Using Learning Communities To Support Innovation Adoption: Lessons from the AHRQ Health Care Innovations Exchange
Using Learning Communities To Support Innovation Adoption: Lessons from the AHRQ Health Care Innovations Exchange
On August 25, 2016, the Innovations Exchange held a Web event titled Using Learning Communities To Support Innovation Adoption: Lessons from the AHRQ Health Care Innovations Exchange.
The event was designed to share results and lessons from the Innovations Exchange’s Learning Communities initiative.
From 2014-2016, the Innovations Exchange sponsored three Learning Communities (LCs) to support innovation adoption in the following high-priority areas:
- Advancing the Practice of Patient- and Family-Centered Care in Hospitals (Florida);
- Reducing Non-Urgent Emergency Services (Detroit); and
- Promoting Medication Therapy Management for At-Risk Populations (Houston)
This Web event was presented in collaboration with AcademyHealth.
Mary P. Nix, M.S., PMP is a health care professional with 30 years of experience in clinical, educational, and research settings. She has led a number of national-level projects that use data, informatics, and technology to disseminate evidence-based health information and service delivery innovations and to support their implementation. Ms. Nix currently works at the U.S. Agency for Healthcare Research and Quality where she serves as the project lead for the AHRQ Health Care Innovations Exchange. She also oversees and sets direction for the National Guideline Clearinghouse™, and National Quality Measures Clearinghouse™.
Lisa Simpson, M.B., B.Ch., M.P.H, FAAP, is the President and Chief Executive Officer of AcademyHealth. A nationally recognized health policy researcher and pediatrician, she is a passionate advocate for the translation of research into policy and practice. Her research focuses on improving the performance of the health care system and includes studies of the quality and safety of care, health and health care disparities and the health policy and system response to childhood obesity. Dr. Simpson has published over 75 articles and commentaries in peer reviewed journals. Before joining AcademyHealth, Dr. Simpson was director of the Child Policy Research Center at Cincinnati Children's Hospital Medical Center and professor of pediatrics in the Department of Pediatrics, University of Cincinnati, and she served as the Deputy Director of the Agency for Healthcare Research and Quality from 1996 to 2002.
Beverley Johnson is President and CEO of the Institute for Patient-and Family-Centered Care in Bethesda, MD. She has provided technical assistance and consultation for advancing the practice of patient- and family-centered care to over 250 hospitals, health systems, federal, state, and provincial agencies, military treatment facilities, and community organizations. She assists hospitals and ambulatory programs with changing organizational culture, facilitation of visioning retreats, and the integration of patient- and family-centered concepts in policies, programs, and practices, as well as in facility design and the education of health care professionals. Ms. Johnson recently served as Project Director for a multi-year initiative to develop resource materials for senior leaders in hospital, ambulatory, and long-term care settings on how to partner with patients, residents, and families to enhance the quality, safety, and the experience of care. Ms. Johnson has co-authored numerous books and publications on patient- and family-centered practice.
Herbert Smitherman, Jr., M.D., M.P.H, FACP is currently the Assistant Dean of Community and Urban Health and an Associate Professor of Internal Medicine at Karmanos Cancer Institute, Wayne State University School of Medicine. He is also President and CEO of Health Centers Detroit Foundation, Inc., a Federally Qualified Health Center Look Alike serving the underserved and uninsured in the city of Detroit and Wayne County. Dr. Smitherman has spent the past 24 years as a practicing physician working with diverse communities in Detroit to develop urban-based primary care delivery systems that integrate the health and social goals and concerns of the community. His research focuses primarily on health issues related to underrepresented and underserved populations and their access to appropriate health care. In 2008, Dr. Smitherman co-authored the health care policy book, Taking Care of the Uninsured: A Path to Reform. In addition, he has traveled and lectured internationally, and has participated in conferences on health matters affecting basic access to care for all people.
Joy P. Alonzo, M.Eng, PharmD, has extensive clinical experience, direct patient care responsibilities, and teaching responsibilities in advanced inter-professional and collaborative ambulatory care practice settings. She has established clinical pharmacy practices and innovative patient services in internal medicine, psychiatric, and pediatric specialties and continues to develop, implement, and evaluate through translational research outcomes associated with these services. In her current roles as Clinical Assistant Professor in the Department of Pharmacy Practice and Translational Research at the University of Houston College of Pharmacy and Associate Director of Pharmacy Services for Texas Children's Health Plan, Dr. Alonzo performs comparative effectiveness research, drug utilization review, and evaluates health care disparities with regard to the Texas Medicaid pediatric population with a special emphasis on behavioral and psychiatric disorders. Dr. Alonzo formerly served as an Assistant Professor of Pharmacy Practice at the Texas A&M Health Science Center and Rangel College of Pharmacy where she was responsible for teaching medical residents, pharmacy students, advanced practice nursing students, and other health care professionals in a collaborative inter-professional environment.
Russ Mardon, Ph.D., is a Westat Associate Director who led the evaluation of three learning communities aimed at implementing quality improvement innovations in primary care and hospital settings for the AHRQ Health Care Innovations Exchange. In earlier work on the project as managing editor, he directed the development of innovation profiles and quality tool summaries for use in quality improvement and disparities reduction initiatives. He also directs an Evidence to Action Network for PCORI in support of 19 awardees studying transitional care interventions. In his former role as director of analysis at the National Committee for Quality Assurance (NCQA), Dr. Mardon produced health plan and medical group comparative reports, conducted quality of care research, and supported NCQA program operations. He holds a doctorate in Operations Research from Northwestern University.
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Picture of Mary P. Nix, Project Lead, AHRQ
The AHRQ Health Care Innovations Exchange provides a resource that supports decisionmaking on potential adoption and implementation of health care innovations and tools.
Image of the Innovation Exchange Learning Communities initiative webpage
Picture of Lisa Simpson, President and CEO, Academy Health, Innovations Exchange Expert Panel Chair
“A select group of potential innovation adopters and stakeholders who interact and engage in a shared learning process to facilitate adaptation and implementation of innovations featured in the Innovations Exchange.”
Picture of Beverly H. Johnson, President and CEO, Institute for Patient- and Family-Centered Care, Expert Faculty, PFCC LC
Patient- and family-centered care (PFCC) is an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families
Partnering with patients and families can lead to measurable improvements in safety and quality
Despite evidence and incentives, hospitals continue to struggle with operationalizing PFCC core concepts in a concrete and meaningful way
Participation in the PFCC LC offered hospital teams the opportunity to:
Charts showing the increase in the number of PFACs and Advisors from September 2014 to June 2016
Chart showing the change in the average scores for the PFCC self-assessment tool items from September 2014 to June 2016
Partnerships with patient and family advisors yielded:
•LC membership brought together directors and managers from similar departments with similar goals; competitive pressures did not pose a barrier
•LC members were transparent with each other about their struggles which fostered collaboration and shared learning
•The LC produced a resource “guide” related to orientation of new patient/family advisors, with the aim to support other hospitals establishing new programs
•Commitment, support, and participation of senior hospital leadership is crucial to implement and sustain successful patient and family advisor programs
•It is essential to appoint an individual with dedicated time and appropriate skills to develop, facilitate, and sustain partnerships with patients and families
•Advancing the practice of PFCC in hospital settings is about change in organizational culture and takes time
Meaningfully involving patient/family advisors in hospital QI efforts improves the patient experience and contributes to important changes in organizational culture.
Reducing Non-Urgent Emergency Services Learning Communitiy (ES LC)
Picture of Herbert C. Smitherman, Jr., Vice Dean, Wayne State University School of Medicine, Emergency Services Learning Community
- ►Identify and assemble library of health care delivery system best practices and policies (innovations) from around the country
The Emergency Services Learning Community’s cross-stakeholder collaboration facilitated system change and improved our delivery system:
From identifying to sharing to adoption to scale up and spread, It Worked.
Picture of Joy P. Alonzo, Clinical Assistant Professor, University of Houston, College of Pharmacy Associate Director of Pharmacy,Texas Children's Health Plan
The MTM LC consists of 14 organizations representing a diverse group of primary care, pharmacy, and academic settings:
►Integrating the pharmacist into a primary care inter-professional care team
“Real world” implementation provides invaluable opportunities for learning.
Picture of Russ Mardon, Learning Communities Evaluation Lead Associate Director, Westat
Learning Communities engage, motivate, and accelerate innovation adoption.
To submit a question:
Please take a moment to fill out the brief evaluation which will appear in your browser.
Kristin Rosengren: Good afternoon and welcome to today's webinar, Using Learning Communities to Support Innovation Adoption: Lessons from the AHRQ Health Care Innovations Exchange.
The audio is being delivered via your computers and so you will need speakers or headphones to hear the audio. If you need an alternate method, please submit a quick question to the Q&A pod which is located in the left portion of your screen. We also want to let you know that if you have technical difficulties at any point you can access live assistance by calling the number listed on the bottom left-hand corner of your screen. We also ask that you turn off your pop-up blocker so we can distribute the survey at the end of the webinar. We would really appreciate your feedback. Lastly, you can submit questions at any time in the Q&A pod. That is on the left of your screen- type in your question and click send. We will try and respond to as many as possible during the time allotted. This is intended to be an interactive forum so we encourage you to submit questions throughout this presentation and we will respond at the end of the webinar when we have time. I want to turn this over to Mary Nix, who is with the Agency for Healthcare Research and Quality, the sponsor of today's event. Ms. Nix serves as the project lead for the AHRQ Health Care Innovations Exchange. Welcome, Mary.
Mary Nix: Thank you and good day everyone. On behalf of the Agency for Healthcare Research and Quality and AcademyHealth, I would like to welcome you to our Web event on the use of learning communities to support innovation adoption. I am Mary Nix with AHRQ’s Center for Evidence and Practice Improvement. We are very excited about today's event and glad to see that you share our enthusiasm. We have over 800 registrants for our event today.
What is the Health Care Innovations Exchange? For those of you who are new to the Innovations Exchange, or for those who have been with us, I would like to give you an overview or a refresher. Through a number of mechanisms the Health Care Innovations Exchange supports decision-making on potential adoption and implementation of health care innovations and tools. We aim to accelerate the diffusion and uptake of novel care delivery strategies that improve health care quality with an emphasis on those that reduce disparities. We facilitate the exchange of information by providing usable information on health service innovations and quality improvement tools on our Web site, which offers a searchable database of service delivery and policy innovation profiles and other content such as attempts at innovations, stories from innovators, and commentaries by experts. The site includes articles and guides about the processes of innovation and adoption. On the Articles and Collections area of the site, you can find a guide to innovation adoption: “Will it Work Here? A Decisionmaker's Guide to Adopting Innovations.” The Innovations Exchange also offers learning and networking opportunities such as virtual and in-person meetings, Web events like this one, and more recently, learning communities.
This brings us to today. In 2014, AHRQ modified the scope of the Innovations Exchange, moving away from the program's previous focus on building the content collection and instead focusing efforts on supporting the adoption of innovations by sponsoring three learning communities, which we abbreviate LCs, on high-priority topics that you will hear much more about today. In addition to leading to meaningful change in care delivery, AHRQ sought to learn more about how to foster adoption and implementation of health care service innovations through these communities.
We don't have time to demo the innovations.ahrq.gov Web site but focus your attention on the work of the learning communities. This slide shows a screenshot of the Learning Communities homepage. From this page, you can access each individual learning community’s page for more detailed information about each of them. We have also made available information about outcomes of each learning community and lessons learned from the learning community initiative.
We wanted to apprise you, in case you had not heard, with funding and leadership changes at AHRQ we have decided to take some time and think strategically about the future of the Innovations Exchange. The current AHRQ contract ends next month, in September 2016. You will hear from the learning communities about their next steps and intentions for sustainability, if any. To capitalize on past investments, however, we are planning to transition the innovations.ahrq.gov Web site from our contractor, Westat, to AHRQ’s Office of Communications. That group will assume responsibility for the Web site. Please note, while content will remain accessible it will not be updated until we, AHRQ, make a programmatic and strategic decision about the future of the Innovations Exchange.
Let’s get going. I'm pleased to introduced today’s moderator, Dr. Lisa Simpson. Lisa is President and Chief Executive Officer at AcademyHealth and has served as Chair of the Innovations Exchange Expert Panel for the last five years. Thank you, Lisa. A nationally recognized health policy researcher and pediatrician, she is a passionate advocate for the translation of research into policy and practice. Her research focuses on improving the performance of health care systems and includes studies of the quality and safety of care and health care disparities.
Lisa Simpson: Thank you to Mary and to AHRQ for your leadership in supporting this important work, and the Innovations Exchange and its next phase around using innovation to implement them in communities. I will give you a bit of an overview of the Innovations Exchange Learning Communities and introduce our fantastic speakers today.
The Innovations Exchange defines a learning community as a select group of potential innovation adopters and stakeholders who interact and engage in a shared learning process to facilitate adaptation and implementation of innovations featured in the Exchange. The participants in these three learning communities shared experiences and learned about their implementation journey as well as receiving ongoing insight from both AHRQ innovators and content experts. While a common collaborative learning approach was applied to the three different topic areas, the various innovation strategies ranged in care settings, patient populations, and care processes. This approach provided AHRQ and all of us a unique opportunity to compare and contrast the experiences across these three learning communities.
You will hear much more from each of the learning community’s champions, but in brief, the three communities are listed here. The first one is focused on patient- and family-centered care in Florida where members agreed to adopt one single innovation across the sites as well as additional optional strategies that supported advancing patient- and family-centered care. The second community focused on reducing non-urgent emergency services in the Detroit metropolitan area aimed to solve the common community challenge and relied on innovations for inspiration and ideas, but did not formally adopt one specific innovation. The third, the medication therapy management community in Houston, was formed specifically to implement and monitor a pilot of a particular innovation.
The speakers for today’s event include the three champions of the learning communities and the program’s evaluator. First we will hear from Beverley Johnson, who is President and CEO of the Institute for Patient- and Family-Centered Care and the expert champion in that community. Bev advances the patient- and family-centered care to 250 hospitals, federal and state agencies, and military organizations. Our second speaker will be Dr. Herb Smitherman, Vice Dean at Wayne State and the champion for the learning collaborative around Reducing Non-urgent Emergency Services. He serves also as a member of the Innovations Exchange Editorial Board. Dr. Smitherman has spent 24 years practicing, working with diverse communities in Detroit to develop urban-based primary care delivery systems that integrate the health and social goals and community needs. His research focuses on health issues related to the underrepresented and underserved populations and their access to appropriate health care.
Our third speaker is Dr. Joy Alonzo, who is a clinical assistant professor at the University of Houston College of Pharmacy and co-chairs with Dr. Aisha Moultry for the Medication Therapy Management Learning Community. Dr. Alonzo has established clinical pharmacy practices and innovative patient services in internal medicine, psychiatric, and pediatric specialties, where she develops, implements, and evaluates translational research outcomes. In her current role, Dr. Alonzo performs comparative effectiveness research, drug utilization review, and evaluates health care disparities in Medicaid pediatric populations.
Our final speaker is Dr. Russ Mardon, the lead evaluator for the Exchange and the innovation communities. Dr. Mardon is Associate Director at Westat and led the evaluation of these three communities. In earlier work on the project he was Managing Editor on the Innovations Exchange and directed the development of innovation profiles and QualityTool summaries. Thank you to each of you for your time. I will turn the program over to Beverley.
Beverley Johnson: It was an honor to participate with all the participating hospitals from Florida. With this learning community, the challenge that we were addressing is to further the implementation of patient- and family-centered care. The learning community shared a definition to establish the focus of all of the work. Patient- and family-centered care is defined in this learning community as an approach to the planning, delivery, and evaluation of health care, that’s really grounded in mutually beneficial partnerships among patients, families and health care professionals. There are four core concepts that are part of this framework- they are respect and dignity, information and collaboration- it was very clear, it can lead to measurable improvements in quality and safety. Even with a great deal of understanding about this, it’s been challenging for hospitals to take those core concepts and integrate them in how the work is done in very concrete and meaningful ways.
The aims of this learning community were three specifically. One, to engage the stakeholders and using evidence-based patient- and family-centered framework that addresses leadership, patient and family partnerships, staff engagement, and performance improvement. All of those were central and the way the work was done in this learning community. The second aim was that the learning community really would assist hospitals in tailoring and implementing strategies from the Innovations Exchange. This is not just taking an innovation that someone else has been successful with and replicating it exactly. It is thoughtfully tailoring it, recognizing the culture and context of each individual organization. The third aim was to really achieve and document both improvements in process and outcome measures that related to each of the innovations that were implemented during the learning community.
Our membership in this community- we had 11 Florida hospitals that really represented a very significant proportion of the population in Florida. 10 million people they served and 50% of the population. The team that participated in the learning community were senior-level managers and leaders- the quality improvement director, C-suite member, patient experience coordinator, patient advocate, the head of the advocacy department within an organization. This was key to some of the work and I served as an expert faculty member- and Bernard Roberson participated in it and a lot of this work of the learning community- and a wonderful partner was the Florida Hospital Association. I think their involvement was important to launch the community and now in sustaining it. This was important in the way this learning community was designed.
Basically, what happened in this initiative was that hospitals worked together to adopt and implement patient- and family-centered strategies that were described in the Innovations Exchange. There were a number of these and all of the members of the community worked on one of those innovations. That was they either developed or expanded their patient and family advisor program. Everybody did that. They used many of the concepts that were described in the Innovations Exchange from the work that was done at Augusta University Medical Center.
I think certainly what the benefits of the learning community participation gave these hospitals- where their leadership was committed to patient- and family-centered care- and this learning community provided an opportunity so they could learn and augment their advisor programs. They could also learn about how to adapt specific patient and family-centered best practices and strategies in their environment. The key feature was that they shared lessons learned and benefited from each other's. They received guidance from the whole team, each other, and the experts that were brought together to address barriers and challenges.
When you look at outcomes, there were seven new patient and family advisor programs. We started the initiative with four of the hospitals having patient and family advisory councils, that wanted to expand how they were involved in more meaningful ways. There were 73 new patient and family advisors across all 11 hospitals, that were recruited and oriented and involved during the learning community. The hospitals adopted a range of additional patient and family-centered care strategies, not just having an advisory program. These included changing the concept of families as visitors, to creating a 24-hour welcoming policy where they support and welcome the presence and participation of families. Another was helping to educate staff across disciplines in what is patient and family-centered communication and how to do that effectively and integrated into their work. Another innovation was use of a communication notebook, and the last year of the project the advisor rounding was an evolution of this work, where people had built the trust in patient and family advisors to begin to implement that innovation.
Here you can see a graphic depiction of the progress, that when we started in September 2014 there were 4 patient advisory councils and in June there were 11 across the 11 hospitals. A growth from 56 advisors to 129 advisors across these 11 hospitals. I think another important part of this learning community was to use an organizational self-assessment tool that looked at patient and family-centered practice. It was an adaptation of one that were developed for “Better Together Partnering with Families.” It looks at key domains that shape organizational culture. For instance, I think it's exciting to report; there was progress in each one of these domains. That's showing a shift in organizational culture from November 2014 to June 2016. In leadership, we were looking at this organizational assessment for are the core concepts of patient- and family-centered care reflected in key documents, and in their vision, mission, and philosophy of care. Are leaders really modeling this in words and actions, so you see partnership lives in the organization? The patients’ and families’ participation in care, are they seen as essential members of the team and included and encouraged to be included in practices such as change of shift and rounds, that families are no longer seen as visitors? And then, human resources, this is key that we build the concepts of patient- and family-centered care into the job descriptions, performance evaluation, the hiring part this is, the continuing education practices and there were many changes in improvement and human resources. The last you can see the growth and having patient and family advisors as a central part of these organizations.
The kinds of partnerships that I've mentioned- some of them that were implemented, there are still others. They partner with patients and families to revise discharge packets so they would be more useful to patients and families. A really important issue in today’s health care. An advisor at Broward Health shares his story as part of orientation. There are so many details covered, what people go away with is, this is his story and how people interacted with him in a respectful, positive way. At Cape Canaveral, with patients and families, they revised the patient handbook. Again, this sets the stage for partnerships throughout a hospital stay. At Health Central they have redesigned admissions paperwork and developed some wonderful checklists and guidance for setting the stage for discharge, right from admissions. They are one of the ones that worked with advisor rounding. Jupiter Medical Center also had family rounding and they developed a new hospital-wide patient and family-centered policy, a way for leaders to say this is important and it’s going to drive how we do the work. It’s not always asking people to do more, but it sets how work is done. At Sacred Heart, they worked on developing a communication notepad and they did a review of hospital policies to look for how inclusive were they and respectful were they to the LGBT community. Those give a range of some of the other ways they did. In terms of how did the learning community help facilitate change, the key strategies are the monthly networking meetings that were participatory, and they talked to the faculty and they talked to each other, sharing successes and asking questions. Another success factor in learning strategy was having the monthly coaching calls with each hospital. Westat’s staff met with leaders of each one of these hospitals to explore how progress was moving along and if people were stuck to ensure there was real accountability. Another was, there was a SharePoint site where tools could be shared. Lastly, we can do all of this work at a distance and be successful- but the power of getting people together at least once a year was really palpable, particularly at the last session. We had in-person meetings each year and when patients and families were involved in more significant numbers in the second in-person meeting, you could see that people really began to understand and I think it helped move it forward even more significantly than in the past.
Another way that change was facilitated was the use of the Innovations Exchange. It clearly saved us an enormous amount of time to be able to point people to a thoughtful review of an innovation and how not to implement it exactly, but that they could adapt it to work within the culture and context of their organization. We brought in some innovators as part of the webinar discussions. They learned so much and there were tools and templates that would enable them to make this work. Having been part of the series all along was very helpful. The learning community membership brought together, we had unique characteristics, they were from similar departments, they built trust and they all dealt with similar issues, so it was easier to establish trust and be transparent. At the end, they developed a guide, jointly, to orient new patient and family advisors. That is now available and will be useful to others.
In summary, the key lesson learned is that the commitment of senior leaders is absolutely crucial to organizational change. The second key point- it's essential to have someone in the organization with dedicated time to work with patient and family advisors and to have the skills and have flexibility and trust building to make that work. The leadership needs to understand that change in organizational culture takes time.
A parting word- meaningfully involving patient and family advisors and hospital QI efforts improves the patient experience and contributes to important changes in organizational culture. It's a delight to turn this over to Dr. Herb Smitherman and for you to hear about his community.
Herbert Smitherman: Thank you very much, Beverley. I appreciate the transition. I am at Wayne State University and I am involved in the Reducing Non-urgent Emergency Services Learning Community.
This was a great experience. I was on the Innovations Editorial Board and helped to assemble the library of health care delivery best practices, and I helped the Agency for Healthcare Research and Quality through a process of identifying and assembling essentially a library of health care delivery best practices and policies from around the country. In our country, if we are going to improve health care outcomes, we need as a country to be able to build best practice databases and share this information among each other, for the purpose of adopting best practices. I looked at this whole AHRQ Health Care Innovations Exchange as three stages. Stage 1 is to identify and assemble the library and that is best practices. Stage 2 is to promote and share and exchange these best practices across the country towards improving care. And stage 3 is what you are seeing and what we are talking about today, that is actually supporting the adoption, scale up, and spread of these best practices and utilization of the library towards improving health care in this country.
Our Reducing Non-emergency Services Learning Community representatives were a collaborative of local leaders, Detroit stakeholders, and national stakeholders including AHRQ staff, Westat staff, national experts, and a local set of stakeholders called the Voices of Detroit initiative. The membership of these community stakeholders is below, which included the EMS services, our public health department, our mental health authority which is involved in supporting the mental health services for the entire county. All the FQHCs, the medical control authority, the Detroit Area Agency on Aging, neighborhood service organizations, our hospitals, and Wayne State University.
The challenge we had, and the drivers for this change, started with the Mayor of the city at that time in 2012, indicating that EMS had an annual deficit of $11 million. At that time, this city was trying to get all of its public debt under control. The mayor reached out to community stakeholders to come together to help solve this, what he considered a community problem. We had significant non-urgent, non-life threatening calls and utilization of EMS for those non-urgent calls. In 2015 we had 1,216 calls from super users, which we define as five or more calls within a 12-month period, and we had over 18,000 non-urgent calls and this was probably double what you see there in 2012. These non-urgent runs were costly, they diverted resources from true emergencies, they increased EMS response times, and clearly contributed to the budget deficits. We also had a large number of calls from a very small number of what we call, hotspot locations. There was really no coordination between emergency services in the emergency room and the community-based primary care mental health, social services, and substance abuse infrastructure in the community.
An example of some of the 911 calls that were considered and designated as non-urgent: boils, rash, sleep difficulties, STIs, toothaches, “I ran out of medications”, transportation needs, minor abrasions, people were calling just to talk. We had a lady when I started, she called 30 times in a three-month period and we sent a social worker to find that her husband had just recently died and she was significantly depressed; she was calling to talk to someone. We got her support services and counseling and her calls immediately stopped. We moved from a person calling 911 30 times in a three-month period and getting an ambulance out, to eliminating all of those calls with actually addressing the person’s basic needs.
The aims of our learning community were quite straightforward. Number 1 is to identify who these high utilizers are of emergency services and develop an effective delivery system that addresses their health care and social needs. Number 2 is to improve coordination between emergency services, primary care, behavioral health, social services, and senior services. And how we did that, is through implemented protocols that were agreed upon among the stakeholders. We allowed EMS to make real time referrals, their responses to 911 calls and if they suspected the condition was not urgent and/or the caller is in need of additional health care or social services, they used their EMS electronic health record to capture their perspective of the patient caller’s health, using a pre-established drop down menu. EMS indicated the patient can receive additional support from a community agency, and the patient is given a choice to opt-out of the referral process. EMS documented in SafetyPad their willingness to be referred, EMS refers them, and they determine which organization it is directed to. This was automatic in the field.
We also provided similar services to what we call the “Top 25 super users ” for 911 calls; these are people who are calling 5 or more times in a 12-month period, and we identified hotspot locations where there were significant numbers of 911 calls. We explored strategies to connect patients at these hotspot areas to appropriate care.
The key steps and processes were really about connecting and coordinating between emergency services, primary care, mental health, substance use, and social services. We built on ongoing efforts with Detroit EMS and Fire which was critically important. We wanted to work with the framework that was in place. We shared data, we leveraged strategies and innovators from the AHRQ Innovations Exchange, and we obtained consensus on strategies among the stakeholders, we attained agreement to implement policy and protocols that were agreed upon among all stakeholders including EMS and Fire.
Our outcomes: we had top 10 hotspots that were identified; almost 60-70% of all spots were senior housing. We got the Agency on Aging and they engaged the entire housing complex- those that were identified as calling and those that were not. We had many fewer 911 calls during the time when clinical services were available at one of our hotspot areas, which was a neighborhood organization for the most indigent and hard to reach. We put a nurse practitioner at the site and we found that the calls went down to zero and when the nurse was gone, the calls went back up to their usual density. Clearly, placing clinical services at the site to address basic health care needs decreased 911 calls.
We had almost 300 EMS referrals. When we instituted this program, the needs identified included dental, utility assistance, transportations, Meals-on-Wheels, chore helpers, visiting physicians- all kinds of needs both social and non-social. We got those needs out to the persons and the 911 calls went down significantly. We had no super users age 60 and above since May 2016 given this program.
We were talking about sustainability and we worked with our local oversight for our emergency services and are transitioning all that we are doing in this collaborative as an advisory committee of the local statutory oversight for emergency services called Detroit East Medical Control Authority.
What is clear is that we utilized local and national experts, which was critically helpful with respect to developing our protocols and models. What was also very important is having dedicated infrastructure. We had lots of stakeholders and people at the meeting, we had monthly meetings and subgroup meetings and subcommittee meetings to keep all of that coordinated and orchestrated and executing the meetings, assembling all the resources. Westat and AHRQ were critically important for continuity and sustainability of the process.
Lessons Learned- we clearly identified the needs and priorities of all the stakeholder organizations; you have to do that early on and you reassess on an ongoing basis. Set the table with the relevant stakeholders and keep revisiting member compositions. It’s important to identify all relevant local resources and be very inclusive.
The learning community infrastructure provided us stability and enabled progress when there were changes in the stakeholder organizations. We had a lot of documentation of what we did, so when new members joined we provided them documentation and we did not have to revisit. Having data is critical in driving change. This means not only identifying what data are needed but sharing data across different entities.
Also, there were barriers inherent in touching this population. We did learn that we had the ACA and we were covering people we were dealing with, especially emergency services- they were the hardest to reach and most recalcitrant part of our community. Access is clearly important; reorganizing the way we deliver services for this very hard to reach and hard to touch population is still an ongoing struggle but we are doing much better in the redesign of our system, in order to better care for this population. Also establish a sustainability plan and work on that in tandem with your process.
The Emergency Services learning community’s cross-stakeholder collaboration facilitated system change and improved our delivery system. It did that because we first identified best practices and innovators within the country; using the AHRQ Health Care Innovations Exchange database, we identified those in the country that were doing this kind of work and doing it well. We called upon them and worked with them and they advised us on how to best facilitate system change and improve our delivery system. And we went from identifying best practices to sharing across these different innovators, their best practices and what they had learned to adoption of what they did and scale up and spread and it worked.
Joy Alonzo: Hi, I’m Joy Alonzo from the University of Houston and I am going to be talking about promoting medication therapy management for at-risk populations (the MTM learning community). Hello to everyone from Houston.
As you can see from this chart, the MTM learning community consisted of a very varied collection of clinicians. Those represented were in various stages of planning, implementing, or executing an MTM project, so they were all very passionate about MTM services. This innovation project is a little unique in that a subset of the active participants in the LC were actually performing the innovation while the rest of us were actually watching and observing and monitoring the intervention; not unlike medical students in a surgical observation. So you can see that there were a lot located in Texas, but there were a number of other geographic locations; and again, all of these individuals were in the process of executing MTM services of their own- and this is very important in that there is a lot of literature suggesting that MTM services are very effective in affecting coordination of care between different services relative to medications- improving adherence, improving clinical outcomes- plus, there is very little written about how to actually stand one up and how to address challenges in your new clinical services.
When we went as a group we were able to discuss aspects of all the MTM interventions that we were all a part of and what was common to all, and to discuss the challenges.
The MTM LC project focused on patients with the following characteristics (noting slide) - they were all socioeconomically disadvantaged and uninsured patients, and were eligible for services at an FQHC, which means they were all uninsured. The patients were adult, primarily Hispanic, and identified as at-risk for poor health outcomes. They had type II diabetes mellitus and were targeted for the pilot intervention because they had uncontrolled clinical markers such as an unacceptable level of (hemoglobin) A1c. The aims were very specific to this population and specific to the goals of the pilot intervention and the MTM LC at large.
One of the key activities was developing an LC charter that we all agreed to. This helped solidify our goals of the LC and to address the needs of all the participants. We identified that regular monthly meetings were also very important to the LC, so we could discuss the pilot and the results, and identify the challenges and issues that were associated with the pilot. We were able to solicit experience and strategies from the LC membership and the LC members were able to relate the topics that we discussed to their own MTM efforts. The monthly Voices From the Field program highlighted the other LC members’ efforts outside of the MyRx pilot and allowed further identification of skills, tools, and resources that were needed by the whole group. The monthly presentations at the learning community meetings were from identified topics and leveraged the experiences of the extended member network. So even though we had 14 entities identified, many more entities were drawn in to capitalize on their expertise. We also found it very important to conduct in-person meetings. We had two in-person meetings, both held here in Houston, and this gave a voice to many more people who maybe were not as prone to discuss individual topics at the monthly membership meetings. We also are developing a case study that we are about to publish, and this summarizes the lessons learned and captured all the resources; it is like a how-to guide for standing up an MTM program and the challenges and issues.
The original MyRx medication adherence program was developed by Dr. Aisha Moultry; she is an associate professor and dean of student services at Texas Southern University College of Pharmacy and Health Sciences, and her team, which included Dr. Uche Ndefu and Dr. Portia Davis. The MyRx implementation was developed to provide medication reconciliation and health education to seniors in the community in their home. This had some limitations, which included lack of timely access to physicians if there was a pharmacist intervention that was suggested. So, for the LC pilot, we decided to adapt the original MyRx- which is featured here on this slide- and tailor it to a clinic-based environment at the Spring Branch FQHC clinic, where we could capitalize on all the providers being in-house.
Some of the key ways that the MyRx implementation was adapted for the clinic setting as opposed to the home-based setting were: integrating the pharmacist into the primary care team- and this way we could capitalize on pharmacists’ unique knowledge of complex medications- we could help the physician optimize the medications across disease states, and we could impact outcomes by improving adherence, ensuring medication access, and overcoming barriers to obtaining medication in this population. We also modified the clinic workflow, and this was very important to a low-income person; low-income persons have barriers such as transportation, time off from work, childcare, and two separate appointments was just not going to be practical for this population. So we co-scheduled the appointments to allow for referral to the clinical pharmacy service immediately, and tried to alleviate some of those barriers.
Additionally, we found that facilitating inter-professional communication was a huge goal of the new MyRx clinic-based implementation and that allowed for standup meetings, or “huddles”, of the pharmacist and the physicians so they could buy in to the process, making sure that all the clinicians would agree on the medication recommendations and approach.
So you can see from the pilot outcomes here, that the patients were identified for possible inclusion in the pilot from the Spring Branch FQHC clinic population of uncontrolled type II diabetics. Over a six-month enrollment period, 57 patients were enrolled into the MyRx pilot program at the Spring Branch clinic. The average hemoglobin A1c of the patients at the beginning of the program was about 10.6 percent. Following the 6-month intervention period, 38 patients returned for a follow up to the clinic; the average hemoglobin A1c of this group was 8.53 percent, which represented a 15.7 percent reduction from enrollment. Additionally, there were some other parameters that improved. The average score on the patient medication adherence questionnaire increased and the average score on the diabetes knowledge questionnaire increased. Also, there were a total of 230 pharmacist interventions documented relative to suggested changes in the medication program for each patient.
So these are some pretty impressive statistics, but the MyRx pilot did have some challenges. Enrolling the target number of patients from the originally identified pool was difficult because the patients did not always understand the value of the program; they didn’t always understand why they needed to see another clinician at the clinic. Initially, there was not a strong enough partnership between the physicians and the pharmacist; and that is quite common in new MTM services. We also had issues relative to retention; patients traveling in and out of the area because there was a high Hispanic population, and they travel back and forth to Mexico and they change address, so we had a low probability of re-contact. There was a high no-show rate which is associated with the FQHC. Coordination of the appointments was difficult; we needed a bilingual pharmacist, and that was difficult to obtain and that impacted the number of days and times that the PCP and the pharmacist could coordinate appointments.
Kristin Rosengren: We are going to shift gears and go to Dr. Mardon while we resolve the issues with Joy’s audio.
Russ Mardon: Thank you, I'm sorry for the technical difficulties, but we’ll continue. This is Dr. Russ Mardon. I am with Westat. What I want to talk about for a few minutes this afternoon is the higher level lessons that we drew from the experience of the learning communities and talk a bit about forming and operating the learning communities and about innovation adoption and implementation.
So this project offered a unique opportunity to compare and contrast these three concurrent learning communities that applied a common collaborative learning approach to very different topic areas and innovation strategies, across a range of care settings, patient populations, and care processes. Through our evaluation we uncovered findings about the adoption and implementation of innovations that may be applicable to other learning networks. We identified lessons related to the startup of learning communities, their ongoing operations, and the innovation implementation process.
First, let me talk about the learning community start up. One of the most important things is the role of the learning community champion. You have heard from the three champions already today, and I think you have a sense of the important role of having a core thought leader and subject matter expert who can be the speed around which the learning community coalesces. The champion is someone who is known and trusted, or recognized as an expert in the field that brings the credibility and the opportunity for success to the learning community. Equally important is who is invited to join the learning community, and it is important to do an assessment to identify organizations that have a common problem and are at the appropriate state of readiness in preparation to be able to work together to solve that problem. This approach keeps the focus on local problem-solving and empowers the participants to develop local solutions based on the best available evidence. It's important to understand the organizational needs of the participants as the initiative begins, and so as part of that Westat conducted a needs assessment early on in the life of the learning communities, and used that to tailor the particular approaches for building consensus and adopting innovations.
Next, once the learning communities were engaged and in operation, it takes a lot of work to get everyone involved and build the types of permanent collaborative relationships that it takes to make significant organizational changes. For these learning communities, we started by developing written charters that laid out the expectations of the participants and the goals towards which they were working. Then, in terms of how they work, that needs to be tailored to the needs and interests of the group. As you've heard, these three learning communities typically met through electronic webinars similar to this one on a monthly basis. There was much additional communication in between those monthly group calls involving leadership teams and core groups and in some cases, one-on-one participation and phone calls with the participants. Throughout that process, it was also important to hold at least one in-person meeting and we found that was crucial for building group cohesion and allowing the participants to build the level of trust that’s necessary to really work together. An in-person meeting provides a level of intensive interpersonal reaction that you really cannot get any other way. We found that essential to hold at least one of those early in the life of the project.
Every learning community experiences challenges. This is hard stuff; if it was easy you would not need to go to such an effort. It's important to be aware that there are going to be ups and downs, and the endpoint is not guaranteed. We have found it helpful to be realistic and set realistic goals, and to celebrate small victories along the way. To be aware that not all organizations will have or maintain the level of interest or level of commitment throughout the life of the learning community. It's important to be flexible and to work with the participants were they are and to enable them to contribute and to benefit as much as possible, based on where they are in the innovation adoption process. Another important thing is to think about sustainability. Learning communities don’t go on forever necessarily, and it’s important to think about sustaining the types of policy changes that we are talking about right from the start. Part of that is financial and it's important to understand and to demonstrate a positive financial return on investment for the innovation. However, even if the innovation change is successful it may require continued ongoing funding and one thing the learning community can do is to provide a framework for collaborative thinking and share securing funding. However, sustainability is not entirely about the money; sustainability is also about making the changes a normal part of daily operations, and integrating them in to routine policies, IT systems, and staffing and clinical workflows at the participating organizations. It's important to think about this right from the start.
I want to talk next about a few things related to implementing innovations. It really takes organizational buy-in, and then it takes difficult- sometimes difficult- technical and clinical work to really make the changes. This takes time and it's important to have the right participants at the table, in the learning community over time, and that may change. What we found, is that at the beginning of the learning community it’s important to have the key decision-makers at the table. You heard our champions talk about the participants at the executive level leaders at the participating organizations, and getting them to buy in and get their organizations on board. But then, it often turns to more technical implementation decisions. How do we actually make these changes? What are the protocols going to be? That moves to a different type of collaboration, and it’s important to document the value proposition at every stage and to structure the decision-making process, so that the group can continue to make progress and not get bogged down over issues that might be particularly challenging. By having those discussions in the collaborative framework of the learning community that can result in more creative solutions. Another interesting thing that every learning community that is working on innovation implementation has to consider is the tradeoff between fidelity to the original innovation and the flexibility that’s needed for local adaptation. There's no single right answer to this. You have heard different stories from the three different communities. Sometimes organizations need to have some flexibility for how they adopt things. On the other hand, if they stray too far from the source innovations and source evidence-base that they are building from, then they may not necessarily achieve the improvements and the gains they are hoping for. That's something to keep in mind, as the work at the learning community moves along.
To sum up, learning communities provide a rich collaborative environment and a well-functioning learning community offers peer support and mentoring, and the opportunity for brainstorming, creativity, and problem solving. It helps newer or less experienced members avoid having to solve problems on their own. It also holds members accountable in a sense by setting expectations, deadlines, and milestones. If somebody knows that next month they are on the hook to develop a certain aspect of the protocol or test some aspect of the innovation, they are motivated to report back to the group, because of these interdependent and personal relationships. A key role of the learning community is to foster this type of collaboration and to aid in the development of protocols, policies, and tools. Certainly, the Innovations Exchange is a valuable source of resources for stimulating this type of creative collaboration.
In conclusion, I would sum this up by saying that learning communities engage, motivate, and accelerate innovation adoption.
Lisa Simpson: Thank you very much to all of the speakers and Joy, if you could take a couple minutes of our Q&A time to summarize the key lessons learned from your interesting learning community.
Joy Alonzo: Yes, I would love to do that. Some of the key lessons learned: it’s true that the additional pilot included few patients; it was a small cohort. We had hoped for more, but because of how we identified the challenges and issues in this implementation to the larger group, who all were also implementing MTM innovations at the time- we were able to take the challenges and strategies that we identified for the MyRx pilot and apply them to our own MTM innovations. In my own case, at the time when I first joined the learning community, I was developing a pediatric MTM program for pediatric asthma patients that were non-adherent. One of the key skills that cut across all the MTM learning community members, and that we felt we were lacking in, was motivational interviewing skills. We identified that as something we all wanted to improve upon and we identified some key lecturers and resources and strategies to improve our motivational interviewing skills, and incorporated that into our monthly membership meetings- we spent a lot of time on that.
Cultural competency was another one that we spent a lot of time on, and I was able to take the skills that I learned through the LC and apply it to my own MTM innovation, and that was much larger – had a bigger backing – because it was associated with a health plan and the Medicaid population. I was able to train 13 other pharmacies and 50 pharmacists; and during the period of time I was involved with the MTM learning community, we performed more than 500 interventions with 500 unique patients. The lessons learned had such a broad reach and by having continuing education, or post-graduate education, on its ear and having it be learner-centered, we as a community projected the next skill we wanted to learn about, because we identified it as a common deficiency, or a common challenge, or a strategy that we needed to incorporate. We identified it in the MyRx, but we applied it to our own resources. So this capability of watching and observing and monitoring another entity performing the innovation and then being able to apply their lessons learned to our own applications, was really invaluable. It was a lot different than having somebody just get up and say, “here is how you do MTM.” This was actually watching someone do it. The extension to the number of patients is really difficult to measure, but you can see that it was exponential. That capability to learn from doing- that learner-centered environment and watching something as a real-world implementation- was invaluable.
Lisa Simpson: Wonderful. Thank you, Joy, that is really helpful. We are now in full Q&A mode. Please don't forget to use the chat pod if you have questions. We will put that slide up again with the instructions. We are going to try to get to as many of them as possible. I have a question for Herb, which is a clarification- did the EMS make those real time referrals in the ambulance, at the site, or once they brought the patient to the hospital?
Herbert Smitherman: The real time referrals were made on site. Once the ambulance or EMS arrived on site, they would identify needs that the patient had, whether they were social needs or primary care needs, or whatever the additional health care or social service needs were. They would capture that person's needs in their electronic medical record, push the button and based on the demographics of the patient, it would go to the appropriate service organization as a fax from the site.
Lisa Simpson: Great, thank you for clarifying. Bev, could you tell us how each of the participating members in your learning community supported each other as they each implemented their patient- and family-centered care strategies?
Beverley Johnson: Thank you for that important question. I think at the beginning, one of the things that frankly scared some of the hospitals was how to recruit and orient and involve these advisors. It just seemed like such a big leap. It was helpful to have some who are ahead, who could demystify that. There are so many myths that if we bring patients and families to the table and begin to talk with them about working with them as partners with us in quality improvement and safety and introducing new programs, that they will have unreasonable demands, it will take too much time. By helping to see how to debunk those myths, and then to be able to talk it through and share tools together, both at the webinar or they would post them in the SharePoint site. It was wonderful to see that they were not competing with each other, but they were willing to help each other out in very practical ways.
Lisa Simpson: Thank you, Beverley. Another question that is focused on patient and family engagement is related to the MTM pilot. Joy, the question is related to so much of patient engagement tends to happen after the design of a project, as opposed to before it gets started. Can you tell us more about patient and family engagement in the design of the pilot?
Joy Alonzo: The identification of the population is really important. In the MyRx implementation we were focused on individuals that can seek treatment at an FQHC, so they are not eligible for insurance. They are not insured, they are, in most cases not insurable. If you are insurable, the FQHC helps you get that insurance and you seek treatment elsewhere. We are talking about an indigent population that may not be citizens, and that's a huge feature and identification of barriers was key and knowing we needed a bilingual pharmacist that would identify with the community was key prior to implementation. And another MTM, you have to understand your population of individuals, who you are addressing, and the target disease state, and why we are addressing that target disease state. Does that make sense?
Lisa Simpson: Yes. That's great, thank you. We have a question which is more general and any one of you could answer. We have heard a lot about what worked and some of your lessons learned. Just as important, were there any specific mistakes that you learned to avoid because of others’ experience or that you made a corrected, what's important to not do when you are organizing a learning community? Does anyone want to take that one on?
Joy Alonzo: This is Joy, just like what you just had- that dead air is really tough. This technology that we used to meet monthly, trying to engage people in talking, was really challenging. We had programming, we had an agenda and speakers, but how do you get people to ask questions and how to get people to engage in the topic? That was difficult. The face-to-face meetings were key in solidifying us as a team. The second year was much better than the first. There was a lot more spirited engagement.
Lisa Simpson: Good comment.
Beverley Johnson: Joy, this is Bev- I totally agree. I think we had some challenges in terms of getting people to talk on the webinars and I think the in-person meeting does help with that. I think the other challenge for us was to help the hospitals see that patient and family advisors and partners in this work were really welcomed to participate in the webinars. I wish we had been able to make that happen. They really should be part of designing the learning community and really at all phases of this innovation work. I think in the future we would want to try to do that in more substantial ways.
Herbert Smitherman: One of the biggest challenges we had was continuously reassessing and identifying the needs and priorities of all the multiple stakeholder organizations. Everyone has agendas, and trying to keep those agendas, addressing those agendas in a real way and keeping the collaborative together, giving the ebbs and flows of those multiple agendas, is a very difficult task. They talk about herding cats for physicians, but this is actually worse. I think that was our biggest challenge. You have to really continue to reassess and reengage and re-ask, and have small group meetings and telephone calls and all of that to make sure you are keeping people on board. Sometimes when you add an entity or stakeholder, it becomes problematic for another stakeholder, which is an interesting process.
Lisa Simpson: Fascinating- great points. Russ, were you able to examine any outcomes– health status or other outcomes- and impact of the learning communities as part of this evaluation?
Russ Mardon: Thanks. The three learning communities were very different in terms of the level of change they were trying to accomplish. For example, the EMS learning community in Detroit was focusing on system-level change; the patient- and family-centered care learning community in Florida was focusing on facility-level change and organizational processes. Where the patient outcomes were the most impacted were in the medication therapy management learning community in Houston. You heard Joy report on some of the improvements in A1c and some of the other clinical indicators. That was where we were able to document most clearly the impact directly on patient outcomes.
Lisa Simpson: Great, thank you. There are a few questions that all get back on the topic of logistics and the intensity and the staff it takes to run these learning communities. Herb, you talked about how important the learning community was as a stable infrastructure when stakeholder organizations came and went. I invite any and all of you to comment about how much time and effort are we talking about here, because this is critical for sustainability and understanding the ROI. Russ, did you do any estimates of the resource requirements for each learning community, and then we will open it up to our champions?
Russ Mardon: Yes. That's a great point. This work does not happen on its own. It takes an active and engaged champion, but staffing. There’s a lot of phone calls and organization and planning and documentation and drafting of documents for the group to review. It really takes a level of staff support. Through AHRQ, we were able to provide not quite a full-time person, but more than half of an FTE for each learning community to provide ongoing communication and staff support. That's a real level of commitment that's necessary to accomplish this type of work.
Lisa Simpson: Thank you.
Herbert Smitherman: This is Herb Smitherman. I could not agree with Russ more. I can't over emphasize the need for dedicated infrastructure resources to execute the meetings and continue all the documentation it requires. The three aspects that I think are critical are first you have to have the infrastructure and that is the actual Innovations Exchange library, some database that you can pull out best practices. You have to be able to access the experts within that and Westat and AHRQ were able to help us get access to those experts and leverage their expertise. Just the literal meeting planning- the monthly meetings, the subgroup meetings, the telephone calls and the Westat and AHRQ staff did some of those calls for us because they got to know the local stakeholders and they were engaging them directly.
Lisa Simpson: Great- great points. We are out of time for any more questions and we have many more that we were not able to get to live today. There are questions about other resources which will be available on the site. Let me now, first thank each of you for joining us today and thank our speakers for providing us with such a great summary and so many important lessons learned that others can take and use in their own practice and improvement efforts. Please note, that in approximately 2 weeks, all registered individuals will receive a link to the archived recording to the session. And finally, please take a second to complete the evaluation about this webinar which will be available momentarily. Don't forget to disable your pop-up blocker. We particularly appreciate your open-ended comments, which are useful. Thank you to all of you and have a great day.