Patient and Provider Engagement in Rural Health Delivery Research: Lessons learned from a primary care obesity treatment trial

Transcription

1 Patient and Provider Engagement in Rural Health Delivery Research: Lessons learned from a primary care obesity treatment trial Christie Befort, PhD University of Kansas Medical Center May 5 th 2017

2 Overview Description of RE-POWER trial Patient and provider engagement strategies Lessons learned

3 1. Increase awareness of evidence linking obesity and cancer 2. Provide tools and resources to help providers address obesity with their patients 3. Build a robust research agenda 4. Advocate for policy and systems change

4 Rural Obesity Disparity % 31.6% 41.3% 35.1% Urban Rural 0 Men Women Befort et al., 2012 NHANES

5 Obesity treatment in primary care currently falls short Only 20-40% of patients get counseled CMS reimburses since 2012 Intensive Behavior Therapy (IBT) for Obesity (G0447) Poor uptake (< 1% of eligible beneficiaries)

6 Models to Address Obesity in Primary Care Fee-for-service Traditional face-toface office visits with PCP Medicare IBT model 15 min face-to-face sessions 14 sessions 1 st 6 mo Then monthly Patient-Centered Medical Home Team-based care, coordination with inclinic lifestyle coach Group Visits (inperson; option for phone) Enhanced access (after hours) Disease Management Referral to centralized phone-based care with obesity treatment specialists Integration with PCP through quarterly progress reports

7 36 practices n=1440 patients BMI kg/m 2 Age years PCP clearance Fee for Service 12 practices n=480 Patient Centered Medical Home 12 practices n=480 Disease Management 12 practices n=480 Primary Outcome: Weight change at 2 years Secondary Outcomes: Quality of life, metabolic syndrome, implementation process measures

8 Study Sites

9 Practice Recruitment 77 practices approached 39 contracts 36 practices enrolled Practice Characteristics N (%) or mean (SD) Ownership Hospital 14 (39%) Private practice 10 (28%) FQHC 11 (31%) VA 1 (3%) Rural Health Clinic 11 (31%) PCMH Status 19 (53%) Provider FTEs MD FTEs 5.0 (3.9) range 1-23 APP FTEs 2.6 (1.7) range 0-8 Patient panel size 9870 (10810) Electronic Health Record 33 (92%) Behavioral staff Registered Dietitian 9 (25%) Mental Health 13 (36%) RUCA code Urban 1 (3%) Large rural (10,000-49,999) 13 (36%) Small (2,500-9,999) 8 (22%) Isolated rural (<2,500) 14 (39%) Miles to large hospital 57.2 (46.5)

10 Patient and provider engagement Study design phase Patient Advisory Board focus group Provider stakeholders interviews Study implementation Central kick-off meeting Central trainings Phone meetings 1-2/month Weekly Weigh-In Newsletter Facebook and website Joint presentations at national and state meetings

11 PCOR Engagement Principles Shared vision and mission Reciprocal relationships Informal, everyone on first name basis Input on budget and payments Transparency and honesty Partnership Hard work acknowledged and celebrated Patients are experts in communication, consenting, and retention Co-learning Sharing of experiences across providers and patients

12 Evidence gaps Lessons learned during implementation: 1. Who delivers it 2. How are they trained 3. Where is it delivered 4. How is it paid for 5. What are most important clinic contextual factors for success

13 How important were each of the following in your decision to participate? (n = 34) Who delivers it Lesson 1: Don t underestimate rural PCP s interest in providing intensive behavioral counseling in-house DM least preferred arm Very important Somewhat important To improve the care you provide to your patients with obesity 29 (85%) 5 (15%) -- To improve overall patient experience of care 19 (56%) 13 (38%) 2 (6%) Not important To improve your training and experience in weight loss counseling 19 (56%) 11 (32%) 4 (12%) For the financial incentives* 9 (26%) 17 (50%) 8 (23%) To gain experience participating in research 8 (24%) 18 (53%) 8 (24%) * MDs more like to rate financial incentives as Very Important (47% MDs vs 6% practice liaison)

14 How trained Lesson 2: Experienced RNs and LPNs are highly trainable on content One-day workshop with bi-monthly telementoring Equal attendance across PCMH and DM arms

15 Where is it delivered Lesson 3: Don t underestimate patients willingness to travel for a beneficial service In PCMH arm, patients preferred to meet inperson rather than by phone Distance traveled: 10 ±13 miles (range <1 to 161 miles)

16 How is it paid for Lesson 4: Practice-level transparency in payments for services produces highest provider and patient engagement Increased FTE/pay for local interventionists important for patient recruitment and attendance

17 What are important contextual factors for success? Consolidated Framework for Implementation Research construct Intervention Characteristics Design Complexity Relative advantage Inner Setting Learning climate Climate compatibility Available resources Process Engaging opinion leaders Planning Healthcare system FQHC Hospital-owned clinic Small private practice

18 Co-Investigators Edward Ellerbeck, MD Kim Kimminau, PhD Allen Greiner, MD Byron Gajewski, PhD Jeff VanWormer, PhD Cyrus DeSouza, MD Mike Perri, PhD Patient Advisory Board Arla Houck Cherie Herredsberg Luanne Kramer Karen Mason Les Lacy Jaynce Johnstone Margaret Kilpatrick Peg Bayles Frank Schotenberg Collaborators Provider Stakeholders Jen Brull, MD Bob Kraft, MD Cindie Wolff, MD Greg Thomas, MD Doug Gruenbacher, MD Krista Postai, CEO Gregg Wenger, MD Bryon Bigham, MD Bethany Enoch, MD Beth Oller, MD Jen McKenney, MD Libby Hineman, MD Heather Harris, MD Staff, postdocs, students Stacy McCrea-Robertson, MS Danny Kurz, MPH Leigh Quarles, MPH Tera Fazzino, PhD Nick Thompson, MPH Susan Ahlstedt, LCSW Lara Bennett, MS, RD Eryen Nelson, MPH Taylor Brumbelow, MPH Nick Marchello, RD Stephanie Punt, MS Fatima Rahman