Family Practice, 2015, Vol. 32, No. 2, 216–223 doi:10.1093/fampra/cmu084 Advance Access publication 31 December 2014
Qualitative Research
Building a primary care/research partnership: lessons learned from a telehealth intervention for diabetes and depression Downloaded from http://fampra.oxfordjournals.org/ at Deakin University Library on November 15, 2015
Aanand D Naika,b,c, Briana Lawrencea,b,d, Lea Kiefera,b, Katherine Ramosa,b,e, Anne Utechb,f, Nicholas Masozeraf, Radha Raof, Nancy J Petersena,b, Mark E Kunika,g,h and Jeffrey A Cullya,g,h VA HSR&D Houston Center of Innovation, Michael E. DeBakey VA Medical Center, bDepartment of Medicine, Baylor College of Medicine, cDepartment of Health Promotion and Behavioral Sciences, University of Texas School of Public Health, dSusan G. Komen Cancer Disparities Trainee, The University of Texas School of Public Health, eDepartment of Counseling Psychology, University of Houston, fPrimary Care Line, Michael E. DeBakey VA Medical Center, g Menninger Department of Psychiatry and Behavioral Science, Baylor College of Medicine and hVA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA. a
*Correspondence to Aanand D. Naik, Michael E. DeBakey VA Medical Center (152), 2450 Holcombe Blvd, Suite 01Y, Houston, TX 77021, USA; E-mail: [email protected]
Abstract Introduction. Evidence-based interventions are often poorly translated into primary care settings due to inadequate integration into organizational cultures and clinical workflows. Study designs that blend evaluation of effectiveness and implementation may enhance uptake of interventions into primary care settings. Community-Based Participatory Research (CBPR) models are useful for developing partnerships between research teams and primary care clinical partners to test blended study designs. Methods. We conducted a formative evaluation of partnership building between a health services research team and a primary care community in US Veterans Affairs Health System to conduct a randomized effectiveness trial of an intervention embedded in routine primary care. The formative evaluation used qualitative data drawn from research/clinical partnership meetings. Data were coded and analysed using qualitative framework analysis. Results. The CBPR model guided development of a research/clinical partnership based on a facilitation team consisting of ‘external facilitators’ (research team), ‘internal facilitators’ (primary care leadership) and a ‘clinical advisory committee’ drawn from the primary care community. Qualitative themes focused on: how the intervention components (‘evidence’) aligned with local clinical cultures, barriers and facilitators to acceptance and adoption of the intervention processes within the context of clinical workflows and identified ‘facilitators’ of intervention uptake and sustainability. Conclusion. A CBPR model can guide the development of research/clinical partnerships. Partnerships can identify barriers and craft modifications to intervention procedures that promote integration and into primary care workflows. Formative research/clinical partnerships are critical for designing and testing interventions focused on implementation and sustainability of new evidence within routine primary care. Key words: Community-based partnership, formative evaluation, implementation, medical home, primary care.
Published by Oxford University Press 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.
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Formative evaluation of a primary care telehealth intervention
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The HOPE intervention
Evidence-based interventions are inconsistently integrated into primary care, and research is often of limited value to primary care providers due to lack of generalizability of results from traditional efficacy designs (1,2). Further, adherence to a paradigm of sequential research from efficacy to effectiveness to implementation of evidence in primary care is excessively prolonged (1,3) Recent advances in research methodologies encourage blending effectiveness research designs with simultaneous evaluation of implementation factors (understanding barriers and facilitators, fidelity to intervention procedures, etc.) to accelerate uptake of evidence into routine primary care (4). The success of these study designs hinges on researchers’ capacity to partner with intended users in developing, integrating and testing novel interventions (1). These research–clinical partnerships are critical for identifying intervention components that affect feasibility; acceptance; and, ultimately, adoption into routine care. Community-based participatory research (CBPR) methods provide a useful framework for forging and sustaining research–clinical partnerships. Wallerstein et al. (5) proposed a four-process model for creating and maintaining CBPR partnerships: (i) reflecting on current resources and relationships; (ii) identifying potential partners; (iii) negotiating the health issue under consideration and (iv) creating a structure for sustainable partnerships. CBPR frameworks combine measures of effectiveness with contextualized interpretations of how interventions integrate into community health and healthcare processes and how they, potentially, fit into the culture. CBPR typically focuses on partnerships between researchers and communities but has served infrequently as a framework for building partnerships between research teams and nonacademic, clinical practice settings (6). We describe the process of building an innovative partnership between a health services research team and a geographically dispersed, primary care provider community, using a CBPR framework, which occurred as part of a larger study of the effectiveness and implementation of a telehealth intervention. We present results from a formative evaluation of the partnership-building process, integration of intervention components into multiple primary care clinics and training of existing primary care staff to serve as intervention providers of a telehealth intervention targeting rural patients with uncontrolled diabetes and depression.
Healthy Outcomes for Patient Empowerment (HOPE) is a behavioural health intervention targeting rural veterans with uncontrolled diabetes and comorbid symptoms of depression. The structure and process of HOPE have been described in detail elsewhere (8). Briefly, HOPE involves a telephone-support intervention, delivered by providers trained as behavioural-health coaches (BHCs) drawn from primary care clinics, to improve diabetes and depression outcomes. BHCs collaboratively work with patients to set self-management goals related to physical (diabetes) and emotional (depression) health needs, provide feedback on performance of health-behaviour action plans and guide patients to resolve barriers to self-management. Clinical outcomes include improvements in depressive symptoms, HbA1c and diabetes distress levels. This research team was led by a medical geriatrician (A.N.) and a clinical psychologist (J.C.), who are clinicians within the local VA community and health services researchers trained in implementation science methods.
Methods Context Community for this study refers to primary care teams at a large Veterans Affairs (VA) medical centre in the southern USA and corresponding community-based regional clinics served by this primary care network. Collectively, these facilities serve over 130 000 US Veterans throughout the Southeast Texas region (greater than 650 km2). VA primary care is oriented into a Patient-Centered Medical Home model, which includes teams consisting of a primary care provider and nurse case manager (7). A licensed vocational nurse or health technician and a clerical associate are also assigned to each team but may be shared among teams in smaller clinics. A dietician, clinical pharmacist, social worker and mental health professional are also assigned to each clinic (7). Each VA outpatient clinic has a director who reports to an overall director of VA primary care services at the parent facility in Houston, TX. The primary care director is responsible for implementing the Patient-Centered Medical Home model. Diabetes with comorbid depression is highly morbid and prevalent in this community.
Methodological framework for building and sustaining a research–primary care partnership Table 1 describes application of the Wallerstein et al. (5). CBPR model (left column) to the HOPE study (middle column). The study team began by ‘self-reflecting’ on its capacity to engage in partnerships through existing relationships with primary care leadership and other community members. In doing so, the team started with an existing relationship with the chief of Primary Care Services at the primary medical centre and an active primary care provider, who became coinvestigators during the grant-writing phase. Having investment and support from primary care leadership set the stage for the partnership-building process by providing access to community members working ‘on the ground’, along with other key stakeholders, e.g. leaders of each community-based clinic.
Measurement model for implementation success We used the Promoting Action on Research in Health Services (PARIHS) framework as an ‘implementation model’ to assist clinical partners in adopting the health-coaching intervention. The PARIHS framework posits three interrelated elements that influence successful implementation of evidence-based practices: the (i) perceived strength of the ‘evidence’, (ii) ‘context’ of the environment and (iii) ‘facilitation’ support created for implementation of the intervention (9). The ‘evidence’ element assesses the perceived nature and strength of the evidence supporting the intervention, clinical experiences with similar interventions, perceptions of patient needs and preferences and awareness of local practice performance on the target conditions or processes. The context element assesses implementation factors within the prevailing organizational culture; the nature of relationships between primary care leadership and individual clinicians and the current capacity for monitoring routine care processes (9,10). Finally, the ‘facilitation’ element evaluates formal facilitation structures put in place by the research–clinical partnership (9,11). For this study, facilitation was multifaceted and included ‘external’ (e.g. research team members) and ‘internal’ (e.g. members of the clinical community) facilitators and an Advisory Committee (CAC) comprising community partners. At the outset, the primary care director (NM) functioned as chief internal facilitator. Given their knowledge of important methods, roles as health services innovators and fringe membership in the community as part-time clinicians, the study PIs (A.N. & J.C.) acted as external facilitators.
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Introduction
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Resultant products/outcomes
1. Reflecting on current resources and relationships for collaboration: Involves ‘self-reflecting’ on, strengths and weaknesses, benefits of partnering with the community (both for our team and for the community) and the current relationship between the study team and the community 2. Identifying potential partners through existing networks, associations and leadership: Involves getting to know the community you intend to work with in order to get a sense of the potential partners that may be the most appropriate collaborators and who will be able to provide insight into the unique context and needs of their community 3. Negotiating the health issue under consideration to ensure that the community’s needs will be met: Involves gathering information on the community’s assets, resources and needs to help prioritize and streamline strategies and research ideas for implementation 4. Creating structure to sustain partnerships through constituency building and organizational development: Involves the development of strong relationships with community partners by demonstrating openness and respect, for the community through consistent and open communication
Form a study team that will assist with potential issues that may arise in the partnership process such as: -Determining how the study team will position itself to conduct the study -Considering the resources we have versus the resources we need -Determining how to get the resources we need Form facilitation team that consists of internal and external facilitators who will collaborate with advisory committees to assist with the process of identifying potential partners
List of existing relationships among study team members with VA executive leadership Working study organizational chart: Social and Organizational Map of VA network
Potential partners: Clinical Advisory Committee Internal facilitator Local champions Behavioural coaches Study Advisory Committee
Engage advisory committees and key primary care members in discussions about the practicality of the study design, implementation and analysis
Streamlined intervention materials Active support from partners in implementing the intervention in the clinic
Incorporate feedback from discipline diverse advisory committees to facilitate greater collaboration Maintain consistent communication with advisory committees and engage in active information sharing about effectiveness and implementation study results
Structures meetings to fully engage partners from all participating outpatient clinics Newsletters, list-serves and email groups to facilitate communication among study team and partners. (add something about lasting structures, e.g. training and development of coaches)
Data collection Formative evaluation procedures (12) were part of this iterative implementation approach, guided by the PARIHS model (9,10). Data for the formative implementation evaluation were collected from in-depth notes from research staff’s personal communication with community partners, field notes taken by external facilitators from visits to community clinics and transcribed minutes of CAC meetings to examine clinical partners’ perceptions of the evidence, context and facilitation elements of the PARIHS model. To maintain consistent and open communication with community partners, external facilitators met periodically with various community partners, such as community clinic directors and staff. Members attended CAC meetings both in-person and by teleconference, with follow-up phone calls by external facilitators when CAC members were absent.
Data analysis Formative evaluation of the research–clinical partnership was based on qualitative coding of responses to key implementation concepts adapted from the Promoting Action on Research Implementation in Health Services framework (PARHIS) model by CAC members and activities of the core facilitation team during facilitation meetings (9,11). Each facilitation meeting was audio recorded with participants’ permission and transcribed verbatim. Additional data were drawn from field notes taken by the core facilitation team during the partnership-building phase of the study. Using a codebook developed a priori from subelements of the PARIHS framework, two study members (BL &LK) reviewed transcripts and assigned codes
(9,13). Distinct themes were identified in the data and documented according to corresponding subelements of the PARIHS framework. If new themes emerged, a new code was defined and added to the codebook. Overarching themes were gathered according to the three elements of the PARIHS framework, supported by direct quotations from the discussion (9,14).
Results Building and sustaining research–primary care partnership: process of facilitation Engagement of primary care leaders and outpatient clinic directors in the partnership model was essential, as they negotiate the specifics of primary care involvement (e.g. use of employee time for training and intervention delivery) and sustainability of the partnership. Table 1 (middle and right columns) describes the process of translating CBPR theory into practical steps useful to build and sustain our research–clinical partnership. The first step (top row of Table 1) asks the research team to define its resource needs and potential study personnel and appraise existing relationships with the community. Figure 1 illustrates the HOPE research team’s efforts to build an appropriate study team (see bottom portion of Figure 1) and mental model of the community it sought to partner with (see top portion of Figure 1). Creating a facilitation team was the next key step to building a functional partnership (second row, Table 1). Given the geographic and bureaucratic complexity of the VA primary care community, we sought to develop a layered facilitation structure, as described in the
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Community-Based participatory research (CBPR) principle
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middle portion of Figure 1. The facilitation team could be viewed on a continuum of research to clinical practice, with ‘external facilitators’ primarily representing the research team, ‘internal facilitators’ primarily representing leadership of the clinical community, and the CAC representing frontline primary care providers within the clinical community (9,12). In identifying potential internal facilitators, the research team sought individuals who were steeped in the culture of their local primary care community and possessed highly influential social qualities that could help enhance implementation and diffusion of the intervention within the broader community. Core facilitation team After the HOPE study was funded and received institutional review board approval, core facilitation teams were expanded to include additional personnel identified by the study PIs and primary care director. For the internal facilitation team, the Health Promotion and Disease Prevention Program Manager (dietician) responsible for carrying out special wellness and prevention initiatives within primary care settings was added. Additional external facilitation team members included the HOPE study coordinator, who had worked with the community on a previous study, and another member of the research team experienced with implementation.
The internal facilitator team acted as guides for external facilitators, explaining primary care culture and differences across community-based clinics, pointing out resources and deficits within the community and connecting other community members to the project. This core facilitation team functioned primarily as an intermediary between research investigators and the broad clinical community (as illustrated in the middle box of Figure 1), holding monthly implementation–development meetings during initial phases of implementation. It also served as a link to specific program supervisors (e.g. primary care mental health, social work services and diabetes specialists) and consulted with the study team on implementation methodology and training for project health-behaviour coaches. These implementation meetings of the core facilitation team resulted in elaboration of implementation goals, specific steps needed to accomplish those goals and a strategy for recruiting a CAC from the primary care community. CAC As recommended by stakeholders, (see third row of Table 1), the project sought input from a CAC to assume the critical responsibility of representing the community’s interests in specific negotiations of how the research–clinical partnership would impact daily routines of the
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Figure 1. HOPE for rural veterans with diabetes and depression: a formative implementation evaluation of an intervention imbedded within the VA Patient Aligned Care Team.
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included formative evaluation of specific aspects of the PARIHS elements, adapted for HOPE. Table 2 describes initial CAC meetings and their primary focus, qualitative questions probed during each meeting and the corresponding element/subelement from the PARIHS framework. On the basis of feedback from the CAC, the full research study team, via weekly face-to-face meetings, incorporated and modified study materials and procedures accordingly to facilitate implementation. Final versions of study materials were distributed for review and approval. Discussions that produced differences of opinion in needed content or processes were either addressed during the meeting or as questions posed to the core facilitation team. Such questions received responses from the facilitation teams and then resolution at the subsequent CAC meeting. After intervention content and processes were finalized, the CAC continued to serve in an advisory capacity, providing feedback on elements related to HBC training, documentation of coach interactions via the electronic medical record, establishing connections between research staff and other community members and serving as local champions for the project. Targeted recruitment of HBCs was directed by the recommendations of CAC members. Sustaining the partnership A universal function of CAC members acting as local facilitators was to help the study team promote and grow the intervention within
Table 2. Qualitative measures by clinical advisory committee meeting topic Meeting topic
Qualitative measures
June 2012 Introducing HOPE
How does the content of the workbook address what you perceive to be your patients needs and preferences? (PARIHS Sub-element: Patient needs and experiences) Given your experience, what do you think of this workbook as a guide to address issues of diabetes and depression? (PARIHS Sub-element: Complexity) Do you think telephone based coaching is currently being utilized as frequently or as effectively as it could be? (PARIHS Sub-element: Local Practice Information) Describe how you could use manualized, telephone-based coaching for teaching diabetes self-management to your veterans? (PARIHS Sub-element: relative advantage) Do you have any additional information to add to the manual to effectively teach these skills? (PARIHS Sub-element: Relative Advantage) What kind of a difference do you think this intervention could make on the day to day experience of your clinic? (PARIHS Sub-element: Relative Advantage and Observability) Given your experience, what do you think of this manual as a guide to introduce the process of coaching? (PARIHS Sub-element: Complexity) How does the content of the workbook address what you perceive to be your needs as a coach? (PARIHS Sub-element: Patient experience, needs and preferences) Do you have any additional information to add to the manual to effectively teach these skills? (PARIHS Sub-element: Relative Advantage) What kind of a difference do you think this intervention could make on the day to day experience of your clinic? (PARIHS Sub-element: Relative advantage and observability) How well do you feel the training will adequately prepare and support the clinician coaches in delivering the HOPE program? (PARIHS Sub-element: Complexity) How easy or difficult do you think it would be for coaches to effectively deliver the intervention? (PARIHS Sub-element: Complexity) How do you think HOPE will impact or change the care coaches provide in your clinic? (PARIHS Sub-element: Culture) How do you think HOPE will impact the professional development of coaches? (PARIHS Sub-element: Culture) Moving beyond our monthly meetings, what are some ways you think you could be helpful in facilitating successful delivery of the intervention? (PARIHS Sub-element: Role of Facilitator)
July 2012 The Process of Behavioural Health Coaching
August 2012 HOPE Coach Training and Development Program
HOPE, Healthy Outcomes Through Patient Empowerment Intervention; PARIHS, Promoting Action on Research Implementation in Health Services.
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primary care community. Selection of CAC members was led by the core facilitation team and based on various criteria, including clinical discipline, site of practice, influential social qualities and prior skills and experience in similar roles. Eventual membership of the CAC was highly interprofessional, consisting of nine members, representing six of the seven regional community-based outpatient clinics within the practice network. There was one physician, one nurse practitioner, one psychologist, one pharmacist, one registered dietitian, two registered nurse care managers and two licensed clinical social workers. The CAC convened by teleconference every other month for the first 6 months of the partnership, facilitated by members of the core facilitation team. During these meetings, CAC members gave feedback regarding specific content and processes of the intervention and its integration into routine workflows. A notable focus of discussions was to increase acceptability and adoption within the community, prevent potential conflicts and assuage concerns and increase motivation to implement the study. As suggested in the bottom row of Table 1, the CAC was the mechanism for adapting aspects of HOPE, based on specific recommendations of the primary care community. For example, the CAC provided valuable insight into local practice and communication patterns and strongly advocated for changes based on patient needs and preferences. The CAC guided study-team decisions on practical implementation matters (e.g. patient assignment, scheduling, continuing education, work credits and documentation in electronic health records). The agenda of each CAC meeting
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the primary care community. With study materials in hand, CAC members made independent presentations at local clinic meetings to encourage visibility for the project. They encouraged discussion and forwarded interest from local primary care staff to external facilitators. As local facilitators, CAC members also explained their early motivations for joining the project and expounded on themes for marketing HOPE in the wider community. The CBPR model also recommends regular communication about study progress to members of the clinical community to maintain partnerships (see bottom row, Table 1). Our research-clinical partnership used several methods to ensure open communication with trained HBCs and other primary care community members. For example, the study team (i) distributed a monthly newsletter with announcements and updates about the study, (ii) held monthly conference calls with HBCs, (iii) had ongoing, quarterly CAC meetings, (iv) provided personalized technical assistance and mentoring to HBCs and (v) created a user-friendly medical-record progress-note template that HBCs could use to document and clearly communicate each telehealth coaching session between HBCs and other primary care clinicians.
(especially recruitment) of the training program. For example, they cautioned that reserving 2 hours to attend HBC training sessions may prove complex; further, supervisor buy-in is essential and advanced planning is needed to facilitate acceptance within regular work hours. In addition, committee members shared how the culture of their environment could both facilitate and hinder training and development. Observing those forces, one CAC member subsequently collaborated with facilitators to create an integration plan for an HBC training program with specific primary care clinicians at her site. Regarding the training format, committee members thought telephone-based training might be better than attempting to conduct face-to-face training, or self-training using the provided coaching materials. The telephone-based training recommendation by the CAC was successfully implemented and used to train all primary care-based HBCs. Given that the HOPE program paralleled many telehealth, patient-centered chronic disease-management initiatives currently in place at the VA, the committee thought coaches would even be comfortable talking with patients about topics that stretched coaches’ feelings of competency. In summary, the activities of the CAC to embed the intervention in primary care workflows, as well as recruitment and training processes of HBCs, are specific and tangible products of the research– clinical partnership. Table 4 provides additional specific examples of the implementation efforts using the PARHIS framework to evaluate early implementation.
Formative evaluation of HOPE project implementation Results of qualitative analyses can be broadly interpreted into three themes related to perceptions of (i) how HOPE components integrate with routine primary care workflows; (ii) the process of telehealth coaching and how best to embed the work of intervention providers (HBCs) into routine primary care workflows and treatment plans and (iii) the recruitment, training and support of primary care clinicians as HBCs. Perceptions of how intervention components integrate with routine primary care From data gathered on committee members’ perceptions, overall themes (i.e. the patient workbook, clinician manual and accompanying training materials) emerged regarding study intervention materials. Based on the clinical experiences of committee members and their perceptions of patient needs and experiences, most comments were related to design, acceptability and integration of study materials (see Table 3 for specific quotations). Perceptions of the health-behavioural coaching processes CAC members reviewed penultimate versions of coaching intervention manuals and offered critical revisions. In sharing their perceptions on the manual-guided, behavioural coaching process, committee members focused on two broad themes: design and quality of the coaches’ manual and its relation to local practices (e.g. telehealth and self-management coaching). To enhance coaching manual adoption into routine workflows, CAC members contributed pertinent information relating to specific language in the manuals used by HBCs during intervention telephone calls. CAC members also participated in development and refinement of an electronic medical record note that would be used by HBCs following HOPE telehealth sessions. This collaboration was essential for integrating HOPE into the primary care treatment plan for each study participant. Perceptions of health behaviour coach recruitment, training and mentorship Three primary themes emerged from discussion of the HBC training and development program: complexity, receptivity and culture. CAC members provided insights to improve acceptability and feasibility
Discussion Our results describe the processes for building and sustaining a successful partnership between a primary care community and a research team for conducting and evaluating a clinical trial of a telehealth intervention for patients with diabetes and depression. Such research–clinical partnerships are necessary for more effective and timely translation of evidence-based interventions into routine clinical practice. Few examples exist of successful partnerships between research teams and clinical practice communities (6). Thoughtfully constructed partnerships can align clinical and research communities in a shared vision of improving primary care practices through rapid translation of evidence-based interventions. Using the CBPR model to guide partnership building, we began with a core facilitation team of internal (primary care leadership) and external (research team) partners/facilitators. This facilitation process started early, during project planning and grew iteratively through broadening the core facilitation team and then forming a CAC representing significant community partners. The CAC legitimized the research–clinical partnership across all primary care community sites, provided a mechanism for integrating community recommendations into study procedures and was an advisory group when new challenges and questions arose. In a review by Westfall et al. (6), primary care communities were involved in only one half (24 of 46) of the practice-based research networks interviewed. Further, about one quarter involved community membership on a council or board; and only six (13%) participated in a manner similar to the CAC described in the HOPE partnership (6). The impact and effectiveness of our partnership-building and maintenance processes are described, using a formative evaluation of our study implementation. Formative evaluations provide critical information to healthcare professionals to understand what is necessary for successful implementation of evidence-based innovations (12,14). Using the PARIHS framework, we describe how successful implementation requires a clear understanding of the evidence
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Table 3. Perceptions of the Healthy Outcomes through Patient Empowerment (HOPE) intervention among community members by thematic category Participant responses
Design Quality and Packaging
-‘Whoever put this together did a great job with the colour and the energy that’s in the book’ -‘My only concern about the workbook is that it is a lot of reading; so it’s very hard I think to get them to read this’ -‘I too enjoyed the colour that was in it. Um matter of fact I think a lot of veterans appreciate more description through pictures in some cases’ -‘intervention manuals help me and helped them [patients] stay focused’. -‘We do our telephone coaching all the time with patients’ -‘Each of our nurses and each of our LVNs have the telephone clinic’ -‘…this was something that all of the PharmDs do’ -‘psychological barriers may be the depression but uh social issues such as you know a lot of our patients are in fixed budgets; they’re on social security or they’re on food stamps and food stamps doesn’t allow you to get the fat free cheese, fat free- you know and I don’t think people realize that; or the- or the diet this or the diet that’. -‘Because you know it [the workbook] talks about health risks and things and even just the wording of it; I felt like it didn’t focus enough on the issue of’ but there’s something you can do about these things’…’ -I don’t feel like that kind of gets mentioned enough in here to really emphasize that these [complications]are specially things you’re looking at if you don’t manage your diabetes well.’ -‘If you use the thought section to create a sense of empowerment about how they have options even given the lifestyle issues that they may have. That they’re on a limited income but they can do this or yes I have diabetes and it might in the long-run if I don’t do this but if I make the right thought process now’. -‘I did read the script and I was thinking at the time when I was reading it that perhaps we would have to kind of modify it kind of based on the patient…’ -‘It gives you some wording on certain areas but mostly it gives you a sense of just how deep, how much detail we might look at for a given topic…’ -‘a good way to stretch your telephone muscles if you- if you’re not using them you know to get some open access’ -‘a lot of our patients like it[tele-health] because they can you know get some attention, reach out and contact us uh more frequently or more easily for brief issues’ -‘Yeah our providers in primary care all have a telephone clinic and our nurses do telemanagement of haemoglobin A1Cs, LDLs and they can report’ -It’s [telemanagement] being used effectively because we have a performance measure tied to it as well -‘the key thing might just be to recognize that you need to plan this out maybe a couple of months in advance’ -‘I don’t see the phone as a barrier, I think, in fact, if you tried to have everyone meet in person; I think that would be the barrier’. -‘I’m absolutely comfortable dealing with depression, but I would have to go over those “optional concept reviews” on diabetes just to get up and ready’
Local practice information
Patient needs, preferences and experience
Coach needs, preferences and experience
Local Practice Information
Complexity
Table 4. PARIHS framework as implemented by the HOPE project PARIHS frameworks
How our study has implemented these frameworks
Evidence: assess the perceived nature and strength of the evidence supporting the intervention, clinical experiences with similar interventions, perceptions of patient needs and preferences and awareness of local practice performance on the target conditions or processes
-Telehealth coaching for depression or diabetes (This differs from our current study in that we are testing telehealth coaching for depression and diabetes -Does HOPE address unmet needs in a way that is acceptable to patients? -Prevalence of uncontrolled diabetes and co-morbid depression rates -CAC members receptivity to HOPE -Integration of HOPE into routine primary care workflows including documentation of coaching sessions in medical records -Willingness of providers to receive training and participate as intervention provider (Health Behaviour Coaches) -Internal facilitators (study PI’s) -External facilitators (primary care Chief) -Advisory Committee -HBC recruitment -Training, support and integration of patient goals and action plans into primary care treatment plans and workflows
Context: assess implementation factors within the prevailing organizational culture, the nature of the relationship between primary care leadership and individual primary care clinicians and the current capacity for monitoring routine care processes Facilitation: evaluates the formal facilitation structures put in place by the research—primary care partnership Also appraises the specific roles, skills/attributes and activities of each facilitation component to promote adoption of key aspects of the HOPE study
PARIHS, Promoting Action on Research Implementation in Health Services framework; HOPE, Health Outcomes Through Patient Empowerment Intervention.
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Category
Formative evaluation of a primary care telehealth intervention supporting the intervention, the culture of the target community and its receptivity and adaptability to change (context) and the necessary level of facilitation—driven primarily by a core facilitation team and a community advisory committee drawn from the primary care clinics (9–11). The HOPE intervention would likely not have occurred without the specific contributions of these key facilitators, given the repeated finding that establishing trust in the community and among community members is essential to successful research/clinical partnerships (15–17). Several factors might limit the generalizability of our results. While we attempted to incorporate varying perspectives from an interprofessional team of clinical partners, the sample size is still small but highly representative of the community. The results may not be applicable to other patient-centred medical homes outside VA and may be limited to only those within the Houston VA region.
With the increasing complexity of emerging health issues, forming partnerships across professions, disciplines and/or organizations can be essential in developing widely adoptable interventions effective in ‘real-world’ settings (18). By successfully partnering with the primary care community early in the process, the research team incorporated valuable input from the clinical community to develop a streamlined intervention tailored to the needs of both the clinical and patient communities. By incorporating these suggestions, the study team anticipates greater acceptance and adoption of the HOPE intervention into routine primary care workflows and successful accomplishment of study aims of the larger upcoming randomized clinical trial (19).
Acknowledgements We wish to thank the Clinical Advisory Committee members for their participation and their invaluable input. We would also like to thank Jessica, Levi Herman, Rebecca Hofstein, Natalie Hundt, Aimee Nguyen, Suzanne Robertson, Robert Snow, Shannon Underwood and Annette Walder for their support in this project.
Declaration Funding: Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service project (10-135, Naik and Cully, MPIs). Houston Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413) at the Michael E. DeBakey VA Medical Center. Ethical approval: The Institutional Review Board of Baylor College of Medicine and the Michael E. DeBakey VA Research and Development Committee approved the current study. Conflict of interest: The authors report no conflicts of interest. The views expressed in this article are the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs.
References 1. Glasgow RE, Lichtenstein E, Marcus AC. Why don’t we see more translation of health promotion research to practice? Rethinking the efficacy-toeffectiveness transition. Am J Public Health 2003; 93: 1261–67. 2. Cochrane LJ, Olson CA, Murray S et al. Gaps between knowing and doing: understanding and assessing the barriers to optimal health care. J Contin Educ Health Prof 2007; 27: 94–102. 3. Greenwald P, Cullen JW. The new emphasis in cancer control. J Natl Cancer Inst 1985; 74: 543–51. 4. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectivenessimplementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care 2012; 50: 217–26. 5. Wallerstein N, Duran B, Minkler M, Foley K. Developing and maintaining partnerships with communities. In: Israel B, Eng E, Schulz AJ, Parker EA, (eds). Methods in Community-Based Participatory Research for Health. San Francisco, CA: Josey-Bass, 2005, pp. 31–51. 6. Westfall JM, VanVorst RF, Main DS, Herbert C. Community-based participatory research in practice-based research networks. Ann Fam Med 2006; 4: 8–14. 7. Primary Care Program Office. PACT concept paper. Washington, DC: U.S. Department of Veterans Affairs. http://www.va.gov/primarycare/pcmh (accessed on 17 November 2013). 8. Naik AD, White CD, Robertson SM et al. Behavioral health coaching for rural-living older adults with diabetes and depression; an open pilot of the HOPE study. BMC Geriatrics 2012; 12: 37–48. 9. Kitson AL, Rycroft-Malone J, Harvey G et al. Evaluating the successful implementation of evidence into practice using the PARIHS framework: theoretical and practical challenges. Implement Sci 2008; 3: 1–12. 10. Helfrich CD, Damschroder JL, Hagedorn HJ et al. A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework. Implement Sci 2010; 5: 82–102. 11. Helfrich CD, Weiner BJ, McKinney MM, Minasian L. Determinants of implementation effectiveness: adapting a framework for complex innovations. Med Care Res Rev 2007; 64: 279–303. 12. Stetler CB, Legro MW, Wallace CM et al. The role of formative evaluation in implementation research and the QUERI experience. J Gen Intern Med 2006; 21: S1–S8. 13. Srivstava A, Thomson SB. Framework Analysis: a qualitative methodology for applied policy research. JOAAG 2009; 4: 72–9. 14. Brown AH, Cohen AN, Chinman MJ, Kessler C, Young AS. EQUIP: Implementing chronic care priniciples and applying formative evaluation methods to improve care for schizophrenia: QUERI series. Implement Sci 2008; 3: 9–21. 15. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Quality Health Care 1998; 7: 149–58. 16. Parker EA, Israel BA, Williams M et al. Community action against asthma: examining the partnership process of a community-based participatory research project. J Gen Intern Med 2003; 18: 558–67. 17. Davis SM, Reid R. Practing participatory research in American Indian communities. Am J Clin Nutr 1999; 69: 755S–59S. 18. Harting J, vaAssema P, Ruland E et al. Implementation of an innovative health service a “real-world” diffusion study. Am J Prev Med 2005; 29: 113–19. 19. Cully JA, Breland JY, Robertson S et al. Behavioral health coaching for rural veterans with diabetes and depression: a patient randomized effectiveness implementation trial. BMC Health Serv Res 2014; 14: 191.
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Qualitative Research
Building a primary care/research partnership: lessons learned from a telehealth intervention for diabetes and depression Downloaded from http://fampra.oxfordjournals.org/ at Deakin University Library on November 15, 2015
Aanand D Naika,b,c, Briana Lawrencea,b,d, Lea Kiefera,b, Katherine Ramosa,b,e, Anne Utechb,f, Nicholas Masozeraf, Radha Raof, Nancy J Petersena,b, Mark E Kunika,g,h and Jeffrey A Cullya,g,h VA HSR&D Houston Center of Innovation, Michael E. DeBakey VA Medical Center, bDepartment of Medicine, Baylor College of Medicine, cDepartment of Health Promotion and Behavioral Sciences, University of Texas School of Public Health, dSusan G. Komen Cancer Disparities Trainee, The University of Texas School of Public Health, eDepartment of Counseling Psychology, University of Houston, fPrimary Care Line, Michael E. DeBakey VA Medical Center, g Menninger Department of Psychiatry and Behavioral Science, Baylor College of Medicine and hVA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA. a
*Correspondence to Aanand D. Naik, Michael E. DeBakey VA Medical Center (152), 2450 Holcombe Blvd, Suite 01Y, Houston, TX 77021, USA; E-mail: [email protected]
Abstract Introduction. Evidence-based interventions are often poorly translated into primary care settings due to inadequate integration into organizational cultures and clinical workflows. Study designs that blend evaluation of effectiveness and implementation may enhance uptake of interventions into primary care settings. Community-Based Participatory Research (CBPR) models are useful for developing partnerships between research teams and primary care clinical partners to test blended study designs. Methods. We conducted a formative evaluation of partnership building between a health services research team and a primary care community in US Veterans Affairs Health System to conduct a randomized effectiveness trial of an intervention embedded in routine primary care. The formative evaluation used qualitative data drawn from research/clinical partnership meetings. Data were coded and analysed using qualitative framework analysis. Results. The CBPR model guided development of a research/clinical partnership based on a facilitation team consisting of ‘external facilitators’ (research team), ‘internal facilitators’ (primary care leadership) and a ‘clinical advisory committee’ drawn from the primary care community. Qualitative themes focused on: how the intervention components (‘evidence’) aligned with local clinical cultures, barriers and facilitators to acceptance and adoption of the intervention processes within the context of clinical workflows and identified ‘facilitators’ of intervention uptake and sustainability. Conclusion. A CBPR model can guide the development of research/clinical partnerships. Partnerships can identify barriers and craft modifications to intervention procedures that promote integration and into primary care workflows. Formative research/clinical partnerships are critical for designing and testing interventions focused on implementation and sustainability of new evidence within routine primary care. Key words: Community-based partnership, formative evaluation, implementation, medical home, primary care.
Published by Oxford University Press 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.
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Formative evaluation of a primary care telehealth intervention
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The HOPE intervention
Evidence-based interventions are inconsistently integrated into primary care, and research is often of limited value to primary care providers due to lack of generalizability of results from traditional efficacy designs (1,2). Further, adherence to a paradigm of sequential research from efficacy to effectiveness to implementation of evidence in primary care is excessively prolonged (1,3) Recent advances in research methodologies encourage blending effectiveness research designs with simultaneous evaluation of implementation factors (understanding barriers and facilitators, fidelity to intervention procedures, etc.) to accelerate uptake of evidence into routine primary care (4). The success of these study designs hinges on researchers’ capacity to partner with intended users in developing, integrating and testing novel interventions (1). These research–clinical partnerships are critical for identifying intervention components that affect feasibility; acceptance; and, ultimately, adoption into routine care. Community-based participatory research (CBPR) methods provide a useful framework for forging and sustaining research–clinical partnerships. Wallerstein et al. (5) proposed a four-process model for creating and maintaining CBPR partnerships: (i) reflecting on current resources and relationships; (ii) identifying potential partners; (iii) negotiating the health issue under consideration and (iv) creating a structure for sustainable partnerships. CBPR frameworks combine measures of effectiveness with contextualized interpretations of how interventions integrate into community health and healthcare processes and how they, potentially, fit into the culture. CBPR typically focuses on partnerships between researchers and communities but has served infrequently as a framework for building partnerships between research teams and nonacademic, clinical practice settings (6). We describe the process of building an innovative partnership between a health services research team and a geographically dispersed, primary care provider community, using a CBPR framework, which occurred as part of a larger study of the effectiveness and implementation of a telehealth intervention. We present results from a formative evaluation of the partnership-building process, integration of intervention components into multiple primary care clinics and training of existing primary care staff to serve as intervention providers of a telehealth intervention targeting rural patients with uncontrolled diabetes and depression.
Healthy Outcomes for Patient Empowerment (HOPE) is a behavioural health intervention targeting rural veterans with uncontrolled diabetes and comorbid symptoms of depression. The structure and process of HOPE have been described in detail elsewhere (8). Briefly, HOPE involves a telephone-support intervention, delivered by providers trained as behavioural-health coaches (BHCs) drawn from primary care clinics, to improve diabetes and depression outcomes. BHCs collaboratively work with patients to set self-management goals related to physical (diabetes) and emotional (depression) health needs, provide feedback on performance of health-behaviour action plans and guide patients to resolve barriers to self-management. Clinical outcomes include improvements in depressive symptoms, HbA1c and diabetes distress levels. This research team was led by a medical geriatrician (A.N.) and a clinical psychologist (J.C.), who are clinicians within the local VA community and health services researchers trained in implementation science methods.
Methods Context Community for this study refers to primary care teams at a large Veterans Affairs (VA) medical centre in the southern USA and corresponding community-based regional clinics served by this primary care network. Collectively, these facilities serve over 130 000 US Veterans throughout the Southeast Texas region (greater than 650 km2). VA primary care is oriented into a Patient-Centered Medical Home model, which includes teams consisting of a primary care provider and nurse case manager (7). A licensed vocational nurse or health technician and a clerical associate are also assigned to each team but may be shared among teams in smaller clinics. A dietician, clinical pharmacist, social worker and mental health professional are also assigned to each clinic (7). Each VA outpatient clinic has a director who reports to an overall director of VA primary care services at the parent facility in Houston, TX. The primary care director is responsible for implementing the Patient-Centered Medical Home model. Diabetes with comorbid depression is highly morbid and prevalent in this community.
Methodological framework for building and sustaining a research–primary care partnership Table 1 describes application of the Wallerstein et al. (5). CBPR model (left column) to the HOPE study (middle column). The study team began by ‘self-reflecting’ on its capacity to engage in partnerships through existing relationships with primary care leadership and other community members. In doing so, the team started with an existing relationship with the chief of Primary Care Services at the primary medical centre and an active primary care provider, who became coinvestigators during the grant-writing phase. Having investment and support from primary care leadership set the stage for the partnership-building process by providing access to community members working ‘on the ground’, along with other key stakeholders, e.g. leaders of each community-based clinic.
Measurement model for implementation success We used the Promoting Action on Research in Health Services (PARIHS) framework as an ‘implementation model’ to assist clinical partners in adopting the health-coaching intervention. The PARIHS framework posits three interrelated elements that influence successful implementation of evidence-based practices: the (i) perceived strength of the ‘evidence’, (ii) ‘context’ of the environment and (iii) ‘facilitation’ support created for implementation of the intervention (9). The ‘evidence’ element assesses the perceived nature and strength of the evidence supporting the intervention, clinical experiences with similar interventions, perceptions of patient needs and preferences and awareness of local practice performance on the target conditions or processes. The context element assesses implementation factors within the prevailing organizational culture; the nature of relationships between primary care leadership and individual clinicians and the current capacity for monitoring routine care processes (9,10). Finally, the ‘facilitation’ element evaluates formal facilitation structures put in place by the research–clinical partnership (9,11). For this study, facilitation was multifaceted and included ‘external’ (e.g. research team members) and ‘internal’ (e.g. members of the clinical community) facilitators and an Advisory Committee (CAC) comprising community partners. At the outset, the primary care director (NM) functioned as chief internal facilitator. Given their knowledge of important methods, roles as health services innovators and fringe membership in the community as part-time clinicians, the study PIs (A.N. & J.C.) acted as external facilitators.
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Introduction
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Resultant products/outcomes
1. Reflecting on current resources and relationships for collaboration: Involves ‘self-reflecting’ on, strengths and weaknesses, benefits of partnering with the community (both for our team and for the community) and the current relationship between the study team and the community 2. Identifying potential partners through existing networks, associations and leadership: Involves getting to know the community you intend to work with in order to get a sense of the potential partners that may be the most appropriate collaborators and who will be able to provide insight into the unique context and needs of their community 3. Negotiating the health issue under consideration to ensure that the community’s needs will be met: Involves gathering information on the community’s assets, resources and needs to help prioritize and streamline strategies and research ideas for implementation 4. Creating structure to sustain partnerships through constituency building and organizational development: Involves the development of strong relationships with community partners by demonstrating openness and respect, for the community through consistent and open communication
Form a study team that will assist with potential issues that may arise in the partnership process such as: -Determining how the study team will position itself to conduct the study -Considering the resources we have versus the resources we need -Determining how to get the resources we need Form facilitation team that consists of internal and external facilitators who will collaborate with advisory committees to assist with the process of identifying potential partners
List of existing relationships among study team members with VA executive leadership Working study organizational chart: Social and Organizational Map of VA network
Potential partners: Clinical Advisory Committee Internal facilitator Local champions Behavioural coaches Study Advisory Committee
Engage advisory committees and key primary care members in discussions about the practicality of the study design, implementation and analysis
Streamlined intervention materials Active support from partners in implementing the intervention in the clinic
Incorporate feedback from discipline diverse advisory committees to facilitate greater collaboration Maintain consistent communication with advisory committees and engage in active information sharing about effectiveness and implementation study results
Structures meetings to fully engage partners from all participating outpatient clinics Newsletters, list-serves and email groups to facilitate communication among study team and partners. (add something about lasting structures, e.g. training and development of coaches)
Data collection Formative evaluation procedures (12) were part of this iterative implementation approach, guided by the PARIHS model (9,10). Data for the formative implementation evaluation were collected from in-depth notes from research staff’s personal communication with community partners, field notes taken by external facilitators from visits to community clinics and transcribed minutes of CAC meetings to examine clinical partners’ perceptions of the evidence, context and facilitation elements of the PARIHS model. To maintain consistent and open communication with community partners, external facilitators met periodically with various community partners, such as community clinic directors and staff. Members attended CAC meetings both in-person and by teleconference, with follow-up phone calls by external facilitators when CAC members were absent.
Data analysis Formative evaluation of the research–clinical partnership was based on qualitative coding of responses to key implementation concepts adapted from the Promoting Action on Research Implementation in Health Services framework (PARHIS) model by CAC members and activities of the core facilitation team during facilitation meetings (9,11). Each facilitation meeting was audio recorded with participants’ permission and transcribed verbatim. Additional data were drawn from field notes taken by the core facilitation team during the partnership-building phase of the study. Using a codebook developed a priori from subelements of the PARIHS framework, two study members (BL &LK) reviewed transcripts and assigned codes
(9,13). Distinct themes were identified in the data and documented according to corresponding subelements of the PARIHS framework. If new themes emerged, a new code was defined and added to the codebook. Overarching themes were gathered according to the three elements of the PARIHS framework, supported by direct quotations from the discussion (9,14).
Results Building and sustaining research–primary care partnership: process of facilitation Engagement of primary care leaders and outpatient clinic directors in the partnership model was essential, as they negotiate the specifics of primary care involvement (e.g. use of employee time for training and intervention delivery) and sustainability of the partnership. Table 1 (middle and right columns) describes the process of translating CBPR theory into practical steps useful to build and sustain our research–clinical partnership. The first step (top row of Table 1) asks the research team to define its resource needs and potential study personnel and appraise existing relationships with the community. Figure 1 illustrates the HOPE research team’s efforts to build an appropriate study team (see bottom portion of Figure 1) and mental model of the community it sought to partner with (see top portion of Figure 1). Creating a facilitation team was the next key step to building a functional partnership (second row, Table 1). Given the geographic and bureaucratic complexity of the VA primary care community, we sought to develop a layered facilitation structure, as described in the
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Community-Based participatory research (CBPR) principle
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middle portion of Figure 1. The facilitation team could be viewed on a continuum of research to clinical practice, with ‘external facilitators’ primarily representing the research team, ‘internal facilitators’ primarily representing leadership of the clinical community, and the CAC representing frontline primary care providers within the clinical community (9,12). In identifying potential internal facilitators, the research team sought individuals who were steeped in the culture of their local primary care community and possessed highly influential social qualities that could help enhance implementation and diffusion of the intervention within the broader community. Core facilitation team After the HOPE study was funded and received institutional review board approval, core facilitation teams were expanded to include additional personnel identified by the study PIs and primary care director. For the internal facilitation team, the Health Promotion and Disease Prevention Program Manager (dietician) responsible for carrying out special wellness and prevention initiatives within primary care settings was added. Additional external facilitation team members included the HOPE study coordinator, who had worked with the community on a previous study, and another member of the research team experienced with implementation.
The internal facilitator team acted as guides for external facilitators, explaining primary care culture and differences across community-based clinics, pointing out resources and deficits within the community and connecting other community members to the project. This core facilitation team functioned primarily as an intermediary between research investigators and the broad clinical community (as illustrated in the middle box of Figure 1), holding monthly implementation–development meetings during initial phases of implementation. It also served as a link to specific program supervisors (e.g. primary care mental health, social work services and diabetes specialists) and consulted with the study team on implementation methodology and training for project health-behaviour coaches. These implementation meetings of the core facilitation team resulted in elaboration of implementation goals, specific steps needed to accomplish those goals and a strategy for recruiting a CAC from the primary care community. CAC As recommended by stakeholders, (see third row of Table 1), the project sought input from a CAC to assume the critical responsibility of representing the community’s interests in specific negotiations of how the research–clinical partnership would impact daily routines of the
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Figure 1. HOPE for rural veterans with diabetes and depression: a formative implementation evaluation of an intervention imbedded within the VA Patient Aligned Care Team.
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included formative evaluation of specific aspects of the PARIHS elements, adapted for HOPE. Table 2 describes initial CAC meetings and their primary focus, qualitative questions probed during each meeting and the corresponding element/subelement from the PARIHS framework. On the basis of feedback from the CAC, the full research study team, via weekly face-to-face meetings, incorporated and modified study materials and procedures accordingly to facilitate implementation. Final versions of study materials were distributed for review and approval. Discussions that produced differences of opinion in needed content or processes were either addressed during the meeting or as questions posed to the core facilitation team. Such questions received responses from the facilitation teams and then resolution at the subsequent CAC meeting. After intervention content and processes were finalized, the CAC continued to serve in an advisory capacity, providing feedback on elements related to HBC training, documentation of coach interactions via the electronic medical record, establishing connections between research staff and other community members and serving as local champions for the project. Targeted recruitment of HBCs was directed by the recommendations of CAC members. Sustaining the partnership A universal function of CAC members acting as local facilitators was to help the study team promote and grow the intervention within
Table 2. Qualitative measures by clinical advisory committee meeting topic Meeting topic
Qualitative measures
June 2012 Introducing HOPE
How does the content of the workbook address what you perceive to be your patients needs and preferences? (PARIHS Sub-element: Patient needs and experiences) Given your experience, what do you think of this workbook as a guide to address issues of diabetes and depression? (PARIHS Sub-element: Complexity) Do you think telephone based coaching is currently being utilized as frequently or as effectively as it could be? (PARIHS Sub-element: Local Practice Information) Describe how you could use manualized, telephone-based coaching for teaching diabetes self-management to your veterans? (PARIHS Sub-element: relative advantage) Do you have any additional information to add to the manual to effectively teach these skills? (PARIHS Sub-element: Relative Advantage) What kind of a difference do you think this intervention could make on the day to day experience of your clinic? (PARIHS Sub-element: Relative Advantage and Observability) Given your experience, what do you think of this manual as a guide to introduce the process of coaching? (PARIHS Sub-element: Complexity) How does the content of the workbook address what you perceive to be your needs as a coach? (PARIHS Sub-element: Patient experience, needs and preferences) Do you have any additional information to add to the manual to effectively teach these skills? (PARIHS Sub-element: Relative Advantage) What kind of a difference do you think this intervention could make on the day to day experience of your clinic? (PARIHS Sub-element: Relative advantage and observability) How well do you feel the training will adequately prepare and support the clinician coaches in delivering the HOPE program? (PARIHS Sub-element: Complexity) How easy or difficult do you think it would be for coaches to effectively deliver the intervention? (PARIHS Sub-element: Complexity) How do you think HOPE will impact or change the care coaches provide in your clinic? (PARIHS Sub-element: Culture) How do you think HOPE will impact the professional development of coaches? (PARIHS Sub-element: Culture) Moving beyond our monthly meetings, what are some ways you think you could be helpful in facilitating successful delivery of the intervention? (PARIHS Sub-element: Role of Facilitator)
July 2012 The Process of Behavioural Health Coaching
August 2012 HOPE Coach Training and Development Program
HOPE, Healthy Outcomes Through Patient Empowerment Intervention; PARIHS, Promoting Action on Research Implementation in Health Services.
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primary care community. Selection of CAC members was led by the core facilitation team and based on various criteria, including clinical discipline, site of practice, influential social qualities and prior skills and experience in similar roles. Eventual membership of the CAC was highly interprofessional, consisting of nine members, representing six of the seven regional community-based outpatient clinics within the practice network. There was one physician, one nurse practitioner, one psychologist, one pharmacist, one registered dietitian, two registered nurse care managers and two licensed clinical social workers. The CAC convened by teleconference every other month for the first 6 months of the partnership, facilitated by members of the core facilitation team. During these meetings, CAC members gave feedback regarding specific content and processes of the intervention and its integration into routine workflows. A notable focus of discussions was to increase acceptability and adoption within the community, prevent potential conflicts and assuage concerns and increase motivation to implement the study. As suggested in the bottom row of Table 1, the CAC was the mechanism for adapting aspects of HOPE, based on specific recommendations of the primary care community. For example, the CAC provided valuable insight into local practice and communication patterns and strongly advocated for changes based on patient needs and preferences. The CAC guided study-team decisions on practical implementation matters (e.g. patient assignment, scheduling, continuing education, work credits and documentation in electronic health records). The agenda of each CAC meeting
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the primary care community. With study materials in hand, CAC members made independent presentations at local clinic meetings to encourage visibility for the project. They encouraged discussion and forwarded interest from local primary care staff to external facilitators. As local facilitators, CAC members also explained their early motivations for joining the project and expounded on themes for marketing HOPE in the wider community. The CBPR model also recommends regular communication about study progress to members of the clinical community to maintain partnerships (see bottom row, Table 1). Our research-clinical partnership used several methods to ensure open communication with trained HBCs and other primary care community members. For example, the study team (i) distributed a monthly newsletter with announcements and updates about the study, (ii) held monthly conference calls with HBCs, (iii) had ongoing, quarterly CAC meetings, (iv) provided personalized technical assistance and mentoring to HBCs and (v) created a user-friendly medical-record progress-note template that HBCs could use to document and clearly communicate each telehealth coaching session between HBCs and other primary care clinicians.
(especially recruitment) of the training program. For example, they cautioned that reserving 2 hours to attend HBC training sessions may prove complex; further, supervisor buy-in is essential and advanced planning is needed to facilitate acceptance within regular work hours. In addition, committee members shared how the culture of their environment could both facilitate and hinder training and development. Observing those forces, one CAC member subsequently collaborated with facilitators to create an integration plan for an HBC training program with specific primary care clinicians at her site. Regarding the training format, committee members thought telephone-based training might be better than attempting to conduct face-to-face training, or self-training using the provided coaching materials. The telephone-based training recommendation by the CAC was successfully implemented and used to train all primary care-based HBCs. Given that the HOPE program paralleled many telehealth, patient-centered chronic disease-management initiatives currently in place at the VA, the committee thought coaches would even be comfortable talking with patients about topics that stretched coaches’ feelings of competency. In summary, the activities of the CAC to embed the intervention in primary care workflows, as well as recruitment and training processes of HBCs, are specific and tangible products of the research– clinical partnership. Table 4 provides additional specific examples of the implementation efforts using the PARHIS framework to evaluate early implementation.
Formative evaluation of HOPE project implementation Results of qualitative analyses can be broadly interpreted into three themes related to perceptions of (i) how HOPE components integrate with routine primary care workflows; (ii) the process of telehealth coaching and how best to embed the work of intervention providers (HBCs) into routine primary care workflows and treatment plans and (iii) the recruitment, training and support of primary care clinicians as HBCs. Perceptions of how intervention components integrate with routine primary care From data gathered on committee members’ perceptions, overall themes (i.e. the patient workbook, clinician manual and accompanying training materials) emerged regarding study intervention materials. Based on the clinical experiences of committee members and their perceptions of patient needs and experiences, most comments were related to design, acceptability and integration of study materials (see Table 3 for specific quotations). Perceptions of the health-behavioural coaching processes CAC members reviewed penultimate versions of coaching intervention manuals and offered critical revisions. In sharing their perceptions on the manual-guided, behavioural coaching process, committee members focused on two broad themes: design and quality of the coaches’ manual and its relation to local practices (e.g. telehealth and self-management coaching). To enhance coaching manual adoption into routine workflows, CAC members contributed pertinent information relating to specific language in the manuals used by HBCs during intervention telephone calls. CAC members also participated in development and refinement of an electronic medical record note that would be used by HBCs following HOPE telehealth sessions. This collaboration was essential for integrating HOPE into the primary care treatment plan for each study participant. Perceptions of health behaviour coach recruitment, training and mentorship Three primary themes emerged from discussion of the HBC training and development program: complexity, receptivity and culture. CAC members provided insights to improve acceptability and feasibility
Discussion Our results describe the processes for building and sustaining a successful partnership between a primary care community and a research team for conducting and evaluating a clinical trial of a telehealth intervention for patients with diabetes and depression. Such research–clinical partnerships are necessary for more effective and timely translation of evidence-based interventions into routine clinical practice. Few examples exist of successful partnerships between research teams and clinical practice communities (6). Thoughtfully constructed partnerships can align clinical and research communities in a shared vision of improving primary care practices through rapid translation of evidence-based interventions. Using the CBPR model to guide partnership building, we began with a core facilitation team of internal (primary care leadership) and external (research team) partners/facilitators. This facilitation process started early, during project planning and grew iteratively through broadening the core facilitation team and then forming a CAC representing significant community partners. The CAC legitimized the research–clinical partnership across all primary care community sites, provided a mechanism for integrating community recommendations into study procedures and was an advisory group when new challenges and questions arose. In a review by Westfall et al. (6), primary care communities were involved in only one half (24 of 46) of the practice-based research networks interviewed. Further, about one quarter involved community membership on a council or board; and only six (13%) participated in a manner similar to the CAC described in the HOPE partnership (6). The impact and effectiveness of our partnership-building and maintenance processes are described, using a formative evaluation of our study implementation. Formative evaluations provide critical information to healthcare professionals to understand what is necessary for successful implementation of evidence-based innovations (12,14). Using the PARIHS framework, we describe how successful implementation requires a clear understanding of the evidence
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Table 3. Perceptions of the Healthy Outcomes through Patient Empowerment (HOPE) intervention among community members by thematic category Participant responses
Design Quality and Packaging
-‘Whoever put this together did a great job with the colour and the energy that’s in the book’ -‘My only concern about the workbook is that it is a lot of reading; so it’s very hard I think to get them to read this’ -‘I too enjoyed the colour that was in it. Um matter of fact I think a lot of veterans appreciate more description through pictures in some cases’ -‘intervention manuals help me and helped them [patients] stay focused’. -‘We do our telephone coaching all the time with patients’ -‘Each of our nurses and each of our LVNs have the telephone clinic’ -‘…this was something that all of the PharmDs do’ -‘psychological barriers may be the depression but uh social issues such as you know a lot of our patients are in fixed budgets; they’re on social security or they’re on food stamps and food stamps doesn’t allow you to get the fat free cheese, fat free- you know and I don’t think people realize that; or the- or the diet this or the diet that’. -‘Because you know it [the workbook] talks about health risks and things and even just the wording of it; I felt like it didn’t focus enough on the issue of’ but there’s something you can do about these things’…’ -I don’t feel like that kind of gets mentioned enough in here to really emphasize that these [complications]are specially things you’re looking at if you don’t manage your diabetes well.’ -‘If you use the thought section to create a sense of empowerment about how they have options even given the lifestyle issues that they may have. That they’re on a limited income but they can do this or yes I have diabetes and it might in the long-run if I don’t do this but if I make the right thought process now’. -‘I did read the script and I was thinking at the time when I was reading it that perhaps we would have to kind of modify it kind of based on the patient…’ -‘It gives you some wording on certain areas but mostly it gives you a sense of just how deep, how much detail we might look at for a given topic…’ -‘a good way to stretch your telephone muscles if you- if you’re not using them you know to get some open access’ -‘a lot of our patients like it[tele-health] because they can you know get some attention, reach out and contact us uh more frequently or more easily for brief issues’ -‘Yeah our providers in primary care all have a telephone clinic and our nurses do telemanagement of haemoglobin A1Cs, LDLs and they can report’ -It’s [telemanagement] being used effectively because we have a performance measure tied to it as well -‘the key thing might just be to recognize that you need to plan this out maybe a couple of months in advance’ -‘I don’t see the phone as a barrier, I think, in fact, if you tried to have everyone meet in person; I think that would be the barrier’. -‘I’m absolutely comfortable dealing with depression, but I would have to go over those “optional concept reviews” on diabetes just to get up and ready’
Local practice information
Patient needs, preferences and experience
Coach needs, preferences and experience
Local Practice Information
Complexity
Table 4. PARIHS framework as implemented by the HOPE project PARIHS frameworks
How our study has implemented these frameworks
Evidence: assess the perceived nature and strength of the evidence supporting the intervention, clinical experiences with similar interventions, perceptions of patient needs and preferences and awareness of local practice performance on the target conditions or processes
-Telehealth coaching for depression or diabetes (This differs from our current study in that we are testing telehealth coaching for depression and diabetes -Does HOPE address unmet needs in a way that is acceptable to patients? -Prevalence of uncontrolled diabetes and co-morbid depression rates -CAC members receptivity to HOPE -Integration of HOPE into routine primary care workflows including documentation of coaching sessions in medical records -Willingness of providers to receive training and participate as intervention provider (Health Behaviour Coaches) -Internal facilitators (study PI’s) -External facilitators (primary care Chief) -Advisory Committee -HBC recruitment -Training, support and integration of patient goals and action plans into primary care treatment plans and workflows
Context: assess implementation factors within the prevailing organizational culture, the nature of the relationship between primary care leadership and individual primary care clinicians and the current capacity for monitoring routine care processes Facilitation: evaluates the formal facilitation structures put in place by the research—primary care partnership Also appraises the specific roles, skills/attributes and activities of each facilitation component to promote adoption of key aspects of the HOPE study
PARIHS, Promoting Action on Research Implementation in Health Services framework; HOPE, Health Outcomes Through Patient Empowerment Intervention.
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Category
Formative evaluation of a primary care telehealth intervention supporting the intervention, the culture of the target community and its receptivity and adaptability to change (context) and the necessary level of facilitation—driven primarily by a core facilitation team and a community advisory committee drawn from the primary care clinics (9–11). The HOPE intervention would likely not have occurred without the specific contributions of these key facilitators, given the repeated finding that establishing trust in the community and among community members is essential to successful research/clinical partnerships (15–17). Several factors might limit the generalizability of our results. While we attempted to incorporate varying perspectives from an interprofessional team of clinical partners, the sample size is still small but highly representative of the community. The results may not be applicable to other patient-centred medical homes outside VA and may be limited to only those within the Houston VA region.
With the increasing complexity of emerging health issues, forming partnerships across professions, disciplines and/or organizations can be essential in developing widely adoptable interventions effective in ‘real-world’ settings (18). By successfully partnering with the primary care community early in the process, the research team incorporated valuable input from the clinical community to develop a streamlined intervention tailored to the needs of both the clinical and patient communities. By incorporating these suggestions, the study team anticipates greater acceptance and adoption of the HOPE intervention into routine primary care workflows and successful accomplishment of study aims of the larger upcoming randomized clinical trial (19).
Acknowledgements We wish to thank the Clinical Advisory Committee members for their participation and their invaluable input. We would also like to thank Jessica, Levi Herman, Rebecca Hofstein, Natalie Hundt, Aimee Nguyen, Suzanne Robertson, Robert Snow, Shannon Underwood and Annette Walder for their support in this project.
Declaration Funding: Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service project (10-135, Naik and Cully, MPIs). Houston Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413) at the Michael E. DeBakey VA Medical Center. Ethical approval: The Institutional Review Board of Baylor College of Medicine and the Michael E. DeBakey VA Research and Development Committee approved the current study. Conflict of interest: The authors report no conflicts of interest. The views expressed in this article are the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs.
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