1. Assessing a Practice Coaching Intervention for Improving Chronic Care in Safety Net Organizations Shinyi Wu, PhD Assessing a Practice Coaching Intervention for Improving Chronic Care in Safety Net Organizations Shinyi Wu, PhD Assistant Professor, Epstein Department of Industrial and Systems Engineering University of Southern California & RAND September 14, 2009, presented at AHRQ Conference

2. Acknowledgement: Co-authors, Sponsor, and Participants Marjorie Pearson, PhD, RANDMarjorie Pearson, PhD, RAND Katie Coleman, MSPH, ICIC, GroupHealthKatie Coleman, MSPH, ICIC, GroupHealth Brian Austin, ICIC, GroupHealthBrian Austin, ICIC, GroupHealth Ed Wagner, MD, ICIC, GroupHealthEd Wagner, MD, ICIC, GroupHealth Wendy Jameson, MPP, MPH, Safety Net InstituteWendy Jameson, MPP, MPH, Safety Net Institute Cindy Brach, MPP, Agency for Healthcare Research and QualityCindy Brach, MPP, Agency for Healthcare Research and Quality The participating healthcare organizationsThe participating healthcare organizations

3. Lessons Learned from CCM Collaboratives Call for Further Implementation Research Teams spent considerable time searching for/developing toolsTeams spent considerable time searching for/developing tools Some teams felt intimidated by taking on the whole model – asked for a sequenceSome teams felt intimidated by taking on the whole model – asked for a sequence Collaboratives were time & resource intensiveCollaboratives were time & resource intensive Many changes were made in ways that were not sustainable financiallyMany changes were made in ways that were not sustainable financially

4. Test A Team Coaching Approach to Help Practices Implement CCM Recognizing that medical practices often need flexible, hands-on support when embarking on a program of practice improvementRecognizing that medical practices often need flexible, hands-on support when embarking on a program of practice improvement –Especially safety-net organizations Testing a coaching intervention (coupled with a toolkit) to disseminate the CCMTesting a coaching intervention (coupled with a toolkit) to disseminate the CCM Funded by AHRQFunded by AHRQ

5. Practice Coaching Design Who were coached?Who were coached? Nine randomly selected primary care teams from two clinics in two California public hospital systems Who were the coaches?Who were the coaches? Two quality improvement experts external to the hospital systems How was coaching structured?How was coaching structured? –Two site visits –Communicated by phone and email –Monthly reports to coaches

6. Three Intervention Phases Phase I: Laying the foundation for successPhase I: Laying the foundation for success –Form Coaching Team –Get Acquainted with Leadership –Orient the Practice Team to the Work Phase II: Active practice coachingPhase II: Active practice coaching –Conduct prework assessment & prepare teams for site visits –Run learning sessions –Support the teams Phase III: Sustaining the gainsPhase III: Sustaining the gains –Close out coaching and expect teams to continue

7. Logic Model: Chain of Action Environment & organizational contexts Workgroup & team effectiveness Changes in system Changes in process Changes in outcomes Practice coaching

8. Evaluation Methods  Quasi-experimental design with three arms  Intervention, internal control, and external control  Implementation assessment through site visits Environmental and organizational contextsEnvironmental and organizational contexts Practice coachingPractice coaching Implementation processImplementation process Perceived impact & lessons learnedPerceived impact & lessons learned  Process & outcomes assessment Participants perceived impactParticipants perceived impact HEDIS diabetes care indicators & utilization measuresHEDIS diabetes care indicators & utilization measures

9. Results: Contexts Environment: Challenging, but not about survivalEnvironment: Challenging, but not about survival Organization: Commit to improving chronic illness care and have some ongoing activitiesOrganization: Commit to improving chronic illness care and have some ongoing activities Leadership support for the project: modestLeadership support for the project: modest Improvement experience: Have previous and ongoing improvement projects; experience variedImprovement experience: Have previous and ongoing improvement projects; experience varied Participants: “Majority” adopters of CCM; randomized to participate so modest level of excitementParticipants: “Majority” adopters of CCM; randomized to participate so modest level of excitement Information system: Average cumbersomeInformation system: Average cumbersome

10. Results: Coaching Coaching is perceived asCoaching is perceived as –a necessary bridge to the toolkit –motivated and prompted people to make changes –extended the horizons of the teams –had a positive effect on team building –built an emotional bond which was a key success factor for coaching The coaching costs approximately $41,000 for the two clinic sites, including time spent in coach training, coaching, travel, and communicationThe coaching costs approximately $41,000 for the two clinic sites, including time spent in coach training, coaching, travel, and communication

11. Suggested Modifications to Our Practice Coaching Approach Coaching should include more face-to-face interactionsCoaching should include more face-to-face interactions An internal coach might be addedAn internal coach might be added Coaching intensity may need to be greater at the beginningCoaching intensity may need to be greater at the beginning Coaches should be more proactive and creative in introducing the toolkitCoaches should be more proactive and creative in introducing the toolkit Continue coaching for a longer period of timeContinue coaching for a longer period of time

12. Coaching Effects on Workgroup and Team Effectiveness Changes in self-efficacy and knowledge:Changes in self-efficacy and knowledge: –Individuals positive on gaining skills, knowledge, and tools to improving clinical care Working as a team:Working as a team: –Coaching did not change the working relationship and team structure, but did strengthen people working together as a team Acquiring health system supportAcquiring health system support –A coach can help problem-solving, but sustained support requires a local leader to organize the efforts

13. Lessons Learned Practice Coaching is a feasible mechanism for facilitating CCM quality improvement in safety net clinic settingsPractice Coaching is a feasible mechanism for facilitating CCM quality improvement in safety net clinic settings –Assessing resources firsthand and tailoring advice –More staff can participate in the practice improvement sessions –Coaching can be delivered with minimal impact on patient access Practice coaching vs. collaborative learningPractice coaching vs. collaborative learning –Providing structured learning time is key Practice coaching can really jump-start the spreadPractice coaching can really jump-start the spread –Especially when there is internal knowledge and experience

14. Implications The field of practice coaching is still evolvingThe field of practice coaching is still evolving –Clearly defining the coaches’ role and regularly checking expectations is important Different models of QI facilitation may work better in different settings and timingDifferent models of QI facilitation may work better in different settings and timing Coaching on business improvement along with quality improvement needs to be further developed and studiedCoaching on business improvement along with quality improvement needs to be further developed and studied

15. For additional information: CCM Toolkit and Coaching Manual: http://www.ahrq.gov/populations/chronix.htm “ Integrating Chronic Care and Business Strategies in the Safety Net: A Toolkit for Primary Care Practices and Clinics” “Practice Coaching Manual” http://www.improvingchroniccare.org RAND Chronic Care Studies: http://www.rand.org/health/surveys_tools/chronic_care_model.htm l Shinyi Wu Email: shinyiwu@esc.edu Thank you