kentucky hsr development: building partnerships margaret m. love, ph.d. university of kentucky...

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


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


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


Conducted pilot project in 6 KAN practices Multiple strategies to increase FOBT rates E.g., chart stickers, information about billing


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


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


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)


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…


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…


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


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


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?


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.


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


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)


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


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)


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 Mel Bennett MD MPH Paul Dassow MD MSPH Robert Hosey MD Jennifer Joyce MD Shersten Killip MD MPH Michael King MD Margaret Love PhD (Co-PI) Samuel Matheny MD MPH Kevin Pearce MD MPH Steve Wrightson MD

College of Public Health Joyce Beaulieu PhD (1st PI) Julia Costich PhD JD Carol Ireson PhD Steve Fleming PhD (2nd PI) F. Douglas Scutchfield MD Sarah Wackerbarth PhD

And thanks to AHRQ… Kay Anderson, PhD P20 HS-011845 R24 HS-011845

kentucky hsr development: building partnerships margaret m. love, ph.d. university of kentucky...

Documents

research designs

research findings

communitybased fp

communitybased pcps

communitybased clinicians80

health care qualitythrough

community needs

primary care practicerespond