Role of Leadership in Successful Adoption of Evidence-Based Care Models

 Our nation’s health delivery system frequently does not meet the unique needs of older adults. Wide gaps remain between value-driven science and evidence-based models and how care is currently delivered for many conditions that disproportionately affect this population.¹ Among the factors that contribute to this challenge, the absence of strong leadership that can drive change is underrecognized and consequently under addressed. Yet such leadership is essential for implementing and spreading innovative approaches that meet the complex needs of this population.^2-4 

With the generous support of The John A. Hartford Foundation and The Atlantic Philanthropies, for the past 13 years the Practice Change Leaders for Aging and Health leadership program has been dedicated to speeding the adoption of care models demonstrated to improve both care delivery and health outcomes for older adults. The interventions scaled were largely derived from models with demonstrated evidence but often modified to suit the unique challenges and constraints of each environment and population served. Implementing such improvements frequently require changes to complex organizational structures and processes, thus requiring a breadth of knowledge and leadership skills that go well beyond clinical or professional expertise.

To meet the challenges of achieving such improvements, selected mid-career leaders positioned across the care continuum participated in the Practice Change Leaders’ shared learning program, which was developed and implemented to impart requisite skills and knowledge, and facilitate interdisciplinary and cross-setting collaboration.⁵ An internal Annual Impact Evaluation was then conducted to quantify the impact of program alumni with respect to the number of older adults served and the number of health professionals’ practice influenced.

The primary purpose of this article is to describe how the program achieved its impact through shaping the growth and development of Practice Change Leaders. We begin by describing the program’s five core components and follow with cases designed to illustrate how these components contributed to leadership growth, model implementation, and the Annual Impact Evaluation outcomes reported in Table 1. We then explore key lessons to more broadly inform current and future health care leadership development efforts with a specific focus on widespread adoption of evidence-based models to improve care delivery.

 The details of the Practice Change Leaders program have been described previously.^6-9 The five core components of program structure and program content that directly pertain to facilitating the spread of evidence-based care are highlighted in Box 1 and serve as the primary framework for conveying the unique attributes of this program. Cases are presented to illustrate the breadth of achievements by Practice Change Leaders and how core components helped drive adoption of models that improve care.

Project Design

Practice Change Leaders designed and completed a project focused on implementing evidence-based models into practice. The project was firmly embedded in the Practice Change Leader’s core responsibilities and their organization’s priorities. Navigating the accompanying challenges inherent to the project—anticipated and unanticipated—served as a primary vehicle for experiential leadership development. The program continuously emphasized not only the building of expertise in the successful implementation of evidence-based models but, equally important, also emphasized how to sustain and scale such models locally, regionally, and nationally. Overcoming common implementation challenges (including maintaining model fidelity, reaching enrollment targets, staff turnover, budgeting, and accessing and analyzing organizational data) were interwoven throughout the experience.

Pods

The program employed small-group pods consisting of 3 to 4 mentors and 3 to 4 Practice Change Leaders and were designed to foster individualized problem-solving and support shared learning. During pod sessions, new learnings from skills sessions and national expert presentations were tailored to Practice Change Leader projects and leadership development. The range of professionals in each pod promoted interprofessional and intersectoral understanding and collaboration. Although many leadership experiences are moving away from face-to-face meetings, this program recognized that tailored attention and group problem-solving are greatly enhanced when mentoring pod members are physically together in one room 3 times each year.  

To further convey how the five core components translated into leadership skills and accomplishments, illustrative case examples of Practice Change Leaders are provided. In addition to highlighting the central role of the project and the value of shared learning pods, the cases are juxtaposed with the descriptions of the remaining three core areas identified in Box 1. Although in most of these cases more than one of the five core components contributed to accomplishments, the most influential component determined the grouping. Descriptions begin with the year each Practice Change Leader joined the program.

Senior Leaders

Practice Change Leaders received mentoring from highly accomplished nationally recognized experts in the development and spread of innovative care models known as Senior Leaders (Box 2). These Senior Leaders contributed valuable insights into navigating internal and external organizational dynamics and change management. Senior Leaders also facilitated opportunities for Practice Change Leaders to receive national exposure and recognition. The case examples in Case Vignettes 1 to 4 illustrate some of the contributions of Senior Leaders. (All of the information included in the case vignettes came from an internal Annual Impact Survey or from email/personal communication of internal data with the Practice Change Leader alumni. A total of 64 alumni responded to the survey.)

Skills

At each face-to-face meeting, Practice Change Leaders participated in skill sessions that employed simulation-based, project-specific learning. The three topics included: (1) engaging stakeholders across multiple health and community organizations, older consumers, and national/state policymakers; (2) making a compelling business case for the adoption and scale of care models; and (3) leveraging both data and stories to engage and persuade decision makers.  Kotter’s principles for leading change were emphasized though modified to fit the unique aging and organizational context.^10,11 The examples in Case Vignettes 5 to 7 briefly describe how skills were converted to results.

External Experts

National external experts provided exposure to real-world examples of driving change and overcoming barriers in such areas as: community-health care system partnerships; advocacy and leveraging public policy; engaging older consumers and caregivers; incorporating multicultural approaches in redesigning care; and integrating specialized services for older adults (eg, behavioral health, geriatric assessments) into traditional health care. The examples of Case Vignettes 8 to 10 illustrate how contributions from national external experts were incorporated into Practice Change Leader projects.

Based upon our review of the existing literature, there is a relative paucity of well-designed research to guide strategies for implementing evidence-based models of care. A number of thoughtful frameworks have been developed that examine the role of leadership in implementing evidence-based care approaches, particularly within single settings.¹² Formal studies that serve to validate these frameworks are needed. Additionally, given the complexity of the evolving health care delivery environment and wide range of desired outcomes,^13,14 we encourage the field to complement formal studies with other approaches including qualitative research and continuous quality improvement. This breadth of approaches would more easily account for the variation at the level of emerging leaders, organizational priorities and dynamics, and the diversity of patients served. Perhaps, the experience described herein may help to draw attention to the need for a greater investment in well-designed studies.

Health professionals spend years preparing for their clinical roles but proportionately little time preparing for administrative or leadership roles that are necessary to secure lasting improvements in the health and well-being of older adults. National and regional health care leadership programs are often organized around a particular discipline or care setting and largely emphasize the acquisition of new skills. Traditional leadership skills are necessary but often not sufficient for achieving transformative changes in complex care delivery. Based on our experience, advancing the spread of evidence-based care to older adults is far more effective through expanding both discipline and organizational boundaries. Many of our program alumni are spreading geriatric-focused efforts beyond the walls of their individual hospitals, nursing homes, home care and social service agencies, and clinics. The recognition that leaders who desire to broadly and effectively influence care need to assume the role of a “boundary spanner” is not unique to this program.¹⁵

One measure of the impact of this program could be its influence on the design of subsequent leadership programs. The following examples illustrate the influence of the Practice Change Leaders approach. With the support of a Center for Medicare and Medicaid Innovation (CMMI) State Innovations Model grant, the State of Oregon developed an interprofessional leadership program modeled after the Practice Change Leaders program and trained a total of three cohorts (45 interdisciplinary professionals) incorporating the program’s format and principles. The Practice Change Leaders Program has also influenced core design elements of the National Veteran’s Affairs Quality Scholars Program. Following a national environmental scan, Centers for Medicare and Medicaid Services/CMMI chose to model its Innovation Advisors Program experience after this program.¹⁶ The American Hospital Association Innovation Center is launching a new national leadership program called the Next Generation Leaders, the fundamental principles of which are also based on this program. Finally, the Practice Change Leaders program is closely aligned with The John A. Hartford Foundation’s effort to promote Age Friendly Health Systems.¹⁷

Observers of the Practice Change Leaders program often overlooked and underappreciated how the bidirectional benefit of participation (to both mentees and mentors) was explicitly incorporated into the program’s design. Nationwide there is a relative shortage of senior professionals who have skills and experience in promoting the spread of evidence-based models for older adults, who are willing to devote time to mentoring, and, further, who possess the qualities of an effective mentor. Based upon an externally conducted qualitative evaluation, the Practice Change Leaders national program office gained insight into why the Senior Leaders participated in every meeting over the 13 years and what they found most valuable beyond the rewards of mentorship in and of itself. In this inquiry, Senior Leaders identified that the program offered them opportunities for further career growth and professional development, exposed them to broader perspectives so as to more effectively drive change in larger or more varied settings, expanded their national peer network, and inspirited greater willingness to take risks in scaling new programs. Senior Leaders also appreciated the support they received from each other and the formation of lasting professional relationships. An explicit focus on fostering the bidirectional benefits of mentoring would appear to be a key element for initiating and sustaining successful leadership programs.

Recognizing that leadership training programs are resource intensive, a natural question arises as to how these programs should be initially financed and then sustained. Many if not most health care professionals emerge from their clinical training with substantial debt and may be reluctant to further pursue leadership training that could add to that debt. An argument could be made that, because payers and health systems directly benefit from having stronger health professional leaders, it would be in their interest to support such endeavors. The CMS/CMMI Innovation Advisors Program referenced above was supported by the Affordable Care Act but operated for only a single cycle. The Practice Change Leaders program was supported through private philanthropy with matching funds from the home organization, but philanthropy support often does not continue indefinitely. In a Practice Change Leaders evaluation conducted 2 years following graduation, an external evaluator surveyed participants’ supervisors and asked them to consider in retrospect what this enhanced training was worth to their organization and what they would be willing to pay for future employees to gain the benefits of the program. While the respondents were impressed with the growth and accomplishments of participants, most were reluctant to express a dollar value despite their positive firsthand experience.

The Practice Change Leaders program has demonstrated a compelling connection between the investment in leadership and the adoption and spread of evidence-based care models. Yet, questions remain as to how such programs should be funded long- term. The observations from our experience suggest that leadership programs continue to seek modifications to create a less resource-intensive approach while still recognizing that successful programs should incorporate opportunities for interdisciplinary and intersectoral learning, skills training linked to specific improvement projects, and professional growth for participants and mentors. Developing the necessary leadership to serve an aging population will require coordinated commitment from philanthropy, health care organizations, and the public sector.

Authors: 
Eric A Coleman, MD, MPH¹ • Nancy A Whitelaw, PhD²

Affiliations:
1 University of Colorado Anschutz Medical Campus, Aurora, CO
2 Practice Change Leaders for Aging and Health, Chelsea, MI

Disclosures:
This work was jointly supported by The John A. Hartford Foundation and The Atlantic Philanthropies. The sponsors did not have a role in the design or preparation of this manuscript.

Address correspondence to:
Eric A Coleman, MD, MPH,
Professor of Geriatric Medicine
University of Colorado Anschutz Medical
Campus
13199 E Montview Blvd, Suite 400
Aurora, CO 80045
Phone: (303) 724-2456
Email: Eric.Coleman@ucdenver.edu