Engaging Important Stakeholders to Assess Gaps in Primary Care for Dementia:

Considering the Forest as Well as the TreesChristina L. Vair, PhD, Clinical Research Psychologist 1

Laura O. Wray, PhD, Executive Director 1,2

Gregory P. Beehler, MA, PhD, Acting Associate Director for Research1,2

J. Riley McCarten, MD, Medical Director 3,4

1VA Center for Integrated Healthcare, 2University at Buffalo, 3VA VISN 23 GRECC, 4University of Minnesota

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session #E2bOctober 16, 2015

Faculty Disclosure

The presenters of this session have NOT had any relevant financial relationships during the

past 12 months.

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Learning Objectives

At the conclusion of this session, the participant will be able to:

• Describe the VHA’s interdisciplinary, team-based approach for whole-person care (Patient Aligned Care Teams and Primary Care-Mental Health Integration) and ways that these partnerships could be utilized in support of integrated care, system transformation, and population health for veterans with dementia.

• Identify important stakeholders within their local setting, including ways to conduct a stakeholder analysis and how to engage stakeholders in addressing program evaluation questions.

• Discuss notable barriers and facilitators to the provision of high quality dementia care within primary care behavioral health models of service delivery and ways to improve quality of PC healthcare services for patients with dementia through engagement of important stakeholders.

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References

1. Cordell, C. B., Borson, S., Boustani, M., Chodosh, J., Reuben, D., Verghese, J. et al. (2013). Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimer’s & Dementia, 9, 141–150.

2. Galvin, J. E., & Sadowsky, C. H. (2012). Practical guidelines for the recognition and diagnosis of dementia. Journal of the American Board of Family Medicine, 25, 267–382.

3. McCarten, J. R., & Borson, S. (2014). Should family physicians routinely screen patients for cognitive impairment? YES: Screening is the first step toward improving care. American Family Physician, 89(11), 861-62.

4. Posavac, E. J., & Carey, R. G. (2007). Program evaluation: Methods and case studies. Upper Saddle River, NJ: Pearson Prentice Hall.

5. Rossi, P. H., Lipsey, M. W., & Freeman, H. E. (2004). Evaluation: A systematic approach. Thousand Oaks, CA: Sage.

6. Wilcock, J., Jain, P., Griffin, M., Thune-Boyle, I., Lefford, F., Rapp, D., & Iliffe, S. (2015). Diagnosis and management of dementia in family practice. Aging & Mental Health, (ahead-of-print), 1-8.

7. Wray, L. O, Wade, M., Beehler, G. P., Hershey, L., & Vair, C. L. (2014). A program to improve identification of undiagnosed dementia in primary care and its association with health care utilization. American Journal of Geriatric Psychiatry, 22, 1282-1291.

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Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

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Disclosure

The views expressed in this presentation are those of the authors and do not necessarily

reflect the position or policy of the Department of Veterans Affairs or the United States

government.

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The Medical Home Model in the VA

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Patient Aligned Care Team (PACT)

Access

Offer same day appointments

Increase shared medical appointments

Increase non-appointment care

Practice Redesign

Redesign team: o Roles o Tasks

Enhance: o Communicationo Teamwork

Improve Processes:o Visit worko Non-visit work

Care Management & Coordination

Focus on high-risk pts:o Identify o Manageo Coordinate

Improve care for:o Preventiono Chronic disease

Improve transitions between PACT and:

o Inpatiento Specialtyo Broader Team

Patient Centeredness: Mindset and Tools

Improvement: Systems Redesign, VA TAMMCS

Resources: Technology, Staff, Space, Community

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Primary Care-Mental Health Integration(PC-MHI)

• Discipline-specific PACT includes Integrated Care for physical and mental health in one setting• Evaluation and treatment for mild to moderate mental health

conditions (depression, substance misuse, anxiety, PTSD)• Follow-up evaluation for positive MH screens

• Behavioral health interventions for chronic disease• Care management• Referral management

• Screening for mental health conditions• Initiation of pharmacological treatment

for mild to moderate mood symptoms• Co-management of Veteran care with

PC-MHI and specialty MH providers • Health Behavior and Prevention• Emphasis on wellness

Secondary and Tertiary Care:• Outpatient Care for treatment resistant, severe or complex illnesses

• PTSD specialty treatment; Substance dependence treatment• Treatment of serious mental illness (including MHICM)

• Full spectrum of psychosocial rehabilitation and recovery services• Inpatient psychiatric care

• Residential treatment• Supported and therapeutic employment

• Homeless programs• Behavioral Health Interdisciplinary Program (BHIP)

PRIMARY CARE

SPECIALTY MH

BHIP

PC-MHI

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Involving Stakeholders to Address Program Improvement

VETERANS HEALTH ADMINISTRATION

Improvement-Focused Approach

• Focus on program improvement• Goals

– serve the needs of stakeholders– provide valid information– offer alternative points of view to those on the frontlines serving

patients – balance recognition of strengths of programs as well as areas for

improvement • “To carry this off without threatening the staff is the most challenging

aspect of program evaluation.” (Posavac & Carey, 2007)

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VETERANS HEALTH ADMINISTRATION

Who are your important stakeholders?

Audience responses:

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VETERANS HEALTH ADMINISTRATION

Primary Stakeholders To Consider

– Policymakers and decision makers– Program sponsors – Evaluation sponsors– Target participants– Program managers– Program staff– Program competitors– Contextual stakeholders – Evaluation and research community

(Rossi, Lipsey, & Freeman, 2004) 14

VETERANS HEALTH ADMINISTRATION

What is a Stakeholder Analysis?

• Process of systematically gathering and analyzing qualitative information to determine whose interests should be taken into account when developing and/or implementing a policy or program.

• One of the first steps you should take in any change project.

– Enables you to identify everyone with a concern or interest who needs to be involved

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Consider the 9 Cs*

• Commissioners: those that pay the organization to do things • Customers: those that acquire and use the organization’s products • Collaborators: those with whom the organization works to develop and

deliver products • Contributors: those from whom the organization acquires content for

products • Channels: those who provide the organization with a route to a market or

customer • Commentators: those whose opinions of the organization are heard by

customers and others • Consumers: those who are served by our customers: ie patients, families,

users • Champions: those who believe in and will actively promote the project • Competitors: those working in the same area who offer similar or

alternative services

*UK National Health Service Institute for Innovation and Improvement16

Understanding Your Stakeholders• What financial or emotional interest do they have in the outcome of your

work? Is it positive or negative? • What motivates them most of all? • What information do they want from you? • How do they want to receive information from you? What is the best way of

communicating your message to them? • What is their current opinion of your work? Is it based on accurate

information? • Who influences their opinions generally, and who influences their opinion of

you? Do some of these influencers therefore become important stakeholders in their own right?

• If they are not likely to be positive, what will win them around to support your project?

• If you don't think you will be able to win them around, how will you manage their opposition?

• Who else might be influenced by their opinions? Do these people become stakeholders in their own right?

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VETERANS HEALTH ADMINISTRATION

Understanding the Implementation Environment

• Uptake and adoption of systems innovations hinge on the healthcare environment into which they are implemented

• This includes attitudes of key stakeholders,– patients, families, providers, administrators . . .

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VETERANS HEALTH ADMINISTRATION

How to Involve Stakeholders

• First, identify stakeholders• Involve stakeholders early• Involve stakeholders continuously • Involve stakeholders actively • Establish a structure

(Rossi, Lipsey, & Freeman 2004)

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VETERANS HEALTH ADMINISTRATION

A Few Tips* • Explain to reluctant interviewees that their views are important

because they the experts• Inform about constructive intent of interviews, assuring anonymity

and encouraging freedom of speech– Opt out of any question or at any time– All input valued; no right or wrong answers

• Conduct interviews at interviewees’ convenience• Use focused, open-ended questions

– Preface questions with introductory statements suited to study objectives

• Include short probe list to ensure that all related topics deemed relevant to the evaluation had been covered

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* Sobo, E. J., Simmes, D. R., Landsverk, J. A., & Kurtin, P. S. (2003). Rapid assessment with qualitative telephone interviews: Lessons from an evaluation of California’s Healthy Families program & Medi-Cal for children. American Journal of Evaluation, 24(3), 399-408.

VETERANS HEALTH ADMINISTRATION

A Few Tips, cont. • Use focused, open-ended questions

– Preface questions with introductory statements• Include short probe list to ensure that important bases are

covered• Create a field-note structure that facilitates ‘analysis’

– Take notes for each question on a separate page– Develop format that allows for easy identification of

• direct quotations• paraphrased material, and• interviewer identification of patterns or hypotheses

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VETERANS HEALTH ADMINISTRATION

A Few Tips, cont. • Intermingle data collection with review and discussion

– Are we beginning to see patterns?– Are there additional questions that we need to ask?– Helpful to debrief or at least jot down a few notes after each interview

of focus group. • Gather all notes and look for patterns• It may be helpful to read through notes and ‘digest’ information for each

of your questions separately• Consider looking for patterns both across and within stakeholder groups• Weigh the findings based on the consistency across interviews/focus

groups• Consider have a recap meeting with your stakeholders once the findings

are summarized22

Gaps in Primary Care for Veterans with Dementia

An example of engaging stakeholders to address dementia care

VETERANS HEALTH ADMINISTRATION

Dementia in Primary Care

• Dementia is a significant public health concern, though rates of detection in primary care (PC) remain low

• Failure to adequately address dementia can result in poor outcomes – higher health care utilization – decreased quality of life for patients and families

• Systems transformation and innovation needed to provide high quality, whole-person care for patients with dementia and their families– VA VISN 2 Recognizing and Assessing Progression of Cognitive

Impairment and Dementia (RAPID) Program

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Pri

mar

y C

are

Pro

vid

er

Dementia Detection in PC

Behavioral Telehealth Center (BTC)

DementiaCare

Manager

Geriatric Evaluation & Management (GEM)

Clinical Reminder used to generate monthly RAPID eligible list +

+

+

+/-

+/-

+/-

VISN 2 “RAPID” Program Overview

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VETERANS HEALTH ADMINISTRATION

Gaps in PC of Veterans with Dementia

• Aims• Method

– Digitally recorded and transcribed semi-structured, telephone-based interviews

– Dual-coder qualitative analysis of transcript text

• Preliminary Results– Identified themes associated with barriers and facilitators to

providing high-quality, patient-centered care to Veterans with dementia and their families

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Barriers to Quality PC for Dementia Identified By

Resource limitations influence choice to screen for dementia and how on-going care is provided*

PCPs, RNs, SW

Time constraints effect if/how detection is managed/prioritized (Includes “More work for me”)

PCPs, RNs, SW, PC-MHI

Perceived limited effectiveness of pharmacological treatment alters whether dementia detection is prioritized

PCPs, PC-MHI

Limited programmatic resources (family support, respite, VA and community resources, APS)

RNs, SW

Lack of training influences whether and how dementia is addressed RNs, SW, PC-MHI

Concerns about “informed consent” and what will be done with the information; Dx in chart may cause patient upset

PC-MHI, SW

Perceptions that patients are afraid of getting the diagnosis and/or families are resistant to CG role; Discussing dx will be uncomfortable

PCPs, RNs, SW, PC-MHI

Late detection limits ability to provide good care SW

Residents and Trainees don’t communicate the dx clearly* SW

Space to administer screening tests* PC-MHI

Nursing unions limit ability to get screens administered* PCPs

It’s hard to develop new habits [work processes]* PCPs

Distance to specialist for some patients PCPs 27

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Identified Facilitators

Facilitators to Quality PC for Dementia Identified By

Team-based approach; PACT model (Medical Home) PCPs, RNs, SW, PC-MHI

Training to increase staff awareness, how to use of screening tools, available programs and resources*

RNs, SW, PC-MHI

Packaged “product” of clinical supports that are disseminated to team PCPs, RNs, PC-MHI

“Pitch” to see the need for this type of collaborative care(Success stories, “what’s in it for staff”; leads to improved quality of care for patients/families; improves safety and ability to tailor care, “The patient gets the care he needs.”)

PCPs, RNs, SW, PC-MHI

Utilization of nursing staff to conduct screening, assist in addressing families needs; PCMHI support in assessment/referral; SW support

PCPs

Linkage to and support from specialty care; SCAN ECHO PCPs

Dx in shared EMR improves coordination and communication (includes inpatient staff)

SW

Experience of successfully managing a challenging patient/family as a team, reduces staff stress

SW

Non-judgmental and open approach to patient and family SW

PC-MHI can support assessment, “deal with implications of dx”, provide CG support and address behavioral symptoms

PCPs, RNs

Metrics (Are we doing the best we can?); QI and research PCPs

VETERANS HEALTH ADMINISTRATION

Our Next Steps • Complete our qualitative analysis• Develop “The Pitch”

– May need to have multiple versions• Develop the package of tools• Return to stakeholders Future Research• Database study of positive and negative outcomes• Development and testing of technology support to ID patients for

screening• Implementation Science work on how to get teams to change

and sustain their practice?29

Questions?

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VETERANS HEALTH ADMINISTRATION

Dementia Q & A

• Current practices in your setting to address dementia – Detection– Diagnosis– On-going care

• Are there stakeholders who would support changing current practice related to dementia? Who are against it?

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VETERANS HEALTH ADMINISTRATION

Additional Resources

• VA VISN 2 Center for Integrated Healthcare– http://www.mirecc.va.gov/cih-visn2/

• World Health Organization– http://

www.who.int/management/partnerships/overall/GuidelinesConductingStakeholderAnalysis.pdf

• National Health Service Institute for Innovation and Improvement– http://

www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/stakeholder_analysis.html

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Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!

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