Research nurses as practice facilitators to disseminate an asthma shared decision making intervention

Practice facilitation is a method of introducing and sustaining organizational change [1]. It involves the use of skilled healthcare professionals called practice facilitators (PFs) to help address the challenges associated with implementing evidence-based guidelines and complex interventions into practice [2]. PFs are individuals who work to achieve continuous quality improvement through a series of incremental plan-do-study-act cycles [1]. These PFs provide a framework for translating research into practice by building relationships, improving communication, fostering change, and sharing resources [3]. Throughout the literature, practice facilitation has been shown to improve evidence-based guideline adoption, preventive care, smoking cessation, chronic illness care including diabetes, and cancer care [2, 4‐11].

Nurses are well positioned to serve as PFs for the implementation of complex interventions. During their training, nurses build skills around being detailed and organized, patient and resilient, and learn how to think critically to make quick decisions [12]. These attributes are essential for practice facilitation, however, there is little evidence currently available to describe nurses in this role.

Additionally, the best strategies to implement complex interventions into practices are still not fully understood. In healthcare, the train-the trainer model leverages the experience of one provider or clinician to train others, who in turn disseminate the information onto others in their workplaces or communities [13‐16]. Combining practice facilitation with the train-the-trainer model has the potential to spread knowledge and skills to a greater extent. Utilizing research nurses as PFs in a train-the-trainer approach, we disseminated a complex intervention for asthma across the state of North Carolina.

Asthma is a complex and costly chronic lung disease that affects 1 in 13 Americans [17]. Over 24 million children and adults are living with asthma in the United States, annually accumulating 10.5 million office visits, 1.8 million emergency department (ED) visits, and 440,000 hospitalizations [18]. The burden of this health care utilization amounts to $56 billion per year in medical expenses, loss of productivity, and premature death [19]. Unfortunately, 10 Americans die every day from complications of their asthma [18]. Interventions are needed to improve patient outcomes given the high prevalence, morbidity, and mortality associated with asthma.

Improving provider adherence to guideline recommendations may help improve outcomes for patients with asthma [20, 21]. Providers often underutilize the National Hearts, Lung, and Blood Institute’s guidelines for managing asthma and adherence is thought to be poor in part because of guideline length and complexity [21‐23]. The guideline’s stepwise approach for managing asthma involves medication selection in varying doses and combinations dependent upon the patient’s age, severity classification, and control level [22]. It can be challenging for busy providers to quickly process this multitude of information when making medication selections with an asthma patient. Interventions, such as shared decision making (SDM) that improve patient/provider communication and simplify the medication selection process may help improve guideline adherence and patients’ outcomes.

SDM is an approach to care delivery that involves patients and providers jointly engaging in decisions around treatment options [24]. In SDM, both the patient and provider share relevant information, thus partner in their health care decisions. For the patient, this may include their personal values and lifestyle choices; for the provider, this may include pertinent disease information and the benefits and risks of various medications. The patient and provider together express their preferences with regards to treatments, such as improving disease control, minimizing side effects, limiting costs, or prioritizing convenience of the regimen. The patient and provider then discuss several evidence-based options and work towards an agreement on a treatment regimen [25, 26]. This SDM process has been shown to improve medication adherence and clinically relevant disease outcomes for patients with asthma [26‐29].

North Carolina (NC) is home to over 635,000 patients with asthma, affecting 8.4% of its residents [30]. The Mecklenburg Area Partnership for Primary Care Research (MAPPR), a practice-based research network (PBRN) based in Charlotte, NC, previously developed and implemented an asthma SDM toolkit intervention at 6 underserved practices through practice facilitation [24, 27, 28, 31‐34]. The intervention involved a team approach utilizing a health coach and toolkit comprised of decision aids, including evidence-based treatment options to streamline the medication selection process and improve asthma control (Fig. 1). To incorporate SDM for asthma care into the practices, the toolkit intervention focused on 5 essential components of SDM: (1) establishing the patient’s perception of current asthma control; (2) addressing medication adherence; (3) providing asthma education including “what is asthma,” controller versus rescue medications, correct inhaler technique, and trigger avoidance; (4) establishing treatment goals and medication preferences; (5) and finally negotiating several evidence-based treatment options based on the patient’s actual severity or control level. Using elements of the chronic care model and community-placed research, the complex toolkit intervention was tailored to fit the needs of each practice individually over a 12-week rollout period [27, 31, 35, 36]. Results from this pragmatic pilot study showed significantly reduced exacerbation rates in pediatric patients with asthma [27].

From 2013 to 2016, the ADAPT-NC (Asthma Dissemination Around Patient-centered Treatments in North Carolina) Study evaluated dissemination methods of the asthma SDM toolkit intervention through a large comparative effectiveness study, building on the work from our previous pilot [24, 27‐29, 31‐34, 37‐42]. Research nurses were trained as PFs to disseminate the intervention. Results of the ADAPT-NC Study showed a significantly higher portion of asthma patients shared equally in the decision-making with their provider in the facilitator-led dissemination arm (75%; 95% CI [71.7, 78.1]) compared to a traditional lunch-and-learn approach (66%; 95% CI [62.8, 69.8]) (p = 0.001) [29]. The facilitator-led arm also had the lowest proportion of patients visiting the ED (14% decrease for facilitator-led (95% CI [+ 4%, − 32%], p = 0.21), 12% decrease for traditional lunch-and-learn (95% CI [+ 11%, − 35%], p = 0.09), and 9% increase for usual care (95% CI [+ 28%, − 10%], p = 0.28)) [29]. These results suggest that complex interventions such as SDM are most effectively implemented in practices using a structured, facilitator-led approach.

The goal of this manuscript is to describe and evaluate the practice facilitation process from the ADAPT-NC Study which successfully utilized research nurses to implement a complex asthma SDM toolkit intervention into primary care practices.

Overall, the asthma SDM intervention was successfully implemented within the 4 PBRNs. All 10 facilitator-led practices remained engaged with their PFs, receiving at least 100 h of PF support in the 18 months post rollout, with 8 out of the 10 practices able to incorporate and sustain SDM visits or clinics. Of the 2 practices not able to fully implement, 1 practice experienced a 75% staffing turnover within the first year of the project and chose to focus on day-to-day clinic operations instead of SDM for asthma care. The other practice struggled with provider buy-in secondary to lack of leadership support in prioritizing SDM.

As previously described, the facilitator-led practices reported higher levels of SDM occurring in their asthma visits compared to the traditional lunch-and-learn practices (75% vs 66%, p = 0.001) and the facilitator-led practices also had the lowest proportion of patients visiting the ED for exacerbations [29].

Practice facilitation utilizing research nurses brought a comprehensive approach to implementation of a SDM toolkit intervention for patients with asthma in the ADAPT-NC Study. Leveraging the train-the-trainer model and elements of community-placed research, this facilitator-led implementation demonstrates effective use of research nurses as PFs to disseminate SDM for asthma care into primary care practices offering the potential for broader dissemination of complex interventions utilizing remote meeting capabilities and research nurses as PFs.

This study adds to the developing knowledge of best practices for implementation of large-scale, complex, primary care interventions through practice facilitation. Baskerville et al. concluded in their systematic review that primary care practices are nearly 3 times more likely to adopt evidence-based guidelines through practice facilitation when there is tailoring of the intervention [7]. Qualitative studies of primary care practice facilitation of complex interventions echo the importance of facilitating team communication, iterative evaluation of the implementation process with real-time feedback, facilitator integration into the practices, and flexibility [43, 44].

To date, there is little evidence directly describing the role of nurses as practice facilitators. However, attributes of nurses most likely associated with success in practice facilitation are well described. These include their empathetic approaches to care, inter- and multidisciplinary team collaboration, as well as training in protocols, evidence-based care, quality improvement, leadership, and communication skills [45‐50].

Research nurses demonstrated these skills during intervention rollouts in the ADAPT-NC Study. Not only had their training taught them to be empathetic and adaptable problem solvers, they also displayed versatile disease knowledge and understanding, along with effective communication skills. This model of practice facilitation leveraging nurses suggests potential as a method to implement research into practice, which may be further adapted to suit the needs of other populations, diseases or conditions, and settings [51].

Throughout the practice facilitation process in the ADAPT-NC Study, the PFs expressed common lessons learned: to be patient, persistent, pliable, and persevere. The PFs needed to patiently await responses from busy providers caring for patients first. Persistence in the form of frequent reminders was important for the PFs to keep the project running on track, sometimes arriving in person if the situation permitted. The PFs showed pliability when providing their practices with ample options and resources to tailor the intervention to their individual needs. Adapting to the changing needs of the varying practices required perseverance in the form of flexibility and quick thinking. The importance of establishing a trusting relationship with the practice, then building upon it with and frequent communication, was paramount to success.

This study demonstrated effective use of research nurses as practice facilitators during the dissemination of an asthma SDM intervention into primary care practices across the state of North Carolina, adding to the knowledge of best practices by describing a model of large-scale implementation of a complex intervention through practice facilitation with nurses. Future randomized controlled trials using practice facilitation should incorporate cost effectiveness analysis to determine the potential impacts of wider adoption.