Working with Community Clinicians: What LA Net members want you to know Lyndee Knox, PhD CEO LA Net: A Primary Care Practice Based Research and Resource.

Working with Community Working with Community Clinicians: What LA Net Clinicians: What LA Net members want you to members want you to

knowknow

Lyndee Knox, PhDLyndee Knox, PhDCEOCEO

LA Net: A Primary Care Practice Based Research and LA Net: A Primary Care Practice Based Research and Resource NetworkResource Network

[email protected]@gmail.comwww.lanetpbrn.netwww.lanetpbrn.net

So what are practice-based So what are practice-based research networks (PBRNs)?research networks (PBRNs)?

A group of ambulatory practices devoted A group of ambulatory practices devoted primarily to patient care -- affiliated with primarily to patient care -- affiliated with each other to investigate questions related each other to investigate questions related to their practiceto their practice

Started 30 years ago in U.S. as a way to Started 30 years ago in U.S. as a way to study process of primary care. Funded study process of primary care. Funded initially by AHRQ, and HRSA and now NIHinitially by AHRQ, and HRSA and now NIH

Why do this? Why do this? 95% of patients visits 95% of patients visits in a year take place in in a year take place in

ambulatory care settings - Need a way to study ambulatory care settings - Need a way to study and improve these settingsand improve these settings

Many findings from research are “castles in the Many findings from research are “castles in the air” air” – interesting but of no real use to our – interesting but of no real use to our clinicians and pts --- our docs rarely encounter clinicians and pts --- our docs rarely encounter patients w/ just 1 dxpatients w/ just 1 dx

19 years to move discoveries from bench to 19 years to move discoveries from bench to bedside to community is too long bedside to community is too long --- one of the --- one of the reasons--- clinicians and patients not involved reasons--- clinicians and patients not involved as partnersas partners

1000 people

800 with symptoms

113 PCP visits

21 visit a hospital outpatient clinic

14 receive home health care13 visit an emergency department

8 are in a hospital

<1 academic health center

New Ecology of Medical Care - 2000

But why in primary care But why in primary care setting? setting?

In an average month:In an average month:

PBRNFocus

113 PCP Visits

Basic Research

Human Research

Practice- and

Community-Based

Research

Practiceand

Community

T1 T2 T3=QI

DisseminationResearch

ImplementationResearch

GuidelinesDevelopment

Meta-analyses;Systematic

Reviews

Not ready for humans Not ready for patients Not ready for practice

Cells Diseases People Practices

Research Pipeline

Why do this? Problems in Why do this? Problems in the pipelinethe pipeline

An average of 19 years from discovery to translation into the community

The story of Beta Blockers

PBRNs were createdPBRNs were created

To overcome barriers to translation To overcome barriers to translation by creating a means for involving by creating a means for involving “community” in research“community” in research

To provide the means for clinicians to To provide the means for clinicians to study the things that matter to them study the things that matter to them and their patientsand their patients

To support dissemination and To support dissemination and effective implementation of effective implementation of innovation in primary careinnovation in primary care

Overview stats on PBRNs Overview stats on PBRNs (2010)(2010)

115 PBRNs in U.S.115 PBRNs in U.S. 8,475 practices or clinics8,475 practices or clinics

2.5 million patients served2.5 million patients served 44,134 providers (MDs, NPs, Pas 44,134 providers (MDs, NPs, Pas

other)other)

From: AHRQ National PBRN Resource Center Survey, 2009

In California, there are at In California, there are at least 4:least 4:

LA Net – Southern CaliforniaLA Net – Southern California SurfNet – San DiegoSurfNet – San Diego Collaborative Research Network – Collaborative Research Network –

UCSFUCSF Rural Network – UC DavisRural Network – UC Davis

A brief history of LA NetA brief history of LA Net

Formed in 2002 w/ funds from HRSA Formed in 2002 w/ funds from HRSA and AHRQand AHRQ

Left USC in 2008 and is now an NPOLeft USC in 2008 and is now an NPO Membership doubled overnithgMembership doubled overnithg 20 CHC members in LA = 165 20 CHC members in LA = 165

practices and > 1 million patient practices and > 1 million patient visitsvisits

LA Net MissionLA Net Mission

To improve the primary health care To improve the primary health care services available to low-income services available to low-income children and families and contribute children and families and contribute to the reduction of health disparities to the reduction of health disparities in LA communities by in LA communities by attracting,attracting, developing, and sharing resourcesdeveloping, and sharing resources and conducting relevant practice-and conducting relevant practice-based research.based research.

Map of LA NetMap of LA Net

LA Net’s social networkLA Net’s social network

MapMap

LA Net:LA Net:

Is governed by 20 clinicians from safety Is governed by 20 clinicians from safety net and researchers from local net and researchers from local universitiesuniversities

Convenes CHCs to develop and Convenes CHCs to develop and implement study ideasimplement study ideas

Provides PEAs part time to practices to Provides PEAs part time to practices to help translate CEFs and support QIhelp translate CEFs and support QI

Serves as a liaison between universities Serves as a liaison between universities and practicesand practices

Performance Feedback

Academic Detailing

Facilitation

IT Support

Local Learning Collaboratives

Effective Implementation of Innovations in Primary Care

Practice Enhancement Assistant

Literature and Exemplar Methods

Okarche, Oklahoma Okarche, Oklahoma 19981998 ““It doesn’t help when the QIO comes in, It doesn’t help when the QIO comes in,

audits my charts, and tells me what a audits my charts, and tells me what a lousy job I am doing. lousy job I am doing.

If they would tell me who is doing a good If they would tell me who is doing a good job, maybe I could talk with them and find job, maybe I could talk with them and find out how to do it better.”out how to do it better.”

Mark Gregory, Mark Gregory, M.D.M.D.

What Mark Didn’t SayWhat Mark Didn’t Say

If they would just tell me:If they would just tell me:

What the literature says I should do.What the literature says I should do. What the guidelines say I should do.What the guidelines say I should do. What my academic colleagues say I should What my academic colleagues say I should

do.do. What the subspecialists say I should do.What the subspecialists say I should do. What CME resources are available.What CME resources are available.

My Philosophy about My Philosophy about NetworksNetworks

People should cultivate People should cultivate networks/communities if that allows networks/communities if that allows them to accomplish or experience them to accomplish or experience things they wouldn’t be able to as well things they wouldn’t be able to as well as individuals.as individuals.For example, reach goals, solve problems, attract For example, reach goals, solve problems, attract

resources, distribute burdens, influence public resources, distribute burdens, influence public policies, increase job satisfactionpolicies, increase job satisfaction

Influenza VaccinationsInfluenza Vaccinations A solo PCP in Grove, OK led a county-wide A solo PCP in Grove, OK led a county-wide

effort to coordinate influenza immunization effort to coordinate influenza immunization efforts in his county.efforts in his county.

He was able to persuade every entity He was able to persuade every entity planning to give flu shots to wait until a set planning to give flu shots to wait until a set date, which was announced throughout the date, which was announced throughout the county.county.

All agreed to share their flu shot supplies All agreed to share their flu shot supplies with any who didn’t have enough, keeping with any who didn’t have enough, keeping track of any exchanges for later track of any exchanges for later reimbursements.reimbursements.

Office phone calls about flu shots Office phone calls about flu shots decreased from around 100 to <10 per day.decreased from around 100 to <10 per day.

A few things I know A few things I know about working w/ about working w/ clinicians in CHCsclinicians in CHCs

Inherently curious & interested in your Inherently curious & interested in your workwork

Want to help and contribute to knowledge Want to help and contribute to knowledge generationgeneration

Want to ensure the needs of their minority Want to ensure the needs of their minority and low-income patients are represented and low-income patients are represented in medical studiesin medical studies

Want to help their patients access the Want to help their patients access the best medicine can offerbest medicine can offer

But they are also:But they are also:

Working at or near capacityWorking at or near capacity Experience chronic staffing shortagesExperience chronic staffing shortages Responding to endless demands to Responding to endless demands to

compensate, improve, and meet compensate, improve, and meet bottom linebottom line

Often cannot get their patients the Often cannot get their patients the care they needcare they need

And are also providing some of the And are also providing some of the best primary care in the countrybest primary care in the country

VideoVideo

So what is the best way So what is the best way to engage CHC to engage CHC

clinicians?clinicians? In the same way you need to be In the same way you need to be

CULTURALLY COMPETENT in working CULTURALLY COMPETENT in working with diverse PATIENTSwith diverse PATIENTS

You need to be CULTURALLY COMPETENT You need to be CULTURALLY COMPETENT in working with their CLINICIANSin working with their CLINICIANS

To do this, you need to understand their To do this, you need to understand their world a bit betterworld a bit better

Some things not to doSome things not to do Take their time away from patient care and Take their time away from patient care and

running their clinicrunning their clinic Ignore their mission –just do your thingIgnore their mission –just do your thing Helicopter out as soon as you canHelicopter out as soon as you can Pay nothing. But if you must, use words like Pay nothing. But if you must, use words like

“stipend” or “honoraria” and make sure it “stipend” or “honoraria” and make sure it doesn’t carry indirectsdoesn’t carry indirects

Take years or better yet never tell them Take years or better yet never tell them what you eventually learnwhat you eventually learn

Leave nothing useful behindLeave nothing useful behind

Lessons Learned Lessons Learned Do good things and the money will Do good things and the money will

follow.follow.

Neither top down nor bottom up Neither top down nor bottom up Goal drivenGoal driven CollaborativeCollaborative ““Finger on the pulse”Finger on the pulse” StrategicStrategic OpportunisticOpportunistic

Lessons Learned Lessons Learned

In the end it is about relationships more In the end it is about relationships more than it is about datathan it is about data Make home visitsMake home visits Connect people to other peopleConnect people to other people Establish multiple communication channelsEstablish multiple communication channels Long breaks at meetingsLong breaks at meetings

Cultivate learning communities Cultivate learning communities

(research is just systematic learning)(research is just systematic learning)

Things you should do…Things you should do…

Engage them as partners, Engage them as partners, NOT recruitment sites NOT recruitment sites

Involve them, talk to the, listen to them at Involve them, talk to the, listen to them at every stage of your project . Yes, at question every stage of your project . Yes, at question formation, yes at findings and dissemination, formation, yes at findings and dissemination, yes throughout.yes throughout.

You may learn something. You may learn something.

Use different strategies – low tech works– Use different strategies – low tech works– emails, listservs, polite note, short voice mailemails, listservs, polite note, short voice mail

Know how your work supports Know how your work supports THEIR MISSION & goals THEIR MISSION & goals

How will your project/study:How will your project/study: help the patients they serve?help the patients they serve? improve the care they provide?improve the care they provide? Improve the work environment? Improve the work environment? strengthen them financially?strengthen them financially?

Know about their past Know about their past experience w/ research & experience w/ research &

do it differentlydo it differently Clinics receive 20-30 requests a year (some Clinics receive 20-30 requests a year (some

receive 0)receive 0) And participate in 2- 3And participate in 2- 3 Receive little to no compensation for thisReceive little to no compensation for this Are Informed about the outcomes of the studies < Are Informed about the outcomes of the studies <

10% time10% time And experience benefit from the findings of the And experience benefit from the findings of the

study < 10% timestudy < 10% time

Leave the practice better than you found itLeave the practice better than you found it

Know the opportunity costs of Know the opportunity costs of your requests: 3 min = 6.4 your requests: 3 min = 6.4

patients not seenpatients not seen The calculus of a CHC clinician:The calculus of a CHC clinician:

15 minute (or less) per patient visit x 8 15 minute (or less) per patient visit x 8 hours hours

32+ patients a day32+ patients a day 3 minutes per patient for research = 96 3 minutes per patient for research = 96

minutesminutes = 6.4 patients not seen in a day= 6.4 patients not seen in a day = 6.4 patients who may not have received = 6.4 patients who may not have received

primary care in yearsprimary care in years = 6.4 patients who may not return again for = 6.4 patients who may not return again for

another yearanother year

Provide MEANINGFUL supportProvide MEANINGFUL support

Clinicians are Clinicians are not grant funded not grant funded – – meetings cost them money – meetings cost them money – pay pay them to be therethem to be there!!

It’s their clinical infrastructure and It’s their clinical infrastructure and relationships that allows you to relationships that allows you to recruit – recruit – pay them for itpay them for it

Fund their internal research and QI Fund their internal research and QI staff when possiblestaff when possible

Be GENEROUS, do good things for Be GENEROUS, do good things for freefree

Plan to stay long-termPlan to stay long-term

Aim for long-term relationshipsAim for long-term relationships Avoid “helicopter” research where Avoid “helicopter” research where

you chopper in with resources, do you chopper in with resources, do your thing, then chopper out -even if your thing, then chopper out -even if its cheaper -– you pay for it in the its cheaper -– you pay for it in the long termlong term

Be usefulBe useful

Do things that will make a real Do things that will make a real difference for the clinicians and difference for the clinicians and patientspatients Will it bring new resources and better Will it bring new resources and better

ways of doing things?ways of doing things? Will it improve care and patient Will it improve care and patient

outcomes?outcomes?

Building Castles in the Building Castles in the AirAir

““And if she asks you why, you can tell And if she asks you why, you can tell her that I told youher that I told youThat I’m tired of castles in the air.”That I’m tired of castles in the air.”

Don McLean Don McLean

Wind PowerWind Power

Castles in the AirCastles in the Air

Most clinical practice guidelinesMost clinical practice guidelines Most clinical decision support systemsMost clinical decision support systems Most disease registriesMost disease registries Immunization registriesImmunization registries The Chronic care modelThe Chronic care model Care managementCare management Effective patient educationEffective patient education The personal health recordThe personal health record

Some things research Some things research that are not that are not

acknowledgedacknowledged The work that is being done now affects <1% of The work that is being done now affects <1% of the U.S. population.the U.S. population.

Replication of successful programs will never Replication of successful programs will never achieve a system-wide infrastructure that achieve a system-wide infrastructure that impacts the entire population.impacts the entire population.

We pretty much know how to translate research We pretty much know how to translate research into practice. We just can’t do it because of the into practice. We just can’t do it because of the lack of an infrastructure within which to deliver lack of an infrastructure within which to deliver the effective interventions consistently to all the effective interventions consistently to all practices and communities over time.practices and communities over time.

Aside from the CTSAs, surprisingly there is no Aside from the CTSAs, surprisingly there is no obvious reason why AHC should be interested in obvious reason why AHC should be interested in community engagementcommunity engagement

InfrastructureInfrastructure

It’s not all about researchIt’s not all about research The infrastructure we need is for The infrastructure we need is for

dissemination, implementation, and dissemination, implementation, and diffusion (QI)diffusion (QI)

It should be funded primarily by the It should be funded primarily by the government (as a public good) and the government (as a public good) and the payers (to save money)payers (to save money)

Once in place, it will support practice- and Once in place, it will support practice- and community-based research, supported by community-based research, supported by project-specific grants and contracts.project-specific grants and contracts.

Some things about CBPR Some things about CBPR that are not acknowledgedthat are not acknowledged

Generation of generalizable knowledge is Generation of generalizable knowledge is not the primary goal of CBPR.not the primary goal of CBPR. To a significant degree, most significant To a significant degree, most significant

research is localresearch is local Dissemination may require home visitsDissemination may require home visits

The “halo effects” of CBPR may be more The “halo effects” of CBPR may be more important than the research itself.important than the research itself. The process is more important than the The process is more important than the

outcomes (but it is extremely important that outcomes (but it is extremely important that we believe the opposite to be true).we believe the opposite to be true).

So some good ideasSo some good ideas

Encourage your funders to invest in Encourage your funders to invest in research infrastructure not just research infrastructure not just studiesstudies

Relationships are research Relationships are research infrastructureinfrastructure

Some good ideasSome good ideas

Make training on CBPR and Participatory Make training on CBPR and Participatory Research mandatory for researchers– Research mandatory for researchers– these approaches create better these approaches create better partnershipspartnerships

Some good ideasSome good ideas

When possible, don’t reinvent the When possible, don’t reinvent the wheel, consider partnering with wheel, consider partnering with support organizations like Practice support organizations like Practice Based Research Networks to reach Based Research Networks to reach clinicians… and patients. clinicians… and patients.

…….They’ve done the difficult part .They’ve done the difficult part already and can save you time and already and can save you time and stressstress

Some good ideasSome good ideas

QI and translation of CEFs into QI and translation of CEFs into primary care may be one of your primary care may be one of your best opportunities for being useful to best opportunities for being useful to practicespractices

RememberRemember

Remember that Research is Remember that Research is notnot a goal a goal

(Goals are desired outcomes for which it (Goals are desired outcomes for which it makes no sense to ask, “Why would you makes no sense to ask, “Why would you want to do that?” or “…so that?”)want to do that?” or “…so that?”) Research is a strategy that should be Research is a strategy that should be

applied when necessary to overcome applied when necessary to overcome obstacles on the way to achieving obstacles on the way to achieving community goalscommunity goals (J. Mold) (J. Mold)

This is good news. It means This is good news. It means researchers, clinicians and patients researchers, clinicians and patients have a lot in common.have a lot in common.

Thank youThank you