Navigating Change: How Outreach Facilitators Can Help Clinicians Improve Patient Outcomes

• Outreach Facilitator
• Patient Outcomes
• Practice Facilitation
• Primary Health Care

A primary care group practice comprising 5 family physicians and multiple allied health personnel was located over 3 sites. It was primarily an urban, English-speaking practice but had patients of various ethnicities. Physicians had a rostered patient load of approximately 1300 each and had access to electronic medical records (EMRs) and Internet resources. The practice had some processes in place for diabetes management and had met its recommended target of measuring 2 glycosylated hemoglobin (HbA1c) levels each for their diabetic patients within a year. However, there remained a group of patients with HbA1c values who were not at target, and the team was unsure about how they could address this difficulty. They wondered how they were performing in other areas and what might need to be changed. What should they do?

Primary care practices face multiple challenges. Patient care is increasingly complex, practice models are changing, and time and money are in short supply. Within this context, making changes to improve patient care can be a daunting task. Often, clinicians have trouble defining what they want to accomplish, are unsure of how to institute changes, or may not know how to evaluate whether the changes have improved the care they deliver to their patients. Therefore, one method that has arisen to help practices make these quality improvements (QIs) is the use of an outreach facilitator (OF). An OF is a health care professional with expertise in organizational change management who can lead and support health care providers down the path of change. Using tools such as chart audits and feedback, OFs help practice physicians recognize challenges and identify goals. Then, by working collaboratively, the OF and the physicians can develop plans to accomplish these goals.

Practices vary considerably in size, organizational culture (eg, paper-based or computer-based practices), and payment models. Therefore, successful facilitation needs to be wide-ranging, multifaceted, and individually tailored to meet the needs of each specific practice. A recent meta-analysis has shown that primary care physicians are almost 3 times more likely to adopt evidence-based guidelines when they are supported by an OF.¹ Currently, there are multiple facilitation programs across Canada and the United States that are engaged in system redesign, improvement of efficiencies, and advanced access (see Table 1). The goal of this article is to describe a project in which we employed the use of outreach facilitators among 83 practices and to elucidate the barriers we encountered and the lessons learned.

Results

Regarding the case study that opened this article, the A&F revealed some areas that piqued the team's interest. We will use this case study to demonstrate specific examples of practice improvements the OF supported; then we will describe the lessons learned from this study to illustrate varying roles within a practice the OF can play.

Case Study Example

Aspirin Use

Recent changes in guidelines for aspirin use and the availability of this medication over the counter has resulted in inconsistent prescribing patterns and documentation among practice providers. In addition, adherence to guidelines of care for hypertension (as measured by blood pressure [BP]) and diabetes care (as measured by HbA1c levels) was lower than expected. Consequently, the OF suggested and discussed possible approaches to address these concerns. First, she provided current aspirin-use recommendations for patients with diabetes and cardiovascular disease in general. The team felt that a lack of consistent aspirin notation in the EMR was a barrier to implementing appropriate medication recommendations and that improving this notation would be an easy change to make. The staff discussed and agreed on specific terminology, embedded an alert for aspirin within the EMR, and decided to write prescriptions for aspirin, even if patients would purchase it over the counter, to ensure appropriate use.

Improving Hypertension Control

In the case study, the A&F had revealed that some patients' BPs were not being adequately monitored and controlled. The majority of the physicians felt that they should be able to achieve targets given the resources that they had available. There also was a feeling among the team that patients needed to take more responsibility for their own health and follow-up appointments. Being cognizant of the different views regarding patient responsibility, the OF presented a systematic review to show how recall works to improve BP control.⁴ In preparation for a recall system, a registry would need to be established. In the meantime, the practice decided that it would use the team members more effectively, develop a BP protocol, and apply for budgetary funds to purchase a BP Tru machine. In a subsequent meeting, the OF followed up on the topic of a recall system. The pharmacist agreed to lead the work and to set the time frames. Until a registry could be established, the team would run a sample search of patients with hypertension who were not at target. The OF introduced the Plan, Do, Study, Act (PDSA) QI tool. The primary care group implemented changes in processes to identify patients, to monitor BP every visit, and to record every BP in the EMR. Within several months they were able to distinguish those patients who were being managed well from those who were falling between the cracks. Those who were less well-managed were thereafter called back into the office more frequently to get their BP under control.

Revisiting Hypertension and HbA1c Levels

Toward the end of the first year of participation, our original case study practice was visited again by the OF during a scheduled visit. The OF wanted to close the loop on the hypertension management QI and brought up the subject of the registry. It seemed that although the small pilot project had worked to a degree, no further action had been taken to establish a registry and work toward those BP target outcomes in a consistent way. After talking about their original plan, and with encouragement from the OF, the team was willing to try again. In addition, talks revolved around an initial area of interest in improving HbA1c outcomes for those patients who were not well managed. The group had put a lot of effort into improving their processes for diabetes care and developing a recall system, but improving outcomes needed another approach. They decided to set up a diabetes group comprising the diabetes team, clinical, and administrative staff, with the clinical coordinator as the leader. They agreed on a step-wise strategy in which they would rationalize referrals to community diabetes education programs to avoid duplication of services, pilot a self-management program within the practice, and hold a training day to finalize their strategy. The OF put them in touch with another team that was willing to share their experiences with setting up a diabetes self-management program. It was hoped that these actions would help some of those patients reach better HbA1c targets.

Lessons Learned

Practice Culture

Practice culture is important to consider when implementing a QI initiative. Autonomy, collegiality, and technological biases are just some aspects of a culture that influence the style of work and adaptation to or acceptance of change. In one paper-based practice, the OF proposed a system for recalling patients with diabetes or hypertension by using a simple file card registry that would only involve a few phone calls a month. By the next visit, the practice had devised a simple system using a dummy billing code. This busy practice put an effective system in place with few resources. They also needed some educational resources for patients, but space was limited and the staff did not want the facilitator to bring paper resources that were difficult to store. After several discussions, it was agreed that small, wallet-sized cards with only a few references to pertinent web sites would be useful, and the team would provide their patients with these cards. Changes had to be practical and tailored to the practice's requirements and culture.

Evaluating Effectiveness

Another of the many lessons learned was that although a practice may be organized, with established programs to improve chronic disease management processes and support for patients in managing their conditions, issues arise with which an OF can assist. We worked with a primary care group practice, recognized as a care leader, that already had patient educational and monitoring programs and had initiated many projects using the data provided by their disease registries. After the first few meetings, the OF wondered whether she had anything to contribute to the team. It became apparent that it was difficult for them to gauge whether an approach had been effective. The OF collated various QI tools and designed a tailored tool that could help them define their objectives and outcomes, plan their intervention, and then evaluate it. She presented it to the team at the next meeting. The tool is now being used routinely and seems to be focusing the team toward effective evaluation of outcomes (see Figure 1).

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Figure 1.

Planning and evaluation form.

Reducing Inefficiencies

OFs can work with practices to identify areas of waste, redundancies, and inefficiencies and to examine the full scope of roles using proven methods such as LEAN and Six Sigma.⁵ Process analyses can be made with Ishekawa diagrams and process mapping strategies.^6,7 An effective tool that is widely used is the PDSA cycle (see Table 3). Once a practice has decided on process or outcome goals, PDSA cycles are a simple way to implement changes and evaluate results. Small changes in processes can be made and then immediately studied for outcomes within a short time frame. If the changes result in progress toward the goals, then actions can be continued. If not, alterations can be made and the changes evaluated. Changes do not need to be complex. Simple things such as reminders in an EMR or paper chart are often very effective.

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Table 3. An Example of Utilizing Plan, Do, Study, Act Cycle

Community Resources

Accurate listings and knowledge of community resources is another important component in the delivery of quality care. Community organizations have been funded through municipal, provincial/state, and federal jurisdictions, but practices often lack an awareness of these local resources. An OF can update and disseminate these resources for maximum use by practitioners and patients alike, resulting in improved health and self-management.

• Received for publication June 7, 2011.
• Revision received December 31, 2011.
• Accepted for publication January 5, 2012.