# Presentation: 025562

## Research in the Real World:

- 			      Rebecca Etz
-  			      Deborah Cohen
- 			      Nicole Isaacson
- 			      Bijal Balasubramanian
- 			      Benjamin Crabtree
- 			      Alfred Tallia

**Lessons Learned from Prescription for Health**

## Let’s Get Real

-  Translation
- Realize the shift from efficacy to effectiveness
-  Dissemination
- Capture context and strategy as well as outcomes
-  Public Health Impact
- Create partnerships in the community

##  Conceptualization
Studying implementation as way to evaluate what ‘works’ in real-life setting (i.e. effectiveness)

 Methods Used
Practice Surveys
Site Visits/Interviews
Online diary

-  Conceptualization
- Studying implementation as way to evaluate what ‘works’ in real-life setting (i.e. effectiveness)
-  Methods Used
- Practice Surveys
- Site Visits/Interviews
- Online diary

**Evaluation of P4H****The Analysis Team’s Focus**

## Evaluation The Analysis Team’s Focus

**      ****Data Analysis – Qualitative Data**
- 				1st: Read the diary data
- 				2nd: Read it again
- 				3rd: Really read the data

## Evaluation The Analysis Team’s Focus

**      ****Data Analysis – Quantitative Data**
- 				1st: Find missing data
- 				2nd: Fix any inconsistencies
- 				3rd: Convert numbers into words

## Let’s Get Real

- 	Translation
- Realize the shift from efficacy to effectiveness
- PBRNs are an ideal environment
- 	Research oriented, but not unusual
- 			85 practices (10 PBRNs)
- 			92% Family medicine practices
- 			Staff turnover of 8-12%

## PBRNs and Getting RealREAIM as our lens

- REAIM was proactively for the first time in practice-based, primary care research
- Across all 10 projects in round 2, P4H

**R**each, **E**ffectiveness, **A**doption, **I**mplementation, **M**aintenance

## PBRNs and Getting RealREAIM as our lens

- REAIM and our qualitative data allowed us to ask
- different kinds of questions:
- How do we take something that we know works, or that we think will work, and put that thing into practice?
- How did you get it to work?
- Why did it work and can we get it to work elsewhere?

## PBRNs and Getting RealREAIM as our lens

- 	Two themes emerged from the diary data – the tensions between...
**	****	****	**Flexibility & Fidelity
- 			    ...an issue of translation
- 			Quality Improvement & Research
- 			     ...an issue of dissemination

## PBRNs and Getting RealFidelity vs Flexibility

- 	Fidelity and Flexibility
- In the primary care setting, interventions are not plug and play
- They are tailored to the contours of the practice
- “... Dr made the comment that we need to come up with something that will work at a 1 nurse office like hers”

## PBRNs and Getting RealFidelity vs Flexibility

- 	Flexibility is a reflection of the inescapable realness of the real world
- 	‘The other striking thing is the varied ways that the practices are implementing the HRA:
- Keep it at reception, given to patients at check in
- Give it to one staff member, he administers all
- Given to all patients of the in house diabetes educator
- Keep it at nurses station, used primarily by 		‘one care giving team’

## PBRNs and Getting RealFidelity vs Flexibility

- Understanding how research is integrated into real life practice is essential
- PBRNs facilitate that translation with all the muckiness that it implies

## Let’s Get Real

- Translation
- Realize the shift from efficacy to effectiveness
- 	Dissemination
- Capture context and strategy as well as outcomes
- Share solutions for navigating the tension between QI and research

## PBRNs and Getting RealQuality Improvement vs Research

**Research is about**
- 	establishing/following protocols, assessing outcomes
- Enrolling the ‘right’ type and number of patients
- Having a bounded data collection period
- Securing funds to pay for research and sometimes the intervention
- Maintaining fidelity – implementing the intervention according to an established protocol

## PBRNs and Getting RealQuality Improvement vs Research

**Quality Improvement is about**
- 	understanding organization and setting
- Tailoring improvement to fit the protocols and procedures of the practice
- Adapting to setting/context, allowing for flexibility
- Institutionalizing the improvement, sustainability

## PBRNs and Getting RealQuality Improvement vs Research

- Front line PCPs are overwhelmed – this is reality
- Choices for recruitment are often about choosing practices positioned for improvement
- PBRNs allow us to see how those that actually take the change on are able to make it happen

## PBRNs and Getting RealQuality Improvement vs Research

- 	On the ground, team members manage patient expectations
- 	“[Staff] report [this] is the first thing the patient asks: 	what do I get for participation?”
- 	Projects that were seamless – where increased service was in the foreground, research in the background – faired best

## PBRNs and Getting RealQuality Improvement vs Research

- 	QI is ‘institutional’ where research is finite in terms of time & resources
- 	“We had practices take a two week break from referring patients ... It has been more difficult than I had anticipated to get them back up and running ...”
- 	“We tried to fine tune our message for the staff ... That is, one patient enrollment per [staff member] per day.”
- 	PBRNs showed us institutionalization was manageable but involved sacrifices

## Investigating with REAIMWhere’s the Tension – QI and Research

- Front line practices don’t have a lot of slack
- Research teams bring resources and it’s hard to hold up when they are gone
- 	“This practice [does] prevention because it’s important, not because it’s reimbursed. [We] offered to keep the intervention on at this practice (but without free services). They pulled the plug on the project.”

## Investigating with REAIMWhere’s the Tension – QI and Research

- 	PBRN based research allows practices to build a line of inquiry that:
- shows the value of what they did
- wins funding enabling translation of 	  research into practice
- 	PBRNs are an environment that makes translation happen

## Let’s Get Real

- Translation
- Realize the shift from efficacy to effectiveness
- Dissemination
- Capture context and strategy, share solutions
- 	Public Health Impact
- Create partnerships in the community
- Fill in the missing elements

## In the Real World ... “linking to community resources is easier said than done”

- _Primary Care _
- _Elements_
- Identify patients at risk
- Capacity to refer patients
- Know how to access community resources

- _Community Resource_
- _Elements_
- Availability
- Affordability
- Accessibility
- Perceived as valuable

## Primary Care ElementsIdentifying Patients at Risk

- Many practices did not have processes in
- place to identify patients at risk...

## Primary Care ElementsIdentifying Patients at Risk

- 	...Project teams were able to help them develop what was needed
- 		“[This] practice had, with the help of our facilitator, 	modified their vital signs template in the EHR 	(eClinical Works) to include smoking.  His staff review 	smoking and update status at every visit. The inclusion 	of smoking as a vital sign plus verbal reminders by the 	nurses keeps the issue in front of [the doctor] and 	appears to have increased referrals to the Quit Line and 	his use of brief counseling strategies.”

## Primary Care ElementsMaking the Referral

- Limited capacity for referrals was a barrier ...
* **	**	*“If we need to print referrals for faxing..., maybe 	someone in the [research team’s] office could do it 	(some concern about stressing the referral person...)”
- Project teams offered different strategies for simplifying referrals
- 		“Having the direct real-time link to the designated 	outreach person...makes it very easy for the physician to 	make the referral... quick and easy.”

## Primary Care ElementsMaking the Time

- Limited time was another barrier ...
* **	**	*“Talked with [Doctor] 6:30 am... had read material, 	[said] it sounded like a good study, as long as it didn’t 	take too much time would be happy to do it (like 30 	seconds).”
- And project teams helped practices met these time constraints
- 		“The rooming staff person reported that she did the 	P4H pop-up as part of the vital signs process. She 	reports it was not extra work/time.”

## Primary Care ElementsKnowing How to Access/Use Resources

**Primary Care Elements****Knowing How to Access/Use Resources**

- Community resources are fluid, many, and difficult to track
- Projects addressed this in a number of ways
- 				Web-tools, HIT, resource cards
- 				People as portals to community resources
- 				Tapping into national, state, or health 				   systems
- 				Building relationships with resources

## Community Resource ElementsAvailability, Affordability...

- Many practices, particularly those in rural and low income areas, reported a scarcity of community resources
- When resources did exist in communities, they were often not affordable
- 	“A barrier for counseling is patients affording it - many would be interested in group visits if free, reason for interest in the study...”
- 	“Currently they will refer to some nutritionists, but sporadic and dependant on what insurance will cover, more often for diabetic patients”

## Community Resource ElementsAccessibility

- 	Grounded and informed by patient need, projects teams took many creative approaches
- Offering in-house counseling
- Developing website and IVR systems
- Offering and paying for branded services
- Leveraging their relationships with community resources

## PBRNs are Real

- P4H projects, and the use of REAIM, show
- PBRNs as an ideal setting in which to innovate
- Providing real-world effectiveness
- 		   Balancing internal and external validity
- Fostering proactive intervention designs
- 		   Greater public appeal and rapid adoption
- Enabling view of *potential* public impact
- 		   Benefit of qualitative and quantitative in unison

## PBRNs are Real

-  Translation
- Integrate: Full integration of RE-AIM model into research and intervention design from project conception
-  Dissemination
- Context: qualitative and quantitative work together to suggest *potential*
-  Public Health Impact
- Adapt: Interventions must be responsive to site specific needs – functional, cultural, emotional