Problem Addressed

• Lack of time: Primary care physicians often lack the time needed to reexamine their practices and implement new technologies and procedures that would improve care and enhance preventive efforts.
• Inadequate communication and documentation systems: Important care-related information may not reach practitioners owing to inadequacies in the practice's medical records and documentation system, but the pressures of patient volume can prevent the practice from adapting more effective communication systems.¹
• Need for customized support: Studies that focus on improving patient care in inpatient or hospital outpatient settings, or that target specific diseases, have limited applicability in community-based practices. Because primary care practices are so individual and unique, quality improvement efforts must be customized to each practice’s organization, finances, and workflow.

Description of the Innovative Activity

• Practice assessments: The practice enhancement assistant assesses the current state of a practice and evaluates the effectiveness of current office systems, processes, and technologies and suggests new systems and interventions that can help improve the quality of patient care and preventive services. The assistant also provides information about how other practices are achieving their goals and identifies the resources needed in each practice. (See the next section for an example of how this worked in diabetes care.) Practice enhancement assistants are supervised by a behavioral scientist and serve eight clinicians working 1 day a week, every other week in each practice.
• Systems training: Practice enhancement assistants train physicians and staff to use information systems, assist practices with problems that occur in their use of information technologies, identify practice and community needs for consultations/referrals, and identify practice and/or community needs for additional training (e.g., continuing medical education or continuing medical education).
• Systems development: As the diabetes example below illustrates, assistants can help develop information systems, patient registries, tracking/monitoring systems, and other processes and systems that can help to facilitate quality improvement.
• Research training: A practice enhancement assistant can train physicians and staff to follow study protocols, collect data for studies requiring intermittent data collection, audit and/or pull charts for others to audit, transfer data, promote improvements that current research shows will improve patient care, collect ideas to improve research protocols, and obtain feedback on manuscripts before submission.
• Quality improvement projects and evaluation: As the diabetes example below illustrates, assistants can help practices develop quality improvement projects (e.g., Plan-Do-Study Act, quality improvement cycles), and then evaluate the results achieved.

References/Related Articles

Contact the Innovator

Results

• Improving the care of patients with diabetes: After identifying six principles used by exemplary practices to improve diabetes care, practice enhancement assistants were deployed to 30 practices to help them implement the principles. After 6 months, the mean improvements in diabetes quality indicators were as follows:
  • Use of angiotensin-converting enzyme (ACE) inhibitors if hypertensive: 69 to 91 percent
  • Use of ACE inhibitors if proteinuria: 74 to 93 percent.
  • Annual foot examinations: 72 to 93 percent.
  • Annual eye examinations ordered: 41 to 62 percent.
  • Annual hemoglobin A1c: 89 to 97 percent.
  • Annual urine for microalbumin: 46 to 68 percent.
• Annual influenza vaccination: 53 to 69 percent.
• Pneumococcal vaccination: 38 to 63 percent.
• Improved mammography screening rates: In a comparison of 16 practices (8 with practice enhancement assistants, 8 without), the practices with practice enhancement assistants had significantly higher screening rates, likely due to the 9-month period during which the assistants worked with these practices to redesign their mammography screening processes. In the control groups, 38 percent of eligible women were offered mammograms, and 92 percent of those eligible received mammograms. By contrast, 53 percent of the eligible patients in the practice enhancement assistant–assisted practices were offered mammograms, and 98 percent of those eligible received mammogram screening. Even the practice enhancement assistant practices, however, still have room for improvement. In 2004, Oklahoma's statewide mammogram screening rate for women more than 40 years old was 68 percent, and nationally the average was 75 percent. Other practice enhancement assistant–linked improvements in Oklahoma are currently being documented.
• Delivery of preventive services: Twenty-four practices participated in a 6-month quality improvement initiative to increase use of wellness visits, standing orders, and recall/reminder systems in an effort to increase delivery of preventive services. Twelve practices had practice enhancement assistants working with them and received performance feedback, peer-to-peer education (academic detailing), and information technology support. The 12 control practices received no intervention support. The success of the interventions was judged by a blinded panel that reviewed transcribed pre- and post-intervention interviews with participating clinicians. Delivery rates of preventive services were determined by chart audits. Practices with practice enhancement assistant–assisted intervention implemented more evidence-based strategies than control practices for adults, for children, and overall. The practice enhancement assistant–assisted practices were also more likely to implement at least one evidence-based strategy for children and to implement standing orders for either children or adults. Rates of mammography screening increased in intervention practices.
• Implementation of a Wellness Portal: Six practice sites (8 clinicians) were randomly assigned to either Wellness Portal intervention or control. Seventy patients at each site were enrolled and followed across 12 months to determine preventive services utilized. Wellness Portal use was tracked in the intervention practices. Practice enhancement assistants helped the intervention sites redesign their office procedures to encourage enrolled patients to bring Wellness Portal preventive services recommendations to their clinician visits. Results indicated that patients in the intervention sites who used the Wellness Portal did increase their uptake of recommended preventive services.²
• Cost-effectiveness: Researchers have demonstrated that similar kinds of practice facilitation in other settings have been a cost-effective way to improve the quality of preventive medicine in primary care. In one study, the cost of a facilitator was offset by a reduction in inappropriate testing and an increase in the provision of appropriate services, producing a net cost savings and an estimated return on investment of 40 percent.³

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Designing the practice enhancement assistant model: University of Oklahoma researchers originally expanded the practice facilitator model to improve the quality and delivery of care to diabetic patients in primary care practices in 1999 and 2000. They retained the research assistant role but also focused on enhancing preventive care and implementing system-wide changes through practice facilitation by the practice enhancement assistant.
• Securing funding: After designing the practice enhancement assistant model, the university's department of family & preventive medicine secured funding for primary care intervention projects from the Robert Wood Johnson Prescription for Health Project, the Oklahoma Health Care Authority, and the Oklahoma Foundation for Medical Quality. Currently, the university hires and trains practice enhancement assistants and offers them to the network practices to assist with research projects or initiatives in which practice interventions and research are simultaneous. The Oklahoma Health Care Authority and the Oklahoma Foundation provide funding currently for Medical Quality.
• Developing job descriptions and training for practice enhancement assistants: Job descriptions and training modules were modified from European models to address community practice-wide improvements and promotion of preventive care. These modules remain adaptable to serve the unique needs of each practice's patient population. Practice enhancement assistant training, available from the University of Oklahoma, is a 2-week process for its own assistants, and a 4-day process for prospective practice enhancement assistants from outside the Oklahoma system. The training covers topics specifically related to practice facilitation as well as administrative and departmental procedures:
  • Human subjects protection training
  • Health Insurance Portability and Accountability Act (HIPAA)
  • Practice-based research skills
  • Medical records review (chart auditing)
  • Rapid cycle quality improvement process (Plan-Do-Study-Act cycles)
  • Group facilitation and motivational methods (quality circles)
  • Practice characterization model, change management approaches
  • The Chronic Care Model and its implications
  • Practice visits and shadowing
  • Health information technology implementation and utilization
  • Best practices study methodology
  • Preventive services guidelines and implementation
  • Evaluation and management coding
  • Electronic Practice Record (demographics, progress notes, and plans for practices)
  • Handouts, patient education materials, practice resources, and project-specific training
• Cultivating physician champions: Usually a clinician champion in each clinic participates in contracting with the network practice enhancement assistants. This provider also serves as the champion of the initiatives within the clinic.

Resources Used and Skills Needed

• Practice enhancement assistants usually have master's degrees in a public health area (e.g., master's of public health in epidemiology or health promotion) and/or experience in a health care setting.
• Practice enhancement assistants must have a valid driver's license and a car, information technology skills, and strong interpersonal skills to attain collaboration and buy-in from physicians who are accustomed to working independently.

Funding Sources

Tools and Other Resources

• Current funding opportunities for practice enhancement assistants in the United States include grants from national (e.g., National Institutes of Health, Agency for Healthcare Research and Quality, Centers For Disease Control and Prevention), state (e.g., state health departments, quality improvement organizations, large health care providers, medical associations), and local (e.g., private industries, foundations) funding sources.
• University of Oklahoma will provide its training materials via e-mail free of charge, or will provide hard copies at cost. Potential practice enhancement assistants can attend a 2- to 4-day training session at cost. More information is available at http://www.okprn.org/peas.html.
• Although practice enhancement assistants are generally employed by academic medical centers in the United States, they become functional members of the primary care practice teams through business associate agreements. Because each practice enhancement assistant is shared by eight practices, each practice funds a proportion of the salary—one-eighth of the approximately $50,000 salary. Practice enhancement assistants are paid through project funding, not by the practice.

Getting Started with This Innovation

• Secure external or internal funding: The annual cost of a practice enhancement assistant, including salary, fringe benefits, and travel, is approximately $50,000 in Oklahoma.
• Develop rules and guidelines for practice enhancement assistants: Practices often establish rules and guidelines that govern practice enhancement assistants, such as how to request and file charts, with which personnel to communicate, policies related to using local information technology resources, and the like.
• Secure buy-in from the primary practices before assigning practice enhancement assistants: Because clinicians tend to work independently, it is essential to get their buy-in before bringing in a practice enhancement assistant who will closely examine the clinic's practices and recommend potentially controversial changes. Before accepting an assistant, the clinic should review its structure and organization, willingness and capacity to change, and commitment to work with the practice enhancement assistant over time.
• Set aside time for relationship-building: Once a practice enhancement assistant is assigned, at least 2 months of time must be available for building relationships between the assistant and the health care staff. During this time, the practice enhancement assistant will learn about the practice and its culture. Without a good relationship, the practice enhancement assistant may not be able to encourage the practice to embark on the difficult changes and reengineering of processes that may be required.

Sustaining This Innovation

• Integrate research and quality improvement into the practice enhancement assistant's job: The Oklahoma practice enhancement assistant model combines both a quality improvement/facilitation role with a research support role. Integrating research and quality improvement activities helps assistants address both aspects of their work and provides a framework for translating clinical findings into practice.
• Seek affiliations with research networks to facilitate cross-learning: It is helpful, but not essential, for a primary care practice hiring a practice enhancement assistant to be affiliated in some way with an academic medical research network to enhance cross-learning between academic and primary care practices.
• Have practice enhancement assistants work with multiple practices: Practice enhancement assistants who work in the same network and with multiple clinics can help to facilitate the sharing of knowledge, success stories, and strategies for overcoming challenges across clinic locations and practice enhancement assistants. In addition, assistants and their champions from each clinic can meet regularly to share success stories and ideas.
• Be willing to adopt new technology: Primary care practices must be willing to use new technologies and documentation systems to improve primary and preventive care and to maximize the benefits of participating in research.

Additional Considerations and Lessons

• A group of practices, which are not part of a research network, could hire and share a practice enhancement assistant. The practice enhancement assistant's focus would be strictly on practice improvement efforts, without the research component.
• It is important to match a practice enhancement assistant's personality and skills with each practice's unique culture and needs because so many of the potential improvements hinge on the relationship between the practice enhancement assistant and the practice’s staff. The practice enhancement assistant must go in with the attitude that she or he is there to help them achieve whatever goals they have identified.

Use By Other Organizations

• Colorado Research Network: This network consists of 500 primary care clinicians in 35 practices, 40 percent of whom are family medicine residents. The network includes residency training sites, community health centers, and university-associated private practices that care for approximately 120,000 patients. It employs one full-time practice facilitator, called a practice-based research coordinator, who is funded by a primary care research unit grant from the Health Resources and Services Administration. The research coordinator spends a half-day weekly in each of 10 practices working on both network and practice-initiated research and quality improvement projects. More information is available at http://www.ucdenver.edu/academics/colleges/medicalschool/departments/familymed/research/PBRN/CaReNet/Pages/CaReNet.aspx.
• Oregon Rural Practice-Based Research Network: This network includes 25 practices in rural communities throughout the state of Oregon. The network's 120 clinician members serve approximately 150,000 patients. Its community of clinicians includes members of academic medical centers, residency programs, private practices, Native American clinics, and community health centers. The network employs three practice enhancement and research coordinators who live in the rural areas in which they work. More information available at: http://www.ohsu.edu/xd/outreach/oregon-rural-practice-based-research-network/index.cfm/.
• University at Buffalo Family Medicine Research Institute and Upstate New York Practice Based Research Network: This network incorporates practice enhancement assistants into research and quality improvement projects. Practice enhancement assistants have been successfully integrated into three university-affiliated practices. Each assistant works 1 or 2 days a week at each practice site to carry out a cross-sectional asthma study and to assist site staff with quality improvement projects. These practice enhancement assistants have successfully overcome a variety of challenges. More information is available at http://fammed.buffalo.edu/unynet/emerging.html.