Assessing a Assessing a Practice Coaching Practice Coaching

Intervention for Improving Intervention for Improving Chronic Care Chronic Care

in Safety Net Organizationsin Safety Net Organizations

Shinyi Wu, PhDShinyi Wu, PhD

Assistant Professor, Epstein Department ofIndustrial and Systems Engineering

University of Southern California & RAND

September 14, 2009, presented at AHRQ Conference

Acknowledgement:Acknowledgement:Co-authors, Sponsor, and Co-authors, Sponsor, and

ParticipantsParticipants• 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 Wendy Jameson, MPP, MPH, Safety Net

InstituteInstitute• Cindy Brach, MPP, Agency for Healthcare Cindy Brach, MPP, Agency for Healthcare

Research and QualityResearch and Quality• The participating healthcare organizationsThe participating healthcare organizations

Lessons Learned from CCM Lessons Learned from CCM Collaboratives Call for Collaboratives Call for

Further Implementation Further Implementation ResearchResearch

• Teams spent considerable time searching Teams spent considerable time searching for/developing toolsfor/developing tools

• Some teams felt intimidated by taking on Some teams felt intimidated by taking on the whole model – asked for a sequencethe whole model – asked for a sequence

• Collaboratives were time & resource Collaboratives were time & resource intensiveintensive

• Many changes were made in ways that Many changes were made in ways that were not sustainable financiallywere not sustainable financially

Test A Team Coaching Test A Team Coaching Approach to Help Practices Approach to Help Practices

Implement CCMImplement CCM • Recognizing that medical practices Recognizing that medical practices

often need flexible, hands-on support often need flexible, hands-on support when embarking on a program of when embarking on a program of practice improvementpractice improvement– Especially safety-net organizationsEspecially safety-net organizations

• Testing a coaching intervention Testing a coaching intervention (coupled with a toolkit) to disseminate (coupled with a toolkit) to disseminate the CCM the CCM

• Funded by AHRQFunded by AHRQ

Practice Coaching DesignPractice Coaching Design

• Who were coached?Who were coached?Nine randomly selected primary care teams Nine randomly selected primary care teams from two clinics in two California public from two clinics in two California public hospital systemshospital systems

• Who were the coaches?Who were the coaches?Two quality improvement experts external Two quality improvement experts external to the hospital systemsto the hospital systems

• How was coaching structured?How was coaching structured?– Two site visitsTwo site visits– Communicated by phone and emailCommunicated by phone and email– Monthly reports to coachesMonthly reports to coaches

Three Intervention PhasesThree Intervention Phases

• Phase I: Laying the foundation for Phase I: Laying the foundation for successsuccess– Form Coaching TeamForm Coaching Team– Get Acquainted with LeadershipGet Acquainted with Leadership– Orient the Practice Team to the WorkOrient the Practice Team to the Work

• Phase II: Active practice coachingPhase II: Active practice coaching– Conduct prework assessment & prepare Conduct prework assessment & prepare

teams for site visitsteams for site visits– Run learning sessionsRun learning sessions– Support the teamsSupport the teams

• Phase III: Sustaining the gainsPhase III: Sustaining the gains– Close out coaching and expect teams to Close out coaching and expect teams to

continuecontinue

Logic Model: Chain of Logic Model: Chain of ActionActionEnvironment & organizational

contexts

Workgroup & team

effectivenessChanges in

systemChanges in

processChanges in outcomes

Practice coaching

Evaluation MethodsEvaluation Methods

Quasi-experimental design with three armsQuasi-experimental design with three armsIntervention, internal control, and external Intervention, internal control, and external controlcontrol

Implementation assessment through site Implementation assessment through site visitsvisits

•Environmental and organizational contextsEnvironmental and organizational contexts•Practice coachingPractice coaching•Implementation processImplementation process•Perceived impact & lessons learnedPerceived impact & lessons learned

Process & outcomes assessmentProcess & outcomes assessment •Participants perceived impactParticipants perceived impact•HEDIS diabetes care indicators & utilization HEDIS diabetes care indicators & utilization measuresmeasures

Results: Contexts Results: Contexts

• Environment:Environment: Challenging, but not about Challenging, but not about survivalsurvival

• Organization:Organization: Commit to improving chronic Commit to improving chronic illness care and have some ongoing activitiesillness care and have some ongoing activities

• Leadership supportLeadership support for the project: modest for the project: modest• Improvement experienceImprovement experience: Have previous and : Have previous and

ongoing improvement projects; experience ongoing improvement projects; experience variedvaried

• ParticipantsParticipants: “Majority” adopters of CCM; : “Majority” adopters of CCM; randomized to participate so modest level of randomized to participate so modest level of excitementexcitement

• Information systemInformation system: Average cumbersome: Average cumbersome

Results: CoachingResults: Coaching• Coaching is perceived asCoaching is perceived as

– a necessary bridge to the toolkita necessary bridge to the toolkit– motivated and prompted people to make motivated and prompted people to make

changeschanges– extended the horizons of the teamsextended the horizons of the teams– had a positive effect on team buildinghad a positive effect on team building– built an emotional bond which was a key built an emotional bond which was a key

success factor for coachingsuccess factor for coaching• The coaching costs approximately $41,000 for The coaching costs approximately $41,000 for

the two clinic sites, including time spent in coach the two clinic sites, including time spent in coach training, coaching, travel, and communication training, coaching, travel, and communication

Suggested Modifications to Suggested Modifications to Our Practice Coaching Our Practice Coaching

ApproachApproach • Coaching should include more Coaching should include more

face-to-face interactionsface-to-face interactions• An internal coach might be addedAn internal coach might be added• Coaching intensity may need to Coaching intensity may need to

be greater at the beginningbe greater at the beginning• Coaches should be more Coaches should be more

proactive and creative in proactive and creative in introducing the toolkitintroducing the toolkit

• Continue coaching for a longer Continue coaching for a longer period of timeperiod of time

Coaching Effects on Coaching Effects on Workgroup and Team Workgroup and Team

EffectivenessEffectiveness• Changes in self-efficacy and knowledge:Changes in self-efficacy and knowledge:

– Individuals positive on gaining skills, knowledge, Individuals positive on gaining skills, knowledge, and tools to improving clinical careand tools to improving clinical care

• Working as a team:Working as a team:– Coaching did not change the working relationship Coaching did not change the working relationship

and team structure, but and team structure, but did strengthen people did strengthen people working together as a teamworking together as a team

• Acquiring health system supportAcquiring health system support– A coach can help problem-solving, but sustained A coach can help problem-solving, but sustained

support requires a local leader to organize the support requires a local leader to organize the effortsefforts

Lessons Learned Lessons Learned • Practice Coaching is a feasible mechanism Practice Coaching is a feasible mechanism

for facilitating CCM quality improvement in for facilitating CCM quality improvement in safety net clinic settingssafety net clinic settings– Assessing resources firsthand and tailoring advice Assessing resources firsthand and tailoring advice – More staff can participate in the practice More staff can participate in the practice

improvement sessionsimprovement sessions– Coaching can be delivered with minimal impact Coaching can be delivered with minimal impact

on patient accesson patient access• Practice coaching vs. collaborative learningPractice coaching vs. collaborative learning

– Providing structured learning time is keyProviding structured learning time is key• Practice coaching can really jump-start the Practice coaching can really jump-start the

spread spread – Especially when there is internal knowledge and Especially when there is internal knowledge and

experienceexperience

ImplicationsImplications

• The field of practice coaching is still The field of practice coaching is still evolvingevolving– Clearly defining the coaches’ role and Clearly defining the coaches’ role and

regularly checking expectations is importantregularly checking expectations is important

• Different models of QI facilitation may Different models of QI facilitation may work better in different settings and work better in different settings and timingtiming

• Coaching on business improvement along Coaching on business improvement along with quality improvement needs to be with quality improvement needs to be further developed and studiedfurther developed and studied

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.html

Shinyi Wu

Email: shinyiwu@esc.edu

Thank youThank you