistics?
           E.g., involving KAN input & evaluating feasibility?
BRIC meets ACCC
   Academic Chronic Care Collaborative
    (ACCC)
       American Association of Medical Colleges
        (AAMC)
       Consortium designed to develop quality
        improvement programs of clinical care,
        evaluation, & research
       University of Kentucky & Department of Family
        and Community Medicine selected as one of 23
        academic health centers
BRIC meets ACCC
   Features of University of Kentucky initiative
       Diabetes as clinical target in the Family Medical
        Center
       Chronic Care Model with quality improvement
        cycles
       Implemented group visits
BRIC meets ACCC
   To supplement College of Medicine funding,
    BRIC provided resources to support
    systematic evaluation and research
       Half year RA assistance in creating, entering and
        managing the Family Medical Center’s Diabetes
        Registry
       Trial period of registry software
       Junior FP travel to national QI meeting
BRIC meets ACCC
   Outcomes
       Multi-year database of over 600 DM patients
       Doctor of Nurse Practitioner (DNP) thesis
       2 Masters of Public Health (MPH) capstone
        projects
           Draft manuscript under development
       3rd MPH capstone underway (for junior FP)
       Medical student summer research project
BRIC meets ACCC
   Outcomes
       Greater sophistication across the department in
        evaluating quality improvement processes
       Collaboration with “non-BRIC” faculty members in
        Public Health and Pharmacy
       Department struggles with how to maintain
        database
       Ongoing systematic evaluation of QI elusive
BRIC II – What (Seemed to) Work
   Leadership from experienced HSRers
    invaluable in the small research project
    partnerships
       Specialized set of topic-relevant skills and
        knowledge
       Project management
           How to get started & what to do next
           Breaking the project down into steps
       Establishing – and pressing – project timeline
       Relationships important to FP growth
BRIC II – Facilitators
   Flexibility built into the multi-year BRIC II
    award enabled research partners to adapt
    (e.g., Medicare Part D)
       In future, solicit KAN input prior to submitting
        grant application or as a development phase
        within a funded application; but would depend on
        time, resources, & FOA
BRIC II – What (Seemed to) Work
   Support for Partnerships
       PI & Co-PI helped Small Research Project
        partners work together
           HSRers had to “chase” FP Fellows; PI & Co-PI helped
            catch them (but also needed to know when to get out
            of the way)
       Co-PI facilitated partnerships with KAN
       PI facilitated partnerships with HSRers
BRIC II – Lessons Learning
   Might more HSRer & PI/CoPI direction
    increase “scholarly productivity” UKy ACCC?
       Note: Actual research using data has been
        conducted by professional degree candidates with
        significant mentorship outside our department
       Do we need to facilitate FP partnering with HSR
        mentors?
       How can we bridge QI processes and typical
        scholarly productivity?
BRIC II – What (Seemed to) Work
   25% protected time needed for junior FP to
    channel time & attention toward research and
    developing own capacity
       E.g., Dedicated day away from the office &
        connection to a national grant-writing program
        helped SK protect time
BRIC II – Lessons Learning
   It’s OK to let success overtake you
       Genesis of College of Public Health
           Center for Health Services Mgt & Research then
            School of Public Health then College
       NIH Clinical & Translational Science Awards
        (CTSA)
           University-wide restructuring to support formation of
            Center for Clinical and Translational Science
           DFCM & KAN leadership in outreach core function
BRIC II – Lessons Learned
   Would have been helpful to have continued
    “BRIC Brass” from BRIC I
       Advisory group of Chair & Academic Vice Chair of
        Fam & Comm Med, and Director of Center for
        Health Services Management and Research (later
        Director of School of Public Health)
       To promote knowledge of faculty activities, buy-in
        and support of program, and view to “bigger
        picture” of university, community, U.S.
Implications for Health Reform
   Overall, in both KAN (PBRN) and ACCC (or
    other health care collaboratives), the
    physicians and their practices are part of the
    solution, that is, for improving health care and
    health outcomes.
Implications for Health Reform
   As primary care plays a central role
       PBRNs can link AHCs & communities to
        implement & evaluate programmatic change and
        quality improvement processes
       PBRNs can help inform policy makers of barriers
        & facilitators to better design systems that work
       PBRNs reach diverse communities and can
        represent diverse types of practice
Implications for Health Reform
   Based on our experience in Kentucky, layers
    of specific types of support can build or
    leverage academic-community partnerships
       Expert HSRers from multiple disciplines
       Primary care physicians trained as research
        collaborators
       Collaborative teams
       Facilitators (people who help with teamwork)
Implications for Health Reform
   However…
       Quality improvement processes require ongoing,
        rapid evaluation
           E.g., Plan-Do-Study-Act (PDSA)
       This is not like traditional interventional research
        models in geological time
       Similarities to traditional research
           Systematic evaluation of impact
           Evidence based change strategies
Implications for Health Reform
   Both practice-based research and QI cycles
    take many university researchers outside
    their “comfort zone”
       Less controlled circumstances
       Participants can benefit from the research (not
        just for the greater good in the future)
Implications for Health Reform
   Special expertise in PBR & QI needed
   HSRers may want retraining to capture rapid
    healthcare change
   Physician faculty may need HSR training/experience
   Facilitated partnerships enable “on-the-job” training
   Funding for partnership development could enable
    new “players” in federally funded research
       New institutions
       New disciplines
UKy BRIC Faculty
Family & Comm Medicine            College of Public Health
     Mel Bennett MD MPH               Joyce Beaulieu PhD (1st PI)
     Paul Dassow MD MSPH              Julia Costich PhD JD
     Robert Hosey MD                  Carol Ireson PhD
     Jennifer Joyce MD                Steve Fleming PhD (2nd PI)
     Shersten Killip MD MPH           F. Douglas Scutchfield MD
     Michael King MD                  Sarah Wackerbarth PhD
     Margaret Love PhD (Co-PI)
     Samuel Matheny MD MPH       And thanks to AHRQ…
     Kevin Pearce MD MPH              Kay Anderson, PhD
     Steve Wrightson MD               P20 HS-011845
                                       R24 HS-011845

				
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posted:8/8/2012
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