Tailoring PACT to the Needs of Women Veterans Using Evidence- Based - - PowerPoint PPT Presentation

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Tailoring PACT to the Needs of Women Veterans Using Evidence- Based - - PowerPoint PPT Presentation

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1 Tailoring PACT to the Needs of Women Veterans Using Evidence- Based Quality Improvement Alison B. Hamilton, PhD, MPH VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy Acknowledgements 2 Funding:

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Tailoring PACT to the Needs of Women Veterans Using Evidence- Based Quality Improvement

Alison B. Hamilton, PhD, MPH VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy

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Acknowledgements

Funding:

  • VA HSR&D CRE 12-026 (Yano, PI)
  • VA Women’s Health Services
  • VA HSR&D Senior Research Career Scientist Award (Yano, RCS 05-195)
  • VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy (CIN 13-417)

Co-Authors:

  • Ismelda Canelo1
  • Britney Chow, MPH1
  • Emmeline Chuang, PhD1,2
  • Julian Brunner, MPH1,2
  • Lisa Rubenstein, MD, MSPH1,2,3,4
  • Elizabeth M. Yano, PhD, MSPH1,2

1VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy 2UCLA Fielding School of Public Health 3UCLA Geffen School of Medicine 4RAND Health

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Disclaimer

The views expressed are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

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Background

  • VA policy guidance for PACT implementation not originally

adapted for special populations

  • Including women Veterans
  • Women Veterans fastest growing segment of new VA users but

represent numerical minority

  • Comorbid physical and mental health burdens

– High rates of MST, PTSD, depression, anxiety

  • Need for gender-specific care
  • Combination complicates primary care delivery

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Background

  • Logistical challenges in delivering gender-sensitive

comprehensive primary care

  • Smaller patient volume affects proficiency

– Gaps in provider and staff gender sensitivity – Discomfort addressing needs of women w/MST histories

  • PACT staffing stretched by need for chaperones, support of co-located

GYN providers, part-time MDs

  • Efforts to establish gender-focused primary care models (e.g., women’s

clinics, WH-PCPs)

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Objectives

  • To test use of an evidence-based quality improvement (EBQI)

strategy for tailoring PACT to meet the needs of women Veterans

  • Focused on local innovations and improvements accomplished by

participating QI teams

  • To better understand the features of EBQI associated with local

innovation success

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Evidence-Based Quality Improvement

  • Systematic approach to developing a multilevel research-

clinical partnership approach to QI1

  • Uses top-down/bottom-up features to engage local organizational

senior leaders and QI teams

  • National policies/strategic directives serve as guides
  • Regional expert panels set innovation design priorities
  • Local QI teams design and implement local projects
  • Researchers serve as technical experts, educators, guides
  • Emphasizes application of prior evidence, measurement, formative

feedback, organizational/provider behavior change methods, local context, and practice facilitation

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1Rubenstein LV, Stockdale SE, Sapir N, et al. A patient-centered primary care practice approach using evidence-based quality improvement: Rationale, methods, and early

assessment of implementation. J Gen Intern Med 2014.

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How did we apply EBQI?2

  • Multilevel VISN stakeholder panel meetings (½ day)
  • Multilevel (Network, Medical Center, Department, Clinic)
  • Interdisciplinary (PC, WH, MH, IT, QI, WVPM…)
  • Expert panel methods, came to consensus on QI priorities
  • EBQI training for local QI teams
  • Jumpstarted local QI project proposals, EBQI “testimony” (prior

experience), national PC & WH leadership call-ins

  • Local QI teams picked one project from QI “roadmap”
  • Research team provided external practice facilitation, formative data

feedback (patient/provider/staff surveys, key stakeholder/team interviews),

  • ngoing across-site calls
  • Progress/results briefings back up the chain

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2 Yano EM et al. Cluster randomized trial of a multilevel evidence-based quality improvement approach to tailoring VA PACT to the needs of women Veterans. Implement Sci. 2016.

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12-Site Cluster Randomized Trial

VISN 1 VISN 4 VISN 12 VISN 23

R

2 E

VAMCs

1 C

VAMC

2 E

VAMCs

1 C

VAMC

2 E

VAMCs

1 C

VAMC

2 E

VAMCs

1 C

VAMC

R R R

3Frayne SM, et al. The VA women’s health practice-based research network: Amplifying women Veterans’ voices in VA research. J Gen Intern Med. 2013.

  • Unbalanced 2:1 allocation to accommodate anticipated

variations in EBQI implementation

  • Within WH Practice-Based Research Network3
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  • EBQI teams collected their own QI project data
  • Research team tracked progress on facilitation calls
  • Key stakeholder interviews with local QI teams
  • Interviews summarized using a template informed by interview guide

topics

  • Summaries organized into matrices to compare and contrast findings

across sites and levels

  • Matrices supported generation of a preliminary codebook for more in-

depth analysis using ATLAS.ti

  • Used a constant comparison analytic approach to elaborate codebook

based on emergent themes, adjusted as each round of interviews was completed

Methods

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EBQI-Supported Innovation Effects

  • ↑ new patient appointment access, 1st appt content
  • 100% assignment to Women’s Health PCP, 0 to >80% get labs before 1st

appt

  • ↑ follow-up abnormal breast cancer screening results
  • 27% ↑ in follow-up documentation, avg 6 day ↓ in follow-up
  • ↑ follow-up abnormal cervical cancer screening
  • <50% abnormals managed per upd’d guidelines, now >85%
  • ↑ coupled reporting of cervical cytology results
  • Pap smear and HPV screening results now 96% compliant
  • ↑ PACT team functioning, climate, performance
  • Virtual team meetings, huddle checklists, team training

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EBQI-Supported Innovation Effects

  • Proactive ID of MH distress/crisis before 1st appt

– Developed high-risk MH list, process to contact  30% need MH intervention  counseling, warm handoffs, appt sched

  • ↑ teratogenic medication risk counseling

– Almost half filled 1+ categ D/X med*, only 37% counseled

  • ↑ residents’ trauma-sensitive communication

– Health psychologist in exam room, post-visit feedback – ↑ communication skills, greater comfort addressing trauma

  • ↑ environment of care for women Veterans

– Response to formative feedback that 1 in 4 harassed at VA – Leadership video, shared medical appts, volunteer escorts

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*D=positive evidence of risk to fetus but potential benefits may outweigh potential risks X=contraindicated in pregnancy

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Results of Key Stakeholder Interviews: What about EBQI Worked?

  • Regional interdisciplinary stakeholder planning
  • Critical for leadership awareness/buy-in, data “powerful”
  • Training of local QI team members
  • Variable access to QI personnel + most focused on Joint Commission
  • Practice facilitation, expert review and feedback
  • Regular calls support accountability, progress, momentum
  • Formative data feedback
  • VA performance data not routinely reported by gender
  • Included new measures (stranger harassment, AUDIT-C)
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  • Evidence of EBQI impacts promoted spread
  • Team function projects  noticeable burnout ↓

– Regional virtual “Grand Rounds” to spread EBQI and project activities that improved team function

  • ↑ follow-up of abnormal cervical cancer screening

– Regional spread of clinical reminder and template

  • ↑ test reporting of cervical cytology results

– Regional spread of methods and policy

Results of Key Stakeholder Interviews: What about EBQI Worked?

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Conclusions

  • Sites participating in EBQI made substantial gains in a wide

range of QI targets

  • Aligned with regional priorities
  • Adapted to local contexts
  • Innovations supported by research-delivered technical support

and formative feedback

  • Fostered employee engagement and design, implementation and

spread of promising practices

  • Otherwise without additional direct funding
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Implications for Partnered Research

  • Trust-building – learn partner priorities, add value
  • Sent easy-to-use research briefs, “cheat sheet” summaries
  • Briefings linked to their priorities/needs
  • Not a “one off,” cannot collect data and just walk away
  • Walk-through formative data collaboratively, answer questions
  • Engagement and time investment varies
  • Partnerships evolve, as does policy climate/environment
  • Explicitly manage and address partner turnover
  • Some relationships run deep, others broad, both important
  • Reliability highly valued, keep promises, don’t fall off radar
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Implications for Partnered Research

  • Some benefits more obvious than others…
  • Access to clinics, local and network resources
  • Senior VA leader engagement got attention of other levels
  • Multilevel stakeholder engagement began to “churn”

– Capitalizes on, leverages existing infrastructure, systems, people

  • Direct engagement of partners in research
  • ↑ focus and relevance of research
  • ↑ uptake, adoption, implementation and spread of EBQI

– VA Women’s Health Services has adopted EBQI to improve care in low-performing VAs (VA QUERI PEC 16-352)

  • Unexpected spinoffs (e.g., national culture campaign)
  • ↑ research team’s satisfaction, success and impacts
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EBQI Teams VISN 1

  • Boston (Megan Gerber, Carolyn Mason-Wholley,

Jay Barrett)

  • West Haven (Luz Vazquez, Lynette Adams, Mary

Driscoll, Andrea Garroway) VISN 4 (and now VISN 5)

  • Pittsburgh (Melissa McNeil, Sonya Borrero, Swati,

Shroff, Val Posa, Joan Zolko)

  • Clarksburg (Lisa Hardman, Frank Gyimesi and

WH PACT team) VISN 12

  • Madison (Christine Kolehmainen, Sandy

Schumacher)

  • Jesse Brown (Sarada Deshpande, Jenny Sitzer,

Howard Gordon) VISN 23

  • Minneapolis (Erin Krebs, Jane Nolting-Brown,

Jamie Matthews)

  • Fargo (Kim Hammer, Margaret Leas, Glenda

Trochmann) Research Team VA HSR&D Center of Innovation (CSHIIP)

  • Elizabeth Yano, PhD, MSPH
  • Lisa Rubenstein, MD, MSPH
  • Ismelda Canelo, MPA
  • Britney Chow, MPH
  • Alison Hamilton, PhD, MPH
  • Jill Darling, MSHS
  • Danielle Rose, PhD, MPH
  • Alissa Simon, MA
  • Anneka Oishi, BA
  • Kristina Oishi, BA

UCLA Fielding School of Public Health

  • Emmeline Chuang, PhD
  • Cindy Cain, PhD
  • Julian Brunner, MPH
  • Selene Mak, MPH

RAND Health

  • Lisa Meredith, PhD
  • Benjamin Bartosky, MPH

VA Women’s Health PBRN

  • Susan Frayne, MD, MPH
  • Diane Carney, MA
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THANK YOU!

  • Alison Hamilton, PhD, MPH: alison.hamilton@va.gov
  • VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy

@alisonh3