Time and cost of “extreme” implementation facilitation to address challenging contexts Mona J. Ritchie, PhD Chuan-Fen Liu, PhD James C. Townsend, DHSc Jeffery A. Pitcock, MPH JoAnn E. Kirchner, MD September 10, 2017

Acknowledgements VA Health Services Research & Development and VA Quality Enhancement Research Initiative Project SDP 08-316: Blended Facilitation to Enhance PCMH Program Implementation (J. Kirchner, PI)

Overview Background Methods Key Findings Discussion Implications

Background Implementing evidence-based practices and programs is challenging* Facilitation has been widely used as an implementation strategy to address challenges in clinical settings** We know little about the cost of implementation facilitation (IF), but hypothesize that application of it is resource intensive, especially when: The innovation is complex The site is under-resourced The context poorly supports change *Greenhalgh et al. 2004; **Baskerville et al. 2012, Stetler et al. 2006

Blended Facilitation Project We tested an implementation facilitation (IF) strategy within the context of a VA system-wide initiative to integrate mental health services in primary care settings using evidence-based care models* The IF strategy consisted of: An external facilitator (EF) and an internal regional facilitator (IRF) in each of 2 networks, and A structured implementation process *Kirchner et al. 2014

Facilitators applied the IF strategy: In 8 primary care clinics identified by network mental health leadership as unlikely to be able to implement PCMHI programs without assistance At all levels of the system (clinic, medical center, and network) Over a 2 ½ year period They incorporated a wide variety of discrete implementation strategies, tailoring them to site needs and resources. Thus..... “Extreme Facilitation”

This presentation focuses on our assessment of: Results of our test of the IF strategy showed that clinics receiving IF compared to those that received only national level support, had: Significantly higher program reach and adoption and these differences were sustained 1 year later* Improved PCMHI program uptake, quality, and adherence to evidence** This presentation focuses on our assessment of: the time facilitators and VA stakeholders spent on IF activities and the organizational cost of IF. *Kirchner et al. 2014; **Ritchie et al. 2017

Methods

Time study Using structured spreadsheets, each week facilitators documented their time and: Participating stakeholders Clinics that benefited from IF Types of activities Descriptive analysis by calculating: Number of persons involved in IF activities Number of hours spent

Organizational cost Obtained salary information for each participant from publicly available web portals Calculated hourly rates for facilitators’ and stakeholders’ salary and benefits and multiplied rates by # of hours Calculated program support assistant salary at 25% effort Calculated travel costs Cost of facilitators’ time in travel Cost of travel expenses obtained from project records

Key Results

Facilitator time across networks   Network A Network C Facilitators Hours % Hours External Facilitator (EF) Activities 141 71% 122 50% Travel 57 29% 121 EF Total 198 100% 243 Internal Regional Facilitators (IRF) 1,792 91% 1,169 81% 171 9% 273 19% IRF Total 1,963 1,442 Total Hours 2,161 1,685 Note that EF devoted only 0.05 FTE to train both IRFs and support implementation at 8 PC clinics! Note that IRF-A devoted more time to IF activities than IRF-C Of the total hours IRFs spent on IF activities, 61% were in Network A and 39% in Network C If the EF only worked with each clinic individually, we could say that the EF averaged 35 hours/clinic on IF activities in Network A and 31 hours/clinic in Network C

Facilitator time across clinics Time spent on activities benefitting all 4 clinics in a network: EF - similar in both networks (37% and 39%) IRF-A: 24%; IRF-C: 56% Network A: both the EF and IRF devoted relatively more time to clinic A2 Network C: EF – more time on clinics C2 and C4 IRF more time on clinic C3

Facilitator time by activity In both networks, the EF focused more on Problem identification/resolution and Preparation/planning In Network A, the IRF focused more on Problem identification/resolution and Stakeholder engagement than the Network C IRF In Network A compared to Network C, the EF focused more on Problem identification/resolution, Stakeholder engagement, and Training/mentoring the IRF Both IRFs focused a significant amount of time on Preparation and planning In Network C, the EF focused more on Assessment and Preparation/planning The Network C IRF focused more than the Network A IRF on learning activities

Facilitator time by month

Stakeholder time   Network A Network C Stakeholder type Person counts Person hours Person Counts Person Hours # % Clinic 54 41% 565 44% 92 46% 571 42% VAMC 46 35% 352 27% 85 43% 669 49% Network 20 15% 302 24% 10 5% 70 National 7 36 3% 8 4% 42 Other experts 6 27 2% 4 12 1% Total all 133 100% 1,281 199 1,363 Clinic stakeholder hours similar in A & C but counts higher in C VAMC stakeholder hours and counts higher in C Network stakeholder hours and counts higher in A Overall, stakeholder hours similar in both networks - counts higher in C

Organizational cost Network A EF & IRF Travel salary & expenses: $27,738 Network C EF & IRF Travel salary & expenses: $50,727

discussion

Discussion Facilitating implementation of complex evidence-based programs in clinics with challenging contexts requires substantial resources It is likely that such clinics need ongoing IF for an extended period of time although internal personnel, trained by experts can provide the majority of IF Facilitators need a significant amount of preparation and planning time In addition to site needs and challenges... Larger system needs can impact time spent on particular activities Competing demands can impact time spent on particular clinics Characteristics of the facilitators themselves can impact the amount of time dedicated to sites, particular activities, and indeed the whole effort

Implications

Implications As systems initiate enterprise-wide implementation efforts, it is essential that leadership: Plan to provide support for sites that may be unable to implement without assistance Encourage and provide time for stakeholders to participate Take into account existing local leadership support or resistance and resources, expectations and characteristic of facilitators

Implications Given the organizational cost, intensive IF strategies may not be practicable on a large scale: Identify sites likely to benefit Tailor IF intensity to local needs Apply very intensive strategies only when most needed

Microsoft Engineering Excellence Contact information Mona J. Ritchie mona.ritchie@va.gov

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