"Lessons Learned with Implementing a Pragmatic Trial of Physical Activity Coaching in COPD"
Huong Q. Nguyen, PhD, RN
Research Scientist, Kaiser Permanente
Affiliate Associate Professor, University of Washington
A presentation of the Southern California Regional Dissemination, Implementation and Improvement Science Webinar Series.
Provided by the UCLA CTSI
Implementing a Pragmatic Trial of Physical Activity Coaching in COPD
1. Lessons Learned with Implementing
a Pragmatic Trial of Physical Activity Coaching
in COPD
Southern California Regional Dissemination, Implementation
and Improvement Science Webinar Series
April 5, 2017
Huong Q. Nguyen, PhD, RN
Research Scientist, Kaiser Permanente Southern California
Affiliate Associate Professor, University of Washington
Kaiser Permanente Research
4. Chronic Care Model
System
Design
5.Decision
Support
6. Clinical
Information
-
Management
Support
2. Health System
Resources and Policies
1. Community
Organization of Health Care
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Productive
Interactions
Informed,
Activated
Patient
Prepared,
Proactive
Practice Team
Self-
Management
Support
Decision
Support
Clinical
Information
Systems
Resources and Policies
Community Health System
Organization of Health Care
Delivery
System
Design
Assess
Advise
AgreeAssist
Arrange
Functional and Clinical Outcomes
http://www.improvingchroniccare.org/
5. Self-Management Support
“the systematic provision of education and supportive
interventions by health care staff to:
increase patients’ skills and confidence in
managing their health problems, including regular
assessment of progress and problems, goal setting,
and problem-solving support.”
~ Institute of Medicine, 2004, Quality Chasm Summit
8. Pulmonary Rehabilitation is the Gold Standard
Best “Medicine” for COPD
8
Uptake remains suboptimal
System Provider Patient
• Space
• Staffing
• Capacity
• Reimbursement
• Knowledge
• Attitude
• Referrals
• Transportation
• Distance
• Scheduling
• Motivation
Johnston et al. (2013). Prim Care Respir J. & Physiother Can 62(4): 368-373
11. Physical Activity Associated with Lower Risk of 30-Day
Readmission
EVS RR, 95%CI P value
0 mins/wk 1.0 -
1-149mins/wk 0.67 (0.55, 0.81) <.001
>150mins/wk 0.66 (0.51, 0.87) <.001
11
Adjusted for age, gender, marital status, race/ethnicity, insurance status, BMI, smoking status,
flu & pneumonia vaccination, use of inhaler medications, comorbidities, previous
hospitalizations, length of stay, discharge disposition, ED/Obs. Stay, and receipt of inpatient
palliative care consultation
n=4,596 patients admitted for a COPD exacerbation with 5,862 index admissions
from Jan 1, 2011 – Dec 31, 2012
Any PA → ↓ 34% readmission risk
Nguyen et al. Annals of ATS (2014)
37. Lessons Learned
Patients
Timing of outreach
may not synchronize
with patient’s
readiness for change
Activation with
coach’s outreach call
w/o “enrolling”
Individualized tailoring
according to patient
needs & preferences
Engaging family
caregivers
Engagement Data/Other
EMR data quality &
timeliness
Unable to integrate
study tools within
EMR
Technology
challenges
Evolving COPD care
practices at study
sites
Multi-stakeholder
engagement in all
aspects of the study
Executive sponsorship
Partnership with 7-
member Patient
Advisory Board (PAB)
Providers’ eagerness
to provide program to
more patients
IRB engaged during
grant proposal & study
start up
39. Executive Sponsors Patient Advisors
Research Staff
Software/IT &
Database Teams
Physical Activity
Coaches
Pulmonary
Chiefs & DAs
40. Lessons Learned:
Use of Existing Clinical Staff (Respiratory Therapists)
Training
No previous research
training or experience
Variable experience
working in outpatient
setting with population
management lens
Learning community
for best practices
– Motivational
interviewing skills
– Peer-to-peer
mentoring
Continuous QC“Culture”
Study FTEs: 30-100%
Clinical patient care
priorities trump research
study responsibilities
Labor regulations &
different job class codes
disallowed home visits
Motivate and empower
– Cross-coverage
Turnover with 6 new
coaches at 3 sites
Balancing pragmatism
and quality control by
research staff
Study management
tools & weekly reports to
ensure timely
completion of study
tasks
Cognitive overload with
many new processes &
disparate IT systems
42. Patients have competing demands
“Patients have the power in chronic disease.
Patients decide what to eat, whether to
exercise, and how often to take their
medications. If people don’t want to do
something, they won’t do it”
Bodenheimer (2007) Motivating Change