Implementing Networks Self-management Tools Through Engaging Patients and Practices
Condition: Patient Self-management Support
Study type: Interventional

Summary: 
      The purpose of this project is to use the Agency for Healthcare Research and Quality patient
      self-management support tools and resources across four practice-based research networks and
      16 member practices using a community-based participatory intervention called Boot Camp
      Translation.
    

Detailed description: 
      Specific Aim 1: Implement the Agency for Healthcare Research and Quality SMS Resources and
      Tools (SMS Library/Toolkit) across four participating networks and 16 practices using Boot
      Camp Translation in a stepped-wedge design.

      Specific Aim 2: Assess the impact of implementation on practice staff and patients engaged in
      chronic care management.

      Specific Aim 3: Identify the factors related to successful implementation.

      Background and Significance:

      With almost one-half of Americans projected to have at least one chronic condition before
      2020 it will be paramount that the health care system reduce the burden to primary care for
      disease management by facilitating the development of activated, informed individuals who are
      proficient in self-management skills. This represents a significant cultural shift in health
      management, and clinicians and staff may lack confidence introducing and promoting
      self-management support (SMS). In fact, SMS is the area of disease management least often
      implemented and most challenging to integrate into usual care. This difficulty occurs at the
      patient and clinician level. Using the Patient Activation Measure (PAM), Hibbard and
      colleagues found that 60% of patients feel passive about managing their own health and a
      third of patients had barriers in knowledge and confidence in caring for themselves.

      The chronic care model describes SMS as one of six key pillars for providing effective
      primary care. A systematic review of the Chronic Care Model applied to diabetes care found
      that although not a single component of the care model emerged as essential, 19 of 20
      interventions that included a self-management component resulted in improved processes or
      outcomes of care. Under the patient-centered medical home (PCMH) model, primary care
      practices have moved to team-based care and care coordination, putting the patient in the
      center of care model. Primary care practices are beginning to provide care coordination
      services, identifying and training care managers to deliver care to complex patients with
      chronic illnesses. This has been shown to be cost-effective with a high degree of patient
      acceptance.

      The four Practice-Based Research Networks (PBRNs) participating in this protocol are part of
      the Meta-network Learning And Research Center (Meta-LARC). In 2012 AHRQ awarded the Oregon
      Rural Practice-based Research Network (ORPRN) a 5-year award as a Center of Excellence in
      Primary Care Practice-based Research and Learning. This support enabled ORPRN to establish a
      collaborative center with the participating PBRNs, using center infrastructure for data
      collection and management.

      Patient involvement has progressed to informing approaches for knowledge transfer with Boot
      Camp Translation (BCT). BCT provides a partnership model where patients are at the elbow with
      primary care clinicians and staff to refine best practices of care at the local level. The
      study uses BCT to increase patient skills and engagement in improving their health. It
      incorporates the BCT model and findings through the interpretive- and theory-based lenses of
      the Consolidation Framework for Implementation Research and the Theory of Planned Behavior,
      as well as intermediate outcome measures of the Patient Activation Measure (PAM) and
      Clinician Support for Patient Activation Measure (CS-PAM), to provide the foundation for
      clinicians, care managers, patients, practice facilitators and researchers to develop optimal
      strategies to make the case for self-management skills and to implement and evaluate the SMS
      Library/Toolkit. Using a stepped wedge study design, these strategies will be replicated and
      improved across all four PBRNs, resulting in tools and a process that can be readily
      reproduced in other primary care practices.

      Primary outcomes will include the CS-PAM scores at baseline, and the end of T2, T3, T4, and
      T5 implementation periods. The structure of the data is hierarchical (individuals nested
      within practices) and longitudinal (repeated measures on individuals over time).

      This specific aim and hypotheses will be approached using a mixed methods evaluation. Theory
      of Planned Behavior (TPB) constructs will be assessed among practice staff in each study time
      period using a survey instrument to measure intention, attitude, social norm and perceived
      behavior control towards use of the SMS Library/Toolkit. The direct measure of attitude will
      be assessed by means of six items using a semantic differential 7-point scale. Six pairs of
      adjectives will be used to assess Aact: for example, "not very useful/very useful" or "not
      very responsible/very responsible". These adjectives will follow sentence: "In the context of
      chronic care management, for me, using items from the SMS Library/Toolkit would be …". Direct
      measure of the social norm (SN) will be assessed by means of three items, each assessed on a
      7-point scale. Three items will be included to assess a direct measure of the perceived
      behavioral control (PBC), each on a 7-point response scale. Finally, intention to use the SMS
      library/toolkit will be assessed by means of three items. The mean composite scores of the
      items assessing each TPB construct will be computed. For all above variables, a positive
      score indicates that the respondent expressed a positive evaluation of the construct.

      The assessment of SMS Library/Toolkit implementation will rely on multiple data sources to
      fully evaluate "what works and where" across different practice settings. Semi-structured key
      informant interviews and guided practice observation comprise the primary data sources.
      Interview and observation guides will use open-ended question, probes, and cues to elicit
      responses and data about key implementation domains: intervention characteristics, outer
      setting (external influences), internal setting, individual characteristics, and
      implementation processes.

      The semi-structured data will be supplemented with closed-ended survey questions (asked
      in-person or self-administered) for questions that can efficiently provide descriptive
      results using categorical or numeric responses. This includes items related to practice
      demographics (e.g., number of providers and staff, patient population, payer mix), individual
      characteristics (e.g., level of training, years in practice, age). This data will be analyzed
      using Qualitative Comparative Analysis to identify the specific components within the
      Consolidated Framework for Implementation Research (CFIR) domains that are important for
      successful implementation of the Library/Toolkit.

      Stepped wedge study design Stepped wedge methods are used for testing interventions that
      involve communities or situations where traditional randomized controlled trial methods are
      not possible. The investigators will randomize the order in which the BCT process is
      implemented within each participating PBRN. Each networks' participating practices will
      receive the BCT intervention at different points along a 10-month period. This will permit
      the investigators to have a two-month period at the beginning of the study period where all
      practices are in a control state for baseline assessment, and gradually implement the BCT
      process over the subsequent eight months.
    

Intervention name(s): Boot Camp Translation - community-participatory process
Intervention type(s): Other
Intervention description(s): Series of meetings and conference calls with expert presentation on patient self-management support, facilitated discussion, and creation of product to bring to community to improve patient self-management support
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: Primary care; Self-management support; Care coordination; Practice-based research network