Dream – Sharing of small group visions for the future

Shared creative visuals, metaphors

The following emerged from collaborative Appreciative Inquiry groups.

“Health Atom” Infrastructure/Bridges

• PBRN infrastructure deals with clinical data, the voice of the marginalized/those who experience inequity, and what all that means for each clinic in a ‘health system’

• We are building bridges that connect fertile academic/research/industry partnerships to fertile PBRN/practice contexts. The bridge is a ‘liminal (transitional) space’ where the ‘good stuff’ happens. We have a stock of wisdom/relationships in communities/clinics who have the ‘map’ to the right questions. The liminal space creates data and connects it to meaning. It spans boundaries. By recognizing and receiving and honoring what each of us contributes, we create virtuous cycles, that contribute to systemic change.

• There are lots of destinations. Our bridges are like the stairs at Hogwarts that magically move and connect to others’.

• The bridges are also like old medieval bridges that had businesses ON them.

• Traffic managers across the bridges are study sections.

Engagement

• Engagement with clinicians across different systems, residencies, practice/clinics (the bridges) – are value-based, increasingl use AI, are EMR informed, multi-disciplinary, multi-sectoral, integrated into medical education, use non-traditional designs, educate funders, catalyze change

• Engagement of the Academy (AAFP) is needed

• Relationships matter

• CTSAs are supporting some PBRNs, i.e. some CTSAs support some PBRNs

Goals

• A goal is to improve providers’ care such that it embraces a ‘culture of inquiry’ to support research that addresses workforce issues, diversity in practice (staff and patient populations), burnout, quality assurance (bringing up the ‘low end’), and includes community-patient involvement.

• Nationally, this will lead to shared goals/principles that will take us ‘over the top’ in terms of better alignment with government funders i.e. expansion of loan forgiveness; and payors i.e. better reimbursement. Common ground makes us collaborators not adversaries.

Shared interest, needs and successes

• PBRNs need shared researcher interest, clinician interest, and patient interest.

• Some PBRNs get ideas from "sentinel" clinicians and staff - folks in the practice that see something and bring it to the group. Many studies derive directly from clinical observations in the practice and community.

• PBRNs need folks that wear "2-hats" i.e. have multiple roles such as a primary care clinician and who also performs research and/or is part of an academic setting. People and teams produce ideas!

• Flexibility is important as proposals do not include definitive methods.

• Reviewers with experience and understanding of PBRN research are needed, as they differ from other university academic researchers. 

• PBRNs are more successful when they have interim, interstitial, and ongoing support (support for staff, care and feeding of practices, developing ideas and projects), and not just project support.

• PBRNs need fertile communities and practices

• PBRNs need fertile academic institutions.

PBRN positioning

• Unicorns – PBRNs are magically positioned to help bend the ‘arc of history’ towards equity but need better infrastructure and resources.

• Sleeping Giant of primary care wisdom/knowledge/expertise both in clinicians and the communities in which practices are situated to care for THEIR patients with ‘boots on the ground’

Pipeline programs

• New pipeline programs that propel, cultivate, and enable learners to take the ‘next step’ - changing the mentality so that there is NO QUESTION whether you as a learner/incoming provider will be involved in primary care research. Learners will see us ‘having fun doing research’ but also demand bandwidth to participate that is included in employment contract, e.g. in some specialties such as oncology, EVERY provider sees it as their duty and part-and-parcel of practice to be involved in research. This is not the current state of primary care. Primary care research must be ‘baked in” to every residency and department.  “Transmogrify” residency research practices, require all Family Medicine residents to be members of NAPCRG, to participate in a PBRN project, create a movement that is a gateway to research e.g. “we are doing a survey together”

Design

Same small groups work to start planning instrumentally first steps to make their emerging visions for the future of PBRNs a reality

• Next steps to ‘build the house’ (infrastructure group) - not just a single “mega-structure” but a collection of ‘inter-connected’ houses with a common space for interaction.

• NIH-funded Centers of Excellence in Primary Care Research

1. Build partnerships that will be able to respond to funding announcements to improve healthcare policy- leverage the Center to create new jobs that the community values

   1. Include FQHCs

2. Repository of clinical/EMR data across populations/systems e.g. data hub with agreements with HIE entities

3. Implementation and Dissemination Core- Clinical PBRN outcomes research, speed-up getting effective interventions in to practice

4. Data analysis core – use or develop methodologies that leverage the PBRN infrastructure and data opportunities

5. Administrative core – institutional commitment to accountability/support the Center e.g. advocate internally in organization for a wider vision of care; negotiate partial return of F&A to the Center of Excellence to support infrastructure; fund 10% of faculty time to do research for 3 years in “sentinel practices” where all docs have designated, protected research time, and all practice staff are recruited/trained to participate. Use each person at the upper limit of their scope of work. Negotiate buy-in from health system managers on the value proposition of the Center (how does what we produce by doing this benefit the organization financially); negotiate for research “RVUs”

6. Training Core for Practice-based research: educate Family docs in integration of research culture into the “job of doctoring”; develop ‘toolkits’ for medical students, residents, fellows relevant to PBRN research

7. Distinctive methodologies – that relate to the CASFM working group methodologies

   1. For example, that use patient advisory boards in response to NAPCRG “Responsible Research in Communities” policy, that study the effectiveness of practice facilitators, define standards for relationships with CTSA or a larger research entity e.g. how PBRNs can best collaborate with CTSAs so that PBRNs are not dis-enfranchised or ghettoized.

8. Use a model that ties financial revenue from research to the clinical institution eg. Using the NIH Cancer Center model for cancer studies e.g. quality incentives that generate income for the primary care clinic in which the research takes place and produce infrastructural support between projects e.g. “support the animals” model (like animal researchers have in place between projects)

9. Connect to other organizations doing similar work at NIH e.g. NCI, NCATs/AHRQ/Common Fund activities may provide more/future funding; American Association of Nurse Practitioners; American Osteopathic Assn., American Association of Physician Assistants.

10. Until this is prioritized/funded, health systems will always cut out pieces of research infrastructure when funding is tight OR attempt to co-opt it for other non-research purposes

Consolidated Small Group Design Working Session (3 groups)

Build off momentum from smaller group discussions.  Refine Design Plan to establish realistic, actionable steps toward implementing the Dream.

Small groups join to work on next steps around 3 topics – 2 groups per topic:

1. Infrastructure

2. Clinician & primary care researcher partnerships

3. Environmental opportunities for advancing PBRN research