Public Health Practice-Based Research: The Washington Experience

1. Public Health Practice-Based Research: The Washington Experience Karen Hartfield, MPH Academic Partnership Coordinator Public Health – Seattle & King County

2. Research should drive and strengthen quality improvement initiatives … but how can we get it done?

3. PBRN Purpose Develop sustainable infrastructure Identify practice questions of interest to LHJs, State DOH and Academic Partners Identify and seek funds to answer practice questions Translate research findings into practice through proactive dissemination

4. PBRN Membership Nine regional LHJs w/PHSKC acting as lead WA State DOH University of Washington School of Nursing University of Washington School of Public Health - NW Center for Public Health Practice Washington State Association of Local Public Health Officials

6. What’s the value of the PBRN to our members? Access to the academic literature and cutting edge models, measures, and methods. Ability to conduct more complex research projects, such as cost benefit analyses Provide the evidence base that what we are doing is effective (or not!) Help us make our case to legislators and funders.

7. Initial Work Identify Executive Committee Develop charter Learn about network member’s interests and skills Hold kick-off retreat to establish research priorities Identify and apply for funds for research priorities Conduct research projects/disseminate findings

8. Top 10 Research INTERESTS - Survey

9. Top Research QUESTIONS - Retreat Impact of funding losses on services and outcomes The role of community in public health service provision Effectiveness of public health interventions Measurement of health outcomes Emergency preparation communication Childhood obesity intervention effectiveness

10. Three network projects H1N1 Funding Loss: The Unfortunate Natural Experiment Variation in Communicable Disease Investigation Practices

11. H1N1 Real Time Assessment Purpose Identify variation in LHJ preparedness & response activities Articulate lessons learned for future flu pandemic/PH emergency Pilot evaluation methodology for other PH emergency planning & responseefforts Methods Four telephone surveys of 15 LHJs (9/09 – 5/10) Two online surveys (10, 2009) Timely results dissemination

12. Tracking H1N1 Vaccine Coverage in ACIP Target Groups Most LHJs were unable to estimate vaccine coverage in ACIP target groups Access to timely, accurate reports on vaccine coverage is critical to inform decisions about target group prioritization, vaccine allocation and other vaccine strategies A timely and efficient statewide vaccine reporting system is needed

13. Community Engagement Partnerships with community stakeholders facilitated public messaging, outreach, and vaccine provision to ACIP target groups LHJs should establish and maintain ongoing relationships & channels of communication with stakeholders as a part of ongoing routine public health activities

14. Statewide Communication and Coordination A stronger statewide health emergency response structure would improve communication & coordination among DOH and LHJs In collaboration with LHJs, WA DOH should consider designing a process to develop common standardized guidelines around: Prioritization of vaccine target groups Vaccine management & allocation Tracking vaccine coverage

15. Useful Planning Activities (May 2010)

16. Evidence-Based Practice Under Pressure: Local public health decisions made during a financial crisis How are decisions to cut programs made? Are funding decisions evidence-based? Are there empirical tools that can be used to make tough decisions? Can we improve quality of public health services by using objective decision-making tools and criteria?

17. Research Questions Describe the variationin cuts in response to the current dramatic fiscal conditions forcing LHD service and system changes in WA. Identify factors that influence the adoption, implementation and maintenance of evidence based public health practices during a fiscal crisis Identify commonalities in decisions made across public health settings based on racial, ethnic and socioeconomic composition of the populations served.

18. Project Methods A mixed method approach that includes an examination of existing local data and the collection of key informant interview data. Data sources include: WA State Activities and Services Inventory, WSALPHO data, and NACCHO Profile data

19. Using the information to inform quality improvement efforts Identify ways to increase the adoption and implementation of evidence based practices for disease prevention and reducing disparities. Identify efficient and consistent strategies for evidence based decision-makingin the face of budgetary crises. Study completed in August 2011

20. Communicable Disease Practice Variation Descriptive study of variation in approaches to CD investigation Online survey using SPSS web-based survey application Collection of LHJ protocols Possible precursor to determining best practices and protocols

21. Selected CD Conditions for Study Animal bite reporting and PEP Pertussis and criteria for PEP Salmonella and food worker policy Hepatitis C criteria for investigation Food borne outbreak and criteria for EH inspections West Nile Virus surveillance

22. Creating a System for Monitoring how Changes in Public Health Services Impact the Health of Vulnerable Populations – upcoming RWJ study Multi-site PBRN study Examine health outcomes related to variation in PH practice to determine “what works” on a national level. Compare effectiveness of various approaches to LHD practice Use findings to improve the quality of LHD practice and health outcomes in vulnerable populations

23. PBRN Challenges Articulating value of PHSSR to LHJs and academics Finding principal investigators Funding infrastructure in a time of diminished resources Difficulty of real time assessment Organizing network meetings

24. PBRN Successes Enthusiastic network of academic and public health practice partners Local and national recognition that descriptive and inferential research can improve quality of public health practice Improved capacity to conduct PHSSR Some increase in funding opportunities (RWJ)

25. Acknowledgements Dr. Betty Bekemeier, University of Washington School of Nursing Dr. Jeffrey Duchin, Public Health – Seattle & King County Dr. Hanne Thiede, Public Health – Seattle & King County Dr. David Fleming, Public Health – Seattle & King County The Washington Public Health Practice-Based Research Network

26. Robin Pendley MPH, CPH Angela T. Dearinger MD, MPH, FAAP Kentucky Public Health Research Network (K-PHReN) COACH 4 DMCommunity Outreach &Change for Diabetes management

27. K-PHReN • Kentucky Public Health Research Network • 17 LHD members • 53/120 KY counties • Kentucky Public Health Association • Kentucky Department of Public Health • University of Kentucky • College of Public Health • Center for Clinical & Translational Science

28. Type II Diabetes in Kentucky • 10% of KY adults have diabetes • 9th in nation • 6th leading cause of death in KY • 40% of KY adults have pre- diabetes • 2002 estimates of indirect and direct costs of DM • $2.9 billion

29. Project Aim • Evaluate the extent to which organizational QIstrategies influence the adoption and implementation of evidence- based interventions identified in the Community Guide to Preventive Services • Sufficient evidence to recommend that Diabetes Self- Management Education (DSME) be provided to adults with Type II DM in community gathering places

30. KY Diabetes Centers of Excellence (DCOE) • Six LHD (all K-PHReN members) • 2 single county LHDs • 4 district LHDs (6-10 counties) • Adults with Type II Diabetes • Goals • Diabetes Self Management Education (DSME) • Behavior change support

31. COACH 4 DM Goals • Overall purpose: Test whether evidence- based strategies lead to systems changes and process improvements within health departments • Method: Facilitate DCOE in design and implementation of a QI project to improve the delivery of existing DSME services • Utilize methods for systems change including: • Assess readiness for systems level change • Assess current practice • Establish process for improved service delivery • Evaluation of new system for service delivery

32. Study Participants • LHD designated as a DCOE (6) • QI Champion • Contact person • Coordinate team meetings • Provide pre/ post intervention data • QI Team • DCOE staff/ DSME educators • 4-6 members

33. Study Protocol:Change Facilitators • UK Office of Research Engagement for Advancing Community Health (REACH) • Previous training in QI facilitation • AHRQ Putting Prevention into Practice • IHI QI Collaborative • Embracing Quality in Local Public Health: Michigan’s QI Guidebook • Applied qualitative methodology • Regulatory compliance in QI research • Previous projects • Primary Care practice- DM management, cancer screening (through primary care PBRN)

34. Study Protocol • Enrollment visit • Consent • Project Overview • Three ½ day facilitation sessions • Monthly • At each DCOE site • Weekly communication with QI teams • Individual project periods • 6-9 months • Data collection & Evaluation

35. Study Protocol- Facilitation • Session One • Readiness for Change • (Modified) Assessment of Chronic Illness Care Version 3.5 (RWJF) • Assessment of current practice • Overview of QI methods/ tools • Specific focus on PDSA • Specific focus on evaluation • Also introduce: RCA, Cause/ Effect diagram, Logic models, Flow mapping • Brainstorming • Tailor training to QI team needs/ preferences

36. Study Protocol- Facilitation • Sessions 2 & 3 • Facilitate PDSA • Guide modifications to QI project plan • Provide additional QI training as needed • Between sessions • Weekly contact • Phone • Email

37. Collaborative Conference • Include all study participants • Discuss early successes and challenges • After 1st & 2nd facilitation session • Tele-video

38. Logic Model Assumption-Improved outcomes not short term External Factors-Previous QI experience, organizational climate

39. Outcomes • 1. Assess effectiveness of systems- based QI methods • Process improvement • Adoption/ Implementation of QI activities • Systems level change • Organizational climate • Behavior change • Knowledge of and comfort with QI • Utilization of pre/post surveys, post- session evaluations, direct observation, interviews

40. Outcomes • 2. Assess impact on DCOE capacity • # enrolled in DCOE • # receiving DSME • # completing DSME • # referrals and referral sources • Care Coordination efforts with PCP • Service delivery changes: • Method, location, content, timing, duration, frequency, language translation availability • DM rates • DM related factors rates (physical activity, diet) • Utilization of pre/post intervention capacity measures

41. Research Drives Quality Improvement: The PBRN Initiative Nancy Winterbauer, PhD Duval County Health Department & University of Florida

42. Objectives • FL-PHPBRN background • Organizational structure • Strengths • QI implementation: Transformational change • Qualitative results • Notes and observations • Transformation, diffusion and readiness • PHPBR to drive QI

43. Florida Center for PHPBR FL-PHPBRN Steering Committee Subcommittees Research Network Development/Academic Health Departments Health Informatics FACHO Regional Consortia Northeast Central Southeast West Central Emerald Coast Southwest Alachua Other CHDs Academic CHD Regional network illustrated for the FACHO Southwest Region Regional University Affiliates and Other Partners Background: FL-PHPBRN organizational structure

44. Background: FL-PHPBRN Organizational Structure

45. Background: FL-PHPBRN strengths • 67 county health departments • Strong SACHO • Communication • Relationships • Strong academic partners • Academic health departments • Health Information Technology

46. QI implementation: Data sources • Evaluating Quality Improvement Approaches to Improve Immunizations in Jacksonville, FL • RWJF-funded, June 15 2009 – June 14 2011; • PIs: Wlliam Livingood, PhD; Radwan Sabbagh, MD • Initial implementation (1st six months) • Social marketing • Customer satisfaction • Employee satisfaction

47. Leadership Commitment Agency-Wide Philosophical Shift Staff External Locus of Control PDCA Positive Results QI implementation: Transformational change Staff Engagement Staff Internal Locus of Control qi : QI Implement Change Staff Capacity Organizational Valuing

48. Transformation, diffusion and readiness in LHD settings • Change valence • Change efficacy • Task demands • Resource availability • Situational factors • Contextual factors • Outcomes • Implementation • qi : QI Weiner, Implementation Science, 2009, 4:67

49. Nancy Winterbauer, PhD Director, Florida Center for Public Health Practice-Based Research Nancy_Winterbauer@doh.state.fl.us 904-253-2056