The Art of Outreach Facilitation

Kate Nash and Dianne LaferriereJanuary 24 2011

The Art of Outreach Facilitation

Brief Review thus far• Chronic Disease Model -acute to chronic focus in

approach to health care• Science of Outreach Facilitation- development of

facilitation and how it has been used in prevention services

• Facilitation is an effective and supportive way of changing practice behaviour, as well as being cost effective

What is a facilitator?

A helper and enabler whose goal is to support others as they achieve exceptional performance.

Facilitation is a way of providing leadership without taking the reins.

Ingrid Bens

Overview of presentation IDOCC: The Improved Delivery of Cardiovascular Care

through Outreach Facilitation Program

The Primary Care Environment (in Ontario)

The Qualities and Skills of a Facilitator

Tools

Tailoring

IDOCC

The Improved Delivery of Cardiovascular Care

Through Outreach Facilitation

IDOCC: Creation of the CCPN• The University of Ottawa Heart Institute

– Prioritized Prevention of CVD – Recognizing the need for a true collaborative approach

• Advent of Local Health Integration Networks– Regionalized focus – Allows for development of Chronic Disease Management in a way that

has never been done before

• Reorganization of Public Health in Ontario and Canada– A focus on integrated approaches to chronic disease prevention– Public Health Agency of Canada, Ministry of Health Promotion

IDOCC: CCPN Priority Initiatives 1. IDOCC initiative

2. Hospital-based Smoking Cessation Network

3. Champlain Get with the Guidelines Initiative

4. Champlain Healthy School aged Children Initiative

5. Champlain Healthy Living and Management Risk Factor Program

6. Champlain Community Heart Health Survey

IDOCC: Recruitment • Complex due to no single entity identifying primary care physicians

• Multiple contacts with OMA, OCFP, CME events, pharmaceutical events,

• Public speaking, promotion through the LHIN, press releases, get opinion leaders and community leaders on board to that they can spread the word and convince their colleagues

• Cold calling- barriers, phone calls, in person visits

• Printed material

• Built our own comprehensive list of primary care physicians

IDOCC Overview

• The ‘Divisions’ were randomly assigned to begin the program as follows:Division

Year 1 Year 2 Year 3 Year 4 Year 5West

Cen-tral East

9 8 4 Baseline FacilitationFacilitation

(Sustainability phase)

Facilitation(Sustainabilit

y phase)On-going program

implementation –

sustainability phase;

Data analysis and

evaluation

2 7 5 Baseline Baseline FacilitationFacilitation

(Sustainability phase)

1 6 3 Baseline Baseline Baseline Facilitation

Evaluation-Key Indicators

• Quality of care process indicators - 29 evidence- and consensus-based indicators chosen to assess whether recommended clinical actions were followed in the clinical situations calling for those actions eg BP taken and recorded at least once in last year

• Outcome of care indicators - 14 evidence-based reflecting whether patients achieved the the recommended treatment goal targets

Source of data: Patient Chart Audit

IDOCC: Practices# of practices # of physicians

Step 1 26 59

Step 2 30 79

Step 3 27 53

Total 83 191

IDOCC: Practices by Model

6%

45%

18%

6% 8%

14%

2%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%%

of P

artic

ipat

ing

Prac

tices

FFS FHG FHO FHN FHT CHC LTC

Primary Care Model Type

IDOCC: EMR/ Paper/Transition

At the time of signing up for IDOCC there were:

• 43 Practices using paper

• 40 Using EMR or a mix of paper/EMR

That figure is constantly changing

IDOCC: Practices by Region

Program implemented in 83 practices

IDOCC: Program Outline

• Consent• Chart audit of 66 randomly abstracted charts• Facilitator provides audit and feedback• Collaborative goal setting• Monthly visits for intensive year, 12-16 weeks for

sustainability year• Chart audit repeated at the end of the study

Patient Diagnoses & Risk Factors (n = 4,896)

HTN – Hypertension CKD – Chronic Kidney DiseaseCAD – Coronary Artery Disease PVD – Peripheral Vascular Disease

83%

46%

77%

18% 13%

30%

6%

21%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% o

f Pat

ient

s w

ith D

iagn

oses

or R

isk

Fact

or

Dyslipidemia Diabetes HTN CKD Stroke CAD PVD Smokers

Diagnoses or Risk Factor

The Primary Care Environment

Complex

&

Evolving

The Primary Care Environment

“ efforts to understand practice should precede efforts to change practice”

The Primary Care Environment

• Complex

• Changing

• Unpredictable

The Primary Care Environment

1. Complexity

2. Payment Models

3. Community

4. Culture

The Primary Care Environment

1. Complexity

Primary Care EnvironmentHealth Care Organization

•Scepticism •Not influenced by financial incentives•Fear of losing autonomy

•Open to new initiatives•Want to maximize billing•Accept CDM challenge

Primary Care EnvironmentLocal factors

•Walk-in clinics

•Sudden population shifts

•Rural practices

Primary Care EnvironmentAppointments System

•Patients can’t get same day appointment

•Overbooked

•Always an hour or more late

Primary Care EnvironmentSelf management•No time•Patient’s responsibility•Saying the same thing for years

•The 3 questions•The 5 As•Focus on those who are ready•Refer

Primary Care Environment

Change

•Change of models

•Change of location

•Change of records

The Primary Care Environment

A physician who has recently moved to EMR tries desperately to retrieve the patient records he has just lost.

The Primary Care EnvironmentUnpredictability

•A productive relationship v a “good” relationship

•The agent for change can be anyone in the team.

•Never Never

The Primary Care Environment

The facilitator is uncertain where to go next with the practice

The Primary Care Environment

And then has a pleasant surprise

The Primary Care Environment

2. Payment Models (Ontario)

2.Payment Models

• FFS- accounts for largest number of practices, physicians and patients seen, no rostering, no other funding

• FHG-(FFS remuneration) but incentives for some conditions, patient rostering, after hours care, THAS, currently some funding for IT

2.Payment Models

• FHN, FHO-capitation, rostering, prevention and disease management incentives, provider governance, use of IT, some allied health personnel, 24/7 access

• FHT- Capitation or salary, rostering, allied health personnel, prevention and disease management incentives, professional or community governance, IT, 24/7 access

2.Payment Models• CHC-salaried, rostering (operates within defined community),

incentives, IT, allied health personnel, community governance, 24/7 access

• AHAC-Aboriginal Health Access Centres- similar to CHCs, include traditional aboriginal approaches to health and wellness- salaried

Russell, GM et al 2009, Muldoon L et al 2009

Patient –Physician Perspectives

• Payment model and organization may not affect day to day practice

• A doctor in a FFS, FHG, or FHO may for most purposes work as a solo physician with receptionist and /or nurse

• There may be more similarities across models than within models

The Primary Care Environment

3. Community

Community•Only CHCs have a “catchment” area•Patients often follow the doctor, therefore the idea of community resources and links becomes complex•Patients find doctors who speak the same language even if geographically distant•Rural/Urban differences•Quebec Patients

The Primary Care Environment

4.Culture

Culture

• The practice culture (shared beliefs and values embedded within an organization)

• Organisational culture

• Patient culture

The Primary Care Environment

Culture can influence the types of programs used to assure Quality- survey from 88 medical groups

• Strong Information culture favoured electronic data systems and evidence based data

• Quality centred culture favoured patient satisfaction surveys• Business orientated culture favoured benchmarking• Collegiate culture appeared to rely more on informal peer

review• Autonomous culture negatively associated with all the

programs ( but not significantly so)

Authors Conclusions

• Culture does not make a difference in quality of care and patients safety

• Culture does affect the slow adoption of quality assurance programs

• It is important to consider congruence

Kaissi et al, 2004

The Primary Care Environment

“ …practices often lack the office systems to support improved chronic illness self-management, delegation, care management and systematic tracking to assure optimal processes and outcomes of diabetes care.”

“ Practices operate on a narrow financial margin, have minimal flexibility in resource use and are quite different from those systems in which adoption of chronic care management components have been demonstrated.” Crabtree et al, 2011

The Qualities and Skills of a Facilitator

Qualities of the Facilitator *

• Skills: presentation training, research and planning, analytical & synthesis skills, observational skills, design & customize interventions, ability to lead groups, interpersonal collaborative skills, communication skills

• work independently, be flexible, creative, sensitive, empathetic, supportive, promotes and guides

*Guiding Facilitation in the Canadian context

Qualities of the Facilitator

• Knowledge skills: primary health care context and office systems, relevant guidelines of care, organizational change, techniques and strategies, group vs individual dynamics

Qualities of the Facilitator

• Personal disposition: encouraging, neutral, inquisitive, non-authoritative leadership style, assertive & confident, focuses on building capacity rather than taking ownership, share knowledge and strategies, change approach as needed, be comfortable with change and dealing with conflict and/or resistance

Qualities of the Facilitator

• Technical, computer skills: library searches, some familiarity with EMRs, good familiarity with word processing and presentation programs

Qualities of the Facilitator

• Organizational skills: identify processes as well as outcomes, work flow, create partnerships, knowledge of QI principles and strategies, provide resources and assist in development and implementation of evidence based practice tools

Tools

Tools • Audit and Feedback• Tailored flow sheets• Patient educational tools- links to community resources and

promoting contact• Community Resources- specialists, awareness, referral forms,

“Ask the Experts” opportunities• Networking Opportunities- shared experiences, successes and

challenges• Summaries of conferences• Guidelines• Web sites

Tools

Relating tools to the Chronic Disease ModelThe Community• Wider health community- Ministry of Health, professional

bodies (College of Physicians and Surgeons), local diabetes programs

• These organizations may offer directives, information, billing incentives, assistance

• Facilitator can identify and help establish liaisons with these partners and/or find these resources for practice

• Eg. Extra phone billing incentives at time of H1N1• Eg. Referrals to specialist care or community programs

Tools

Relating tools to the Chronic Disease ModelThe Health system Organization• MOHLTC, Champlain LHIN and family practices are

all focused on diabetes care- what is being done at all of the levels? Eg. BDDI

• QIIP, DRCC, IDOCC, other programs • Transfer knowledge and facilitate linkages among

organizations

Tools

Relating tools to the Chronic Disease ModelDelivery System Design• Define roles and tasks-writing descriptions• Encourage the development of planned visits for

continuity of care, follow up• Help team explore improved communications• Will shift focus from episodic reactive focus to a

proactive one

Tools

Relating tools to the Chronic Disease ModelDecision Support• Audit and feedback• Evidenced based guidelines• Literature searches• Provider education- CME opportunities, conference

summaries, network meetings to share knowledge and strategies

• Patient education- increase population awareness of the pertinent guidelines for care- posters in office, focused visit handouts

• Increasing specialist care into primary care- reviewing specialist availability, updating accuracy of forms and contacts

Tools

Relating tools to the Chronic Disease ModelClinical Information System Support

• Registries- EMR or paper• Reminders in charts- EMR or paper• Flowsheets, practice aids- (tape measures)• Encourage periodic reviews to look at performance

and efficacies

Tools

Relating tools to the Chronic Disease ModelPatient Self Management• Increase patient knowledge through education• Increase ownership of health – self management programs-

identify, inform and promote• Action plans- ranging from simple to complex, feedback to

patients • Promoting the idea that patient and team are working together

to improve or maintain health- both patients and staff need to agree (attitude change)

• Provide ongoing support for practices and patients

Tailoring

Tailoring

“Practice assessment and intervention tailoring are complex and intuitive processes and are generally not amenable to linear or sequential steps and simple descriptions”. Ruhe, 2009

“ Tailored interventions have the potential to match motivations and acknowledge conditions within the practice environment that influence and sustain change efforts.” Bobiak, 2009

Systematic Review, Baker 2009

• 26 studies• Tailored interventions can change professional

practicehowever

• As yet there is insufficient evidence on the most effective approaches to tailoring including how barriers should be identified and how interventions should be selected to address barriers”.

Tailoring

Interventions can be tailored more effectively by:

Assessing the practice’s capacity for change

Appraising the cultural-structural fit

The Art of Facilitation

Practical Considerations

• Don’t reinvent the wheel- easier and time saving to adapt existing tools, if possible

• Everyone has their own style- what works for one practice may not in another

• On the journey, there may be hold ups, barriers and detours

• Keep the destination in sight and close the loops

A Complex Journey but

Try and close the loops

ReferencesBaker R et al, Tailored Interventions to overcome identified barriers to change: effects on professional practice

And health care outcomes. Cochrane Database of Systematic Reviews 2010Bens I, Facilitation at a Glance, GOAL QPC & AQPBobiak S et al, Q manage Health Care Vol. 18, No 4, pp. 278-284, 2009Carter C et al, Q Manage Health Care Vol. 16, No 3 pp 194-204, 2007Crabtree et al, Medical Care Dugan et al, J. Ambulatory Care Manage, Vol. 34, No 1, pp.47-57, 2011Guiding Facilitation in the Canadian context: Enhancing Primary Health Care, Multi-jurisdictional

Collaboration, Dept of Health and Community Services, Newfoundland, 2006Hogg W, International Journal for Quality in Health Care Vol. 20, No 5, pp. 308-313, 2008Kaissi et al, Health Manage Rev 2004, 29(2) 129-138Muldoon L et al Health Care Management Forum 2009Ruhe M et al, Q Manage Health Care Vol. 18, No 4, pp 268-277Russell, GM et al Annals of Family Medicine 2009, Strange KC. J Family Pract. 43(4). Pp. 358-360, 1996