Facilitating practice implementation

Clinical Tools and Implementation - facilitating practice implementation

1. Quality improvement basics
2. Aligning PATHWEIGH goals with HEDIS and other clinic priorities
3. Giving and using feedback in monthly reports and monthly survey
4. Workflows
5. Optimizing EPIC support

Quality Improvement (QI) Basics:

Practices and QI Teams will incorporate regular tests of change and improvements to advance goals related to PATHWEIGH implementation. Setting realistic and measurable goals to implement and sustain PATHWEIGH will be key to success. Reference the AHRQ Primary Care Facilitator Curriculum at Practice Facilitation Handbook | Agency for Healthcare Research and Quality (ahrq.gov).

The aim of PATHWEIGH is to achieve a healthy weight for patients through weight loss and weight loss maintenance for selected patients when needed.  We recommend the same be true for your clinic’s implementation of PATHWEIGH.  We know many patients desperately want help and they can be successful with adequate direction and support. 

Some good initial questions for the QI team may be: 

• How can we activate patients to schedule weight-prioritized visits? 
• Is our clinic ready and enthusiastic to deliver weight-prioritized visits? 
• Do we have the right team to achieve our goals? 
• What other team members or resources do we think we need? 
• How do we balance this with other clinic priorities?

Once you settle on a question, the next step is to begin setting goals. It is important to ensure that goals are Specific, Measurable, Attainable, Realistic, and Timely (SMART). Setting SMART goals helps practices break big changes down into manageable steps that feel less overwhelming and more achievable. 

Specific – use specific language while planning goals. 

Measurable – set goals that can be measured.  

Attainable – be sure that goals are attainable, not impossible.  

Realistic – can goals be reached in a realistic time – setting a goal for a year from now will not help meet immediate goals. 

Timely – be sure to set a goal that have time requirements.  

Establishing weight prioritized visits with patients is an essential area of focus and practice goals. With the go live of PATHWEIGH in EPIC, a new visit type was created to denote weight prioritized visits. These visits give patients and clinicians protected time to discuss weight management, goals for weight loss, and appropriate treatment plans in an intentional visit, guided by PATHWEIGH. Beginning to use the visit type may represent a change for practices. Making your team aware of the visit type code and building its use into practice workflow may require some education and testing. 

Some sample goals:

• We will place a placard at the front desk asking patients if they would like medical assistance with their weight, and, if so, to schedule a weight-prioritized visit. 
• Each provider will conduct one weight-prioritized visit per week. 
• The practice champion or facilitator will report on success of the above goals at the monthly all-clinic meeting to ensure accountability. 
• The PATHWEIGH team will be consulted within 60 days when the above goals are not being met. 
• 50% of providers will complete the obesity e-learning module within 6 months. 

Aligning PATHWEIGH goals with HEDIS and other clinic priorities:

At the practice level, tracking electronic clinical quality measure (eCQM) data related to the use of PATHWEIGH will allow your practice to measure if implementation of PATHWEIGH is translating to improved patient outcomes.  You can align your PATHWEIGH work with other goals such as HEDIS or Primary Care First goals.  With team input, practices can set quality improvement goals using current eCQM benchmarks and then be able to objectively monitor progress over time. This is an important step to ensure that interventions are working. Examples of eCQMs that practices may use to track progress include, but are not limited to: 

• Controlling High Blood Pressure | eCQI Resource Center (healthit.gov) 
• Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) | eCQI Resource Center (healthit.gov) 
• Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | eCQI Resource Center (healthit.gov) 

Reference AHRQ Primary Care Practice Facilitator Curriculum, module 13 for more training on Measuring and Benchmarking, https://pcmh.ahrq.gov/sites/default/files/attachments/pcpf-module-13-measuring-and-benchmarking.pdf 

Once practices choose the eCQM(s) that will be tracked during PATHWEIGH implementation, a process for pulling and validating practice level data will need to be established. Ideally, practice level data should be reviewed monthly (minimum quarterly) to gauge progress towards implementation goals and improved patient outcomes.

Developing PATHWEIGH Workflows

• Any new service introduced into the practice setting requires some consideration to workflow. Understanding the who, what, why, how, and when of providing a new form of care is essential not only to starting something new but sustaining something that is working well. For additional information regarding workflow, please reference the AHRQ Primary Care Facilitator Curriculum at Practice Facilitation Handbook | Agency for Healthcare Research and Quality (ahrq.gov).
• The current overall workflow is shown below.  There are four general steps:

Of note, this workflow addresses only the core use of PATHWEIGH at a patient visit. Ongoing visits over time are recommended so patients may progress with continuing weight loss. In addition, in considering implementation more broadly, it is important to examine workflow processes to support referrals to integrated behavioral health providers or other individuals within the clinic who may support weight related patient goals in primary care.  There are also workflow implications for scheduling weight prioritized visits and administering pre-visit screenings.

Ideas you can use

• Practices may choose to identify a subset of patients to test implementation of PATHWEIGH, such as patients with BMI > 25 kg/m2, who can be identified proactively or during visit check in.
• There are opportunities for clinicians to seek e-consults with obesity management specialists, including endocrinology, behavioral health, and physicians experienced in the use of prescription medications to treat overweight and obesity.
• Introducing this opportunity for professional consult as well as considering workflow implications for accessing e-consults will also be essential for adoption in practice. 

Optimizing EPIC Support:

Any Epic related issues can be addressed through the online chat function. The entire EPIC team fields these live chats 7:30 am to 5:00 pm Monday through Friday.

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