The Reflective Practitioner Process in LANet

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The Reflective Practitioner Process in LANet

• Lyndee Knox, Ph.D.
• Carmela Lomonaco
• University of Southern California
• Knox_at_usc.edu

LA Net Los Angeles first Practice-based Research
Network devoted to health disparities
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Research in health care

• Most research in medicine/health care takes place
  in labs removed from community (efficacy not
  effectiveness)
• Takes place in labs removed from health care
  providers (HCP)
• Problem getting lab/bench research implemented in
  field (up to 12 yrs for full implementation)

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Medicines response (primary care)

• Establish Practice-Based Research Networks
  (PBRNs)
• Research labs in the community, made up of
  providers community residents
• Focused on patient oriented evidence that
  matters (POEMS) e.g. directly impacts care
• 89 primary care PBRNs in US at present
  available to you.

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Funding

• Agency for Health Care Quality and Research
  (AHRQ) 150K to 1mil/yr
• National Institutes of Health (NIH) - 150K to
  gt1mil
• NICHD National Childrens Study Pilot largest
  longitudinal health study in history
  (environmental exposures incl violence)(2.9 bil)

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LANet

• 200 providers
• 20 clinics
• 250,000 to 500,000 patient visits yr
• Inner-city LA low income, immigrant, at risk,
  underserved populations

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LA Net
4 Residency Clinics
Pomona
11 Community Clinics
3 Clinics with multiple sites
West Covina
LA Net
Hollywood Center
Alvarado
Hollywood Wilshire
Marengo
Beverly
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Approaches to project generation

• Top down (outside researcher uses clinics/docs as
  lab)
• Problems
• HCPs patients out of loop (also
  administrators)
• uptake of solutions is slow
• resistance from docs, practice
• resistance from community

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An alternative approach

• Community based participatory research
• Engage subjects/participants as partners
• Action oriented social change
• An approach more than a method

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RP CBPR

• Engages community(subjects) as partners in
  research process (in this case HCPs)
• Studies are oriented toward change, not theory
  testing

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5 steps in RF Process

• Step 1 Generate topics real time
• Step 2 Select top 3 using network vote
• Step 3 Evaluate and finalize questions
• Step 4 Select top 1 using network vote
• Step 5 Design and implement study w/ providers

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RP in LANet

• Annual
• Have implemented two cycles
• Costs- 15 20K
• Funding from DFM, HRSA

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Step 1 Generate topics real time

• Paged 60 providers 2xs over 2 weeks during work
  hours
• Asked What problems or concerns have you
  encountered today w/ a patient or delivering care
  that you would like to see the network study?
• Generated 50/- topics each cycle

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Example Topics

• Cultural differences in newborn feeding practices
• Patient satisfaction with PCPs
• Patient use of CAM
• Using email to communicate with patients
• Health literacy in Latino patients
• Patient access to medication
• Pediatric obesity prevention
• Youth exposed to violence

• Time on complicated patients that is not
  billable
• What are characteristics of diabetes with
  HgA1Cgt7
• What are L-T effects of inhaled steriods
• How manage problematic child behaviors in office
• Resources for patients w/ dementia
• Domestic violence identification

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Steps 2 3 Have members select top 3

• Hold Forum (food, fun, social)
• Vote on top 3
• Guided discussion to evaluate these questions

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Evaluation criteria
Will it change my practice? Will it change my
colleagues practice? Is it feasible? Is it
publishable? Is it fundable? Is there a
provider champion?
How does immigration affect feeding practices?
Patients compliance/ satisfaction w/ provider
counseling?
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Steps 2 3 Have members select top 3

• Refine question further in groups
• Literature search etc where does this enter
  conversation

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Step 4 On-line voting

• Recommendations e-mailed to network members
• Members vote for 1 topic
• 25 network members voted in 2003

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Step 5 Work w/ HCPs (and patients) to Design
Implement

• Review of literature to id gaps
• Formulate question that meets 6 criteria
• Select study design
• IRB
• Implementation and management of study
• Publications, presentations and grant
  applications
• Curricula developed/adopted for provider training
  in each of these areas

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Step 5 Design and implement

• Meet monthly (almost)/or intensives
• Social time!!!, training, project management
• Members are network providers, interested
  non-network members, outside researchers, network
  staff (N12/-)

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LANet RP-Outcomes

• (3) provider-generated studies completed/under
  way
• (1) paper presentation at NAPCRG
• (2) manuscripts under preparation
• (2) grant proposals HRSA and R21 to NCI
• (5) collaborative projects w/outside researchers

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Outcomes

• Interest from Dean, Provost, Childrens Hosp,
  Planning Councils - new partnerships and
  possibilities
• Violence relevant
• Evaluation of a violence curriculum
• Project to improve implementation of Staying
  Healthy (State mandated tool that includes some
  viol screening)
• Parent training intervention to deliver by
  providers

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Sample budget

• Total 14K to 28K
• Director/staff time 10 time - 8K
• Forum costs -food,facility rental 1K
• Working groups-food, etc 500
• Pilot project- 5K to 15K(excludes cost of
  provider participant time)

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Lyndee Knox, Ph.D.University of Southern
Californiaknox_at_usc.edu626-457-4220Carmela
LomonacoUniversity of Southern
Californiaclomonac_at_usc.edu
LA Net Los Angeles first Practice-based Research
Network devoted to health disparities