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

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: • 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 Canelo 1 • Britney Chow, MPH 1 • Emmeline Chuang, PhD 1,2 • Julian Brunner, MPH 1,2 • Lisa Rubenstein, MD, MSPH 1,2,3,4 • Elizabeth M. Yano, PhD, MSPH 1,2 1 VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy 2 UCLA Fielding School of Public Health 3 UCLA Geffen School of Medicine 4 RAND Health

Disclaimer 3 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.

Background 4 • 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 4

Background 5 • 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)

Objectives 6 • 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 6

Evidence-Based Quality Improvement 7 • Systematic approach to developing a multilevel research- clinical partnership approach to QI 1 • 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 1 Rubenstein 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. 7

How did we apply EBQI? 2 8 • 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), ongoing across-site calls • Progress/results briefings back up the chain 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. 8

12-Site Cluster Randomized Trial 9 • Unbalanced 2:1 allocation to accommodate anticipated variations in EBQI implementation VISN 1 VISN 4 VISN 12 VISN 23 R R R R 2 E 1 C 2 E 1 C 2 E 1 C 2 E 1 C VAMCs VAMC VAMCs VAMC VAMCs VAMC VAMCs VAMC • Within WH Practice-Based Research Network 3 3 Frayne SM, et al. The VA women’s health practice - based research network: Amplifying women Veterans’ voices in VA research. J Gen Inter n Med. 2013.

Methods 10 • 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 10

EBQI-Supported Innovation Effects 11 • ↑ new patient appointment access, 1 st appt content • 100% assignment to Women’s Health PCP, 0 to >80% get labs before 1 st 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 11 11 11 11

EBQI-Supported Innovation Effects 12 Proactive ID of MH distress/crisis before 1 st 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 *D=positive evidence of risk to fetus but potential benefits may outweigh – Leadership video, shared medical appts, volunteer escorts potential risks X=contraindicated in pregnancy 12 12 12 12

Results of Key Stakeholder Interviews: 13 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)

Results of Key Stakeholder Interviews: 14 What about EBQI Worked? • 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

Conclusions 15 • 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

Implications for Partnered Research 16 • 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

Implications for Partnered Research 17 • 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