The Art of Outreach Facilitation
Kate Nash and Dianne Laferriere
January 24 2011
The Art of Outreach Facilitation
Brief Review thus far
• Chronic Disease Model -acute to chronic focus in
approach to health care
• Science of Outreach Facilitation- development of
facilitation and how it has been used in prevention
services
• Facilitation is an effective and supportive way of
changing practice behaviour, as well as being cost
effective
What is a facilitator?
A helper and enabler whose goal is to support others
as they achieve exceptional performance.
Facilitation is a way of providing leadership without
taking the reins.
Ingrid Bens
Overview of presentation
 IDOCC: The Improved Delivery of Cardiovascular Care
through Outreach Facilitation Program
 The Primary Care Environment (in Ontario)
 The Qualities and Skills of a Facilitator
 Tools
 Tailoring
IDOCC
The Improved Delivery of Cardiovascular Care
Through Outreach Facilitation
IDOCC: Creation of the CCPN
• The University of Ottawa Heart Institute
– Prioritized Prevention of CVD
– Recognizing the need for a true collaborative approach
• Advent of Local Health Integration Networks
– Regionalized focus
– Allows for development of Chronic Disease Management in a way that
has never been done before
• Reorganization of Public Health in Ontario and Canada
– A focus on integrated approaches to chronic disease prevention
– Public Health Agency of Canada, Ministry of Health Promotion
IDOCC: CCPN Priority Initiatives
1. IDOCC initiative
2. Hospital-based Smoking Cessation Network
3. Champlain Get with the Guidelines Initiative
4. Champlain Healthy School aged Children Initiative
5. Champlain Healthy Living and Management Risk Factor Program
6. Champlain Community Heart Health Survey
IDOCC: Recruitment
• Complex due to no single entity identifying primary care physicians
• Multiple contacts with OMA, OCFP, CME events, pharmaceutical
events,
• Public speaking, promotion through the LHIN, press releases, get
opinion leaders and community leaders on board to that they can
spread the word and convince their colleagues
• Cold calling- barriers, phone calls, in person visits
• Printed material
• Built our own comprehensive list of primary care physicians
IDOCC Overview
• The ‘Divisions’ were randomly assigned to begin the program as
follows:
Division
West
9
Cen
-tral
8
Year 1
Year 2
Year 3
Year 4
Facilitation
Facilitation
(Sustainability
phase)
Facilitation
(Sustainability
phase)
Year 5
East
4
Baseline
2
7
5
Baseline
Baseline
Facilitation
Facilitation
(Sustainability
phase)
1
6
3
Baseline
Baseline
Baseline
Facilitation
On-going
program
implementation
– sustainability
phase;
Data analysis
and evaluation
Evaluation-Key Indicators
• Quality of care process indicators - 29 evidence- and
consensus-based indicators chosen to assess whether
recommended clinical actions were followed in the
clinical situations calling for those actions eg BP taken
and recorded at least once in last year
• Outcome of care indicators - 14 evidence-based reflecting
whether patients achieved the the recommended
treatment goal targets
Source of data: Patient Chart Audit
IDOCC: Practices
# of practices
# of physicians
Step 1
26
59
Step 2
30
79
Step 3
27
53
Total
83
191
IDOCC: Practices by Model
45%
50%
% of Participating Practices
45%
40%
35%
30%
25%
18%
20%
14%
15%
10%
8%
6%
6%
2%
5%
0%
FFS
FHG
FHO
FHN
FHT
Primary Care Model Type
CHC
LTC
IDOCC: EMR/ Paper/Transition
At the time of signing up for IDOCC there were:
• 43 Practices using paper
• 40 Using EMR or a mix of paper/EMR
That figure is constantly changing
IDOCC: Practices by Region
Program implemented in 83
practices
IDOCC: Program Outline
•
•
•
•
•
Consent
Chart audit of 66 randomly abstracted charts
Facilitator provides audit and feedback
Collaborative goal setting
Monthly visits for intensive year, 12-16 weeks for
sustainability year
• Chart audit repeated at the end of the study
Patient Diagnoses & Risk Factors (n = 4,896)
% of Patients with Diagnoses or Risk Factor
100%
90%
80%
70%
60%
50%
40%
83%
77%
30%
46%
20%
30%
18%
10%
21%
13%
6%
0%
Dyslipidemia
Diabetes
HTN
CKD
Stroke
CAD
PVD
Smokers
Diagnoses or Risk Factor
HTN – Hypertension
CAD – Coronary Artery Disease
CKD – Chronic Kidney Disease
PVD – Peripheral Vascular Disease
The Primary Care Environment
Complex
&
Evolving
The Primary Care Environment
“ efforts
to understand practice should
precede efforts to change practice”
The Primary Care Environment
• Complex
• Changing
• Unpredictable
The Primary Care Environment
1. Complexity
2. Payment Models
3. Community
4. Culture
The Primary Care Environment
1. Complexity
Primary Care Environment
Health Care Organization
•Scepticism
•Not influenced by financial
incentives
•Fear of losing autonomy
•Open to new initiatives
•Want to maximize billing
•Accept CDM challenge
Primary Care Environment
Local factors
•Walk-in clinics
•Sudden population shifts
•Rural practices
Primary Care Environment
Appointments System
•Patients can’t get same day
appointment
•Overbooked
•Always an hour or more late
Primary Care Environment
Self management
•No time
•Patient’s responsibility
•Saying the same thing for
years
•The 3 questions
•The 5 As
•Focus on those who are ready
•Refer
Primary Care Environment
Change
•Change of models
•Change of location
•Change of records
The Primary Care Environment
A physician who has recently
moved to EMR tries
desperately to retrieve the
patient records he has just lost.
The Primary Care Environment
Unpredictability
•A productive relationship v a “good” relationship
•The agent for change can be anyone in the team.
•Never
Never
The Primary Care Environment
The facilitator is uncertain where to go next with the practice
The Primary Care Environment
And then has a pleasant surprise
The Primary Care Environment
2. Payment Models (Ontario)
2.Payment Models
• FFS- accounts for largest number of practices,
physicians and patients seen, no rostering, no other
funding
• FHG-(FFS remuneration) but incentives for some
conditions, patient rostering, after hours care, THAS,
currently some funding for IT
2.Payment Models
• FHN, FHO-capitation, rostering, prevention and
disease management incentives, provider governance,
use of IT, some allied health personnel, 24/7 access
• FHT- Capitation or salary, rostering, allied health
personnel, prevention and disease management
incentives, professional or community governance,
IT, 24/7 access
2.Payment Models
• CHC-salaried, rostering (operates within defined
community), incentives, IT, allied health personnel,
community governance, 24/7 access
• AHAC-Aboriginal Health Access Centres- similar to
CHCs, include traditional aboriginal approaches to
health and wellness- salaried
Russell, GM et al 2009, Muldoon L et al 2009
Patient –Physician Perspectives
• Payment model and organization may not affect day
to day practice
• A doctor in a FFS, FHG, or FHO may for most
purposes work as a solo physician with receptionist
and /or nurse
• There may be more similarities across models than
within models
The Primary Care Environment
3. Community
Community
•Only CHCs have a
“catchment” area
•Patients often follow the
doctor, therefore the idea of
community resources and links
becomes complex
•Patients find doctors who
speak the same language even
if geographically distant
•Rural/Urban differences
•Quebec Patients
The Primary Care Environment
4.Culture
Culture
• The practice culture (shared beliefs and values
embedded within an organization)
• Organisational culture
• Patient culture
The Primary Care Environment
Culture can influence the types of programs used
to assure Quality- survey from 88 medical groups
• Strong Information culture favoured electronic data systems
and evidence based data
• Quality centred culture favoured patient satisfaction surveys
• Business orientated culture favoured benchmarking
• Collegiate culture appeared to rely more on informal peer
review
• Autonomous culture negatively associated with all the
programs ( but not significantly so)
Authors Conclusions
• Culture does not make a difference in quality of care
and patients safety
• Culture does affect the slow adoption of quality
assurance programs
• It is important to consider congruence
Kaissi et al, 2004
The Primary Care Environment
“ …practices often lack the office systems to support
improved chronic illness self-management,
delegation, care management and systematic tracking
to assure optimal processes and outcomes of diabetes
care.”
“ Practices operate on a narrow financial margin, have
minimal flexibility in resource use and are quite
different from those systems in which adoption of
chronic care management components have been
demonstrated.”
Crabtree et al, 2011
The Qualities and Skills of a Facilitator
Qualities of the Facilitator *
• Skills: presentation training, research and planning,
analytical & synthesis skills, observational skills,
design & customize interventions, ability to lead
groups, interpersonal collaborative skills,
communication skills
• work independently, be flexible, creative, sensitive,
empathetic, supportive, promotes and guides
*Guiding Facilitation in the Canadian context
Qualities of the Facilitator
• Knowledge skills: primary health care context and
office systems, relevant guidelines of care,
organizational change, techniques and strategies,
group vs individual dynamics
Qualities of the Facilitator
• Personal disposition: encouraging, neutral,
inquisitive, non-authoritative leadership style,
assertive & confident, focuses on building capacity
rather than taking ownership, share knowledge and
strategies, change approach as needed, be
comfortable with change and dealing with conflict
and/or resistance
Qualities of the Facilitator
• Technical, computer skills: library searches, some
familiarity with EMRs, good familiarity with word
processing and presentation programs
Qualities of the Facilitator
• Organizational skills: identify processes as well as
outcomes, work flow, create partnerships, knowledge
of QI principles and strategies, provide resources and
assist in development and implementation of
evidence based practice tools
Tools
Tools
• Audit and Feedback
• Tailored flow sheets
• Patient educational tools- links to community resources and
promoting contact
• Community Resources- specialists, awareness, referral forms,
“Ask the Experts” opportunities
• Networking Opportunities- shared experiences, successes and
challenges
• Summaries of conferences
• Guidelines
• Web sites
Tools
Relating tools to the Chronic Disease Model
The Community
• Wider health community- Ministry of Health, professional
bodies (College of Physicians and Surgeons), local diabetes
programs
• These organizations may offer directives, information, billing
incentives, assistance
• Facilitator can identify and help establish liaisons with these
partners and/or find these resources for practice
• Eg. Extra phone billing incentives at time of H1N1
• Eg. Referrals to specialist care or community programs
Tools
Relating tools to the Chronic Disease Model
The Health system Organization
• MOHLTC, Champlain LHIN and family practices are
all focused on diabetes care- what is being done at all
of the levels? Eg. BDDI
• QIIP, DRCC, IDOCC, other programs
• Transfer knowledge and facilitate linkages among
organizations
Tools
Relating tools to the Chronic Disease Model
Delivery System Design
• Define roles and tasks-writing descriptions
• Encourage the development of planned visits for
continuity of care, follow up
• Help team explore improved communications
• Will shift focus from episodic reactive focus to a
proactive one
Tools
Relating tools to the Chronic Disease Model
Decision Support
• Audit and feedback
• Evidenced based guidelines
• Literature searches
• Provider education- CME opportunities, conference
summaries, network meetings to share knowledge and
strategies
• Patient education- increase population awareness of the
pertinent guidelines for care- posters in office, focused visit
handouts
• Increasing specialist care into primary care- reviewing
specialist availability, updating accuracy of forms and contacts
Tools
•
•
•
•
Relating tools to the Chronic Disease Model
Clinical Information System Support
Registries- EMR or paper
Reminders in charts- EMR or paper
Flowsheets, practice aids- (tape measures)
Encourage periodic reviews to look at performance
and efficacies
Tools
Relating tools to the Chronic Disease Model
Patient Self Management
• Increase patient knowledge through education
• Increase ownership of health – self management programsidentify, inform and promote
• Action plans- ranging from simple to complex, feedback to
patients
• Promoting the idea that patient and team are working together
to improve or maintain health- both patients and staff need to
agree (attitude change)
• Provide ongoing support for practices and patients
Tailoring
Tailoring
“Practice assessment and intervention tailoring are
complex and intuitive processes and are generally not
amenable to linear or sequential steps and simple
descriptions”.
Ruhe, 2009
“ Tailored interventions have the potential to match
motivations and acknowledge conditions within the
practice environment that influence and sustain
change efforts.”
Bobiak, 2009
Systematic Review, Baker 2009
• 26 studies
• Tailored interventions can change professional
practice
however
• As yet there is insufficient evidence on the most effective
approaches to tailoring including how barriers should be
identified and how interventions should be selected to address
barriers”.
Tailoring
Interventions can be tailored more effectively by:
Assessing the practice’s capacity for change
Appraising the cultural-structural fit
The Art of Facilitation
Practical Considerations
• Don’t reinvent the wheel- easier and time saving to
adapt existing tools, if possible
• Everyone has their own style- what works for one
practice may not in another
• On the journey, there may be hold ups, barriers and
detours
• Keep the destination in sight and close the loops
A Complex Journey but
Try and close the loops
References
Baker R et al, Tailored Interventions to overcome identified barriers to change: effects on professional practice
And health care outcomes. Cochrane Database of Systematic Reviews 2010
Bens I, Facilitation at a Glance, GOAL QPC & AQP
Bobiak S et al, Q manage Health Care Vol. 18, No 4, pp. 278-284, 2009
Carter C et al, Q Manage Health Care Vol. 16, No 3 pp 194-204, 2007
Crabtree et al, Medical Care
Dugan et al, J. Ambulatory Care Manage, Vol. 34, No 1, pp.47-57, 2011
Guiding Facilitation in the Canadian context: Enhancing Primary Health Care, Multi-jurisdictional
Collaboration, Dept of Health and Community Services, Newfoundland, 2006
Hogg W, International Journal for Quality in Health Care Vol. 20, No 5, pp. 308-313, 2008
Kaissi et al, Health Manage Rev 2004, 29(2) 129-138
Muldoon L et al Health Care Management Forum 2009
Ruhe M et al, Q Manage Health Care Vol. 18, No 4, pp 268-277
Russell, GM et al Annals of Family Medicine 2009,
Strange KC. J Family Pract. 43(4). Pp. 358-360, 1996