1. Chet Fox MD Elizabeth Stewart PhD, MBA Robyn Wearner, RD NIH R01 DK090407-

2.  Collaborators  Wilson Pace MD  Elizabeth Stewart PhD  Miriam Dickinson PhD  Joe Vassalotti MD  Linda Kahn PhD  Cathy Bryan MS  Hai Fang PhD  People who attended our workshop at this conference in 2009

3.  In the words from the Matrix, “Time is always against us. http://www.youtube.com/watch?feature=pla yer_detailpage&v=M3hge6Bx-4w http://www.youtube.com/watch?feature=pla yer_detailpage&v=M3hge6Bx-4w

4.  Only 10% of practices in UNYNET were aware of existence of CKD guidelines 1  A national study showed PCP unaware of CKD guidelines 2  Fox, C. H., A. Brooks, et al. (2006). "Primary care physicians' knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study." Journal of the American Board of Family Medicine: JABFM 19(1): 54-61  Boulware, L. E., M. U. Troll, et al. (2006). "Identification and referral of patients with progressive CKD: a national study." American Journal of Kidney Diseases 48(2): 192- 204.

5.  7.4 hours for screening 3  3.5 hours chronic disease management if patients are stable  10.6 for unstable patients 4  Ostbye, T., K. S. Yarnall, et al. (2005). "Is there time for management of patients with chronic diseases in primary care?" Annals of Family Medicine 3(3): 209-14.  Yarnall, K. S., K. I. Pollak, et al. (2003). "Primary care: is there enough time for prevention?" American Journal of Public Health 93(4): 635-41.

6.  CKD is an increasingly serious problem especially in patients with HTN and DM

7.  CKD affects 26 million Americans  Prevalence is 13%  It consumes 28% of the Medicare Budget  This was 6.9% in 1993  Costs for 2008 were $57 Billion dollars  DM+ CKD increases mortality rate 6 fold  CKD disproportionally affects African Americans and Hispanics http://usrds.org

9. Intervention Component QI SYSTEMS/TOOLS/ STRATEGIES T – team approach R – reminder systems A – audit & feedback N – Networked information systems & registries PEOPLE S – site coordinator L – local clinician champion A – administrative oversight, support& resources QI FOCUS T - target E – education & evidence

10.  Academic Detailing  Point of Care Decision Support  Practice Facilitation  Performance Feedba ck

14. INTERMEDIATE  Dx of CKD  Use of ACE/ARB  Non-use of NSAIDS  BP <130  HbA1C < 7 if DM  LDL < 100  Referral to Nephrology for GFR <30 DEFINITIVE  Death  Renal replacement required  50 % decline in kidney function  Cost of care

15.  Academic Detailing  Point of Care Decision Support  Practice Facilitation  Performance Feedba ck

17.  “Specially trained individuals who work with primary care practices to make meaningful changes designed to improve patient outcomes.” (DeWalt, 2010)  “Help physicians & improvement teams develop the skills they need to adapt clinical evidence to the specific circumstance of their practice. ” (Dewalt, 2010)  “Distinguished from consultants through their specialized training, broad scope of practice, and longer-term, more holistic relationship with a practice (Knox, 2010)

18.  Review of facilitation (25 studies) revealed some evidence of the effectiveness of facilitation in improving quality of care for diabetic patients, improving rates of preventive services, and screenings for hemoglobin disorders.  In some cases, facilitation also resulted in cost savings for the practices.  In some practices, effects of facilitation faded after the intervention ended; larger practices were less likely to benefit b/c of scale of operations needed for improvement (Nagykaldi, Mold & Aspy, 2005)

19.  Evaluation team for the the AAFP National Demonstration Project examined the role of facilitation in helping practices improve their “adaptive reserve” (a practice’s ability to make and sustain change) and the relationship between adaptive reserve and implementation of more NDP components.  The NDP had 36 practices nation-wide, randomized to either facilitated or self-directed arm.  Practices were measured for adaptive reserves by a validated instrument 3x over 2 years.

21. Access to Care & Information Health care for all Same-day appointments After-hours access coverage Lab results highly accessible Online patient services e-Visits Group visits Practice Management Disciplined financial management Cost-Benefit decision-making Revenue enhancement Optimized coding & billing Personnel/HR management Facilities management Optimized office design/redesign Change management Practice Services Comprehensive care for both acute and chronic conditions Prevention screening and services Surgical procedures Ancillary therapeutic & support services Ancillary diagnostic services Care Management Population management Wellness promotion Disease prevention Chronic disease management Care coordination Patient engagement and education Leverages automated technologies Continuity of Care Services Community-based services Collaborative relationships Hospital care Behavioral health care Maternity care Specialist care Pharmacy Physical Therapy Case Management Practice-Based Care Team Provider leadership Shared mission and vision Effective communication Task designation by skill set Nurse Practitioner / Physician Assistant Patient participation Family involvement options Quality and Safety Evidence-based best practices Medication management Patient satisfaction feedback Clinical outcomes analysis Quality improvement Risk management Regulatory compliance Health Information Technology Electronic medical record Electronic orders and reporting Electronic prescribing Evidence-based decision support Population management registry Practice Web site Patient portal

23.  Results are not unequivocal; however, the peer- reviewed evidence, the case studies, and the anecdotes shared by all those involved in facilitator- type activities point in a positive direction.  Skilled facilitators wear multiple hats: coaches, consultants, relationship referees, therapists, analysts cheerleaders, “bad cops” and so forth.  The question is not, do they work? The question is…

24.  Scalable  Feasible  Affordable “Dolly”….. NOT a facilitator!!!

25.  Relationship building is critical for practice/facilitator success. Baseline site visits were extremely helpful.  However, subsequent site visits were infrequent – average 2x/year. Initial goodwill & trust was enough to power the off-site facilitation for duration of project.  Vast majority of facilitation was done virtually:  Emails (thousands)  Phone calls (1:1 or conference calls/meetings)  Some webinars/teleconferencing, but technology was still clumsy even 4 yrs ago.

26.  20 practices across U.S., 2 PT facilitators  How do we leverage facilitator skills sets & experiences with technology and travel budget to create the optimal package???  We are hopeful in the power of the new & improved webcam… it may be virtual facilitation, but not faceless facilitation.  Let’s take a look…

27. This slide is meant to amuse you while we get the technology in motion.

28.  Howdy Hello from your facilitator, Robyn.  Today’s agenda:  Aims Statement/Action Plan  Discussion of Practice Issues  Other possible topics: ▪ Feedback Reports? ▪ Process Mapping?

33. Thank you for your time and attention. We’d love to hear your thoughts, ideas, questions, comments & criticisms about virtual facilitation. chetfox@gmail.com estewart@aafp.org Robyn.wearner@ucdenver.edu

34.  http://www.lanetpbrn.net/la-net-releases- report-2010-ahrq-practice-facilitation- resource-primary-care-improvements http://www.lanetpbrn.net/la-net-releases- report-2010-ahrq-practice-facilitation- resource-primary-care-improvements  http://www.annfammed.org/content/8/Suppl _1/S33.full Effect of Facilitation on Practice Outcomes in the National Demonstration Project Model of the Patient-Centered Medical Home http://www.annfammed.org/content/8/Suppl _1/S33.full