A Practical Approach to Establishing a Practice-Based Research Network Stakeholder Engagement Infrastructure

History and Need for Renewed Engagement Infrastructure

In 1995, Southeast Regional Clinicians Network (SERCN) was designated as a PBRN of FQHCs and Primary Care Associations (PCAs) in 8 southeastern states and is administered from the National Center for Primary Care (NCPC) at Morehouse School of Medicine in Atlanta, Georgia. FQHCs compose the primary care safety net and provide comprehensive primary care, dental, and mental health services to a disproportionately poor, minority, and medically underserved population. Every state has a PCA, which is a leadership and advocacy organization for the state's FQHCs that serves as a resource for training and technical assistance. SERCN encompasses the 8 states that make up the Department of Health and Human Services Region IV (Alabama, Mississippi, North Carolina, South Carolina, Florida, Georgia, Kentucky, and Tennessee). These states are home to 203 FQHCs with over 1700 clinic sites serving over 4 million patients.

SERCN was an active PBRN until 2011, after the departure of the network director. However, the NCPC maintained relationships with key stakeholders and successfully engaged all states in a large funding proposal in 2015. The NCPC recruited a new network director in late 2015 who was charged to revitalize the network. This was no simple task given the infrastructure challenges of the preceding years, the network's broad geographic catchment area, and limited funding support and personnel. Despite these challenges, the director and network coordinator engaged leaders of all the state PCAs in the network to assess their broad needs and explore opportunities for projects from late 2015 through early 2016.

Securing Funding to Build Stakeholder Engagement Infrastructure

This initial stakeholder engagement process led the team to conclude that funding would be needed to effectively rebuild the network's stakeholder engagement infrastructure. This decision was driven by the significant time needed, the large geographic footprint of the network, and the realization that harmonizing regional versus state specific needs and values around research would require a structured approach. The team applied for a PCORI Engagement Award in February of 2016 and their project titled, Engaging Stakeholders to Build Infrastructure for patient centered outcomes research (PCOR) in the Primary Care Safety Net, was funded from July 2016 through June 2018. The overall timeline and activities and products of the project are outlined in Figure 1.

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Figure 1.

Overview of SERCN PBRN engagement infrastructure building project timeline, activities, and products SERCN, southeast regional clinicians network; PBRN, practice-based research networks.

Network-Wide Listening and Engagement Sessions

To engage a broad group of stakeholders, SERCN worked with PCAs to identify state-wide PCA events attended by geographically diverse FQHC stakeholders. Listening sessions were scheduled at these events with the help of key PCA leaders. A relationship-building phase with PCA leaders led up to coordinating the listening session. We worked with PCA meeting organizers to identify and recruit English speaking FQHC and PCA stakeholders who had interest or experience as leaders, clinicians, or quality/research personnel. Some barriers to recruitment included the time constraints and competing demands of PCA personnel. We addressed these through persistent communication, relationship building, and reciprocal support of the conference as a speaker or exhibitor. Participants were recruited via email and/or phone before the scheduled meeting by PCA partners using the conference registration list. During the sessions, attendees were detailed on the mission and goals of SERCN and the focus group objectives. These sessions built the foundation of the SERCN communication platform and leadership pipeline; attendees signed up for SERCN communications and self-identified if they were interested in a SERCN leadership position. Most importantly, these sessions allowed the SERCN team to understand key health issues and research, quality, and operational priorities of network stakeholders.

Eight sessions (1 per state) were conducted from August 2016 to May 2017. There were a total 74 participants and groups ranged in size from 3 to 13 stakeholders. Stakeholders included clinicians, nurses, health information technology experts, quality improvement staff, FQHC leaders, PCA leaders, and community organization leaders. Participants were compensated with a $50 gift card for their participation and refreshments were provided. Listening sessions lasted approximately 90 minutes. Each session was recorded and transcribed verbatim. The session was structured using a guide but use of the guide was flexible based on dynamics of each group (Table 1). The same facilitator, the network director, who had training in qualitative and PBRN research methods, conducted all the focus groups.

Qualitative Analysis of Stakeholder Research and Training Needs Assessment

The SERCN research team included 1 clinician researcher who conducted all the listening sessions and 2 qualitative research assistants, 1 with a doctorate in sociology and 1 with master's level training. The team identified emergent themes from the focus group transcripts and notes using an immersion crystallization approach.¹³

Convening Network Stakeholders

In year 2, we identified 1 or 2 key stakeholders in each state who participated in the listening sessions and/or self identified as interested in a SERCN leadership position to attend a network-wide stakeholder meeting in Atlanta. The regional stakeholder engagement conference was held on February 19, 2018 at Morehouse School of Medicine. SERCN reimbursed attendees for travel expenses. The objectives of this meeting were: 1) to engage SERCN stakeholders around practice-based research in the primary care safety net; 2) to define a SERCN research agenda; 3) to establish a SERCN steering committee; and 4) to learn how SERCN could improve stakeholder engagement efforts. Stakeholders convened at the regional conference were thought leaders in their organizations and included clinical quality leaders, medical directors, and member and patient engagement specialists at PCAs and FQHCs. These state champion stakeholders were convened for several reasons: 1) SERCN relies on PCA partners to identify FQHC needs and act as an intermediary for project proposal and implementation phases, 2) they understood the high-level needs of the region and could identify common ground for the direction of our regional network, and 3) they held influential positions and were well suited to translate the network research agenda into action. Thirteen stakeholders attended, representing all states in the network. This was largely a working meeting, although we invited outside speakers on topics of identified interest to the group. See Appendix for the full conference agenda.

Translation of Needs Assessment Findings to Actionable Research Agenda

The network director led a workshop to guide the stakeholder group through a process of crafting a needs-based research agenda that incorporated key health issues in the region, operational/quality priorities of SERCN members, existing quality improvement infrastructure, and future goals/needs around research and training drawn from the regional listening sessions. The workshop lasted 2 hours and began with a review of the qualitative data collected from year 1 of the project using a PowerPoint presentation format.

The network director then asked stakeholders to translate, condense, and prioritize the themes of the listening sessions into a research agenda for the network. Some of the guiding questions used to facilitate this discussion included: 1) What are the high-level values that we will uphold in our work together? 2) What priority areas and populations were consistently identified across the region as areas of need and interest? 3) How should we work with network stakeholders? The network director facilitated the discussion using active-listening techniques, checked for understanding, and asked probing and clarifying questions. The network director took notes and edited the documents on a PowerPoint slide projected on a screen and received real-time feedback on documentation from the group. Group consensus was reached around what to include in each of the final research agenda components. The documents were presented as living documents that would be updated as the needs of network stakeholders evolved. The group divided the research agenda into 3 parts: 1) Key Priority Areas and Populations (Table 2), 2) Collaborative Principles, and 3) Research Procedures (Table 3).

The priority areas defined by SERCN stakeholders reflected the medical and social complexity of patients seen in FQHCs and traditional values of PBRNs.^14,15 Priority areas included implementing models that bolstered FQHC infrastructure through workforce stability and wellness; measuring the economic and health impact that FQHCs have on their communities; development and testing models of care for medically and socially complex patients health information technology; and behavioral health and substance use disorder integration into primary care.

SERCN stakeholders formulated overarching guidelines for collaboration and made specific recommendations to integrate stakeholder wisdom across the spectrum of research processes, from project identification to dissemination. Notable collaborative guidelines included cultivation of an environment of trust and transparency, the importance of crediting stakeholders for their contributions, a commitment to regular 2-way communication in person and via conference call, and the role of the network to serve as a clearinghouse for scalable ideas/models of care. Stakeholders were specific about how SERCN should involve stakeholders at each stage of the research process and valued stakeholder input on project identification, the testing and implementing of sustainable care models, minimizing recruitment and data reporting efforts through technical support, shared interpretation of results, and dissemination strategies that use traditional and nontraditional platforms. In addition, stakeholders identified that the work produced by the network be used as an engagement tool for a broader group of health center stakeholders.

Election of Executive Steering Committee

Nomination forms were distributed to all attendees for a position on the 3-person Steering Committee. The responsibilities of the Steering Committee members were described before the nomination process and included: 1) provide guidance on the strategic direction of the network, project selection, and results dissemination; 2) attend quarterly conference calls; 3) attend yearly in person meetings; 3) commit to a 2-year term. All nominated individuals were included on ballots that were distributed and tallied. Steering Committee members were announced at the end of the meeting.

Stakeholder Definition of Facilitators and Barriers to Conducting Research in the Network

In a 1-hour workshop, stakeholders divided into small groups to identify barriers and facilitators to operationalizing the new SERCN research agenda. This facilitated discussion was organized into a multi-level framework to distinguish challenges and strengths across a broad variety of stakeholder groups and organizational levels. The most significant barriers to implementing research included limited time and human capital to implement projects and the most consistent facilitators to success included the human capital, relationships, and experience of past success across multiple levels of the organizational structure. A full list of the multi-level barriers and facilitators to the implementation of the research agenda are detailed in Table 4.

Stakeholder Input on Engagement Approaches

As a portion of the same small group workshop, stakeholders gave feedback on SERCN engagement approaches and how approaches might be adapted to better meet their needs in the future. This discussion was segmented to identifying differing engagement needs and preferences across network stakeholder groups. Stakeholder subgroups included advocacy and policy stakeholders, funders and academic partners, PCAs, FQHCs, and patients. Stakeholders recommended engaging national advocacy partners at the National Association for Community Health Centers, the Health Resources and Services Administration, and state PCA government relations offices to explore opportunities for collaboration around policy, payor, quality measurement, and legislative issues impacting FQHCs regionally and nationally. Engagement strategies for academic partners and funders included presentations at research meetings and peer reviewed publications as well as cultivating relationships with funders around the potential for practice-based research in FQHCs to improve relevance of research to communities and translatability of research outcomes. PCA stakeholders preferred email, conference/phone calls, in person centralized conferences yearly, and in person outreach to PCA events as mechanisms of engagement. Stakeholders recommended that we receive feedback from and disseminate information to FQHC stakeholders through the PCAs in each state because PCAs had well-established relationships with FQHC staff and knowledge of the needs and strengths of health centers in their states. When engaging patients, stakeholders recommended leveraging FQHC and PCA relationship with community-based organizations, mailings, social media, and messaging through local media outlets as effective potential engagement strategies.