Practice Facilitation

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					LA Net, A Project of Community Partners

Lyndee Knox, PhD and members of the
  2010 Practice Facilitation (Coaching)
Consensus Meeting – Los Angeles, Ca
   How do we support quality improvement in
    the safety net more effectively?
   Learning collaboratives have produced
    positive change; but have not been
    sufficient to reach desired targets. More Is
   Prior project funded by AHRQ to develop a “toolkit” to
    support practice-led implementation of the Chronic Care
    Model (CCM) in the safety net.
    Integrating Chronic Care and Business Strategies in the Safety Net. AHRQ
      Publication NO. 08-0104-EF. Prepared by: MacColl Institute for Healthcare
         Innovation, RAND Health, and the California Health Care Safety Net
                             Institute. TOO: Cindy Brach

   Practices had difficulty implementing on their own, so
    AHRQ explored use of Facilitators (PFs), developed
    preliminary resources for them, and conducted a pilot
    investigation of their impact.
Integrating Chronic Care and Business Strategies in the Safety Net: A Practice
      Coaching Manual. Written by: Coleman, Pearson, Wu 2009; Edited by:
                                  Cindy Brach
   Current project is next phase of the ARHQ
    CCM in the Safety Net project. It involves:
    a) consensus meeting (working group) on
    PF, and b) implementation and evaluation
    of a PF intervention in 20 safety net
     MAFPRN    (Kevin Peterson, Master Contract
      Holder), LA Net (Lyndee Knox, PI), AHRQ
      TOO (Cindy Brach)
•   Practice facilitators are specially trained individuals
    who assist primary care clinicians in research and quality
    improvement projects.

•   They are distinguished from consultants through
    specialized training, broad scope of practice, and long-
    term relationships with an organization, its providers and
    its patients.
Adrienne Bowes (Redwood)                Katy Smith (UOHSC)
Brenda Fraser(QIIP)                     Kelly Pfeifer (SF Health Plan)
Carolyn Sheperd (Clinica Campesina)     Kevin Peterson (UMN)
Cathy Catrambone (Rush)                 Leif Solberg (Health Partners)
Chuck Kilo (GreenField Health & OUSU)
                                        Lisa Kodmur (L.A. Care)
Cindy Brach (AHRQ)
                                        Lisa Letourneau (Quality Counts)
Cindy Dickinson (Southwest)
Clare Liddy (Un of Ottawa)              Lyndee Knox (L.A. Net)
Craig Jones (Vt Blueprint for Health)   Mary Ruhe (Rush)
Corey Sevin (IHI)                       Michael Barr (ACP)
Darren DeWalt (UNC)                     Mike Herndon (OK Healthcare
Doug Eby (SouthCentral)                 Authority)
Elizabeth Stewart (Un of Texas)         Neil Solomon (Health Net)
Ellen Christiansen (Coastal Health      Paul Vandeventer (Community
     Alliance)                          Partners)
Grace Floutsis (Oscar Romero)           Perry Dickinson (U. Colorado)
James Mold (UOHSC)                      Roland Palencia (L.A. Care)
John Kotick (FHCCGLA)                   Rich Seidman (L.A. Care)
June Levine (L.A. Net)
                                        Sophia Chang (CHCF)
Kate Coleman (MacColl)
                                        Tom Bodenheimer (UCSF)
                                        Trish O’Brien (QIIP)
                                        Veenu Aulakh (CHCF)
•   What to call it
•   The evidence supporting it
•   Its goals and methods
•   How to allocate the resource
•   More and less effective approaches
•   How to manage a program
•   Funding and infrastructure needs
•   Research questions
   Decision rules
      Name should appeal to customer (the PCP)
      Should support scientific publication and development
       of the field
      Should contribute to development of a common

   Recommendation: Practice Facilitation is: 1)
    acceptable to PCP; 2) appropriately reflective of activity;
    and 3) likely to yield scientific publications
         Findings are inconsistent and inconclusive at this point

   Recent meta analysis (Bakerville, 2009) is encouraging – review of
    19 studies showed moderate significant effects for practice
    behavior change diminishing with complexity of change, and higher
    facilitator to practice ratios. Link to dissertation available at:

   NDP study comparing PF to self-directed (Nutting et al, 2010)
    mixed, showing modest differences between self-directed and
    PF pratices in adaptive reserve and proportion of NPD
    components implemented. Intensity of PF was less than Mold
    model, primary modality was distal (email/phone/web).

   Yet to be published studies show value but also indicate need for
    additional resources in addition to facilitation to enact and
    sustain complex change.
   Is it the health care system, practice, or the patient?

   Agreement: The primary sphere of influence for PF is
    the practice

   This includes administrative, clinical, QI systems, and a
    practice’s connections to the outside (other organizations
    & community)
   Goals of PF are to improve quality, access and
    improve financial viability at the practice level. (Triple

   The issue of cost is particularly important. PF and
    changes it supports like PCMH will likely increase costs
    for primary care practices which may reduce financial
    viability. This is a problem that needs more thought.

   Ultimately there should be a business case for change or
    it will be difficult to sustain.
   These were hard to define and are likely project and
    practice specific.

   Some recommended by group:
      Create capacity for population management
      Create capacity to use data to improve process and
       quality improvement
      Build organizational capacity for change: priority, will,
       knowledge and ability (Solberg)
      Instill hope
      There were many others…
   PF might support more complex changes:
      Electronic visits,
      group visits,
      team-based care,
      wellness promotion, and
      Proactive population management
   Facilitation is a scarce resource
   That should be directed towards practices most likely to
    benefit (not highly dysfunctional, not exemplars)
   That want facilitation
   And towards early adopters (most likely to support
    “spread” based on Rogers work in diffusion) in the
    practice community, that can drive “diffusion” of
    improvements through their practice-based social
The Facilitation Ecology
Goals:                                                                                         Payers
Improved patient outcomes
                                                        Exemplar                               Health system
Improved patient experience
Reduced costs


                                           Low Functional practices

                                            Survival level practices

         Practices that want to engage in improvement                  Practices that do not
•   Approaches:
     – Humanistic/self-actualizing --- when org/climate needs
     – Facilitation/coordination ---- when knowledge resides in practice
     – Technical assistance ---- when undertaking s/t where know doesn’t
       reside in practice

•   General agreement: Approach should fit: a) needs of practice, and b)
    goal of the intervention. For interventions where a practice already
    possess the knowledge (and skills) needed to implement the target
    improvement, the most appropriate PF approach may be
    facilitation/coordination to assist the practice to utilize/actualize this
    existing knowledge/skill. For interventions where a practice does not
    already possess the knowledge/skill, then the most appropriate PF
    approach may be to provide/broker deep technical assistance on the
    topic. Most PF interventions are likely to require a combination of the
    three approaches.

•   The goodness of fit between PF approach, practice need, and
    improvement goals is an important factor in determining the eventual
    effectiveness of the PF intervention. The lack of a good fit between
    approach and the needs of the practice and the improvement goals can
    contribute to general dissatisfaction with the PF encounter.
•   Determining “practice readiness” is a critical first step to the process

•   Some readiness criteria:
     – Support of leadership
     – Change is a priority
     – Basic functionality across most organizational systems
     – Sufficient “adaptive reserve” to make the changes (e.g. the time,
       money, people, they need to make desired changes)
     – In vivo demonstration of willingness and ability to engage in a
       change process
     – They do not have “change fatigue” – which may become
       increasingly common in coming years with reform underway.
       This concept needs additional consideration.
References: Some tools for
assessing practice readiness for
Organizational Readiness for Change (ORC)
    Lehman, W.E.K, JM Greener, DD Simpson. (2002). Assessing
    Organizational Readiness for Change. Journal of Substance Abuse
    Treatment 22: 197-209.
Learning Teams for Reflective Adaptation (ULTRA) readiness survey
    Ohman-Strickland, PA et al. (2006). Measuring organizational attributes of
    Primary Care Practices: Development of a New Instrument. Health
    Research and Educational Trust 42 (3): 1257-1273.
Predicting Outcomes of Org Change Survey
    Gustafson DH, Sainfort F, Eichler M, Nutting PA, Dickinson WP, et al.
    Developing and testing a model to predict outcomes of organizational
    change. Health Services Research (2003) 38 (2): 751-776.
   Location of facilitators:
      Internal
      External
      Embedded or hybrid

   General agreement: Internal is ineffective. Internal “facilitators” get pulled
    away from facilitation role by competing demands, and often lack the
    distance they need to drive change. Possible exception to this is IPA or
    other type organization, where facilitator is internal to organization but not
    to individual practice. Hybrid and external models are preferred.
    Embedded or hybrid may be most effective.
•   Type of facilitator
     – Generalist (facilitative and QI skills)
     – Specialist (expert knowledge in particular area: e.g. billing)
     – Team (multiple persons led by generalist)

•   General agreement: Team facilitation approach is preferable. It
    may also be more expensive.

•   The team consists of a “generalist facilitator” who commands core
    skills in facilitation, QI and essential technical elements, and then
    manages a “team” of “specialist” facilitators that he/she brings in
    based on specific needs of practice.
   Modalities:
      In person
      Email and phone and web
      Combination
   No clear agreement here: Trend towards predominately
    in-person being more effective. But what constitutes a
    good mix is not clear yet and may be practice specific.
   Use of IT in PF has been limited mainly to a strategy for
    reducing costs of PF. Its use to increase the impact
    of PF needs consideration.
   Average interventions range from 100-200 contact
    hours, with a minimum dose of 120 hours.

   Not enough information yet to suggest what constitutes a
    sufficient dosage of PF. This may be difficult to tease
    out but it important to know b/c of implications for cost
    and design. Prevention and intervention science in
    behavioral health has had success in developing some
    guidelines on interaction “dosage” based on 20-30 years
    of research.

   Will likely vary on the type and magnitude of change
    being sought. And the particular traits of the practice.
•   Schedule for facilitation
     – Intensive: All day, everyday for 4 wks w/ follow-up
     – Consistent: Weekly for ½ for 10 months or more
     – Intermittent: PRN
     – Combination of the above

•   No clear preference for schedule emerged in discussion. Depends
    on factors such as project goals, funding structure and timeline, PF
    staffing model, budget.
   PF can be provided:
      As a stand alone intervention
      In combination with other approaches
          w/ traditional learning collaborative as a primary or secondary
          w/ academic detailing (peer to peer influence/learning)

          w/ local learning collaboratives

   General agreement: PF should be provided in combination with other
    resources and approaches including collaboratives and also payment

   No clear agreement on PF and collaborative combination designs. Some
    suggest collaboratives are best for providing tools and peer
    pressure/external motivation. PF provides the ability to tailor the
    information to the needs of the site, give deep technical support and
    directly facilitate change at practice level.
   Variations in the way a practice makes money (fee for service,
    capitated), is organized (CHC, other staff model, small or group
    independent), is staffed (MD, MD-mid-level), and size (small,

   Affect motivation for improvement, the drivers for improvement,
    feasibility and resources available to support improvement,
    improvement goals, and the business case for improvement

   While PF skills used across practices remain consistent, these
    variations have implications for scope of PF knowledge, PF goals
    and strategies.
•   Infrastructure needs
•   Hiring issues
•   Training & supervision of PFs
•   Recruiting practices for facilitation
•   Cost
•   Sources of funding
•   Evaluating your services
•   PBRNs and university research programs
•   QI organizations
•   State Health Departments
•   HIT Regional Extension Centers
•   Trusted intermediaries such as clinical associations
•   National Health Service (Canada)

     Proposed: National Primary Care Extension Service
   Divided on issue of clinical experience:
      Some say PF must have clinical experience to be
       able to provide relevant assistance.
      Others say not essential (esp. w/ team coaching
         can gain this type of knowledge on the job
         say clinical experience can be a detriment by
          introducing historic turf/power issues, limiting PF’s
          perspective/options considered
   Some say most important to have very good
    interpersonal and facilitative skills

   Others say technical expertise is more important than
    any of the above: how to do panel management,
    implement group visits, practice redesign – the “nuts
    and bolts”
   Both consultant and employee models are used

   No clear agreement: Employee model may be more
    effective for ensuring fidelity to a particular model. But
    consultants may do this equally well. May be person
•   Communication and interpersonal skills
•   General facilitative skills
•   Specific QI skills
•   Select deep technical skills in specific high need/yield areas
    (not yet defined)

Two core competencies resource documents:
AHRQ Consensus Group. 2010. Working Draft: Core
  competencies for generalist coaches. Available online at:
Fraiser, B. 2009. Quality Improvement Coach Competencies.
   Available online at:
•   Most common approach is through intensive workshop, combined
    with on-going supervision

•   Internship in clinical environment not necessary, gain this on the
    job in first 4 weeks.

Training resources for facilitators
    – PEA training manual (Jim Mold)
    – IPIP training materials (Darren deWalt – not ready yet)
    – Impact BC training materials (
    – IHI’s newly launched PC series (Corey Sevin – first session July)
    – Small practice eDesign (Sophia Chang, CHCFoundation – not
      ready yet)
    – Improving Chronic Care Practice Coaching Manual
    – Dartmouth Coach (Margie Godfrey, not ready yet,
              A complete list is available at:
   General agreement: The work of Facilitators is
    challenging and at times taxing, requires intensive
    interpersonal work, and can involve the sometimes
    difficult work of a non-MD establishing credibility with
    an MD. As such, PFs need strong support systems at
    the home office in the form of supervision, learning
    communities with other PFs, and social/emotional

   General agreement: Weekly PF supervision, learning
    and support sessions are essential for on-going
    professional development, emotional support and idea
•   Addressing practice’s concerns about being overwhelmed by
    other projects/activities
     • PF as organizer across change initiatives
     • PF as resource to develop comprehensive improvement
       “plan” for practice that weaves together and leverages
       across on-going projects

•   Identifying and using PF to respond to practice’s internal
    and external improvement pressures and goals

•   Must ultimately improve finances and/or life of PCPs and staff
    to be viable long term
   Costs for practice facilitation can range from $10,000 to
    $45,000 per practice for average 120-200 hour
    intervention. Depending on PF staffing model, goals,
•   Mainly short-term and project limited funds:

    –   Grants (for research)
    –   QI contracts from payers
    –   By clinics
    –   HIT REC centers (possible source)

•   This may change through proposed Primary Care
    Extension Program (Mold)
Recurring theme: Financial impact and PF

   PF can support some useful changes in the present
   But buy-in, impact and also uptake of improvements
    by PCPs may be limited
   Until a practice sees clear financial and life quality
    benefits for improving care and outcomes
•   Disseminate summary report
     – Wiki for collective additions to report

•   Prepare curriculum and facilitator “toolkit” (to complement
    CCM Toolkit already developed by AHRQ)
     – Wiki for collective additions to both

•   Evaluate PF intervention to increase implementation of
    Chronic Care Model in 20 safety net practices in LA

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